[Mucous membrane pemphigoid with ocular involvement. Part II: therapy]

Long-term outcomes of fornix reconstruction and cicatricial entropion repair in ocular mucous membrane pemphigoid and drug-related secondary pemphigoid

OBJECTIVE

To investigate the long-term outcomes of fornix reconstruction and cicatricial entropion repair in patients with ocular mucous membrane pemphigoid (MMP) and secondary MMP.

METHODS

Retrospective chart review of patients with MMP undergoing either fornix reconstruction (with amniotic membrane or buccal mucosal graft) or Wies cicatricial entropion repair between January 1, 2000, and September 1, 2020. Patients had a positive mucosal biopsy and (or) clinical features of MMP or secondary MMP. The primary outcome was overall success of fornix reconstruction based on fornix depth maintenance at latest follow-up. Secondary outcomes included resolution of trichiasis, visual acuity, and improvement of subjective symptoms.

RESULTS

Eight patients (10 eyes) with a diagnosis of MMP (3 males and 5 females; median age, 71 years) and 4 patients (4 eyes) with a diagnosis of secondary MMP (2 females and 2 male; median age, 87 years) were enrolled. Mean follow-up was 22.7 months (range, 0.3-87.5 months) for MMP patients and 15.4 months (range, 3.0-43.9 months) for secondary MMP patients. For MMP eyes, 30.0% underwent fornix reconstruction, 60.0% underwent entropion repair, and 10.0% received both. Re-formation of symblepharon and loss of fornix depth occurred in all MMP eyes at an average of 6.4 ± 7.0 months postoperatively, and trichiasis recurred in all patients at the last follow-up visit. In secondary MMP patients, 75.0% of the eyes showed recurrence of symblepharon, and 66.7% re-formed trichiasis. Both MMP and secondary MMP patients had short-term symptom improvements.

CONCLUSIONS

Fornix reconstruction and cicatricial entropion repair in our cohort of MMP and secondary MMP patients resulted in short-term symptomatic improvement, but recurrence was seen, on average, at 6 months postoperatively.

[Treatment of ocular mucous membrane pemphigoid]

Ocular mucous membrane pemphigoid is the manifestation of a systemic autoimmune disease. As autoantibodies circulating in the blood cannot be adequately treated by eye drops, systemic immunosuppressive treatment of this autoimmune disease naturally plays the most important role. Ophthalmic topical or even surgical procedures are only used as supportive measures or usually to control ocular complications that have developed. Patients with the typical clinical picture are treated causally with systemic immunosuppression causally, nurturing eye drops, as well as by minimally invasive surgery if complications arise, if possible in an inflammation-free state, in accordance with the guidelines if the diagnosis is positive but also if the biopsy and serology are repeatedly negative after exclusion of all differential diagnoses. Purely topical anti-inflammatory treatment is insufficient to prevent irreversible progression of scarring conjunctivitis. Corresponding treatment recommendations have been formulated in current European as well as German guidelines and are presented here as an overview.

[Health-related quality of life after implantation of a keratoprosthesis with biological haptic]

BACKGROUND

Many studies report comparatively good long-term results among patients with keratoprostheses with biological haptic. However, overall costs are correspondingly high. A clear cost-benefit relationship is therefore desirable.

OBJECTIVE

This study investigates health-related quality of life after implantation of a keratoprosthesis with biological haptic.

MATERIALS AND METHODS

We present a retrospective analysis of medical data of 25 patients treated between 1996 and 2006 at the Department of Ophthalmology, University Hospital Homburg/Saar and the Klinikum Offenburg. Health-related quality of life was assessed by means of a questionnaire based on validated instruments, with particular emphasis on physical symptoms, mental health, functional limitations, and social interactions.

RESULTS

At a patient age of 49.8 ± 15.7 years (minimum-maximum: 19-78 years; 6 female, 19 male), the mean duration of corneal blindness was 13.8 ± 13.1 years (minimum-maximum: 1-47 years). Changes in visual acuity and subjective satisfaction were statistically significant (p <0.001). Quality of life (on a scale of 1 to 6: median 2) at the time "before the onset of eye disease" and ≥15 months after surgery were identical. Patients with a postoperative visual acuity ≤0.1 (n =11) also showed a statistically significant (p =0.016) benefit in this context.

CONCLUSION

The expenditures and costs of keratoprosthetics can be justified by an improvement in the health-related quality of life of the persons concerned. Even a postoperative visual acuity of ≤0.1 correlates with a statistically significant improvement in the subjective quality of life of these patients.

