[Contact allergy to beta blockaders in eye drops: cross allergy?]

INTRODUCTION

Beta-blockers in eye-drops are widely used for the treatment of glaucoma. The potential allergic effect was only recently recognized.

CASE REPORT

A 65-year-old man had been treated with eye-drops containing beta-blockers for bilateral chronic glaucoma for 14 years. During the last two years, he developed eczema localized on the upper and lower eyelids. Allergy screening confirmed the implication of timolol and befunolol which had been used successively. Later prescription of eye-drops containing carteolol led to recurrence of the eczema.

DISCUSSION

This case of contact allergy with three different beta-blockers in the same patient is similar to others reported in the literature. All beta-blockers have a similar chemical structure, but it cannot act as a haptene. The proposed hypothesis is a cross-sensitivity which develops after primary metabolism to a common aldehyde. The risk of recurrence is high if another beta-blocker eye-drop compound is prescribed in a sensitized patient. The risk of side effects in such sensitized patients when taking oral beta-blockers is unknown.

Dioxopromethazine-induced photoallergic contact dermatitis followed by persistent light reaction

BACKGROUND

Although photosensitivity after photoallergy to topical phenothiazine antihistamines is well known, there have been no previous reports of dioxopromethazine inducing this phenomenon.

OBJECTIVE

A housewife used 0.5% dioxopromethazine in Prothanon gel for palpebral pruritus and developed severe dermatitis of the lower eyelids with spread to the sun-exposed areas.

METHODS

The minimal erythema doses and the minimal infiltrate doses for ultraviolet A (UVA) and ultraviolet B (UVB) were established before photopatch testing and at intervals up to 497 days thereafter. Test sites were read up to 144 hours after irradiation. Photopatch testing was performed with Prothanon gel, dioxopromethazine hydrochloride 0.001% to 0.5%, and the standard photopatch test tray (Hermal/Trolab). For patch testing, various series of the German Contact Dermatitis Group were applied.

RESULTS

Minimal erythema doses for UVA were diminished before photopatch testing and at intervals up to 500 days after Prothanon gel was discontinued. Exposure to UVB provoked abnormal delayed infiltrated reactions. Clinically the photosensitivity persisted within this period. Photoallergic reactions were seen with Prothanon gel, dioxopromethazine hydrochloride 0.005% to 1.0%, and promethazine hydrochloride 0.1%. The patient gave positive patch test reactions to various fragrance materials, balsam of Peru, costus oil, and propylene glycol.

CONCLUSION

Because topical dioxopromethazine may cause photoallergic contact dermatitis followed by long-lasting photosensitivity even after contact has been discontinued, its withdrawal from the market is recommended.

[Edematous swelling of the eyelids caused by contact allergy]

Cosmetics and ophthalmological topical preparations are the main causes of allergic contact eczema about the eye. In most cases, clinical signs are conjunctival injection, blepharitis, periorbital dermatitis and edema of lids, often combined with itching. Pure edematous swelling of the eyelids should not immediately be blamed on a contact allergy, but sufficiently evaluated to exclude a benign or malignant process of the eyelids, orbita, lacrimal duct and paranasal sinus. We present a patient with pure edematous swelling of the eyelids due to a contact allergy by the sympathicomimetic phenylephrine hydrochloride, an uncommon allergen.

Skin atrophy of the eyelid induced by topical ophthalmic corticosteroids

A case of eyelid skin atrophy caused by long-term application of topical ophthalmic corticosteroids for chronic uveitis is reported. Skin punch biopsy of the uveitic eye showed moderate atrophy of both epidermis and dermis (compared to normal skin on the other eye) resulting from a reduction in the three main fibrous components of the skin, namely type I and type III collagens, and elastic fibers. To our knowledge, this is the first report of skin atrophy in this association.

