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Azzopardi M, Chong YJ, Sreekantam S, Barry RJ, Poonit N, Rauz S, Murray PI. Real-World Experience in the Use of Immunosuppression for the Management of Inflammatory Eye Disease. Ocul Immunol Inflamm 2024:1-10. [PMID: 38349962 DOI: 10.1080/09273948.2024.2311743] [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: 11/01/2023] [Accepted: 01/24/2024] [Indexed: 02/15/2024]
Abstract
PURPOSE Patients with sight-threatening inflammatory eye disease (IED) are maintained on systemic immunosuppression whilst in long-term clinical remission. There are no clear guidelines on the duration of remission before implementing treatment withdrawal. We present a real-world analysis on the use of immunosuppression in IED in long-term remission and consider strategies for withdrawal. METHODS Adult IED patients on systemic immunosuppression were categorised into four disease groups: Corneal Transplant Survival Strategies (CTSS), Ocular Surface Disease (OSD), Non-infectious Uveitis (NIU) and Scleritis. Patients with Behçet's disease were excluded. Data on systemic immunosuppressants and biologics used; duration of treatment; reasons for drug discontinuation; disease activity/remission status; duration of clinical remission with an emphasis on patients who had been in remission for a minimum of 24 months were captured. RESULTS Out of a total of 303 IED patients, 128 were on systemic immunosuppression with a clinical remission of their ocular disease for ≥24 months. The median duration of remission was 4-5 years with the longest duration of remission 22 years, and some patients on immunosuppression for up to 23 years. Sixty patients stopped at least one immunosuppressive agent without prior discussion with a health-care practitioner. CONCLUSION Progressive conditions, such as cicatrising conjunctivitis may require lifelong immunosuppression, but patients with NIU and Scleritis and those on CTSS, immunosuppression withdrawal should be considered if they remain in remission for 2 years. Any patient stopping a medication should be contacted immediately for counselling. These data will better inform patients, encourage adherence and aide formal guideline development.
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Affiliation(s)
- Matthew Azzopardi
- Centre for Inflammatory Eye Disease, Birmingham and Midland Eye Centre, Sandwell and West Birmingham NHS Trust, Birmingham, UK
- Academic Unit of Ophthalmology, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Yu Jeat Chong
- Centre for Inflammatory Eye Disease, Birmingham and Midland Eye Centre, Sandwell and West Birmingham NHS Trust, Birmingham, UK
| | - Sreekanth Sreekantam
- Centre for Inflammatory Eye Disease, Birmingham and Midland Eye Centre, Sandwell and West Birmingham NHS Trust, Birmingham, UK
| | - Robert J Barry
- Centre for Inflammatory Eye Disease, Birmingham and Midland Eye Centre, Sandwell and West Birmingham NHS Trust, Birmingham, UK
- Academic Unit of Ophthalmology, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Natraj Poonit
- Centre for Inflammatory Eye Disease, Birmingham and Midland Eye Centre, Sandwell and West Birmingham NHS Trust, Birmingham, UK
- Academic Unit of Ophthalmology, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Saaeha Rauz
- Centre for Inflammatory Eye Disease, Birmingham and Midland Eye Centre, Sandwell and West Birmingham NHS Trust, Birmingham, UK
- Academic Unit of Ophthalmology, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Philip I Murray
- Centre for Inflammatory Eye Disease, Birmingham and Midland Eye Centre, Sandwell and West Birmingham NHS Trust, Birmingham, UK
- Academic Unit of Ophthalmology, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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Feng J, Liu Y, Ren Y, Shi W, Kang H, Tan Y, Wu R, Zhang G, He Y. Evaluation of Dry Eye Severity and Ocular Surface Inflammation in Patients with Pemphigus and Pemphigoid. Ocul Immunol Inflamm 2024; 32:62-70. [PMID: 36637982 DOI: 10.1080/09273948.2022.2154680] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 11/29/2022] [Indexed: 01/14/2023]
Abstract
PURPOSE To evaluate ocular surface involvement, tear cytokine levels, and histopathological changes in pemphigus and pemphigoid patients. METHODS A total of 22 patients (15 pemphigus and 7 pemphigoids) and 21 non-diseased controls were enrolled in our study. All participants underwent ocular surface evaluation, which included ocular surface disease index test, slit lamp observation, dry eye-related examination, tear multicytokine analysis, and conjunctival impression cytology. RESULTS Pemphigus and pemphigoid patients presented much more severe conjunctivochalasis, corneal epithelial defects, corneal opacity, symblepharon and dry eye. Severe ocular surface squamous metaplasia and a significant increase of tear macrophage inflammatory protein-1beta, tumor necrosis factor-alpha, interleukin (IL)-1β, IL -6, and IL-8 occurred in pemphigus and pemphigoid patients. CONCLUSIONS Our results revealed that ocular surface inflammation and dry eye persist in most pemphigus and pemphigoid patients, and do not occur in parallel with the systemic course. Regular ophthalmological examinations and local anti-inflammatory should be provided for pemphigus and pemphigoid patients.
