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Sodha D, Patzelt S, Djalilian AR, Jain S, Geerling G, Schmidt E, Amber KT. The Role of Serology in the Diagnosis of Ocular Predominant Mucous Membrane Pemphigoid and the Search for an Ocular-Specific Autoantigen. Ocul Immunol Inflamm 2024:1-14. [PMID: 39241171 DOI: 10.1080/09273948.2024.2397715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 08/19/2024] [Accepted: 08/22/2024] [Indexed: 09/08/2024]
Abstract
Ocular predominant mucous membrane pemphigoid (oMMP) is a severe subtype of MMP that can lead to scarring and blindness. While conjunctival biopsy for direct immunofluorescence (DIF) is considered the gold standard for diagnosis, limited sensitivity results in a false-negative rate upwards of 40%. Likewise, it remains unclear to what extent a negative biopsy, whether false-negative or true-negative, results in a different prognosis, with patients previously termed "pseudopemphigoid" demonstrating comparable disease progression. Serologic testing allows for a less invasive means to demonstrate circulating autoantibodies against known autoantigens in pemphigoid diseases. Patients with MMP, particularly oMMP, however, typically demonstrate low titers of circulating autoantibodies, limiting the diagnostic utility of these tests. The autoantigen integrin β4 has been previously reported to be a specific marker of pure ocular MMP, while in the majority of patients with oMMP, the identified target antigens are BP180 (type XVII collagen) and laminin 332. Recent studies have, however, demonstrated inconsistent reactivity and specificity for integrin β4 as an ocular-specific marker in MMP. Herein, we review the role of serologic testing in the diagnosis and prognosis of oMMP, as well as the current understanding of autoantigens in oMMP.Abbreviations: BMZ - basement membrane zone, DIF - direct immunofluorescence, IIF - indirect immunofluorescence, MMP - mucous membrane pemphigoid, oMMP - ocular predominant mucous membrane pemphigoid.
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Affiliation(s)
- Dharm Sodha
- Medical Student, University of Illinois at Chicago College of Medicine, Chicago, Illinois, USA
| | - Sabrina Patzelt
- Department of Dermatology, Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - Ali R Djalilian
- Department of Ophthalmology, The University of Illinois at Chicago College of Medicine - Illinois Eye and Ear Infirmary, Chicago, Illinois, USA
| | - Sandeep Jain
- Department of Ophthalmology, The University of Illinois at Chicago College of Medicine - Illinois Eye and Ear Infirmary, Chicago, Illinois, USA
| | - Gerd Geerling
- Department of Ophthalmology, University of Düsseldorf, Düsseldorf, Germany
| | - Enno Schmidt
- Department of Dermatology, Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Kyle T Amber
- Department of Dermatology, Rush University Medical Center, Chicago, Illinois, USA
- Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
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Ruiz-Lozano RE, Colorado-Zavala MF, Ramos-Dávila EM, Quiroga-Garza ME, Azar NS, Mousa HM, Hernández-Camarena JC, Stinnett SS, Daluvoy M, Kim T, Sainz-de-la-Maza M, Hall RP, Rodriguez-Garcia A, Perez VL. Ocular Mucous Membrane Pemphigoid: The Effect of Risk Factors at Presentation on Treatment Outcomes. Ophthalmology 2024; 131:1064-1075. [PMID: 38452874 DOI: 10.1016/j.ophtha.2024.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 02/25/2024] [Accepted: 02/29/2024] [Indexed: 03/09/2024] Open
Abstract
PURPOSE Analyze the influence of risk factors at presentation in the long-term immunosuppressive therapy (IMT) outcomes of ocular mucous membrane pemphigoid (OMMP). DESIGN Retrospective multicenter study. PARTICIPANTS Patients with OMMP seen at the Duke Eye Center, Tecnologico de Monterrey, and Hospital Clinic of Barcelona from 1990 to 2022. METHODS Data at presentation on demographics, direct immunofluorescence, ocular findings, sites of extraocular manifestations (EOMs), and previous treatments in patients with a clinical or laboratory diagnosis of OMMP, were analyzed with multivariable analysis and Kaplan-Meier plots to identify factors associated with adverse outcomes. MAIN OUTCOME MEASURES (1) Inflammatory control (no conjunctival inflammation in both eyes at 3 months on IMT); (2) relapse (new-onset inflammation after absolute control in either eye); (3) progression (≥ 1 cicatrizing stage progression in either eye); and (4) vision loss (≥ 2 Snellen lines). RESULTS A total of 117 patients (234 eyes), 61% (71/117) of whom were women, with a mean age of 66.6 (SD: 12.4) years (range: 37-97 years) and median follow-up of 34 months (interquartile range: 16-66 months; range: 3-265 months), were enrolled. Inflammatory control was achieved in 57% of patients (67/117), with high-risk EOM (HR-EOM), including esophageal, nasopharyngeal, and/or genital involvement (adjusted odds ratio [aOR]: 12.51; 95% confidence interval [CI]: 2.61-59.99; P = 0.002) and corneal scarring (aOR: 3.06; 95% CI, 1.15-8.14; P = 0.025), as significant risk factors for persistent inflammation. Disease relapse, progression, and vision loss occurred in 20% of patients (23/117), 12% of patients (14/117), and 27% of patients (32/117), respectively. Baseline corneal scarring was a risk factor for relapse (adjusted hazard ratio: 4.14; 95% CI: 1.61-10.62; P = 0.003), progression (aOR: 11.46; 95% CI: 1.78-73.75; P = 0.010), and vision loss (aOR: 3.51; 95% CI: 1.35-9.10; P = 0.010). HR-EOM was associated with stage progression (aOR, 34.57; 95% CI, 6.57-181.89; P<0.001) and vision loss (aOR, 8.42; 95% CI, 2.50-28.42; P = 0.001). No significant differences were found between IMT regimes and relapse (P = 0.169). CONCLUSIONS Ocular mucous membrane pemphigoid presenting with HR-EOMs and corneal scarring has an increased risk of stage progression and vision loss. Corneal scarring and severe inflammation at baseline were associated with an increased risk of relapse. A disease progression staging system incorporating both the HR-EOMs and corneal involvement is required to predict the visual outcome of OMMP better. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- Raul E Ruiz-Lozano
- Department of Ophthalmology, Foster Center for Ocular Immunology at Duke Eye Center, Duke University School of Medicine, Durham, North Carolina; Tecnologico de Monterrey, School of Medicine and Health Sciences, Institute of Ophthalmology and Visual Sciences, Ocular Immunology and Uveitis Service, Monterrey, Mexico
| | - Maria F Colorado-Zavala
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Institute of Ophthalmology and Visual Sciences, Ocular Immunology and Uveitis Service, Monterrey, Mexico
| | - Eugenia M Ramos-Dávila
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Institute of Ophthalmology and Visual Sciences, Ocular Immunology and Uveitis Service, Monterrey, Mexico
| | - Manuel E Quiroga-Garza
- Department of Ophthalmology, Foster Center for Ocular Immunology at Duke Eye Center, Duke University School of Medicine, Durham, North Carolina
| | - Nadim S Azar
- Department of Ophthalmology, Foster Center for Ocular Immunology at Duke Eye Center, Duke University School of Medicine, Durham, North Carolina
| | - Hazem M Mousa
- Department of Ophthalmology, Foster Center for Ocular Immunology at Duke Eye Center, Duke University School of Medicine, Durham, North Carolina
| | - Julio C Hernández-Camarena
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Institute of Ophthalmology and Visual Sciences, Ocular Immunology and Uveitis Service, Monterrey, Mexico
| | - Sandra S Stinnett
- Associate Professor of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Melissa Daluvoy
- Department of Ophthalmology, Cornea and External Disease Service at Duke Eye Center, Duke University School of Medicine, Durham, North Carolina
| | - Terry Kim
- Department of Ophthalmology, Cornea and External Disease Service at Duke Eye Center, Duke University School of Medicine, Durham, North Carolina
| | - Maite Sainz-de-la-Maza
- Department of Ophthalmology, Hospital Clinic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Russell P Hall
- Department of Dermatology, Duke University School of Medicine, Durham, North Carolina
| | - Alejandro Rodriguez-Garcia
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Institute of Ophthalmology and Visual Sciences, Ocular Immunology and Uveitis Service, Monterrey, Mexico.
| | - Victor L Perez
- Department of Ophthalmology, Foster Center for Ocular Immunology at Duke Eye Center, Duke University School of Medicine, Durham, North Carolina.
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Timtim E, Barahimi B, Mawn LA, Sobel RK. Sebaceous carcinoma masquerading as ocular mucous membrane pemphigoid. Orbit 2024; 43:531-534. [PMID: 37097073 DOI: 10.1080/01676830.2023.2204489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 04/12/2023] [Indexed: 04/26/2023]
Abstract
Sebaceous carcinoma is a known mimicker of benign conditions, leading to frequent delays in diagnosis and proper treatment. We present two patients with chronic cicatrizing conjunctivitis initially diagnosed as ocular mucous membrane pemphigoid (MMP) and later found to have sebaceous carcinoma. Both patients presented with unilateral conjunctivitis that failed to improve with topical and systemic therapy, eventually developing fornix foreshortening and extensive symblepharon. Case 1 was diagnosed with ocular MMP based on clinical features alone, while Case 2 was diagnosed with biopsy-negative disease. Months to years later, both patients developed lid lesions found to be sebaceous carcinoma and underwent exenteration. As diagnosis and treatment of ocular MMP without positive direct immunofluorescence testing becomes increasingly accepted, clinicians should consider sebaceous carcinoma as the initial diagnosis or as a developing phenomenon during immunosuppression in the setting of chronic inflammation. A low threshold for repeat biopsy should be maintained.
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Affiliation(s)
- Elise Timtim
- Department of Ophthalmology and Visual Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Behin Barahimi
- Department of Ophthalmology and Visual Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Louise A Mawn
- Department of Ophthalmology and Visual Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Rachel K Sobel
- Department of Ophthalmology and Visual Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Bocanegra-Oyola N, Pardo-Pizza D, Cifuentes-González C, Oliver-Hernández MV, Romero-Osorio MJ, Romero-Santos S, Parra-Tanoux D, Barragán AM, de-la-Torre A. Clinical Characteristics of Ocular Mucous Membrane Pemphigoid: A Systematic Review and Meta-Analysis. Ocul Immunol Inflamm 2024:1-17. [PMID: 39074301 DOI: 10.1080/09273948.2024.2376746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 06/17/2024] [Accepted: 06/28/2024] [Indexed: 07/31/2024]
Abstract
PURPOSE To synthesize the evidence and generate a combined weighted measure on the frequency of ocular manifestations of mucous membrane pemphigoid (OMMP). METHODS Systematic literature review and meta-analysis, searching PubMed, Embase, VHL, and Google Scholar. Articles reporting patients with mucous membrane pemphigoid and ocular involvement were included. At least, two reviewers independently and in parallel participated in all the following phases; preliminary screening, full-text review, risk of bias assessment by validated tools, and data extraction. Qualitative analysis and meta-analysis were conducted. This study was previously registered in PROSPERO (CRD42023451844). RESULTS Thirty-five studies met the inclusion criteria, comprising 1,439 patients and 1,040 eyes summarized in qualitative analysis. Twenty-eight studies were included in the meta-analysis. Ages included ranged from 60.4 to 75 years. Women were reported with more frequency. The mean time for diagnosis was 55.1 months, usually with bilateral ocular disease in 90% (95% CI 78%; 96%). Trichiasis and entropion were the most frequent manifestations in up to 92%, followed by symblepharon and punctate keratitis. Ankyloblepharon, persistent epithelial defects, and visual impairment were less frequent complications. Direct immunofluorescence positivity in conjunctival biopsies was 54% (95% CI 43%; 64%). Extraocular involvement was highly frequent, being oral and skin involvement the most frequently reported. CONCLUSIONS Our systematic review and meta-analysis evidenced that patients around 60 years of age are the most affected population with a female preponderance, usually with bilateral ocular involvement. Trichiasis and entropion were the most frequent findings; although visual impairment and persistent epithelial defects were less reported, they should not be overlooked in suspected OMMP.