[Involvement of mucous membranes in autoimmune bullous diseases]

Autoimmune bullous diseases are characterized by intraepidermal or subepidermal autoantibody deposition that leads to blisters and secondary erosion. Mucous membranes are frequently affected in pemphigus vulgaris and always involved in cicatricial and mucosal pemphigoid. Mucosal lesions are detected less frequently in patients with bullous pemphigoid or epidermolysis bullosa acquisita. The diagnosis of autoimmune bullous disorders is based on determination of the subtype of autoantibodies bound in the skin and the clinical picture. Treatment is based on immunosuppression related to the type of disease and severity of the mucosal symptoms. Ocular involvement in mucosal pemphigoid and pemphigus vulgaris requires systemic treatment.

Sealing of the gap between the conjunctiva and tenon capsule to improve symblepharon surgery

PURPOSE

To report the surgical outcome of "sealing the gap" in treating symblepharon caused by various etiologies other than recurrent pterygium.

DESIGN

Retrospective, interventional case series.

METHODS

Sixteen eyes of 14 patients with pathogenic symblepharon were consecutively operated by conjunctival recession, sealing the gap between recessed conjunctiva and Tenon capsule with a running 9-0 nylon suture, and covering of the bare sclera with amniotic membrane. For severe symblepharon where there was conjunctival shortening, oral mucosa graft was added. Outcome measures include ocular surface inflammation, fornix reformation, and restoration of ocular motility.

RESULTS

The underlying causes of symblepharon included Stevens-Johnson syndrome (n = 6), chemical burn (n = 5), ocular cicatricial pemphigoid (n = 1), thermal burn (n = 1), following excision of conjunctival squamous cell carcinoma (n = 1), conjunctival scarring following exposed buckle (n = 1), and immune dysregulation (n = 1). Twelve eyes (75%) had an average of 1.6 ± 0.9 previous surgeries. Before surgery, ocular motility restriction was significantly correlated with the severity of symblepharon. During the follow-up period of 17.1 ± 13.6 months, 13 eyes (81.3%) achieved complete success, 2 eyes (12.5%) achieved partial success, and 1 eye with immune dysregulation had failure (6.3%). There was no correlation between the success rate and the severity of symblepharon. After surgery, the ocular motility and inflammation were significantly improved. Visual acuity had improved in 2 of 15 eyes.

CONCLUSIONS

Sealing the gap between the conjunctiva and Tenon capsule is an important step in the surgical management of pathogenic symblepharon. This method not only avoids the use of mitomycin C, but also creates a strong barrier to prevent recurrence, restore ocular surface integrity, reform a deep fornix, and regain full ocular motility.

Novel applications of Rituximab in dermatological disorders

Rituximab is a monoclonal therapeutic anti-CD20 antibody that has been approved for use in lymphoma and rheumatoid arthritis. Over the past decade several reports based on case series and observational studies have recorded the benefits of rituximab in particular groups of dermatological patients. Off-label use of rituximab in many dermatological indications is not uncommon in many countries in the world. This article reviews the available data that may be of use to the practicing dermatologist. Because of its potential complications, paucity of clinical data, and cost considerations, rituximab is favoured only when standard systemic therapies fail or corticosteroids are absolutely contraindicated. Further research is required in this field.

[Treatment-refractory anti-laminin 332 mucous membrane pemphigoid. Remission following adjuvant immunoadsorption and rituximab]

Mucous membrane pemphigoid (MMP) is clinically characterized by predominant involvement of mucous membranes which in case of conjunctival lesions can lead to blindness. In MMP, autoantibodies are directed against different proteins of the dermal-epidermal junction; in 25% of cases, laminin 332 is the target. Anti-laminin 332 MMP with ocular involvement is particularly difficult to treat. A 46-year-old Caucasian man with anti-laminin 332 pemphigoid and extensive oral and nasal erosions as well as severe conjunctival involvement did not respond to intravenous dexamethasone-cyclophosphamide pulses combined with oral cyclophosphamide. After initiation of a therapeutic regimen originally established for the treatment of pemphigus, including immunoapheresis and rituximab in combination with intravenous dexamethasone-cyclophosphamide pulses and oral mycophenolate mofetil, lesions cleared within 4 months and circulating autoantibody levels became undetectable 3 months later. This is the first report of the successful use of adjuvant immunoapheresis and rituximab in previously treatment-refractory anti-laminin 332 MMP.