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Affiliation(s)
- Jianing Feng
- Department of Ophthalmology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Ophthalmology, Hunan Clinical Research Center of Ophthalmic Disease, Changsha, Hunan, China
- Xi'an People's Hospital (Xi'an Fourth Hospital), Shaanxi Eye Hospital, Northwest University Affiliated People's Hospital, Xi'an, Shaanxi Province, China
| | - Yingyi Liu
- Department of Ophthalmology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Ophthalmology, Hunan Clinical Research Center of Ophthalmic Disease, Changsha, Hunan, China
| | - Yuerong Ren
- Department of Ophthalmology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Ophthalmology, Hunan Clinical Research Center of Ophthalmic Disease, Changsha, Hunan, China
| | - Wen Shi
- Department of Ophthalmology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Ophthalmology, Hunan Clinical Research Center of Ophthalmic Disease, Changsha, Hunan, China
| | - Huanmin Kang
- Department of Ophthalmology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Ophthalmology, Hunan Clinical Research Center of Ophthalmic Disease, Changsha, Hunan, China
| | - Yixin Tan
- Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Ruifang Wu
- Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Guiying Zhang
- Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yan He
- Department of Ophthalmology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Ophthalmology, Hunan Clinical Research Center of Ophthalmic Disease, Changsha, Hunan, China
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Sharon Y, Anesi SD, Martinez CE, Huang AJW, Foster CS, Chu DS. Repository Corticotropin Injection as an Alternative Treatment for Refractory Ocular Mucous Membrane Pemphigoid. Cornea 2022; 41:45-51. [PMID: 34050065 DOI: 10.1097/ico.0000000000002771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 04/03/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this study was to report the clinical course and outcome of patients with refractory ocular mucous membrane pemphigoid (MMP) treated by repository corticotropin injection (RCI). METHODS Patients with biopsy-proven ocular MMP treated with RCI from 3 tertiary medical centers were evaluated. Medical records between January 2013 and January 2021 were reviewed and deidentified to retrieve relevant disease-related data. Primary outcome measures included conjunctival inflammatory activity, change in Foster clinical conjunctival scarring staging after RCI treatment, and the development of ocular and systemic complications. RESULTS Included were 15 patients (10 women and 5 men; 36-95 yrs of age) with a mean follow-up of 4.5 years. Most of the patients (80%) had Foster stage 3 at presentation, and all patients had active MMP. Each patient had failed to respond to at least 1 immunomodulatory drug during the follow-up, and 9 (60%) patients had treatment failure of at least 2 other agents before the use of RCI. The mean duration of RCI treatment was 21 months (range, 3-54 mo). Foster stage did not change in any of the 15 patients at the last follow-up. Nine patients continued RCI therapy at the last follow-up, and in all of them, the disease activity of MMP was well controlled. No serious adverse events because of RCI were documented during the follow-up in any treated patient. CONCLUSIONS RCI may serve as an alternative or an adjunctive treatment in patients with severe and refractory ocular MMP. Treatment with RCI seems to be safe and well-tolerated.