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Affiliation(s)
- Natalia Bocanegra-Oyola
- Epidemiology Specialization Program, Universidad CES, Medellín, Colombia and Universidad del Rosario, Bogotá, Colombia
- Neuroscience (NEUROS) Research Group, Neurovitae Research Center, Institute of Translational Medicine (IMT), School of Medicine and Health Sciences, Universidad del Rosario, Bogota, Colombia
| | - Daniella Pardo-Pizza
- Neuroscience (NEUROS) Research Group, Neurovitae Research Center, Institute of Translational Medicine (IMT), School of Medicine and Health Sciences, Universidad del Rosario, Bogota, Colombia
| | - Carlos Cifuentes-González
- Neuroscience (NEUROS) Research Group, Neurovitae Research Center, Institute of Translational Medicine (IMT), School of Medicine and Health Sciences, Universidad del Rosario, Bogota, Colombia
| | - María Valentina Oliver-Hernández
- Neuroscience (NEUROS) Research Group, Neurovitae Research Center, Institute of Translational Medicine (IMT), School of Medicine and Health Sciences, Universidad del Rosario, Bogota, Colombia
| | | | - Sofía Romero-Santos
- Neuroscience (NEUROS) Research Group, Neurovitae Research Center, Institute of Translational Medicine (IMT), School of Medicine and Health Sciences, Universidad del Rosario, Bogota, Colombia
| | | | - Ana M Barragán
- Public Health Research Group, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
| | - Alejandra de-la-Torre
- Neuroscience (NEUROS) Research Group, Neurovitae Research Center, Institute of Translational Medicine (IMT), School of Medicine and Health Sciences, Universidad del Rosario, Bogota, Colombia
- Ophthalmology Interest Group-Universidad del Rosario(OIG UR), Neuroscience (NEUROS) Research Group, Neurovitae Research Center, Institute of Translational Medicine (IMT), School of Medicine and Health Sciences, Universidad del Rosario, Bogota, Colombia
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Khan HM, Wirth MA, Dolman PJ, Yeung SN, Iovieno A. Long-term outcomes of fornix reconstruction and cicatricial entropion repair in ocular mucous membrane pemphigoid and drug-related secondary pemphigoid. CANADIAN JOURNAL OF OPHTHALMOLOGY 2024; 59:e200-e205. [PMID: 37028445 DOI: 10.1016/j.jcjo.2023.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 02/26/2023] [Accepted: 03/13/2023] [Indexed: 04/09/2023]
Abstract
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.
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Affiliation(s)
- Haaris M Khan
- Faculty of Medicine, University of British Columbia, Vancouver, BC
| | - Magdalena A Wirth
- Department of Ophthalmology, University Hospital Zurich, Zurich, Switzerland
| | - Peter J Dolman
- Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, BC
| | - Sonia N Yeung
- Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, BC
| | - Alfonso Iovieno
- Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, BC..
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Taketani Y, Dehghani S, Sinha S, Freitag SK, Papaliodis G, Foster S, Dohlman TH, Dana R. Concurrence of Ocular Cicatricial Pemphigoid in Chronic Ocular Graft-Versus-Host Disease. Cornea 2024; 43:387-390. [PMID: 38128104 DOI: 10.1097/ico.0000000000003386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 08/04/2023] [Indexed: 12/23/2023]
Abstract
PURPOSE The aim of this study was to report a series of 3 patients with ocular graft-versus-host disease (oGVHD) with progressive cicatricial conjunctival changes who were diagnosed with ocular cicatricial pemphigoid (OCP) after conjunctival biopsy. METHODS This study was a retrospective case series. RESULTS Three patients who received hematopoietic stem cell transplantation for hematologic malignancies developed oGVHD and subsequently were diagnosed with OCP. Case 1 was a 73-year-old woman with oGVHD who developed symblepharon and showed positive IgA, IgG, and C3 staining of the basement membrane zone (BMZ) on conjunctival biopsy, consistent with OCP. She was systemically treated with tacrolimus and prednisone with resolution of conjunctival inflammation. Case 2 was a 68-year-old man with oGVHD who developed symblepharon, severe dry eye, and corneal epithelial defect. An initial conjunctival biopsy was negative, but a repeat biopsy performed 10 years later showed positive BMZ IgA and IgG staining. Healing of the epithelial defect was achieved after treatment with high-dose systemic cyclosporine. Case 3 was a 75-year-old woman with oGVHD who had a nonhealing corneal epithelial defect and symblepharon with positive IgA BMZ staining on conjunctival biopsy, consistent with OCP. The patient responded well to methotrexate with healing of the epithelial defect. CONCLUSIONS Although low-grade conjunctival fibrotic changes may be observed in chronic oGVHD, development of severe and progressive cicatricial changes, including symblepharon formation, should prompt consideration of biopsy to rule out concurrent OCP, the management of which differs from that of oGVHD.
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Affiliation(s)
- Yukako Taketani
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA; and
| | - Shima Dehghani
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA; and
| | - Shruti Sinha
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA; and
| | - Suzanne K Freitag
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA; and
| | - George Papaliodis
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA; and
| | - Stephen Foster
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA; and
- Massachusetts Eye Research and Surgery Institution, Waltham, MA
| | - Thomas H Dohlman
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA; and
| | - Reza Dana
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA; and
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Jain N, Jakati S, Shanbhag SS, Basu S. Direct Immunofluorescence Findings and Factors Affecting Conjunctival Biopsy Positivity in Ocular Mucous Membrane Pemphigoid. Cornea 2024; 43:159-165. [PMID: 37699562 PMCID: PMC10752260 DOI: 10.1097/ico.0000000000003382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 07/25/2023] [Accepted: 08/07/2023] [Indexed: 09/14/2023]
Abstract
PURPOSE The aim of this study was to describe the direct immunofluorescence (DIF) findings and factors affecting conjunctival biopsy positivity in patients clinically diagnosed with ocular mucous membrane pemphigoid (OMMP). METHODS This retrospective observational case series included patients with clinical OMMP who underwent conjunctival biopsy for DIF in at least 1 eye between 2018 and 2021 in an institutional setting. The primary outcome measures were association of age and chronic ocular complications with biopsy positivity. RESULTS Of 61 patients, DIF positivity was seen in 33 (54.1%) clinically suspected cases of OMMP. Of 39 patients who underwent bilateral biopsy, 23 (59%) were positive, of which 12 (52%) were positive in both eyes while 11 (48%) were positive in 1 eye. Of 22 patients who underwent unilateral biopsy, 10 (45%) were positive. Of the 100 biopsied eyes, 45 (45%) were DIF positive. Among the immunoreactants studied, linear deposition of C3 was seen in all 45 positive eyes (100%). Increasing age was significantly associated with higher likelihood of biopsy negativity ( P = 0.032), whereas a greater Sotozono chronic ocular complication score, indicative of disease severity, was associated with low likelihood of biopsy positivity ( P = 0.0042) and lower overall expression of immunoreactants on DIF ( P = 0.0007). CONCLUSIONS Older patients and patients with more severe ocular surface disease sequelae are likely to have negative DIF results. To optimize the chances of confirming the diagnosis of OMMP by DIF, both eyes should be biopsied early in the disease course. If 1 eye is being biopsied, the less affected eye must be chosen.
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Affiliation(s)
- Neha Jain
- Shantilal Shanghvi Cornea Institute, L V Prasad Eye Institute, Hyderabad, Telangana, India
| | - Saumya Jakati
- Ophthalmic Pathology Laboratory, L V Prasad Eye Institute, Hyderabad, Telangana, India; and
| | - Swapna S. Shanbhag
- Shantilal Shanghvi Cornea Institute, L V Prasad Eye Institute, Hyderabad, Telangana, India
| | - Sayan Basu
- Shantilal Shanghvi Cornea Institute, L V Prasad Eye Institute, Hyderabad, Telangana, India
- Centre for Ocular Regeneration (CORE), Prof. Brien Holden Eye Research Centre (BHERC), L V Prasad Eye Institute, Hyderabad, Telangana, India
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Moussa S, Tong M, Robert MC, Harissi-Dagher M, Ahmad S, Jabbour S. Survey: Preferred practice patterns in the diagnosis of mucous membrane pemphigoid amongst cornea specialists. Eur J Ophthalmol 2024; 34:112-118. [PMID: 37226437 PMCID: PMC10757388 DOI: 10.1177/11206721231178110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 05/08/2023] [Indexed: 05/26/2023]
Abstract
PURPOSE To evaluate preferred diagnostic tools and treatment decision-making factors in cases suspicious of mucous membrane pemphigoid (MMP) amongst ophthalmologists and cornea specialists. METHODS Web-based survey, consisting of 14 multiple choice questions, posted to the Cornea Society Listserv Keranet, the Canadian Ophthalmological Society Cornea Listserv, and the Bowman Club Listserv. RESULTS One hundred and thirty-eight ophthalmologists participated in the survey. Eighty-six percent (86%) of respondents were cornea trained and practiced in either North America or Europe (83%). Most respondents (72%) routinely perform conjunctival biopsies for all suspicious cases of MMP. For those who do not, fear that biopsy will exacerbate inflammation was the most common reason to defer investigation (47%). Seventy-one percent (71%) performed biopsies from perilesional sites. Ninety-seven percent (97%) ask for direct (DIF) studies and 60% for histopathology in formalin. Most do not recommend biopsy at other non-ocular sites (75%), nor do they perform indirect immunofluorescence for serum autoantibodies (68%). Immune-modulatory therapy is started following positive biopsy results for most (66%), albeit most (62%) would not let a negative DIF influence the choice of starting treatment should there be clinical suspicion of MMP. Differences in practice patterns as they relate to level of experience and geographical location are contrasted to the most up-to-date available guidelines. CONCLUSION Responses to the survey suggest that there is heterogeneity in certain practice patterns for MMP. Biopsy remains an area of controversy in dictating treatment plans. Identified areas of need should be targeted in future research.
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Affiliation(s)
- Sarah Moussa
- Faculty of Medicine, McGill University, Montréal, Canada
| | - Maya Tong
- Ophthalmology department, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, Canada
| | - Marie-Claude Robert
- Ophthalmology department, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, Canada
| | - Mona Harissi-Dagher
- Ophthalmology department, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, Canada
| | - Sajjad Ahmad
- Department of Ophthalmology, Moorfields Eye Hospital, London, UK
| | - Samir Jabbour
- Ophthalmology department, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, Canada
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Chacun S, Rezkallah A, Kodjikian L, Sève P, Mathis T, Denis P. Glaucoma and conjunctival fibrosis: A case report. J Fr Ophtalmol 2023; 46:e361-e364. [PMID: 37586900 DOI: 10.1016/j.jfo.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 03/05/2023] [Indexed: 08/18/2023]
Affiliation(s)
- S Chacun
- Service d'ophtalmologie, hôpital de la Croix-Rousse, hospices civils de Lyon, 103, grande-rue de la Croix-Rousse, 69317 Lyon cedex 4, France.
| | - A Rezkallah
- Service d'ophtalmologie, hôpital de la Croix-Rousse, hospices civils de Lyon, 103, grande-rue de la Croix-Rousse, 69317 Lyon cedex 4, France
| | - L Kodjikian
- Service d'ophtalmologie, hôpital de la Croix-Rousse, hospices civils de Lyon, 103, grande-rue de la Croix-Rousse, 69317 Lyon cedex 4, France; UMR-CNRS 5510 Matéis, université de médicine Lyon 1, Lyon, France
| | - P Sève
- Service de médecine interne, hôpital de la Croix-Rousse, hospices civils de Lyon, 103, grande-rue de la Croix-Rousse, 69317 Lyon cedex 4, France
| | - T Mathis
- Service d'ophtalmologie, hôpital de la Croix-Rousse, hospices civils de Lyon, 103, grande-rue de la Croix-Rousse, 69317 Lyon cedex 4, France; UMR-CNRS 5510 Matéis, université de médicine Lyon 1, Lyon, France
| | - P Denis
- Service d'ophtalmologie, hôpital de la Croix-Rousse, hospices civils de Lyon, 103, grande-rue de la Croix-Rousse, 69317 Lyon cedex 4, France
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Di Zazzo A, Cutrupi F, De Antoniis MG, Ricci M, Esposito G, Antonini M, Coassin M, Micera A, Perrella E, Bonini S. Tissue Remodeling in Ocular Mucous Membrane Pemphigoid. Invest Ophthalmol Vis Sci 2023; 64:17. [PMID: 38095906 PMCID: PMC10723221 DOI: 10.1167/iovs.64.15.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 11/09/2023] [Indexed: 12/17/2023] Open
Abstract
Purpose Ocular mucous membrane pemphigoid (OcMMP) is a rare eye disease characterized by relapsing-remitting or persisting long-lasting inflammatory events associated with progressive scarring. Despite long-term immunomodulating therapy, abnormal fibrosis keeps worsening in patients with OcMMP. This study investigates the fibrotic process in patients with OcMMP, as well as the critical role of the epithelium in modulating the local fibrosis. Methods In this prospective, observational pilot study, patients affected by long-lasting OcMMP were compared with age- and gender-matched healthy controls. Clinical grading was assessed, and conjunctival biopsy and impression cytology were performed. Conjunctival samples were used for quantifying the expression of transcripts regulating the inflammatory and fibrogenic processes. Results Ocular surface clinical and functional markers worsened in patients with OcMMP with fibrotic disease progression. In more advanced disease stages, both impression cytologies and conjunctival biopsies revealed increased tissue remodeling and profibrotic markers (α-SMA and TGF-β), and decreased levels of inflammatory markers (I-CAM1, IL-10, and IL-17). Increased epithelial expression of profibrotic markers and histological changes were detected. Conclusions Chronic OcMMP is characterized by a progressive, aberrant self-sustaining fibrotic process that worsens clinical signs and symptoms. Conjunctival epithelial cells may transdifferentiate into myofibroblast-like phenotypes when chronically exposed to high levels of inflammation, as in the case of OcMMP. Tissue remodeling markers in OcMMP could be used as early diagnostic, prognostic, and therapeutic biomarkers, harvested in a non-invasive and painless procedure such as impression cytologies.
