British Journal of Ophthalmology, 1987, 71, 326-330

Tear electrophoretic changes in Nigerian children aftermeaslesO KOGBE' AND S LIOTET2

From the 'Department ofOphthalmology, ABU Hospital, Zaria, Nigeria, and 2Laboratoire du Centre Nationald'Ophtalmologie des Quinze-Vingts, Paris, France

SUMMARY At the laboratory of the National Centre of Ophthalmology, Paris, tear electrophoresison cellulose acetate support was studied in 56 Nigerian children-32 during and shortly aftermeasles infection and 24 healthy controls. The controls had a normal pattern, while those withmeasles had patterns consistent with inflammation, most severe in the first week but showingvarying degrees of recovery by the third week. Four weeks after measles all cases suffering frommalnutrition had patterns with an additional peak. This was shown on further investigation byelectrophoresis on polyacrylamide cellulose gel and immunoelectrophoresis to be due to serumtransferrin. The normal protein pattern of tears is shown to be altered during and after measlesinfection.

Clinical observations and reports from Nigeria,"Zambia,5 Uganda,6 Kenya,7 and Tanzania' confirmthat measles is the commonest cause of cornealulceration and the leading cause of blindness inchildren in Africa south of the Sahara. It wouldappear to be responsible for much of the 200000annual cases of blindness attributed to xerophthalmiain this region. Measles, which can be very severe inAfrican children, is frequently associated with arapidly progressive corneal ulceration (up to 1% inNigeria') and protein calorie malnutrition. This isbecause most of the children are affected by measlesbetween the ages of 1 and 2 years, which correspondsto their weaning period, when they go off the breastbefore they can take an adult diet.' During the attackof measles protracted high fevers, severe anorexia,and frequent oral candidiasis worsen the nutritionalstatus of the affected children.The pathogenesis of this corneal ulceration follow-

ing measles remains obscure. Its similarity to kerato-malacia led to the estimation of serum retinol-binding protein levels. The results have not beensignificantly decreased in malnourished children withor without measles to support the theory that thecondition may be primarily a manifestation ofvitamin A deficiency.

Moreover, administering vitamin A, althoughCorrcspondence to Dr 0 Koghc, 110 ruc Pierre Brossolettc, 92320Chatillon, France.

effecting an appreciable rise in the concentration ofboth serum retinol and retinol-binding protein,"'does not, combined with topical antibiotics, acceler-ate healing of the corneal ulceration, unlike kerato-malacia with secondary bacterial infection. Measles"and malnutrition'2 have separately been observedto cause a state of severe depression in cellularimmunity. So it was proposed that the severe cornealulceration is due to an abnormally severe secondaryherpes simplex infection,'3 calling for a trial ofantiviral agents combined with forms of immuno-therapy such as interferon or levamisole.

Recent work on the functions of the tear fluid onthe cornea in keratitis sicca syndrome suggested thepossibility that the lacrimal gland (an epithelial tissuederivative) might be affected by the measles virus.We investigated the tears produced by children

during the course of measles infection by studying thecomposition and levels of tear proteins.

Materials and methods

SUBJECTSIn August 1984 and in January 1985 samples of tearswere collected from children presenting at thepaediatric unit of Ahmadu Bello University Hospitalin Zaria and Kaduna, University College Hospital,Ibadan, State Hospital, Ikeja, and Health CentreTundunwada, Jos. The date of onset of measles, and

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Tear electrophoretic changes in Nigerian children after measles

I I. x 1 J L. itFig. I Control: normalpattern. Fig. 3 Measles week 2: type 2 pattern.

its ocular and systemic complications, were recorded.Fifty-six children were seen: 32 had measles, while 24with no history or clinical evidence of measles servedas controls matched for age. The ages of the childrenranged between 6 months and 3 years.

METHODSSamples of tear fluid were collected by capillaritywith a sterile pointed-ground pipette, between 9 amand 12 noon to minimise evaporation, formol vapourbeing used as a stimulant for lacrimation. Thespecimens were centrifuged and the supernatant

Fig. 2 Measles week 1: serum-like pattern.

stored at 40C until electrophoresis was performedon cellulose acetate support in glycine tris-buffersolution. The strip was stained by Ponceau red,decolorised, and cleared. Further differentiation andidentification of proteins was done by carrying outelectrophoresis on the polyacrylamide cellulose gelof fresh aliquots of tear samples from cases showingan abnormal change; so also was immunoelectro-phoresis of whole serum, diluted serum, and tears inthe presence of whole human antiserum on agarose.

Results

The number of children suffering from measles wassurprisingly small, as there had been a successfulmeasles vaccination campaign the year before. Manypaediatric units had to be visited to collect tearsamples from 56 children. It was generally observedthat the controls produced tears much more readilythan those suffering from measles.