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Affiliation(s)
- Yael Sharon
- Department of Ophthalmology, Rabin Medical Center, Petah-Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Metropolitan Eye Research and Surgery Institute, Palisades Park, NJ
| | - Stephen D Anesi
- Massachusetts Eye Research and Surgery Institution (MERSI), Waltham, MA
- Ocular Immunology and Uveitis Foundation (OIUF), Waltham, MA
| | - Christine E Martinez
- Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St. Louis, MO
- Department of Ophthalmology and Visual Sciences, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Andrew J W Huang
- Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St. Louis, MO
| | - Charles Stephen Foster
- Massachusetts Eye Research and Surgery Institution (MERSI), Waltham, MA
- Ocular Immunology and Uveitis Foundation (OIUF), Waltham, MA
- Department of Ophthalmology, Harvard Medical School, Boston, MA; and
| | - David S Chu
- Metropolitan Eye Research and Surgery Institute, Palisades Park, NJ
- Institute of Ophthalmology and Visual Science, New Jersey Medical School, Rutgers University, Newark, NJ
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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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5
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Disease Relapse After Drug-Free Remission in Ocular Mucous Membrane Pemphigoid. Am J Ophthalmol 2021; 223:21-27. [PMID: 32976845 DOI: 10.1016/j.ajo.2020.09.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 09/13/2020] [Accepted: 09/13/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE To quantitate the risk of relapse of ocular and extraocular disease among patients with mucous membrane pemphigoid (MMP) who had undergone drug-free remission. DESIGN Retrospective, comparative, interventional case series. METHODS There were 167 patients with biopsy-proven MMP who were seen at the Wilmer Eye Institute between November 1984 and December 2019. Among the 167 patients, 119 patients had ocular involvement and 103 of those patients received systemic treatment for MMP. The main outcome measures were the incidence of ocular remission, incidence rate of disease relapse after remission, and risk factors for disease relapse. RESULTS Over a median follow-up time of 7 years, 74 of 103 treated patients (71.8%) experienced drug-free remission (incidence rate = 0.28/person-year [PY], 95% confidence interval [CI] 0.22-0.35/PY). Most patients (80/103, 77.7%) received cyclophosphamide therapy. Thirteen of the 74 patients (17.6%) had disease relapse after remission: 4 with ocular disease only, 4 with extraocular disease only, and 5 with both. The rate relapse of ocular MMP was 0.020/PY (95% CI 0.009-0.038/PY), and the rate of relapse of MMP at any site (ocular or extraocular site) was 0.029/PY (95% CI 0.015-0.050/PY). The use of cyclophosphamide was associated with a greater chance of remission (hazard ratio [HR] = 3.84, P < .0001) and a lower risk of relapse (HR = 0.32, P = .05) compared with other immunosuppressive drugs except for rituximab. Five patients experienced drug-free remission after rituximab therapy and none of them had relapse (median follow-up after remission = 3.6 years). When use of cyclophosphamide or rituximab was compared with all other treatments, the risk of MMP relapse at any site (HR = 0.17, P = .02) and of ocular MMP (HR = 0.11, P = .007) were significantly lower. CONCLUSIONS Rates of relapse of MMP after drug-free remission are low but not zero; therefore, monitoring of patients remains necessary. Relapses were not observed among those patients treated with rituximab who had remission; however, follow-up duration in those patients was shorter than the whole MMP cohort and the sample size was small.