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Affiliation(s)
- Antonio Di Zazzo
- Ophthalmology, Foundation Campus Bio-Medico University Hospital, Rome, Italy
| | - Francesco Cutrupi
- Ophthalmology, Foundation Campus Bio-Medico University Hospital, Rome, Italy
| | | | - Milena Ricci
- Ophthalmology, Foundation Campus Bio-Medico University Hospital, Rome, Italy
| | - Graziana Esposito
- Research and Development Laboratory for Biochemical, Molecular and Cellular Applications in Ophthalmological Science, IRCCS-Fondazione Bietti, Rome, Italy
| | - Marco Antonini
- Ophthalmology, Foundation Campus Bio-Medico University Hospital, Rome, Italy
| | - Marco Coassin
- Ophthalmology, Foundation Campus Bio-Medico University Hospital, Rome, Italy
| | - Alessandra Micera
- Research and Development Laboratory for Biochemical, Molecular and Cellular Applications in Ophthalmological Science, IRCCS-Fondazione Bietti, Rome, Italy
| | - Eleonora Perrella
- Anatomical Pathology, Foundation Campus Bio-Medico University Hospital, Rome, Italy
| | - Stefano Bonini
- Ophthalmology, Foundation Campus Bio-Medico University Hospital, Rome, Italy
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11
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Jakubowska B, Pietrzyk E, Maciejewicz P, Kowalewski C, Wozniak K. Diagnostic and prognostic values of conjunctival and oral biopsies analyzed by direct immunofluorescence in patients with mucous membrane pemphigoid. Front Med (Lausanne) 2023; 10:1257288. [PMID: 38020098 PMCID: PMC10663220 DOI: 10.3389/fmed.2023.1257288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 10/05/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Mucous membrane pemphigoid (MMP) is diagnosed on the basis of a characteristic clinical picture (a predilection for mucosal involvement and scarring in the affected tissues) and a positive direct immunofluorescence (DIF) result. Methods In this study, we compare the diagnostic and prognostic values of conjunctival and oral biopsies analyzed by DIF in patients with MMP. Sixteen patients with MMP and mucosal involvement as a predominant symptom were classified into three groups based on the clinical picture. Oral and conjunctival DIF were performed on all patients. Results Our study showed that patients with simultaneous oral and conjunctival involvement had a positive oral DIF in 83% and a positive ocular DIF in 100% of the examined cases, respectively. Patients with isolated ocular MMP had a positive oral DIF in 50% and a positive ocular DIF in 66% of the examined cases, respectively. Patients with only oral involvement with MMP had a positive oral DIF in 100% and a positive ocular DIF in 50% of the examined cases, respectively. Discussion Oral biopsy should be performed first and is usually sufficient for the diagnosis, even in patients with exclusively ocular MMP, whereas in patients without clinical ocular involvement, ocular DIF is positive in half of the cases and may be a predictive factor for ocular lesions in the future.
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Affiliation(s)
- Beata Jakubowska
- Department of Immunodermatology, Medical University of Warsaw, Warsaw, Poland
| | - Ewelina Pietrzyk
- Department of Immunodermatology, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland
| | - Piotr Maciejewicz
- Department of Ophthalmology, Medical University of Warsaw, Warsaw, Poland
| | - Cezary Kowalewski
- Department of Immunodermatology, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland
| | - Katarzyna Wozniak
- Department of Immunodermatology, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland
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12
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Panthagani J, Suleiman K, Vincent RC, Ong HS, Wallace GR, Rauz S. Conjunctival transcriptomics in ocular mucous membrane pemphigoid. Ocul Surf 2023; 30:142-149. [PMID: 37690517 DOI: 10.1016/j.jtos.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 09/07/2023] [Accepted: 09/07/2023] [Indexed: 09/12/2023]
Abstract
PURPOSE Ocular Mucous Membrane Pemphigoid (OcMMP) is an orphan disease characterized by chronic autoimmune-driven conjunctival inflammation leading to progressive scarring, debilitating symptoms, and blinding sequelae. This feasibility study aims to demonstrate conjunctival genetic transcriptomic analyses as a putative tool for interrogation of pathogenic signaling pathways in OcMMP. METHODS Conjunctival RNA profiling using the NanoString nCounter Human Fibrosis panel was undertaken on RNA extracted from conjunctival swabs obtained from 6 MMP patients (8 eyes; 4 M/2F; median age 78 [range 64-84] years); and 8 age-matched control participants (15 eyes; 3 M/5F; median age 69.5 [range 69-88] years). Data from 770 genes were analyzed with ROSALIND HyperScale architecture and stratified according to the level of clinically visible bulbar conjunctival inflammation. Normalization, fold-changes (≥+1.5-fold or ≤ -1.5-fold) and p-values adjustment (<0.05) using the Benjamini-Hochberg method were calculated. RESULTS 93 differentially expressed genes (DEGs) were observed between OcMMP versus controls of which 48 were upregulated, and 45 downregulated. The top 4 upregulated DEGs represented fibrosis (COL3A1, COL1A1, FN1 and THBS1) while the key under-expressed genes (SCIN, HMGS2, XCL1/2) were indicative of ocular surface failure (goblet cell loss, keratinization, vulnerability to secondary infections). Forty-four pathways had a global significance score ≥2, the most significant being those related to extracellular matrix (ECM) remodeling, synthesis, and degradation. These pathways were accentuated in eyes with visible inflammation. CONCLUSIONS NanoString methodology acquired via a simple conjunctival swab identifies profibrotic genes in OcMMP group and differentiates inflamed eyes. Longitudinal sampling and following investigative intervention will further mechanistic insight and development of novel biomarkers to monitor disease progression.
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Affiliation(s)
- Jesse Panthagani
- Academic Unit of Ophthalmology, Institute of Inflammation and Ageing, University of Birmingham, UK; Birmingham and Midland Eye Centre, Sandwell and West Birmingham NHS Trust, Birmingham, UK
| | - Kusy Suleiman
- Academic Unit of Ophthalmology, Institute of Inflammation and Ageing, University of Birmingham, UK; Birmingham and Midland Eye Centre, Sandwell and West Birmingham NHS Trust, Birmingham, UK
| | - Rachel C Vincent
- Academic Unit of Ophthalmology, Institute of Inflammation and Ageing, University of Birmingham, UK
| | - Hon Shing Ong
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore; Corneal and External Diseases Department, Singapore National Eye Centre, Singapore, Singapore; Ophthalmology & Visual Sciences Academic Clinical Programme, Duke-NUS Medical School, Singapore
| | - Graham R Wallace
- Academic Unit of Ophthalmology, Institute of Inflammation and Ageing, University of Birmingham, UK
| | - Saaeha Rauz
- Academic Unit of Ophthalmology, Institute of Inflammation and Ageing, University of Birmingham, UK; Birmingham and Midland Eye Centre, Sandwell and West Birmingham NHS Trust, Birmingham, UK.
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13
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Haralanova V, Meier K, Pleyer U. [Diagnostics of ocular mucous membrane pemphigoid]. DIE OPHTHALMOLOGIE 2023; 120:484-495. [PMID: 37147531 DOI: 10.1007/s00347-023-01856-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/04/2023] [Indexed: 05/07/2023]
Abstract
The diagnosis of ocular mucous membrane pemphigoid (MMP) remains a challenge as the timing and choice of diagnostic methods have a decisive influence on its quality. A systematic approach is required that includes a comprehensive medical history, critical evaluation of the clinical findings and targeted laboratory testing. The diagnosis is complicated by the fact that some patients present purely clinically the symptoms of MMP without fulfilling the required immunohistochemical and laboratory criteria. Basically, the diagnosis of ocular MMP is based on three pillars: 1) medical history and clinical findings, 2) positive immunohistological (direct immunofluorescence) tissue sample and 3) specific serological autoantibodies. As the diagnosis of ocular MMP often implies prolonged systemic immunomodulatory treatment in predominantly older patients, the accurate diagnosis and approach are of critical relevance. The aim of this article is to present the recently updated diagnostic procedure.
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Affiliation(s)
- Velina Haralanova
- Klinik für Augenheilkunde, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - Katharina Meier
- Klinik für Dermatologie, Venerologie und Allergologie, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Deutschland
| | - Uwe Pleyer
- Klinik für Augenheilkunde, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Deutschland.
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14
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Roth M, Fangerau H, Geerling G. [Ocular pemphigoid-New insights into an ancient clinical picture]. DIE OPHTHALMOLOGIE 2023; 120:460-461. [PMID: 37173601 DOI: 10.1007/s00347-023-01864-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/11/2023] [Indexed: 05/15/2023]
Affiliation(s)
- M Roth
- Klinik für Augenheilkunde, Universitätsklinikum Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland.
| | - H Fangerau
- Institut für Geschichte, Theorie und Ethik der Medizin, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - G Geerling
- Klinik für Augenheilkunde, Universitätsklinikum Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland
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15
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Roth M, Yaici R, Geerling G. [Clinical aspects of ocular mucosal pemphigoid]. DIE OPHTHALMOLOGIE 2023; 120:472-477. [PMID: 37095414 DOI: 10.1007/s00347-023-01854-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/24/2023] [Indexed: 04/26/2023]
Abstract
Mucosal pemphigoid is a rare chronic autoimmune disease that also affects the eyes in more than two thirds of all cases. Especially in the early phase of the ocular manifestation, the findings are subtle and the disease is often not recognized. The aim of this article is to provide the clinical aspects of ocular mucosal pemphigoid so that timely diagnostics can be initiated when this disease is suspected.
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Affiliation(s)
- M Roth
- Klinik für Augenheilkunde, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland.
- Universitätsaugenklinik Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland.
| | - R Yaici
- Klinik für Augenheilkunde, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - G Geerling
- Klinik für Augenheilkunde, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
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16
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Lopez SN, Cao J, Casas de Leon S, Dominguez AR. Utility of Direct Immunofluorescence using buccal mucosal biopsies in those with suspected isolated Ocular Mucous Membrane Pemphigoid. Ophthalmology 2022; 129:1171-1176. [DOI: 10.1016/j.ophtha.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 05/19/2022] [Accepted: 06/02/2022] [Indexed: 10/18/2022] Open
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Farrag A, Chan A, Tong L. Cicatricial Conjunctivitis and Concurrent Clinical Features: A Case Study. Clin Med Insights Case Rep 2022; 15:11795476221100605. [PMID: 35601266 PMCID: PMC9121463 DOI: 10.1177/11795476221100605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 04/27/2022] [Indexed: 11/22/2022] Open
Abstract
Purpose: We report a case of cicatricial conjunctivitis to illustrate the clinical approach for
management of such a case. This is a 52-year-old Chinese man who presented with
bilateral red eyes associated with itching for a year. He had a history of chronic itchy
rash in the chest and the arms. Otherwise there was no history of autoimmune disease,
asthma, sinusitis, or drug allergy. On examination, he had diffuse hyperemia over both
conjunctivae, with symblepharon involving the inferior bulbar and palpebral
conjunctivae, associated with cicatrization of the caruncles, and obliteration of
inferior lacrimal puncta. There were mild subtarsal papillary reaction with Meibomian
gland dysfunction and presence of inferior mis-directed eyelashes. The corneas showed
multiple foci of superficial epitheliopathy. A clinical diagnosis of chronic cicatricial
conjunctivitis was made, with differential diagnosis of chronic atopic allergic
conjunctivitis. Conjunctival biopsy was performed from the inferior conjunctival
adhesions and it showed patchy chronic stromal inflammation with focal lymphoplasmacytic
sub-epithelial infiltrates and loss of goblet cells. The stroma shows marked fibrosis,
with no evidence of mast cells or eosinophils. In particular, there were no deposits of
IgA, IgM, C3, and fibrinogen in the basement membrane. The patient was treated with
topical loteprednol, glucocorticoids and artificial tears, and his symptoms improved
after treatment. Conclusion: We present a man with cicatricial conjunctivitis with chronic subconjunctival
inflammation and fibrosis but no immune deposits in the conjunctival basement membrane
on histology, to illustrate the clinical approach and diagnostic challenges in managing
such a case.