[Propacetamol and new occupational contact dermatitis]

We describe the cases of three hospital nurses who presented eczematous lesions on the hands and eyelids. They worked in surgery department or in post anaesthesia recovery room, all preparing syringes of Pro-Dafalgan (propacetamol: parenteral paracetamol form). They were not sensitive to oral paracetamol or occupational products and latex. During week-end or holidays when they stopped handling Pro-Dafalgan, the eczema recovered but relapsed on working. A few cases are described in the literature so precautions begin to be preconized for healthcare workers but they are not usually in practice. Test performed with solvent, paracetamol, latex, formol and other hospital allergen tests were negative. The only allergen would be propacetamol because all tests performed with it were strongly positive. Following the official evaluation method in pharmacovigilance, based on chronologic and semiologic criterias, considering the positivity of rechallenge and specific tests, propacetamol imputability was probable in all our cases. It is preconized to declare cases to Regional Pharmacovigilance Centers to complete information about handling risks of this very usual analgesic.

[Molluscum contagiosum in immunosuppression with methotrexate: multiple warts with central depressions of the eyelids]

BACKGROUND

Poxvirus induced molluscum contagiosum is known to occur in children, elderly people and in patients with the acquired immune deficiency syndrome AIDS.

PATIENT AND METHODS

We report on a 49-year-old patient who presented with a three-month history of multiple skin-coloured prominent warts on his right upper and lower eye-lid. On examination, the warts showed a central cavity and measured 2-6 mm in diameter. For his "mixed connective tissue disease" (MCTD) the patient took methotrexate in a weekly dosage of 7.5 mg since 3 years. Diagnosis of MCTD was made 7 years before. The warts were excised and studied histopathologically. One year postoperatively, there was no recurrence of the lesions.

CONCLUSION

Drug induced immunosuppression as with methotrexate may be associated with multiple periocular lesions due to molluscum contagiosum.

Localized dystrophic periocular calcification: a complication of intralesional corticosteroid therapy for infantile periocular hemangiomas

Two female infants with eyelid hemangiomas developed prickly, rock-hard, subcutaneous crystals following intralesional corticosteroid injections. In each case, the crystals were isocentered on the injection locus and partly eroded the skin, causing local discomfort and inflammation. This complication occurred after two treatment sessions and presented 8 to 9 months after the second injection. An MRI scan showed subcutaneous calcification in the location of the injected orbital hemangioma in one patient. Histopathologic examination confirmed calcification in areas of degenerate hemangioma. There was no recurrence of either hemangioma or calcium deposition following surgical excision. Localized dystrophic calcification may be a late complication of intralesional corticosteroid therapy of periocular hemangiomas.

Oculo-bulbar myasthenia gravis induced by cytokine treatment of a patient with metastasized renal cell carcinoma

OBJECTIVE

The occurrence of autoimmune diseases or deterioration of pre-existing disorders has recently been described after cytokine treatment. The present report gives evidence for acquired myasthenia gravis induced by externally administered interferon-alpha and interleukin-2 in a patient with metastasized renal cell carcinoma. Electromyographic investigations did not reveal generalised myasthenia gravis. However, a highly elevated titre of antibodies against the human acetylcholine receptor and a significant improvement in clinical symptoms during therapy with anticholinesterase drugs, combined with a decremental response in electronystagmography, indicated an intermittent mainly oculo-bulbar form of myasthenia gravis.

Light microscopic comparison of surfactant-induced eye irritation in rabbits and rats at three hours and recovery/day 35

Limited information exists on the pathologic changes occurring with surfactant-induced ocular irritation in the context of accidental human exposures and animal tests used to assess for such irritation. The purpose of this study was to begin to characterize the pathologic changes that occur with surfactants in the context of standard animal tests and compare the response in rats to that in rabbits. Representative anionic, cationic, and nonionic surfactants causing slight to severe ocular irritation were directly applied to the corneas of rabbits and rats at a dose of 10 microliters. Eyes and eyelids of each animal were macroscopically examined for signs of irritation beginning 3 hr after dosing and periodically until recovery or day 35. Eyes and eyelids from animals in each group were collected for microscopic examination after 3 hr and at recovery or day 35. Microscopically, all of the surfactants caused erosion, denudation, and/or necrosis of the conjunctival and corneal epithelium in rabbits and rats. Necrosis of keratocytes was observed in rabbits and rats treated with the severely irritating cationic surfactant and in rats treated with anionic surfactants that were mildly irritating and moderately irritating. Corneal endothelial changes were observed in rabbits and rats with only the cationic surfactant. Changes in eyes of rabbits and rats that had not recovered by day 35 included decreased prominence of goblet cells, conjunctivalization of the corneal epithelium, neovascularization and fibrosis of the cornea, and presence of devitalized stroma. Overall, the changes in rabbits and rats were similar and suggest that the rat may be used as a surrogate for the rabbit in studies to understand better mechanisms of surfactant-induced eye irritation.