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Sharon Y, Cui D, Akpek EK, Chu DS. Cicatrizing conjunctivitis as an uncommon manifestation of primary Sjögren's syndrome. Ocul Surf 2020; 19:38-42. [PMID: 33264685 DOI: 10.1016/j.jtos.2020.11.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/25/2020] [Accepted: 11/26/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE To report occurrence of cicatrizing conjunctivitis as an extraglandular ocular manifestation of primary Sjögren's syndrome (SS). METHODS Medical charts of all patients with SS evaluated at two tertiary ophthalmological referral centers were reviewed. Patients who demonstrated clinical findings of cicatrizing conjunctivitis were included in this review. Patient and disease-related data including ocular complications, therapies and outcomes were collected. RESULTS Eight patients with a diagnosisis of SS were noted to have cicatrizing conjunctivitis findings over a period of 11 years (between 2009 and 2020). Mean age of patients was 79. All patients had a negative immunoreactant deposition in conjunctival biopsy. Mean follow-up time was 6 years (range, 18-197 months). Three patients had progression of conjunctival scarring. Worsening of vision occurred in 4 patients due to corneal complications, including ulceration, perforation and scarring. CONCLUSIONS SS is an under-recognized etiology of severe progressive cicatrizing conjunctivitis that can lead to ocular morbidity and loss of vision without appropriate management.
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Affiliation(s)
- Yael Sharon
- Department of Ophthalmology, Rabin Medical Center, Petah-Tikva, Israel; Metropolitan Eye Research and Surgery Institute, Palisades Park, NJ, USA.
| | - David Cui
- Ocular Surface Diseases and Dry Eye Clinic, Division of Cornea and External Diseases, The Wilmer Eye Institute, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Esen K Akpek
- Ocular Surface Diseases and Dry Eye Clinic, Division of Cornea and External Diseases, The Wilmer Eye Institute, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David S Chu
- Metropolitan Eye Research and Surgery Institute, Palisades Park, NJ, USA; Institute of Ophthalmology and Visual Science, New Jersey Medical School, Rutgers University, Newark, NJ, USA
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7
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Corral-Magaña O, Morgado-Carrasco D, Fustà-Novell X, Iranzo P. Penfigoide de mucosas: cuando la mucosa oral puede ser la clave para el diagnóstico de una estenosis esofágica de origen desconocido. ACTAS DERMO-SIFILIOGRAFICAS 2020; 111:792-794. [DOI: 10.1016/j.ad.2019.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 03/05/2019] [Accepted: 04/20/2019] [Indexed: 11/25/2022] Open
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8
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Mucous membrane pemphigoid: When the mouth can give a clue to the diagnosis of an esophageal stenosis of unknown origin. ACTAS DERMO-SIFILIOGRAFICAS 2020. [DOI: 10.1016/j.adengl.2020.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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9
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Transmucosal Boston Keratoprosthesis Type I in a Patient With Advanced Ocular Cicatricial Pemphigoid. Cornea 2020; 39:1563-1565. [PMID: 32881715 DOI: 10.1097/ico.0000000000002413] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To describe a novel surgical technique using the Boston Keratoprosthesis (KPro) type I in a patient with advanced ocular cicatricial pemphigoid (OCP) using oral mucosa for covering the prosthesis. METHODS We present the case of an 85-year-old man previously diagnosed with type 2 diabetes and advanced OCP nonresponsive to immunosuppressive treatment, whose best-corrected visual acuity was light perception and projection in both eyes. After examination, Boston KPro type I in the right eye was contemplated because osteo-odonto KPro and Tibial bone KPro were not feasible because of the patient's osteoporosis and edentulism. Reconstruction of the ocular surface was first performed using oral mucosa to release the symblepharon and try to deep the fornices. Three months later, the oral mucosa was lifted, and the Boston KPro type I was implanted using the patient's own cornea. Then, a modification of the standard surgical technique was carried out, replacing the use of contact lens for covering the prosthesis with an oral mucosa graft with a central trephination as an alternative option in fornix foreshortening cases. RESULTS After 11 months, visual acuity was stable to 0.2 decimal. No postoperative complications have been encountered, and prosthesis was in place. CONCLUSIONS The surgical technique of transmucosal Boston KPro type I may be considered a surgical alternative in patients with advanced OCP who present with severe fornix foreshortening, where osteo-odonto KPro or Tibial bone KPro cannot be performed due to osteoporosis or edentulism or when the Boston KPro type II is not readily available.