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Affiliation(s)
| | - Anita Chan
- Singapore National Eye Centre, Singapore
- Singapore Eye Research Institute, Singapore
- Duke-National University of Singapore, Singapore
| | - Louis Tong
- Singapore National Eye Centre, Singapore
- Singapore Eye Research Institute, Singapore
- Duke-National University of Singapore, Singapore
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18
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Low L, Suleiman K, Shamdas M, Bassilious K, Poonit N, Rossiter AE, Acharjee A, Loman N, Murray PI, Wallace GR, Rauz S. Gut Dysbiosis in Ocular Mucous Membrane Pemphigoid. Front Cell Infect Microbiol 2022; 12:780354. [PMID: 35493740 PMCID: PMC9046938 DOI: 10.3389/fcimb.2022.780354] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 03/16/2022] [Indexed: 12/27/2022] Open
Abstract
Mucous Membrane Pemphigoid is an orphan multi-system autoimmune scarring disease involving mucosal sites, including the ocular surface (OcMMP) and gut. Loss of tolerance to epithelial basement membrane proteins and generation of autoreactive T cell and/or autoantibodies are central to the disease process. The gut microbiome plays a critical role in the development of the immune system. Alteration in the gut microbiome (gut dysbiosis) affects the generation of autoreactive T cells and B cell autoantibody repertoire in several autoimmune conditions. This study examines the relationship between gut microbiome diversity and ocular inflammation in patients with OcMMP by comparing OcMMP gut microbiome profiles with healthy controls. DNA was extracted from faecal samples (49 OcMMP patients, 40 healthy controls), amplified for the V4 region of the 16S rRNA gene and sequenced using Illumina Miseq platform. Sequencing reads were processed using the bioinformatics pipeline available in the mothur v.1.44.1 software. After adjusting for participant factors in the multivariable model (age, gender, BMI, diet, proton pump inhibitor use), OcMMP cohort was found to be associated with lower number of operational taxonomic units (OTUs) and Shannon Diversity Index when compared to healthy controls. Within the OcMMP cohort, the number of OTUs were found to be significantly correlated with both the bulbar conjunctival inflammation score (p=0.03) and the current use of systemic immunotherapy (p=0.02). The linear discriminant analysis effect size scores indicated that Streptococcus and Lachnoclostridium were enriched in OcMMP patients whilst Oxalobacter, Clostridia uncultured genus-level group (UCG) 014, Christensenellaceae R-7 group and butyrate-producing bacteria such as Ruminococcus, Lachnospiraceae, Coprococcus, Roseburia, Oscillospiraceae UCG 003, 005, NK4A214 group were enriched in healthy controls (Log10 LDA score < 2, FDR-adjusted p <0.05). In conclusion, OcMMP patients have gut dysbiosis correlating with bulbar conjunctival inflammation and the use of systemic immunotherapies. This provides a framework for future longitudinal deep phenotyping studies on the role of the gut microbiome in the pathogenesis of OcMMP.
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Affiliation(s)
- Liying Low
- Academic Unit of Ophthalmology, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | - Kusy Suleiman
- Academic Unit of Ophthalmology, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | - Mohith Shamdas
- Academic Unit of Ophthalmology, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | - Kerolos Bassilious
- Academic Unit of Ophthalmology, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
- Birmingham and Midland Eye Centre, Sandwell and West Birmingham National Health Service (NHS) Trust, Birmingham, United Kingdom
| | - Natraj Poonit
- Birmingham and Midland Eye Centre, Sandwell and West Birmingham National Health Service (NHS) Trust, Birmingham, United Kingdom
| | - Amanda E. Rossiter
- Institute for Microbiology and Infection, University of Birmingham, Birmingham, United Kingdom
| | - Animesh Acharjee
- College of Medical and Dental Sciences, Institute of Cancer and Genomic Sciences, Centre for Computational Biology, University of Birmingham, Birmingham, United Kingdom
- Institute of Translational Medicine, University Hospitals Birmingham National Health Service (NHS), Foundation Trust, Birmingham, United Kingdom
- National Institute for Health Research (NIHR) Surgical Reconstruction and Microbiology Research Centre, University Hospital Birmingham, Birmingham, United Kingdom
| | - Nicholas Loman
- Institute for Microbiology and Infection, University of Birmingham, Birmingham, United Kingdom
| | - Philip I. Murray
- Academic Unit of Ophthalmology, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
- Birmingham and Midland Eye Centre, Sandwell and West Birmingham National Health Service (NHS) Trust, Birmingham, United Kingdom
| | - Graham R. Wallace
- Academic Unit of Ophthalmology, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | - Saaeha Rauz
- Academic Unit of Ophthalmology, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
- Birmingham and Midland Eye Centre, Sandwell and West Birmingham National Health Service (NHS) Trust, Birmingham, United Kingdom
- *Correspondence: Saaeha Rauz,
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Singh S, Donthineni PR, Shanbhag SS, Senthil S, Ong HS, Dart JK, Basu S. Drug induced cicatrizing conjunctivitis: A case series with review of etiopathogenesis, diagnosis and management. Ocul Surf 2022; 24:83-92. [PMID: 35247582 DOI: 10.1016/j.jtos.2022.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 02/25/2022] [Accepted: 02/26/2022] [Indexed: 12/30/2022]
Abstract
Drug induced cicatrizing conjunctivitis (DICC) is defined as a disease in which conjunctival cicatrization develops as a response to the chronic use of inciting topical and, rarely, systemic medications. DICC accounts for up to one third of cases of pseudopemphigoid, a large group of cicatrizing conjunctival diseases sharing similar clinical features to those of mucous membrane pemphigoid (MMP) but generally without the morbidity of progressive scarring or the need for systemic immunosuppression. The preservatives in topical anti-glaucoma medications (AGM) are the most frequently implicated inciting causes of DICC although topical antivirals, vasoconstrictors and mydriatics and some systemic drugs have been implicated. The literature review summarizes the classification, epidemiology, etiopathogenesis, histopathology, clinical presentation, diagnosis, management, and treatment outcomes of DICC in the context of a case series of 23 patients (42 eyes) with AGM induced DICC, from India and the UK. In this series all subjects reacted to preserved AGM with one exception, who also reacted to non-preserved AGM. At diagnosis >70% of eyes showed punctal scarring, inflammation, and forniceal shortening. Pemphigoid studies were negative in the 19/23 patients in whom they were carried out. DICC can be classified as non-progressive, progressive with positive pemphigoid immunopathology or progressive with negative pemphigoid immunopathology. It is unclear whether progressive DICC is a stand-alone disease, or concurrent (or drug induced) ocular MMP. Progressive cases should currently be treated as ocular MMP. The diagnosis can be made clinically when there is rapid resolution of symptoms and inflammation, usually within 1-16 weeks, after withdrawal of suspected inciting medications, ideally by temporary substitution of oral carbonic anhydrase inhibitors. If the response to withdrawal is uncertain, or the progression of inflammation and scarring continues then patients must be evaluated to exclude concurrent (or drug induced) MMP, and other potential causes of CC, for which the treatment and prognosis is different. Management, in addition to withdrawing inciting medications, may require short-term treatment of conjunctival inflammation with steroids, treatment of associated corneal disease with contact lenses or surface reconstructive surgery, control of intra-ocular pressure with non-preserved AGM and, in some, surgery for glaucoma or for trichiasis and entropion.
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Affiliation(s)
- Swati Singh
- Ophthalmic Plastic Surgery, Orbit and Ocular Oncology Services, L V Prasad Eye Institute, Hyderabad, Telangana, India; Centre for Ocular Regeneration, L V Prasad Eye Institute, Hyderabad, Telangana, India
| | | | - Swapna S Shanbhag
- The Cornea Institute, L V Prasad Eye Institute, Hyderabad, Telangana, India
| | - Sirisha Senthil
- VST Centre for Glaucoma Care, L V Prasad Eye Institute, Hyderabad, Telangana, India
| | - Hon Shing Ong
- National Institute of Health Research (NIHR), Moorfields Biomedical Research Centre, London, UK; Corneal and External Diseases Department, Singapore National Eye Centre, Singapore
| | - John Kg Dart
- National Institute of Health Research (NIHR), Moorfields Biomedical Research Centre, London, UK
| | - Sayan Basu
- Centre for Ocular Regeneration, L V Prasad Eye Institute, Hyderabad, Telangana, India; The Cornea Institute, L V Prasad Eye Institute, Hyderabad, Telangana, India.
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20
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Hwang S, Kuo SC. Corneal perforation in ocular cicatricial pemphigoid: A CARE-compliant case report. Medicine (Baltimore) 2021; 100:e28266. [PMID: 34941105 PMCID: PMC8702268 DOI: 10.1097/md.0000000000028266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 11/25/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Ocular cicatricial pemphigoid (OCP) is a potentially blinding, rare systemic autoimmune disease. The definite etiology of OCP remains under debate, early diagnosis is important to prevent rapid deterioration. The majority of the discussion has been focused on its medical therapeutic strategy, while little effort has been made to study the role of amniotic membrane transplantation (AMT). We describe the first case of OCP with minimal immunosuppressant and initial ocular surface reconstruction procedure using double layer AMT. PATIENT CONCERNS A 66-year-old female patient presented to our outpatient department with right eye pain for several days. DIAGNOSIS Slit lamp examination revealed the right eye cornea perforation with iris incarceration and total collapse of anterior chamber. Symblepharon formation and severe fornix shortening was also noted. While bulbi phthisis with ankyloblepharon and ocular surface keratinization was observed in the left eye. The final diagnosis was right eye stage III ocular cicatricial pemphigoid complicated with corneal perforation and iris prolapsed. INTERVENTIONS The patient underwent ocular surface reconstruction with the aid of amniotic membrane. The first layer of the amniotic membrane was attached with tissue adhesive and fibrin glue while the second layer amniotic membrane came with a conformer ring which supported the fornix space that was recreated. Postoperative care included topical medications for inflammation alleviation. Systemic immunosuppressive agents were not administered except for oral prednisolone. OUTCOMES No recurrence of symblepharon was noted during the one year follow-up. LESSONS We aim at highlighting the possible important role of AMT in advance OCP. Further investigation is still needed for providing evidence to incorporate the procedure into treatment protocol.
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Affiliation(s)
- Suan Hwang
- Department of Ophthalmology, Chi Mei Medical Center, Tainan, Taiwan
| | - Shu-Chun Kuo
- Department of Ophthalmology, Chi Mei Medical Center, Tainan, Taiwan
- Department of Optometry, Chung Hwa University of Medical Technology, Tainan, Taiwan
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21
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Cifuentes-González C, Amaris-Martínez S, Reyes-Guanes J, Uribe-Reina P, de-la-Torre A. Incidence, prevalence, and demographic characteristics of ocular cicatricial pemphigoid in Colombia: data from the National Health Registry 2009-2019. Int J Ophthalmol 2021; 14:1765-1770. [PMID: 34804868 PMCID: PMC8569568 DOI: 10.18240/ijo.2021.11.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 04/08/2021] [Indexed: 11/23/2022] Open
Abstract
AIM To provide an epidemiological characterization of ocular cicatricial pemphigoid (OCP) in Colombia. METHODS We conducted a cross-sectional study using SISPRO. We applied the specific code of the International Classification of Diseases for Ocular Pemphigoid, from 2009-2019 to estimate prevalence, incidence, and the demographic status of the disease in Colombia. RESULTS The estimated average prevalence was 0.22 per 1 000 000 inhabitants, and the estimated average incidence was 0.24 per 1 000 000 inhabitants. With a female predominance of 62.5%, and a male/female ratio of 1:1.6. The group of patients diagnosed with the disease after the age of 80 presented the highest prevalence. The departments with the highest prevalence were Antioquia, Bogotá, and Santander. CONCLUSION There are important differences between worldwide and Colombian prevalence and incidence data, which may be related to genetic and epigenetic factors, and the possible underdiagnosis of the disease. According to the results, OCP is an extremely rare disease in Colombia. Nevertheless, it is important to encourage awareness of the disease due to its devastating consequences.
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Affiliation(s)
- Carlos Cifuentes-González
- Neuroscience Research Group, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá 111221, Colombia
| | - Stefania Amaris-Martínez
- Neuroscience Research Group, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá 111221, Colombia
| | - Juliana Reyes-Guanes
- Escuela Barraquer Research Group, Escuela Superior de Oftalmología del Instituto Barraquer de América, Bogotá 110111, Colombia
| | - Pilar Uribe-Reina
- Neuroscience Research Group, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá 111221, Colombia
- Escuela Barraquer Research Group, Escuela Superior de Oftalmología del Instituto Barraquer de América, Bogotá 110111, Colombia
| | - Alejandra de-la-Torre
- Neuroscience Research Group, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá 111221, Colombia
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22
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Besagar S, London AO, Jairam MP, Trief D, Dagi Glass LR. Chronic Early-Stage Ocular Cicatricial Pemphigoid. Ophthalmic Plast Reconstr Surg 2021; 37:e209-e213. [PMID: 34293790 DOI: 10.1097/iop.0000000000002021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Ocular cicatricial pemphigoid (OCP) represents an insidious, autoimmune-mediated disease of the conjunctiva, initially presenting as chronic conjunctivitis and progressing to fibrosis, cicatrization, and eventually blindness secondary to corneal keratinization. This series reports 3 cases presenting with chronic conjunctivitis lasting an average of 10 years without cicatrix formation, ultimately diagnosed as OCP based on direct immunofluorescence of conjunctival biopsy samples. This chronic conjunctivitis without fibrosis suggests the possibility of an OCP subtype with a prolonged early stage or prodrome prior to cicatrization, which may benefit from early diagnosis and treatment to prevent complications of this disease.