The diagnosis and treatment of autoimmune blistering skin diseases

BACKGROUND

Autoimmune blistering skin diseases are a heterogeneous group of disorders associated with autoantibodies that are directed against desmosomal structural proteins (in pemphigus diseases) or hemidesmosomal ones (in pemphigoid diseases and epidermolysis bullosa acquisita), or else against epidermal/ tissue transglutaminases (in dermatitis herpetiformis). Knowledge of the clinical presentation of these disorders and of the relevant diagnostic procedures is important not just for dermatologists, but also for general practitioners, ophthalmologists, ENT specialists, dentists, gynecologists, and pediatricians.

METHODS

The literature on the subject was selectively reviewed. There are no existing guidelines available in Germany.

RESULTS

The recently developed sensitive and specific assays for circulating autoantibodies in these diseases now enable a serological diagnosis in about 90% of cases. The incidence of autoimmune blistering skin diseases in Germany has doubled in the last 10 years, to a current figure of about 25 new cases per million persons per year, because of improved diagnostic techniques as well as the aging of the population. Accurate and specific diagnosis is the prerequisite for reliable prognostication and appropriate treatment. For severe and intractable cases, more effective treatments have recently become available, including immunoadsorption, high-dose intravenous immunoglobulin, the anti-CD20 antibody rituximab, and combinations of the above.

CONCLUSION

The diagnostic assessment of autoimmune blistering skin diseases can be expected to improve in the near future as new serological testing systems are developed that employ recombinant forms of the target antigens. The treatments currently in use still need to be validated by prospective, controlled trials.

Autoimmune bullous dermatoses in the elderly: an update on pathophysiology, diagnosis and management

Elderly individuals are susceptible to autoimmune bullous dermatoses (ABDs), which may be associated with high morbidity and mortality. ABDs result from an autoimmune response to components of the basement membrane zone at the dermal-epidermal junction or desmosomes. Bullous pemphigoid results from autoimmunity to hemidesmosomal proteins present in the basement membrane of stratified squamous epithelia. Patients present with tense blisters in flexural areas of the skin. Mild disease may be treated with potent topical corticosteroids, while extensive disease usually requires systemic corticosteroids or systemic immunosuppressive agents such as azathioprine. Mucosal pemphigoid affects one or more mucous membranes that are lined by stratified squamous epithelia. The two most commonly involved sites are the eye and the oral cavity. Lesions frequently result in scar formation that may cause blindness. Patients with severe disease or ocular involvement require aggressive therapy with corticosteroids and cyclophosphamide. Epidermolysis bullosa acquisita results from autoimmunity to type VII collagen in the anchoring fibrils of the basement membrane. Lesions may either arise on an inflammatory base or be non-inflammatory and result primarily from trauma. Treatment options include corticosteroids, dapsone, ciclosporin, methotrexate and plasmapheresis/immunoapheresis. Paraneoplastic pemphigus results from autoimmunity to multiple desmosomal antigens. The disorder is associated with neoplasms, especially leukaemia, lymphoma and thymoma. Patients present with stomatitis and polymorphous skin eruption. The disease may respond to successful treatment of the underlying neoplasm or may require immunosuppressive therapy.

[Optimizing therapy in patients with severe autoimmune blistering skin diseases]

Autoimmune bullous diseases are a heterogeneous group of disorders that can be subdivided according to the level of split formation in the intraepidermal blistering pemphigus diseases and subepidermal bullous disorders, latter including pemphigoid diseases, epidermolysis bullosa acquisita (EBA), and dermatitis herpetiformis. In the majority of autoimmune bullous disorders, disease activity can be sufficiently controlled by systemic corticosteroids in combination with further immunsuppressants/-modulants such as dapsone, doxycycline, azathioprine, mycophenolate mofetil, or methotrexate. In contrast, in pemphigus, mucous membrane pemphigoid, and EBA, treatment is challenging and conventional immunosuppressive therapy induces clinical remission only in a minority of patients. Until recently, only cyclosphosphamide and high-dose intravenous immunoglobulin (IVIG) were available as potent second-line therapies. Meanwhile, immunoadsorption and the monoclonal anti-CD20 antibody rituximab have been established as further therapeutic options. The present review focuses on efficacy, adverse events, treatment protocols, and mechanisms of action of IVIG, immunoadsorption, and rituximab in the treatment of severe and/or refractory patients with bullous autoimmune diseases.