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10
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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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Chen E, Reynolds HH, Graham LV. Ocular cicatricial pemphigoid treated with intramuscular corticotropin injections. JAAD Case Rep 2020; 6:450-452. [PMID: 32382644 PMCID: PMC7200478 DOI: 10.1016/j.jdcr.2020.02.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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12
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Fung AT, Tran T, Lim LL, Samarawickrama C, Arnold J, Gillies M, Catt C, Mitchell L, Symons A, Buttery R, Cottee L, Tumuluri K, Beaumont P. Local delivery of corticosteroids in clinical ophthalmology: A review. Clin Exp Ophthalmol 2020; 48:366-401. [PMID: 31860766 PMCID: PMC7187156 DOI: 10.1111/ceo.13702] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 11/21/2019] [Accepted: 12/09/2019] [Indexed: 12/22/2022]
Abstract
Locally administered steroids have a long history in ophthalmology for the treatment of inflammatory conditions. Anterior segment conditions tend to be treated with topical steroids whilst posterior segment conditions generally require periocular, intravitreal or systemic administration for penetration. Over recent decades, the clinical applications of periocular steroid delivery have expanded to a wide range of conditions including macular oedema from retino-vascular conditions. Formulations have been developed with the aim to provide practical, targeted, longer-term and more efficacious therapy whilst minimizing side effects. Herein, we provide a comprehensive overview of the types of periocular steroid delivery, their clinical applications in ophthalmology and their side effects.
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Affiliation(s)
- Adrian T. Fung
- Westmead Clinical SchoolDiscipline of Clinical Ophthalmology and Eye Health, University of Sydney, Sydney, New South WalesAustralia
- Department of Ophthalmology, Faculty of Medicine and Health SciencesMacquarie UniversitySydneyNew South WalesAustralia
- Save Sight InstituteCentral Clinical School, Discipline of Clinical Ophthalmology and Eye Health, University of Sydney, Sydney, New South WalesAustralia
| | - Tuan Tran
- Save Sight InstituteCentral Clinical School, Discipline of Clinical Ophthalmology and Eye Health, University of Sydney, Sydney, New South WalesAustralia
| | - Lyndell L. Lim
- Royal Victorian Eye and Ear HospitalMelbourneVictoriaAustralia
- Centre for Eye Research AustraliaMelbourneVictoriaAustralia
- University of MelbourneMelbourneVictoriaAustralia
| | - Chameen Samarawickrama
- Westmead Clinical SchoolDiscipline of Clinical Ophthalmology and Eye Health, University of Sydney, Sydney, New South WalesAustralia
- Save Sight InstituteCentral Clinical School, Discipline of Clinical Ophthalmology and Eye Health, University of Sydney, Sydney, New South WalesAustralia
- Liverpool Clinical School, Faculty of MedicineUniversity of New South WalesSydneyNew South WalesAustralia
| | | | - Mark Gillies
- Save Sight InstituteCentral Clinical School, Discipline of Clinical Ophthalmology and Eye Health, University of Sydney, Sydney, New South WalesAustralia
| | - Caroline Catt
- Save Sight InstituteCentral Clinical School, Discipline of Clinical Ophthalmology and Eye Health, University of Sydney, Sydney, New South WalesAustralia
- Children's Hospital WestmeadWestmeadNew South WalesAustralia
| | | | | | | | - Lisa Cottee
- Eye Doctors Mona ValeSydneyNew South WalesAustralia
| | - Krishna Tumuluri
- Westmead Clinical SchoolDiscipline of Clinical Ophthalmology and Eye Health, University of Sydney, Sydney, New South WalesAustralia
- Department of Ophthalmology, Faculty of Medicine and Health SciencesMacquarie UniversitySydneyNew South WalesAustralia
- Save Sight InstituteCentral Clinical School, Discipline of Clinical Ophthalmology and Eye Health, University of Sydney, Sydney, New South WalesAustralia