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Affiliation(s)
- Sonya Besagar
- Columbia University, Vagelos College of Physicians and Surgeons, New York, New York, U.S.A
| | - Ashley O London
- Columbia University, Vagelos College of Physicians and Surgeons, New York, New York, U.S.A
| | - Meghan P Jairam
- Columbia University, Vagelos College of Physicians and Surgeons, New York, New York, U.S.A
| | - Danielle Trief
- Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University Irving Medical Center, New York, New York, U.S.A
| | - Lora R Dagi Glass
- Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University Irving Medical Center, New York, New York, U.S.A
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23
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Ocular mucous membrane pemphigoid: novel treatment strategies. Curr Opin Allergy Clin Immunol 2021; 21:486-492. [PMID: 34269741 DOI: 10.1097/aci.0000000000000767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To describe current treatments of ocular mucous membrane pemphigoid (OMMP), including conventional systemic immunosuppression (CIST) and novel biologic agents. RECENT FINDINGS CIST remains the main stay therapy for the management of OMMP. The choice of agents is tailored to disease severity - mild disease is treated with dapsone, whereas moderately severe cases are often treated with mycophenolate mofetil or sulfa-based drugs and severe cases are treated with cyclophosphamide. In recalcitrant disease newer biologics such as Rituximab, intravenous immunoglobins and tumour necrosis alpha antagonists have proven to be effective in disease control. Control of inflammation with topical therapy and halting conjunctival fibrosis remain as areas of unmet clinical needs. SUMMARY OMMP is largely treated with CIST. The recent introduction of new biologic agents could shape the way the disease is treated in the near future.
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24
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Schmidt E, Rashid H, Marzano A, Lamberts A, Di Zenzo G, Diercks G, Alberti‐Violetti S, Barry R, Borradori L, Caproni M, Carey B, Carrozzo M, Cianchini G, Corrà A, Dikkers F, Feliciani C, Geerling G, Genovese G, Hertl M, Joly P, Meijer J, Mercadante V, Murrell D, Ormond M, Pas H, Patsatsi A, Rauz S, van Rhijn B, Roth M, Setterfield J, Zillikens D, C.Prost, Zambruno G, Horváth B, Caux F. European Guidelines (S3) on diagnosis and management of mucous membrane pemphigoid, initiated by the European Academy of Dermatology and Venereology - Part II. J Eur Acad Dermatol Venereol 2021; 35:1926-1948. [PMID: 34309078 PMCID: PMC8518905 DOI: 10.1111/jdv.17395] [Citation(s) in RCA: 83] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 03/24/2021] [Indexed: 01/21/2023]
Abstract
This guideline has been initiated by the task force Autoimmune Blistering Diseases of the European Academy of Dermatology and Venereology, including physicians from all relevant disciplines and patient organizations. It is a S3 consensus-based guideline that systematically reviewed the literature on mucous membrane pemphigoid (MMP) in the MEDLINE and EMBASE databases until June 2019, with no limitations on language. While the first part of this guideline addressed methodology, as well as epidemiology, terminology, aetiology, clinical presentation and outcome measures in MMP, the second part presents the diagnostics and management of MMP. MMP should be suspected in cases with predominant mucosal lesions. Direct immunofluorescence microscopy to detect tissue-bound IgG, IgA and/or complement C3, combined with serological testing for circulating autoantibodies are recommended. In most patients, serum autoantibodies are present only in low levels and in variable proportions, depending on the clinical sites involved. Circulating autoantibodies are determined by indirect IF assays using tissue substrates, or ELISA using different recombinant forms of the target antigens or immunoblotting using different substrates. The major target antigen in MMP is type XVII collagen (BP180), although in 10-25% of patients laminin 332 is recognized. In 25-30% of MMP patients with anti-laminin 332 reactivity, malignancies have been associated. As first-line treatment of mild/moderate MMP, dapsone, methotrexate or tetracyclines and/or topical corticosteroids are recommended. For severe MMP, dapsone and oral or intravenous cyclophosphamide and/or oral corticosteroids are recommended as first-line regimens. Additional recommendations are given, tailored to treatment of single-site MMP such as oral, ocular, laryngeal, oesophageal and genital MMP, as well as the diagnosis of ocular MMP. Treatment recommendations are limited by the complete lack of high-quality randomized controlled trials.
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25
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Rashid H, Lamberts A, Borradori L, Alberti‐Violetti S, Barry R, Caproni M, Carey B, Carrozzo M, Caux F, Cianchini G, Corrà A, Diercks G, Dikkers F, Di Zenzo G, Feliciani C, Geerling G, Genovese G, Hertl M, Joly P, Marzano A, Meijer J, Mercadante V, Murrell D, Ormond M, Pas H, Patsatsi A, Prost C, Rauz S, van Rhijn B, Roth M, Schmidt E, Setterfield J, Zambruno G, Zillikens D, Horváth B. European guidelines (S3) on diagnosis and management of mucous membrane pemphigoid, initiated by the European Academy of Dermatology and Venereology - Part I. J Eur Acad Dermatol Venereol 2021; 35:1750-1764. [PMID: 34245180 PMCID: PMC8457055 DOI: 10.1111/jdv.17397] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 05/17/2021] [Indexed: 12/15/2022]
Abstract
This guideline on mucous membrane pemphigoid (MMP) has been elaborated by the Task Force for Autoimmune Blistering Diseases of the European Academy of Dermatology and Venereology (EADV) with a contribution of physicians from all relevant disciplines and patient organizations. It is a S3 consensus-based guideline encompassing a systematic review of the literature until June 2019 in the MEDLINE and EMBASE databases. This first part covers methodology, the clinical definition of MMP, epidemiology, MMP subtypes, immunopathological characteristics, disease assessment and outcome scores. MMP describes a group of autoimmune skin and mucous membrane blistering diseases, characterized by a chronic course and by predominant involvement of the mucous membranes, such as the oral, ocular, nasal, nasopharyngeal, anogenital, laryngeal and oesophageal mucosa. MMP patients may present with mono- or multisite involvement. Patients' autoantibodies have been shown to be predominantly directed against BP180 (also called BPAG2, type XVII collagen), BP230, laminin 332 and type VII collagen, components of junctional adhesion complexes promoting epithelial stromal attachment in stratified epithelia. Various disease assessment scores are available, including the Mucous Membrane Pemphigoid Disease Area Index (MMPDAI), the Autoimmune Bullous Skin disorder Intensity Score (ABSIS), the 'Cicatrising Conjunctivitis Assessment Tool' and the Oral Disease Severity Score (ODSS). Patient-reported outcome measurements (PROMs), including DLQI, ABQOL and TABQOL, can be used for assessment of quality of life to evaluate the effectiveness of therapeutic interventions and monitor disease course.
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26
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Ong HS, Dart JK, Mehta JS. A Review of Clinical Disease Scoring Systems for Cicatricial Diseases of the Conjunctiva. Front Med (Lausanne) 2021; 8:664572. [PMID: 34447757 PMCID: PMC8382718 DOI: 10.3389/fmed.2021.664572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 07/15/2021] [Indexed: 11/29/2022] Open
Abstract
Cicatricial conjunctival diseases (CCDs), are a diverse group of ocular surface diseases characterized by chronic scarring of the conjunctiva. These diseases can cause significant ocular morbidity. They are life-long once acquired and can be debilitating, painful diseases leading to visual loss. A recent international consensus of ocular surface disease experts have placed emphasis on the need of validated clinical disease scoring systems for CCDs, important for the objective evaluation of disease severity, outcomes of therapies, and longitudinal monitoring of disease. This review aims to describe the various published clinical disease scoring systems available for CCDs and evaluates the benefits and limitations of each system. It can be used as a guide for clinicians managing patients with CCDs and for researchers evaluating potential therapies in clinical trials.
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Affiliation(s)
- Hon Shing Ong
- Corneal and External Diseases Department, Singapore National Eye Centre, Singapore, Singapore.,Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore, Singapore.,Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, National Institute of Health Research (NIHR), UCL Institute of Ophthalmology, London, United Kingdom.,Duke-NUS Graduate Medical School, Singapore, Singapore
| | - John K Dart
- Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, National Institute of Health Research (NIHR), UCL Institute of Ophthalmology, London, United Kingdom.,Corneal and External Diseases Department, Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom
| | - Jodhbir S Mehta
- Corneal and External Diseases Department, Singapore National Eye Centre, Singapore, Singapore.,Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore, Singapore.,Duke-NUS Graduate Medical School, Singapore, Singapore.,School of Material Science and Engineering, Nanyang Technological University, Singapore, Singapore
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27
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Abstract
The red eye is one of the most common cause encountered in ophthalmic practice but a red eye is not always related to eye diseases, instead, it may be a clinical sign of several systemic diseases which may the alarmin signal of sight-threatening or life-threatening condition. Frequently, GPs, pediatricians, immunologists, and rheumatologists are the first landing of patients with a "red eye." This paper is addressed to non-ophthalmic specialists who may be faced with patients having a red eye. Inspection of the external eye under standard office lighting or with a bright light can be easily and accurately made by a general practitioner. Three major caveats should alert the GPs to promptly refer the patient to the ophthalmologist: the presence of pain; the loss of the natural corneal transparency and specular reflex; and any patient-described reduction of visual acuity. In most cases, a red eye is due to occasional and mild ocular surface reaction as consequence of exposure of the external eye to irritants and naturally occurring environmental agents. In these cases washing the eye with a tear lubricant may help in relief of symptoms. If this treatment fails within a few days, a consultation with an ophthalmologist is suggested. The role of the general physician is crucial in the decision making to judge the severity of the ocular condition. Managing a red eye often requires the support of other specialists. Our goal is not only to preserve vision but to globally cure the patient health.
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Affiliation(s)
- Stefano Bonini
- Department of Ophthalmology, University of Rome Campus BioMedico, Rome, Italy
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28
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Vazirani J, Donthineni PR, Goel S, Sane SS, Mahuvakar S, Narang P, Shanbhag SS, Basu S. Chronic cicatrizing conjunctivitis: A review of the differential diagnosis and an algorithmic approach to management. Indian J Ophthalmol 2021; 68:2349-2355. [PMID: 33120615 PMCID: PMC7774214 DOI: 10.4103/ijo.ijo_604_20] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Cicatrizing conjunctivitis constitutes a group of chronic local and systemic disorders that cause conjunctival scarring. A systematic approach is required to sift through the clinical history, examination, and laboratory investigations of patients to arrive at the correct diagnosis of the underlying cause. Establishing the etiology is critical, as the therapeutic approach changes based on the cause of conjunctival inflammation. Effective management of patients with the condition requires knowledge of multiple modalities such as systemic immunosuppressive therapy, use of scleral contact lenses, and surgery for ocular surface and vision improvement. We review the clinical features of this condition and present diagnostic and treatment algorithms to help simplify the complexities in its management. This review attempts to place all the relevant information on chronic cicatrizing conjunctivitis together in one place for the benefit of cornea and ocular surface specialists, general ophthalmologists, and ophthalmology residents.