Neonatal orbital irritant contact dermatitis caused by gentamicin ointment

The common preventive therapy in our department for newborns' eyes is tetracycline ophthalmic ointment. Due to temporary shortage of tetracycline ophthalmic ointment for one week in December 1991, the preventive therapy given to seventy-one newborns was gentamicin sulfate ophthalmic ointment. Five babies (7 percent of all newborns) experienced marked edema of the eyelids, foci of erythema, and serous exudate within the first days of life. The lesions regressed gradually and disappeared entirely within two to three weeks without any complications. These lesions represent the first description of orbital irritant contact dermatitis in newborns, most probably caused by topical gentamicin preparation. However, one cannot exclude sensitivity to paraben, which is the preservative used in gentamicin ointment, or a synergistic action of both agent and preservative.

Histiocytic cytophagic panniculitis which developed during interferon-alpha therapy

A 59-year-old woman developed edema of the face and eyelids during interferon (IFN)-alpha-2b therapy for chronic hepatitis C with a cumulative dose of 6 million x 47 units. Despite cessation of the therapy, the edema progressed and was followed by exophthalmos, pyrexia, liver dysfunction, pancytopenia, and disseminated intravascular coagulation. Two months after initial presentation, she died of hemorrhagic shock and was diagnosed with histiocytic cytophagic panniculitis at autopsy. This may be a hitherto unrecognized adverse effect of therapeutic IFN alpha.

Cyclosporin protects the eyelid skin from injury after injection of doxorubicin

PURPOSE

The myotoxic drug doxorubicin can treat blepharospasm and hemifacial spasm permanently when injected directly into the eyelid of patients. One side effect of this treatment is the dose-related occurrence of injury to the skin overlying the injection site. The purpose of this study was to determine if injection of the immunosuppressive agent cyclosporin into rabbit eyelids before doxorubicin treatment could reduce the occurrence of injury to the overlying skin and to determine the effect of cyclosporin pretreatment on doxorubicin-induced muscle fiber loss.

METHODS

Anesthetized rabbits received injections of varying doses of cyclosporin 20 minutes before injection of either 0.5, 1, or 2 mg doxorubicin. The rabbits were examined daily, and epithelial changes were recorded as to duration, time of onset, and healing. When the skin was completely healed, the animals were killed and eyelid tissue was prepared for morphometric determination of muscle fiber number. Acute inflammation was quantitatively assessed using an Evans blue assay.

RESULTS

At specified doses, cyclosporin improved the doxorubicin chemomyectomy protocol in three ways. It delayed the onset of skin injury at the higher doses of doxorubicin, and it markedly decreased the duration of skin injury. At some doses, cyclosporin completely prevented the formation of epithelial defects. The combination, however, did not increase muscle loss compared to doxorubicin alone; in fact, it had a slightly myoprotective effect. A dose range for cyclosporin administration was determined that resulted in a quantitative and dose-dependent reduction in inflammation at the injection site.

CONCLUSIONS

The injection of cyclosporin into the eyelids before doxorubicin treatment delayed the onset, reduced the duration, and limited the extent of development of eyelid skin injury. Perhaps by limiting cytokine release, cyclosporin decreased the inflammatory reaction compared to that seen with doxorubicin alone. This combination has the potential to improve patient acceptance of doxorubicin chemomyectomy for the treatment of blepharospasm and hemifacial spasm.