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Ormaechea MS, Hassan M, Onghanseng N, Park JH, Mahajan S, Al-Kirwi KY, Uludag G, Halim MS, Schlaen A, Sepah YJ, Do DV, Nguyen QD. Safety of systemic therapy for noninfectious uveitis. Expert Opin Drug Saf 2019; 18:1219-1235. [PMID: 31801415 DOI: 10.1080/14740338.2019.1692810] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Introduction: The treatment strategies for noninfectious uveitis (NIU) aim to achieve disease remission, prevention of recurrences, and preserving vision, while minimizing the side effects associated with the therapies used.Areas covered: The index review aims to provide a detailed overview of the adverse events and safety parameters associated with the systemic therapies for the management of the NIU.Expert opinion: Despite being the cornerstone of management of acute cases of NIU, long-term corticosteroid use is associated with multi-system side effects, requiring the use of steroid-sparing agents. Adalimumab was recently approved by the FDA for the management of NIU based on the results of VISUAL studies. Similarly, newer drugs targeting various aspects of the inflammatory cascade are being developed. However, until we completely understand the molecular pathways of the inflammatory diseases, the therapeutic profile of these newer agents needs to be broad enough to suppress inflammatory cascade and narrow enough to spare normal cellular processes. Another strategy that has shown some potential in decreasing the systemic side effects is to provide local drug delivery. Therefore, the future of management of NIU is very bright with many novel therapeutic agents and strategies of drug delivery on the horizon.
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Affiliation(s)
- Maria Soledad Ormaechea
- Department of Ophthalmology, Hospital Universitario Austral, Buenos Aires, Argentina.,Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Muhammad Hassan
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Neil Onghanseng
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Jung Hyun Park
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA.,Department of Ophthalmology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | | | - Khalid Yusuf Al-Kirwi
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA.,Department of Ophthalmology, Imamein Khadhimein Medical City University Hospital, Baghdad, Iraq
| | - Gunay Uludag
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | | | - Ariel Schlaen
- Department of Ophthalmology, Hospital Universitario Austral, Buenos Aires, Argentina
| | - Yasir J Sepah
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Diana V Do
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
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Clinical Characteristics and Outcomes of Ocular Cicatricial Pemphigoid: A Cohort Study and Literature Review. Cornea 2019; 38:1406-1411. [PMID: 31356420 DOI: 10.1097/ico.0000000000002080] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Ocular cicatricial pemphigoid (OCP) is a rare systemic autoimmune disease and a potentially blinding subepithelial blistering disorder. The purpose of this study was to describe the clinical spectrum of the disease and to assess the efficacy and safety of immunosuppressive agents in a cohort of patients with OCP. METHODS We conducted a monocentric retrospective cross-sectional cohort study of all unselected consecutive patients diagnosed with progressive OCP. Ocular and extra ophthalmological involvement as well as histological findings were gathered. Other outcomes were exposures to immunosuppressive agents defined by the use of a particular treatment. For each exposure, success in controlling ocular inflammation was graded as a complete response, response, or failure. Relapses and adverse events (AE) were also recorded. RESULTS Seventeen patients (34 affected eyes), 35% of whom were women, were included, with an age at diagnosis of 75 ± 11 years. Corneal involvement was diagnosed in 30 of 34 eyes, and 22 of 34 eyes had progressive fibrosing conjunctival involvement. Sixty-two exposures to immunosuppressive agents or biologics were recorded: dapsone, n = 26; mycophenolate mofetil, n = 6; azathioprine, n = 4; cyclophosphamide, n = 10; rituximab, n = 14; and intravenous immunoglobulin, n = 2. Rates of response and of complete response achievement during the first 3 months were 84% and 45%, respectively. Response rates were 100%, 100%, 86%, 85%, and 80% for intravenous immunoglobulin, mycophenolate mofetil, rituximab, dapsone, and cyclophosphamide, respectively. Thirteen percent of those drugs were discontinued because of an adverse event in 4 patients. CONCLUSIONS This study describes the efficacy of immunosuppressants or biologics with an acceptable safety profile for OCP.