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Affiliation(s)
- Jayesh Vazirani
- Center for Excellence in Cornea and Ocular Surface Disorders, Excel Eye Care, Ahmedabad, Gujarat, India
| | | | - Sahil Goel
- Department of Ophthalmology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Sayali S Sane
- The Cornea Institute, L V Prasad Eye Institute, GMR Varalakshmi Campus, Visakhapatnam, Andhra Pradesh, India
| | - Sheetal Mahuvakar
- Cornea and Refractive Services, Dr Nagpal's Retina Foundation, Ahmedabad, Gujarat, India
| | - Purvasha Narang
- Cornea, Refractive Surgery and Ocular Surface Services, L J Eye Institute, Ambala, Haryana, India
| | - Swapna S Shanbhag
- The Cornea Institute, L V Prasad Eye Institute, Hyderabad, Telangana, India
| | - Sayan Basu
- The Cornea Institute, L V Prasad Eye Institute, Hyderabad, Telangana, India
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29
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Rashid H, Meijer JM, Diercks GFH, Sieben NE, Bolling MC, Pas HH, Horvath B. Assessment of Diagnostic Strategy for Mucous Membrane Pemphigoid. JAMA Dermatol 2021; 157:780-787. [PMID: 33909024 DOI: 10.1001/jamadermatol.2021.1036] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance An accurate diagnosis of mucous membrane pemphigoid (MMP) is essential to reduce diagnostic and therapeutic delay. Objective To assess the diagnostic accuracy of direct immunofluorescence microscopy on mucosal biopsy specimens and immunoserology in a large cohort of patients with suspected MMP. Design, Setting, and Participants This retrospective cohort study was carried out in a single tertiary care center for blistering diseases between January 2002 and March 2019. Eligible participants were patients with suspected MMP and paired data on at least a mucosal biopsy specimen for direct immunofluorescence microscopy (DIF) and indirect immunofluorescence microscopy (IIF) on a human salt-split skin substrate (SSS). In addition, an optional DIF test on a skin biopsy specimen and one or more performed routine immunoserologic tests were analyzed. Data analysis was conducted from April 2019, to June 2020. Main Outcomes and Measures Diagnostic accuracy of DIF, IIF SSS, and immunoblot for BP180 and BP230. Results Of the 787 participants, 121 (15.4%) received the diagnosis of MMP (50 men [41.3%], 71 women [58.7%]; mean [SD] age at diagnosis, 60.1 [17.7] years). Sixty-seven of the patients with MMP (55.4%) had monosite involvement, of which oral site was the most frequently affected (51 [42.1%]). No significant difference was found between the sensitivity of DIF on a perilesional buccal biopsy and a normal buccal biopsy (89.3% vs 76.7%). Three patients with solitary ocular involvement showed a positive DIF of only the oral mucosa. In 6 patients with a negative mucosal DIF, a skin biopsy confirmed diagnosis of MMP. Overall, IIF SSS was less sensitive (44.6%), but highly specific (98.9%). The sensitivity of immunoblot (66.1%) was higher compared to SSS, but with lower specificity (91.3%). Conclusions and Relevance This comparative diagnostic accuracy study of a cohort of 787 patients found a high sensitivity of a mucosal DIF biopsy for diagnosis of MMP, and lower sensitivity of serologic analysis. A biopsy can be taken from either perilesional or normal buccal mucosa. An additional DIF biopsy of another mucosal site or of affected or unaffected skin may increase the diagnostic yield and is recommended in patients with negative DIF results and high clinical suspicion.
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Affiliation(s)
- Hanan Rashid
- University of Groningen, University Medical Center Groningen, Department of Dermatology, Center of Blistering Diseases, European Reference Network-Skin Member, the Netherlands
| | - Joost M Meijer
- University of Groningen, University Medical Center Groningen, Department of Dermatology, Center of Blistering Diseases, European Reference Network-Skin Member, the Netherlands
| | - Gilles F H Diercks
- University of Groningen, University Medical Center Groningen, Department of Pathology, Groningen, the Netherlands
| | - Nini E Sieben
- University of Groningen, University Medical Center Groningen, Department of Dermatology, Center of Blistering Diseases, European Reference Network-Skin Member, the Netherlands
| | - Maria C Bolling
- University of Groningen, University Medical Center Groningen, Department of Dermatology, Center of Blistering Diseases, European Reference Network-Skin Member, the Netherlands
| | - Hendri H Pas
- University of Groningen, University Medical Center Groningen, Department of Dermatology, Center of Blistering Diseases, European Reference Network-Skin Member, the Netherlands
| | - Barbara Horvath
- University of Groningen, University Medical Center Groningen, Department of Dermatology, Center of Blistering Diseases, European Reference Network-Skin Member, the Netherlands
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30
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James H, Paley GL, Brasington R, Custer PL, Margolis TP, Paley MA. Tofacitinib for refractory ocular mucous membrane pemphigoid. Am J Ophthalmol Case Rep 2021; 22:101104. [PMID: 34007952 PMCID: PMC8111584 DOI: 10.1016/j.ajoc.2021.101104] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 01/18/2021] [Accepted: 04/11/2021] [Indexed: 12/30/2022] Open
Abstract
Purpose To report the successful use of tofacitinib in the treatment of refractory ocular mucous membrane pemphigoid (MMP). Observations Two patients with ocular MMP presented with refractory disease after failure of multiple therapies. Treatment with tofacitinib led to durable control of conjunctival inflammation within 8 weeks and no apparent progression of sub-conjunctival fibrosis. One patient maintained absence of apparent disease activity over 16 months of follow-up. Cessation of tofacitinib in the other patient led to disease relapse which was reversed by re-initiation of therapy. Conclusions and importance Small molecule inhibitors of Janus kinases, such as tofacitinib, may offer an effective treatment option for refractory ocular MMP.
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Affiliation(s)
- Hayley James
- Department of Ophthalmology and Visual Sciences, Washington University in Saint Louis, Center for Outpatient Health, 6th floor, 4901 Forest Park Avenue, Saint Louis, MO, 63110, USA
| | - Grace L Paley
- Department of Ophthalmology and Visual Sciences, Washington University in Saint Louis, Center for Outpatient Health, 6th floor, 4901 Forest Park Avenue, Saint Louis, MO, 63110, USA
| | - Richard Brasington
- Department of Ophthalmology and Visual Sciences, Washington University in Saint Louis, Center for Outpatient Health, 6th floor, 4901 Forest Park Avenue, Saint Louis, MO, 63110, USA.,Division of Rheumatology, Department of Medicine, Washington University in Saint Louis, Center for Advanced Medicine, 5th floor Suite C, 4921 Parkview Place, Saint Louis, MO, 63110, USA
| | - Philip L Custer
- Department of Ophthalmology and Visual Sciences, Washington University in Saint Louis, Center for Outpatient Health, 6th floor, 4901 Forest Park Avenue, Saint Louis, MO, 63110, USA
| | - Todd P Margolis
- Department of Ophthalmology and Visual Sciences, Washington University in Saint Louis, Center for Outpatient Health, 6th floor, 4901 Forest Park Avenue, Saint Louis, MO, 63110, USA
| | - Michael A Paley
- Division of Rheumatology, Department of Medicine, Washington University in Saint Louis, Center for Advanced Medicine, 5th floor Suite C, 4921 Parkview Place, Saint Louis, MO, 63110, USA
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31
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Cifuentes-González C, Amaris-Martínez S, Reyes-Guanes J, Uribe-Reina P, de-la-Torre A. Ocular Cicatricial Pemphigoid, Sjögren's Syndrome, and Hashimoto's Thyroiditis as a Multiple Autoimmune Syndrome: A case report. Eur J Ophthalmol 2021; 32:NP52-NP55. [PMID: 33601905 PMCID: PMC9294440 DOI: 10.1177/1120672121996637] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Purpose: To present a rare and novel association of Ocular Cicatricial Pemphigoid,
Sjögren’s Syndrome, and Hashimoto’s Thyroiditis as a Multiple Autoimmune
Syndrome. Case report: A 43-year-old Colombian female, presented with corneal ulcers, associated
with trichiasis. At the ophthalmological examination forniceal shortening OU
and symblepharon OD was found. Conjunctival biopsy was performed, evidencing
linear deposition of IgG and IgA antibodies along the basement membrane of
the conjunctiva, confirming Ocular Cicatricial Pemphigoid diagnosis. After
12 years, the patient presented constitutional symptoms, xerostomia, and
worsening of xerophthalmia. Laboratory tests showed positive Anti-TG,
Anti-TPO, Anti-Ro, and Anti-La antibodies, and salivary gland biopsy was
consistent with Sjögren’s Syndrome. Due to these findings, Hashimoto’s
Thyroiditis and Sjögren’s Syndrome were diagnosed, defining a Multiple
Autoimmune Syndrome. Conclusion: A novel association of Multiple Autoimmune Syndrome is presented in this
case. Ophthalmologists and other specialists involved in the evaluation and
treatment of patients with autoimmune diseases, should be aware of this
clinical presentation. A multidisciplinary approach in this condition is
important for optimum treatment instauration and follow-up, in order to
prevent complications.
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Affiliation(s)
- Carlos Cifuentes-González
- Research Group in Neurosciences NeURos, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
| | - Stefania Amaris-Martínez
- Research Group in Neurosciences NeURos, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
| | - Juliana Reyes-Guanes
- Escuela Barraquer. Research Group, Escuela Superior de Oftalmología del Instituto Barraquer de América, Bogotá, Colombia
| | - Pilar Uribe-Reina
- Research Group in Neurosciences NeURos, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia.,Escuela Barraquer. Research Group, Escuela Superior de Oftalmología del Instituto Barraquer de América, Bogotá, Colombia
| | - Alejandra de-la-Torre
- Research Group in Neurosciences NeURos, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
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32
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Fuschetto T, Kurtz KS, Delgado-Ruiz RA. Implant and prosthetic rehabilitation of a patient with mucous membrane pemphigoid. J Prosthet Dent 2021; 127:22-26. [PMID: 33390271 DOI: 10.1016/j.prosdent.2020.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 09/24/2020] [Accepted: 09/24/2020] [Indexed: 10/22/2022]
Abstract
Mucous membrane pemphigoid (MMP) is an autoimmune condition characterized by subepithelial separation and deposition of autoantibodies and complement along the basement membrane zone. The disease results in the development of vesiculobullous lesions of the mucous membranes and skin. This report discusses the surgical treatment and management and the prosthetic implant rehabilitation of a patient with mucous membrane pemphigoid. The rationale for this treatment was to fabricate a prosthesis that was stable and did not rub against the gingival tissues and that was easily cleaned. The overdenture attachment system used provides more stability than other attachment systems while allowing the prosthesis and abutments to be easily cleaned.
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Affiliation(s)
- Thomas Fuschetto
- Prosthodontic Resident, Department of Prosthodontics and Digital Technology, School of Dental Medicine, Stony Brook University, Stony Brook, NY; Private practice, Westchester County, NY.
| | - Kenneth S Kurtz
- Clinical Professor of Prosthodontics and Director, Division of Maxillofacial Prosthetics, Department of Prosthodontics and Digital Technology, School of Dental Medicine, Stony Brook University, Stony Brook, NY
| | - Rafael A Delgado-Ruiz
- Associate Professor, Department of Prosthodontics and Digital Technology, School of Dental Medicine, Stony Brook University, Stony Brook, NY
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33
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Chukwuma O, Saikaly SK, Montanez-Wiscovich M, Winslow C, Motaparthi K. Ocular pseudopemphigoid with concomitant eyelid dermatitis secondary to rosacea. JAAD Case Rep 2020; 7:62-64. [PMID: 33354609 PMCID: PMC7744808 DOI: 10.1016/j.jdcr.2020.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Olivia Chukwuma
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida
| | - Sami K. Saikaly
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida
| | | | | | - Kiran Motaparthi
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida
- Correspondence to: Kiran Motaparthi, MD, Department of Dermatology, University of Florida Health-Springhill, 4037 NW 86th Terrace, 4th Floor, Gainesville, FL 32606.
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34
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Messmer EM. Hornhautveränderungen bei Liderkrankungen. Ophthalmologe 2020; 117:949-961. [DOI: 10.1007/s00347-020-01219-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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35
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Morel M, DeGrazia T, Ward L, Behshad S, Kim HJ, Feldman R. Single Center Retrospective Study of Patients with Ocular Mucous Membrane Pemphigoid (MMP). Ocul Immunol Inflamm 2020; 30:256-261. [DOI: 10.1080/09273948.2020.1783322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Mark Morel
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Taryn DeGrazia
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Laura Ward
- Rollins School of Public Health, Atlanta, Georgia, USA
| | - Soroosh Behshad
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Hee Joon Kim
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ron Feldman
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia, USA
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36
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Autoantibody Detection for Diagnosis in Direct Immunofluorescence-Negative Mucous Membrane Pemphigoid: Ocular and Other Sites Compared. Ophthalmology 2020; 128:372-382. [PMID: 32745569 DOI: 10.1016/j.ophtha.2020.07.052] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 07/03/2020] [Accepted: 07/27/2020] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To assess whether a panel of serum pemphigoid autoantibody tests could be used to confirm an immunopathologic diagnosis of mucous membrane pemphigoid (MMP) in direct immunofluorescent negative (DIF-) MMP patients. DESIGN Prospective cross-sectional study. PARTICIPANTS Seventy-six patients with multisite MMP with 45 matched control participants. METHODS Enzyme-linked immunosorbent assays (ELISAs) for BP180 and BP230 (MBL International), immunoglobulin A (IgA) A and immunoglobulin G indirect immunofluorescence (IIF) on human salt-split skin and the keratinocyte footprint assay for anti-laminin 332 antibodies. MAIN OUTCOME MEASURES Sensitivity and specificity of autoantibody detection and significant differences for individual tests and test combinations for MMP involving different sites. RESULTS All DIF- patients (24/73 [31.8%]) had either ocular-only disease or ocular involvement in multisite disease. Serum pemphigoid autoantibodies were detected in 29 of 76 MMP patients (38.2%) compared with 3 of 45 control participants (6.7%). Autoantibody reactivity detected by any 1 or more of the tests was present in 6 of 24 DIF- patients (25%) compared with 22 of 49 DIF positive (DIF+) patients (44.9%). Ocular-only MMP serum reactivity was not significantly different for any test or test combination compared with control participants, whereas DIF- multisite ocular MMP differed for 1 ELISA and 3 of 7 test combinations. By contrast, for DIF+ nonocular MMP patients, all the individual tests, apart from IgA IIF, and all test combinations were significantly different compared with those for control participants. For the entire MMP cohort, the sensitivity of all individual tests was low, having a maximum of 21.05% for BP180 reactivity but increasing to 38.16% for an optimal test combination. Disease activity was associated strongly with positive serologic findings. CONCLUSIONS Pemphigoid serum autoantibody tests did not provide immunopathologic evidence of MMP in ocular-only MMP patients but showed limited value in DIF- multisite ocular MMP patients. The requirement for immunopathologic confirmation of MMP by autoantibody detection is inappropriate for DIF- ocular-only MMP patients, resulting in missed diagnoses, delayed therapy, and poor outcomes. Alternative diagnostic criteria for ocular-only MMP are required to exclude the other causes of scarring conjunctivitis until more sensitive and specific immunopathologic tests become available.