Adverse ocular effects associated with niacin therapy

In a retrospective survey of patients taking medication for hyperlipidaemia, those taking niacin (nicotinic acid) were more likely (p < 0.05) to report sicca syndromes, blurred vision, eyelid oedema, and macular oedema compared with those who never took niacin. Additionally, 7% of those taking niacin discontinued the drug owing to adverse ocular side effects, while none of the other lipid lowering agents were found to cause these side effects (p = 0.016). Data from spontaneous reporting systems support a possible association of decreased vision, cystoid macular oedema, sicca-like symptoms, discoloration of the eyelids with or without periorbital or eyelid oedema, proptosis, loss of eyebrow or eyelashes, and superficial punctate keratitis with the use of niacin in high doses. Decreased vision may be marked, and if the drug is not discontinued, may progress to cystoid macular oedema. All ocular side effects listed above are reversible if the association with niacin is recognised and the drug is discontinued; both the incidence and severity of the ocular side effects seem to be dose dependent.

[Sclerosing lipogranulomatosis of the eyelids after ethmoid sinus surgery: a complication after ointment tamponade!]

We report on an instructive case of an infrequent but severe complication after paranasal sinus surgery. The use of ointment-covered nasal packing for haemostasis can cause inoculation of ointment into the orbita, if the medical orbital wall has been injured intraoperatively. A postoperative intraorbital haematoma may spread ointment droplets into subcutaneous tissues of the eyelid and cause local sclerosing lipogranulomatosis. The case reported here underlines the resulting therapeutical problems as have been mentioned in the literature. Only complete excision of the lipogranuloma can prevent recurrences. We conclude that ointment should not be used with nasal packings after paranasal sinus surgery if an intraoperative lesion of the orbital wall is likely to occur.

[Chronic lipogranuloma (paraffin granuloma) of the eyelids and orbits after endonasal paranasal sinus operation]

During the last five years 10 patients received surgical treatment in our eye clinic for tumours of the eyelids and the orbit that had developed after endonasal sinus surgery. In most patients the first signs of lid or orbital involvement had occurred 4 weeks after ENT surgery and after a unilateral or bilateral postoperative haematoma had subsided. The histological examination of the surgical specimens showed chronic sclerosing lipogranuloma containing large vacuoles surrounded by epithelioid and giant cells, typical of a so-called paraffin granuloma. MR-spectroscopy detected high concentrations of paraffin in the specimens of 3 patients. Since paraffin is a constituent of many ointments, we assume that the granulomatous reaction was elicited by the ointment tampons routinely applied to the wound area following sinus surgery. The bleeding acted as a vehicle to distribute the paraffin into the surrounding tissues.

Orbital and palpebral paraffinoma

Paraffinoma is a well-recognized complication of paraffin injection. We describe a 44-year-old man who had an ethmoidectomy for chronic sinusitis. A communicating fracture of the ethmoid bone into the orbit occurred intraoperatively. The nasal cavity was subsequently packed with gauze containing a petrolatum-based antibiotic ointment. Bilateral, periocular swelling developed 1 week later. Optical and electron microscopic studies revealed a paraffinoma.

[Ocular side effects of drugs]

Drug-induced side effects manifested by the human eye are characterised by the specific anatomical, histological and functional features of the eye. Such ocular changes may arise after local or systemic drug application. The following article outlines the clinically relevant common drug-related side effect on the lids, cornea, conjunctiva, lens, retina, uvea, and the optic nerve, as well as effects on the intraocular pressure, refraction and accommodation.

Abnormalities of the visual system in infants exposed to cocaine

The authors describe 13 cocaine-exposed infants with optic nerve abnormalities, delayed visual maturation, and prolonged eyelid edema. Prolonged and potentially vision-threatening eyelid edema is a new clinical entity. The pharmacology of cocaine, its easy access to fetal circulation, and its neurotropic characteristics can be used to explain optic nerve abnormalities and delayed visual maturation. In infants with any of these eye abnormalities, a careful investigation for cocaine abuse is advisable.