ELECTROPHORESISAll 23 controls had white eyes with no clinicalevidence of conjunctivitis. Electrophoresis of theirtears showed a splitting into four main bands (Fig. 1).All 19 cases seen during the first week of measlesinfection had mild to severe conjunctivitis; three hada normal pattern of tear proteins and 16 had patternssimilar to that of serum.

During the second week of measles the number ofcases seen was much less, as the majority hadrecovered, and only those with complicationsreported to the hospital. All seven had mild conjunc-tivitis. The pattern of tear electrophoresis was stilllargely similar to that of serum (Fig. 2) in five out ofthe seven cases, but showed a type 2 pattern (Fig. 3)

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Fig. 4 Abnormalpeak.

abnormality first described by Liotet et al."4 One ofthem had in addition an abnormal peak in the middleband (Fig. 4), indicating an appearance of a newprotein.The only patient whose tears were collected in the

third week had recovered from measles. He had noclinical conjunctivitis, and showed a normal patternof tear electrophoresis. The others seen were too illand had dry eyes as they just cried noisily withoutshedding any tears.

All five cases seen at four weeks after measles wereon treatment for secondary infections and varyingdegrees of malnutrition. They had no clinical con-junctivitis but had various corneal erosions. In all fivethe tear electrophoretic patterns were abnormal, asan additional narrow band with a pointed peakshowed up on an otherwise normal pattern in twocases (Fig. 5) and on a serum-like pattern in threecases (Fig. 6).Whereas five of six malnourished children without

a history of measles or corneal disease had patternssimilar to the controls', one child who had healing

Fig. 5 Abnormalpeak.

Fig. 6 Abnormalpeak.

bilateral corneal ulcerations following meningitisalso had an additional band similar to that seen incases four weeks after measles.

All the tears showing this additional band wereexamined by electrophoresis on the gel of polyacryla-mide cellulose (Fig. 7) and by immunoelectro-phoresis (Fig. 8). A prominent band was observed inthe position of serum transferrin. We could notdetermine its quantity as we did not have the specificmonovalent antiserum.

Discussion

The observed reduced tear production in childrensuffering from measles is highly suggestive of measlesaffecting the lacrimal gland function in tear produc-tion. Not only is the quantity reduced, the qualityalso appears to be altered.On normal tear electrophoresis our results agreed

with that of Liotet et al. '" who described four bandsseen on electrophoresis of normal tears on celluloseacetate support.During measles the appearance of an electro-

phoretic pattern like that of serum (Fig. 2) in thepresence and absence of clinical conjunctivitis morethan confirms McClellan et al. 's experience which ledthem to say that children with conjunctivitis could besaid to be crying serum. 6

In normal children only a limited amount of serumproteins are found in tears,'72' because a closedblood-tear barrier exists. Hence measles must cause aderangement of this barrier, so that serum proteinsmove freely into tears from the conjunctival vesselsand/or from the lacrimal gland. It is remarkable thatthis derangement can be detected by tear electro-phoresis four weeks after the onset of measles when,

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Fig. 7 Serum transferrin band (arrowed).

clinically, recovery from conjunctivitis appears tohave taken place. This can either mean that theblood-tear barrier remains open for a while or thatthe lacrimal gland has not yet recovered. Either way,tear electrophoresis is a simple, non-invasive meansof assessing lacrimal gland function and conjuncti-vitis.The appearance of serum transferrin in electro-

phoresis of tears from all children with measlescomplicated by malnutrition and corneal erosioncould be another index of derangement caused bymeasles. Malnutrition per se cannot be incriminated,as all those affected only by malnutrition had normalpatterns. The fact that this derangement was likewiseseen in a patient who had not measles but meningitiswith malnutrition and healed bilateral corneal ulcera-tions suggests that the derangement may be the causeor the effect of the corneal lesions. The quantity ofserum transferrin is too large (from the peak) to belikely to be due to filtration. So we propose twohypotheses:

(1) The first is local synthesis, which is unlikely,because the usual site of synthesis is in the liver,though this should be considered in view of thereports of synthesis at other sites.2' 22

Fig. 8 Serum transferrin band (arrowed).

(2) More likely, there could be an active transportfrom the vascular sector into the tears. The factor forthis is yet unknown, although such observations havebeen made on the cerebrospinal fluid,23 vitreous, andaqueous humour.24 This active transportation ofserum transferrin will be a source of loss to the bodyand may partly explain the finding of low valuesin malnourished Nigerian children reported byDossetor et al. 21

This could explain another means by whichmeasles renders children malnourished. It will beinteresting to find out if the same abnormality occursin liquid secretions and filtrations such as saliva,cerebrospinal fluid, and aqueous humour aftermeasles.The ready help and co-operation of the staff of the laboratory of thehospital des Quinze-Vingts and the pediatrics clinics in Nigeria areacknowledged with thanks.

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Acceptedfor publication 15 July 1986.

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