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de la Sen-Corcuera B, Montero-Iruzubieta J, Sánchez-Ávila RM, Orive G, Anitua E, Caro-Magdaleno M, Merayo-Lloves J. Plasma Rich in Growth Factors for the Treatment of Cicatrizing Conjunctivitis. Clin Ophthalmol 2020; 14:1619-1627. [PMID: 32606577 PMCID: PMC7306461 DOI: 10.2147/opth.s252253] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 06/04/2020] [Indexed: 12/12/2022] Open
Abstract
Purpose The objective was to evaluate the clinical results obtained from the use of immunosafe plasma rich in growth factors (isPRGF) in the treatment of patients with cicatrizing conjunctivitis (CC) who had not responded to the usual therapy. Patients and Methods This is a retrospective study that included patients diagnosed with CC, in whom isPRGF was used in different phases (I: eye drops; II: eye drops and injectable; III: eye drops, injectable and surgical treatment) to achieve control of the inflammation. As a clinical follow-up of the patients, the better corrected visual acuity (BCVA), degree of inflammation (measured from 1 to 4), the severity of the CC, Schirmer I test, IOP and TBUT were analyzed. The adverse events were also evaluated. Results Ten eyes (6 patients) were evaluated, 50% corresponded to Stevens–Johnson Syndrome and 50% to ocular mucous membrane pemphigoid. The mean age was 59.7 ± 16.5 (39–80) years, and 50% were women. Fifty per cent of the cases were initially considered severe CC, and 10% of the cases (one eye of one patient) were considered severe CC at the end of the treatment (p = 0.046). The initial degree of inflammation was 2 in 4 eyes, 3 in two eyes, and 4 in 4 eyes, and final inflammation degree was 1 in all cases (p = 0.004). Twenty per cent of the cases achieved stability in Phase I of the treatment with immunosafe PRGF, 70% with both Phases I and II, and only one case underwent Phase III to achieve stability. The IOP improved significantly (p = 0.027) though the BCVA, TBUT and Schirmer I test showed no significant changes. The follow-up time was 23.1 ± 6.7 (13.6–30.3) months. No adverse effects were reported. Conclusion Treatment with PRGF technology in its injectable and topical immunosafe formulations may be a novel alternative for the treatment of patients with CC, given its complement activity modulating effect, as well as its anti-inflammatory, antifibrotic and regenerative properties.
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Affiliation(s)
- Borja de la Sen-Corcuera
- Biotechnology Institute (BTI), Vitoria, Spain.,University Institute for Regenerative Medicine and Oral Implantology (UIRMI), Vitoria, Spain
| | - Jesús Montero-Iruzubieta
- Clínica Cartujavisión, Sevilla, Spain.,Hospital Universitario Virgen de Macarena, Sevilla, Spain
| | - Ronald M Sánchez-Ávila
- Biotechnology Institute (BTI), Vitoria, Spain.,Instituto Universitario Fernández-Vega, Fundación de Investigación Oftalmológica, Universidad de Oviedo, Oviedo, Spain
| | - Gorka Orive
- Biotechnology Institute (BTI), Vitoria, Spain.,University Institute for Regenerative Medicine and Oral Implantology (UIRMI), Vitoria, Spain
| | - Eduardo Anitua
- Biotechnology Institute (BTI), Vitoria, Spain.,University Institute for Regenerative Medicine and Oral Implantology (UIRMI), Vitoria, Spain
| | | | - Jesús Merayo-Lloves
- Instituto Universitario Fernández-Vega, Fundación de Investigación Oftalmológica, Universidad de Oviedo, Oviedo, Spain
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Signaling lipids as diagnostic biomarkers for ocular surface cicatrizing conjunctivitis. J Mol Med (Berl) 2020; 98:751-760. [PMID: 32313985 PMCID: PMC7220886 DOI: 10.1007/s00109-020-01907-w] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/24/2020] [Accepted: 04/02/2020] [Indexed: 12/23/2022]
Abstract
Abstract Metabolomics has been applied to diagnose diseases, predict disease progression, and design therapeutic strategies in various areas of medicine. However, it remains to be applied to the ocular surface diseases, where biological samples are often of limited quantities. We successfully performed proof-of-concept metabolomics assessment of volume-limited cytology samples from a clinical form of chronic inflammatory cicatrizing conjunctivitis, i.e., ocular MMP and discovered metabolic changes of signaling lipid mediators upon disease onset and progression. The metabolomics assessment revealed active oxylipins, lysophospholipids, fatty acids, and endocannabinoids alterations, from which potential biomarkers linked to inflammatory processes were identified. Possible underlying mechanisms such as dysregulated enzyme activities (e.g., lipoxygenases, cytochrome P450, and phospholipases) were suggested which may be considered as potential therapeutic targets in future studies. Key messages Metabolic profile of the ocular surface can be measured using impression cytology samples. Metabolomics analysis of ocular pemphigoid is presented for the first time. The metabolomics assessment of OCP patients revealed active oxylipins, lysophospholipids, fatty acids, and endocannabinoids alterations. Several oxylipins are identified as diagnostic biomarkers for OCP.
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Anesi SD, Eggenschwiler L, Ferrara M, Artornsombudh P, Walsh M, Foster CS. Reliability of Conjunctival Biopsy for Diagnosis of Ocular Mucous Membrane Pemphigoid: Redetermination of the Standard for Diagnosis and Outcomes of Previously Biopsy-Negative Patients. Ocul Immunol Inflamm 2020; 29:1106-1113. [PMID: 32130051 DOI: 10.1080/09273948.2020.1716988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Purpose: To demonstrate the reliability of conjunctival biopsy analyzed by direct immunofluorescence (DIF) and supplemented with avidin-biotin complex immunoperoxidase (ABC) in diagnosing oMMP, and report therapy response in biopsy-positive patients, particularly when previously biopsy-negative elsewhere.Methods: Retrospective outcomes review of 136 consecutive patients after conjunctival biopsy for suspected oMMP.Results: Among 136 patients, 66% were diagnosed with oMMP by DIF and 13% via supplemental ABC immunoperoxidase. Sensitivity increased from 79.6% with DIF to 95.6% with supplemental ABC. Among 57 biopsy-positive patients, 77% were in remission at 1-year follow-up and 88% after 2 years. Of 34 previous biopsy-negative but now biopsy-positive patients with a 2-year follow-up, 91% achieved remission, including all 16 diagnosed via DIF and ABC.Conclusion: Conjunctival biopsy analyzed by histopathology and DIF supplemented by ABC has high reliability for diagnosing oMMP and is a useful tool to use before starting long-term immunomodulatory therapy in a patient with suspected oMMP.
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Affiliation(s)
- Stephen D Anesi
- Massachusetts Eye Research and Surgery Institution, Waltham, Massachusetts, USA.,The Ocular Immunology and Uveitis Foundation, Waltham, Massachusetts, USA
| | - Laura Eggenschwiler
- Massachusetts Eye Research and Surgery Institution, Waltham, Massachusetts, USA.,The Ocular Immunology and Uveitis Foundation, Waltham, Massachusetts, USA
| | - Mariantonia Ferrara
- Massachusetts Eye Research and Surgery Institution, Waltham, Massachusetts, USA.,The Ocular Immunology and Uveitis Foundation, Waltham, Massachusetts, USA.,Department of Neuroscience, Reproductive and Odontostomatological Science, Federico II University, Naples, Italy
| | - Pichaporn Artornsombudh
- Massachusetts Eye Research and Surgery Institution, Waltham, Massachusetts, USA.,The Ocular Immunology and Uveitis Foundation, Waltham, Massachusetts, USA
| | - Marisa Walsh
- Massachusetts Eye Research and Surgery Institution, Waltham, Massachusetts, USA.,The Ocular Immunology and Uveitis Foundation, Waltham, Massachusetts, USA
| | - C Stephen Foster
- Massachusetts Eye Research and Surgery Institution, Waltham, Massachusetts, USA.,The Ocular Immunology and Uveitis Foundation, Waltham, Massachusetts, USA.,Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
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Ong HS, Minassian D, Rauz S, Mehta JS, Dart JK. Validation of a clinical assessment tool for cicatrising conjunctivitis. Ocul Surf 2020; 18:121-129. [DOI: 10.1016/j.jtos.2019.10.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 10/19/2019] [Accepted: 10/31/2019] [Indexed: 12/13/2022]
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You JY, Eberhart CG, Karakus S, Akpek EK. Characterization of Progressive Cicatrizing Conjunctivitis With Negative Immunofluorescence Staining. Am J Ophthalmol 2020; 209:3-9. [PMID: 31560878 DOI: 10.1016/j.ajo.2019.09.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 09/18/2019] [Accepted: 09/18/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE To characterize the clinical features of patients with direct immunofluorescence (DIF)-negative mucous membrane pemphigoid (MMP). DESIGN Retrospective case series. METHODS Thirty-six patients who underwent a conjunctival biopsy for suspected MMP were included. Demographic and clinical information was collected. Main outcome measures included visual acuity, Foster stages, presence of extraocular involvement, history of autoimmune disease, and durations of follow-up. RESULTS Thirty-two patients had a negative DIF. Of those, 2 had a positive DIF on repeat biopsy. Eleven showed progression of conjunctival scarring during a median follow-up of 42 months (range, 8-100 months) and were diagnosed with biopsy-negative MMP. Another 11 patients with a median follow-up of 54 months (range, 15-138 months) were diagnosed with cicatrizing conjunctivitis of other causes. The median visual acuity of patients with biopsy-negative MMP at presentation was significantly lower compared to patients with cicatrizing conjunctivitis of other causes (20/400 vs 20/40, P = .02). Conjunctival scarring score at presentation in both biopsy-positive and biopsy-negative MMP groups was significantly higher compared to patients with cicatrizing conjunctivitis of other causes (median Foster stage, 3 vs 1, P = .009; and 3 vs 1, P = .01, respectively). CONCLUSIONS Patients with progressive cicatrizing conjunctivitis likely have MMP in the absence of alternate diagnoses. Our findings emphasize that suspicion for MMP must remain high for patients who have Foster stage 3 conjunctival scarring on presentation or worsening of scarring during follow-up, even in the setting of negative DIF.
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Ormond M, McParland H, Thakrar P, Donaldson ANA, Andiappan M, Cook RJ, Escudier ME, Higham J, Hullah E, McMillan R, Taylor J, Shirlaw PJ, Challacombe SJ, Setterfield JF. Validation of an Oral Disease Severity Score (ODSS) tool for use in oral mucous membrane pemphigoid. Br J Dermatol 2019; 183:78-85. [PMID: 31571192 DOI: 10.1111/bjd.18566] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Mucous membrane pemphigoid (MMP) is a rare autoimmune bullous disease predominantly affecting the oral mucosa. Optimal management relies upon thorough clinical assessment and documentation at each visit. OBJECTIVES The primary aim of this study was to validate the Oral Disease Severity Score (ODSS) for the assessment of oral involvement in MMP. We also compared its inter- and intraobserver reliability with those of the oral parts of the Mucous Membrane Pemphigoid Disease Area Index (MMPDAI), Autoimmune Bullous Skin Disorder Intensity Score (ABSIS) and Physician's Global Assessment (PGA). METHODS Fifteen patients with mild-to-moderately severe oral MMP were scored for disease severity by 10 oral medicine clinicians from four U.K. centres using the ODSS, the oral sections of MMPDAI and ABSIS, and PGA. Two clinicians rescored all patients after 2 h. RESULTS In terms of reliability, the interobserver ODSS total score intraclass correlation coefficient (ICC) was 0·97, MMPDAI activity 0·59 and damage 0·15, ABSIS total 0·84, and PGA 0·72. The intraobserver ICCs (two observers) for ODSS total were 0·97 and 0·93; for MMPDAI activity 0·93 and 0·70 and damage 0·93 and 0·79; for ABSIS total 0·99 and 0·94; and for PGA 0·92 and 0·94. Convergent validity between ODSS and MMPDAI was good (correlation coefficient 0·88). The mean ± SD time for completion of ODSS was 93 ± 31 s, with MMPDAI 102 ± 24 s and ABSIS involvement 71 ± 18 s. The PGA took < 5 s. CONCLUSIONS This study has validated the ODSS for the assessment of oral MMP. It has shown superior interobserver agreement over MMPDAI, ABSIS and PGA, and superior intraobserver reliability to MMPDAI. It is quick and easy to perform. What's already known about this topic? There are no validated scoring methodologies for oral mucous membrane pemphigoid (MMP). Proposed disease activity scoring tools for MMP include the Mucous Membrane Disease Area Index (MMPDAI) and the Autoimmune Bullous Skin Disorder Intensity Score (ABSIS). The Oral Disease Severity Score (ODSS) has been validated for use in oral pemphigus vulgaris (PV). It has been shown to be reliable and sensitive in both lichen planus (LP) and MMP. What does this study add? The ODSS has been shown to be a thorough, sensitive and reproducible, yet quick scoring tool for the assessment of oral involvement in MMP. Its versatility for use in oral PV, MMP and LP is an added advantage over other scoring methodologies. What are the clinical implications of this work? We propose that the ODSS be used as a clinical scoring tool for monitoring activity in oral MMP in clinical practice as well as for use in multicentre studies.
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Affiliation(s)
- M Ormond
- Department of Oral Medicine, St John's Institute of Dermatology, Guy's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, U.K
| | - H McParland
- Department of Oral Medicine, St John's Institute of Dermatology, Guy's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, U.K
| | - P Thakrar
- Department of Oral Medicine, Birmingham Dental Hospital and School of Dentistry, Birmingham, U.K
| | - A N A Donaldson
- Biostatistics and Research Methods Centre, King's College London Faculty of Dentistry, Oral& Craniofacial Sciences, London, U.K
| | - M Andiappan
- Biostatistics and Research Methods Centre, King's College London Faculty of Dentistry, Oral& Craniofacial Sciences, London, U.K
| | - R J Cook
- Department of Oral Medicine, St John's Institute of Dermatology, Guy's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, U.K.,Centre for Oral Clinical and Translational Sciences, King's College London Faculty of Dentistry, Oral& Craniofacial Sciences, London, U.K
| | - M E Escudier
- Department of Oral Medicine, St John's Institute of Dermatology, Guy's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, U.K.,Centre for Host-Microbiome Interactions, King's College London Faculty of Dentistry, Oral& Craniofacial Sciences, London, U.K
| | - J Higham
- Department of Oral Medicine, Birmingham Dental Hospital and School of Dentistry, Birmingham, U.K
| | - E Hullah
- Department of Oral Medicine, St John's Institute of Dermatology, Guy's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, U.K
| | - R McMillan
- Department of Oral Medicine, Eastman Dental Hospital, UCLH/Eastman Dental Institute, UCL, London, U.K
| | - J Taylor
- Department of Oral Medicine, Glasgow Dental Hospital and School, Glasgow, U.K
| | - P J Shirlaw
- Department of Oral Medicine, St John's Institute of Dermatology, Guy's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, U.K
| | - S J Challacombe
- Department of Oral Medicine, St John's Institute of Dermatology, Guy's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, U.K.,Centre for Host-Microbiome Interactions, King's College London Faculty of Dentistry, Oral& Craniofacial Sciences, London, U.K
| | - J F Setterfield
- Department of Oral Medicine, St John's Institute of Dermatology, Guy's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, U.K.,Centre for Host-Microbiome Interactions, King's College London Faculty of Dentistry, Oral& Craniofacial Sciences, London, U.K.,St John's Institute of Dermatology, Guy's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, U.K
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Shanbhag SS, Chanda S, Donthineni PR, Sane SS, Priyadarshini SR, Basu S. Clinical clues predictive of Stevens-Johnson syndrome as the cause of chronic cicatrising conjunctivitis. Br J Ophthalmol 2019; 104:1005-1009. [DOI: 10.1136/bjophthalmol-2019-314928] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 09/24/2019] [Accepted: 09/27/2019] [Indexed: 11/04/2022]
Abstract
PurposeThis study aimed to identify the clinical clues in patients with chronic cicatrising conjunctivitis (CCC), that were suggestive of Stevens-Johnson syndrome (SJS) as the aetiology.MethodsThis was a cross-sectional observational study of 75 patients presenting with CCC from 2016 to 2018. Those with a documented diagnosis of SJS (n=43) were included as cases; while those with a positive serology or tissue biopsy for a non-SJS condition were included as controls (n=32). The features in the medical history and clinical examination that were positively and negatively associated with SJS were scored +1 and −1, respectively. A receiver operating characteristic (ROC) curve analysis was performed to detect the threshold score for optimal sensitivity and specificity of the scoring system.ResultsNo single feature had absolute sensitivity and specify for SJS. The 10 positive features suggestive of SJS (p<0.0001) included (1) history of: acute conjunctivitis, fever or drug intake preceding conjunctivitis, peeling of skin on pressure, loss of nails and severe morbidity with hospital admission; and (2) clinical features of: skin discoloration, nail disfigurement, lip-margin dermalisation, lid-margin keratinisation and distichiasis. The two negative criteria were history of mucosal ulcers without skin involvement and recurrent mucosal ulceration. On ROC analysis, a score of >5 showed a sensitivity of 90.7% and specificity of 93.8% for the diagnosis of SJS.ConclusionsThe combination of clinical clues identified in this study can help clinicians confirm SJS as the aetiology of conjunctival cicatrisation, especially when reliable documentation of the acute episode is not available.
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Taurone S, Spoletini M, Ralli M, Gobbi P, Artico M, Imre L, Czakò C, Kovàcs I, Greco A, Micera A. Ocular mucous membrane pemphigoid: a review. Immunol Res 2019; 67:280-289. [DOI: 10.1007/s12026-019-09087-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Carey B, Setterfield J. Mucous membrane pemphigoid and oral blistering diseases. Clin Exp Dermatol 2019; 44:732-739. [DOI: 10.1111/ced.13996] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2019] [Indexed: 01/30/2023]
Affiliation(s)
- B. Carey
- Oral Medicine Dental Institute Guy's and St Thomas’ NHS Foundation Trust London UK
| | - J. Setterfield
- Oral Medicine Dental Institute Guy's and St Thomas’ NHS Foundation Trust London UK
- Centre for Host‐Microbiome Interactions King's College London Faculty of Dentistry, Oral and Craniofacial Sciences London UK
- St John's Institute of Dermatology Guy's and St Thomas’ NHS Foundation Trust London UK
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Georgoudis P, Sabatino F, Szentmary N, Palioura S, Fodor E, Hamada S, Scholl HPN, Gatzioufas Z. Ocular Mucous Membrane Pemphigoid: Current State of Pathophysiology, Diagnostics and Treatment. Ophthalmol Ther 2019; 8:5-17. [PMID: 30694513 PMCID: PMC6393250 DOI: 10.1007/s40123-019-0164-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Indexed: 12/11/2022] Open
Abstract
Mucous membrane pemphigoid (MMP) is a systemic cicatrizing autoimmune disease that primarily affects orificial mucous membranes, such as the conjunctiva, the nasal cavity, the oropharynx, and the genitalia. Ocular involvement occurs in about 70% of all MMP cases. Ocular MMP (OcMMP) also encompasses the conditions linear immunoglobulin A disease, mucosal dominated epidermolysis bullosa acquisita, and anti-laminin 332/anti-epiligrin/anti-laminin 5 pemphigoid. It is a complex clinical entity that may lead to ocular surface failure and result in inflammatory and infectious complications, as well as potentially devastating visual loss. Early diagnosis and appropriate treatment are of paramount importance and require a high level of expertise as this condition can be extremely challenging to diagnose and treat even for experienced clinicians. In this review we provide an up-to-date insight on the pathophysiology of OcMMP, with an emphasis on the current state of its diagnostics and therapeutics. Our the aim is to increase our understanding of OcMMP and highlight modern diagnostic and therapeutic options.
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Affiliation(s)
| | | | - Nora Szentmary
- Department of Ophthalmology, Saarland University Medical Center, Homburg/Saar, Germany
- Department of Ophthalmology, Semmelweis University, Budapest, Hungary
| | | | - Eszter Fodor
- Department of Ophthalmology, Semmelweis University, Budapest, Hungary
| | - Samer Hamada
- Corneo-Plastic Unit, Queen Victoria Hospital, East Grinstead, UK
| | - Hendrik P N Scholl
- Department of Ophthalmology, Basel University Hospital, Basel, Switzerland
- Institute of Molecular and Clinical Ophthalmology Basel (IOB), Basel, Switzerland
| | - Zisis Gatzioufas
- Department of Ophthalmology, Basel University Hospital, Basel, Switzerland.
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Kamaguchi M, Iwata H. The Diagnosis and Blistering Mechanisms of Mucous Membrane Pemphigoid. Front Immunol 2019; 10:34. [PMID: 30740099 PMCID: PMC6357922 DOI: 10.3389/fimmu.2019.00034] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 01/08/2019] [Indexed: 12/30/2022] Open
Abstract
Mucous membrane pemphigoid (MMP) is a mucous membrane-dominated autoimmune subepithelial blistering disease that is caused by autoantibodies against various autoantigens in basement membrane zone (BMZ) proteins, including collagen XVII (COL17). Clinicians face diagnostic problems in detecting circulating antibodies and targeted antigens in MMP. The diagnostic difficulties are mainly attributed to the low titers of MMP autoantibodies in sera and to heterogeneous autoantigens. Additionally, no unanimous diagnostic criteria have been drawn for MMP, which can result in delayed diagnoses or misdiagnoses. This review aims to integrate and present currently available data to clarify diagnostic strategies and to present diagnostic criteria for MMP. The ultimate blistering mechanism in MMP has not been elucidated, and such mechanism is especially obscure in COL17-type MMP. In bullous pemphigoid (BP), which is the most common autoimmune subepidermal blistering disease, some patients show oral lesion as well as predominant skin lesions. However, there is no fundamental explanation for the onset of oral lesions in BP. This article summarizes innovative research perspectives on the pathogenesis of oral lesions in pemphigoid. Finally, we propose a potential pathogenesis for COL17-type MMP.
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Affiliation(s)
- Mayumi Kamaguchi
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan.,Department of Oral Diagnosis and Medicine, Hokkaido University Graduate School of Dental Medicine, Sapporo, Japan
| | - Hiroaki Iwata
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Sarny S, Hucke M, El-Shabrawi Y. Treatment of Mucous Membrane Pemphigoid With Janus Kinase Inhibitor Baricitinib. JAMA Ophthalmol 2018; 136:1420-1422. [DOI: 10.1001/jamaophthalmol.2018.3789] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Stephanie Sarny
- Department of Ophthalmology, General Hospital Klagenfurt, Klagenfurt, Austria
- Department of Ophthalmology, Medical University Graz, Graz, Austria
| | - Miriam Hucke
- Department of Internal Medicine, General Hospital Klagenfurt, Klagenfurt, Austria
| | - Yosuf El-Shabrawi
- Department of Ophthalmology, General Hospital Klagenfurt, Klagenfurt, Austria
- Department of Ophthalmology, Medical University Graz, Graz, Austria
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Abstract
PURPOSE OF REVIEW This review offers recommendations for monitoring disease status in ocular cicatricial pemphigoid as well therapeutic options including local and systemic therapies. RECENT FINDINGS A negative biopsy on direct immunofluorescence does not preclude a diagnosis of OCP. If a patient's cicatrization is active and/or progressive, systemic immunosuppression should be commenced. SUMMARY OCP is a chronic systemic autoimmune disease that requires systemic immunosuppression.
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Hübner F, Setterfield J, Recke A, Zillikens D, Schmidt E, Dart J, Ibrahim S. HLA alleles in British Caucasians with mucous membrane pemphigoid. Eye (Lond) 2018; 32:1540-1541. [PMID: 29743586 DOI: 10.1038/s41433-018-0092-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 01/17/2018] [Indexed: 11/09/2022] Open
Affiliation(s)
- F Hübner
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - J Setterfield
- Guy's and St Thomas's NHS Foundation Trust and King's College London, London, UK
| | - A Recke
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - D Zillikens
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - E Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany.,The Lübeck Institut of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - J Dart
- National Institute of Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - S Ibrahim
- The Lübeck Institut of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany.
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