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Herwig-Carl MC, Loeffler KU. [Differential diagnoses of dry eye syndrome and blepharitis]. Ophthalmologe 2019; 115:107-113. [PMID: 29270640 DOI: 10.1007/s00347-017-0631-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Dry eye syndrome and blepharitis are diseases that affect many patients from different age groups. There is not only a great variability in the manifestation between patients but they also show a mixture of associated symptoms. Thus, very different ocular and systemic diseases have to be included in the differential diagnosis of a primary dry eye disorder. This article provides a structured overview of these differential diagnoses and their characteristic appearance as well as the pitfalls and therapeutic options.
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Affiliation(s)
- M C Herwig-Carl
- Sektion Ophthalmopathologie, Universitäts-Augenklinik Bonn, Ernst-Abbe-Str. 2, 53127, Bonn, Deutschland.
| | - K U Loeffler
- Sektion Ophthalmopathologie, Universitäts-Augenklinik Bonn, Ernst-Abbe-Str. 2, 53127, Bonn, Deutschland
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Buonavoglia A, Leone P, Dammacco R, Di Lernia G, Petruzzi M, Bonamonte D, Vacca A, Racanelli V, Dammacco F. Pemphigus and mucous membrane pemphigoid: An update from diagnosis to therapy. Autoimmun Rev 2019; 18:349-358. [PMID: 30738958 DOI: 10.1016/j.autrev.2019.02.005] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 11/02/2018] [Indexed: 12/23/2022]
Abstract
Pemphigus diseases (PDs) and mucous membrane pemphigoid (MMP) are a group of immune-mediated mucocutaneous disorders clinically characterized by the formation of blisters, erosions and ulcers. The skin and mucous membranes are predominantly affected, with the oropharyngeal mucosa as the initially involved site. Ocular involvement is also a frequent feature of these diseases. Because of the considerable overlap in their clinical presentations, the diagnosis of PDs vs. MMP can be challenging. A recognition of their specific immunological and histopathologic features is crucial in the differential diagnosis. Treatment modalities include systemically administered corticosteroids, steroid-sparing immunosuppressive agents, and biologic therapies (rituximab, intravenous immunoglobulins, and anti-tumor necrosis factor agents). Topical, oral, conjunctival, or intralesional corticosteroids as well as anti-inflammatory drugs and antibiotics are prescribed as needed.
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Affiliation(s)
- Alessio Buonavoglia
- Department of Biomedical Sciences and Human Oncology, Unit of Internal Medicine "Guido Baccelli", University of Bari Medical School, Bari, Italy
| | - Patrizia Leone
- Department of Biomedical Sciences and Human Oncology, Unit of Internal Medicine "Guido Baccelli", University of Bari Medical School, Bari, Italy
| | - Rosanna Dammacco
- Department of Ophthalmology and Neuroscience, University of Bari Medical School, Bari, Italy
| | - Giuseppe Di Lernia
- Department of Biomedical Sciences and Human Oncology, Unit of Internal Medicine "Guido Baccelli", University of Bari Medical School, Bari, Italy
| | - Massimo Petruzzi
- Interdisciplinary Department of Medicine, Section of Dentistry, University of Bari Medical School, Bari, Italy
| | - Domenico Bonamonte
- Department of Biomedical Sciences and Human Oncology, Dermatology Unit, University of Bari Medical School, Bari, Italy
| | - Angelo Vacca
- Department of Biomedical Sciences and Human Oncology, Unit of Internal Medicine "Guido Baccelli", University of Bari Medical School, Bari, Italy
| | - Vito Racanelli
- Department of Biomedical Sciences and Human Oncology, Unit of Internal Medicine "Guido Baccelli", University of Bari Medical School, Bari, Italy.
| | - Franco Dammacco
- Department of Biomedical Sciences and Human Oncology, Unit of Internal Medicine "Guido Baccelli", University of Bari Medical School, Bari, Italy.
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Shi Y, Xie C, He Y, Liu H, Zhu B, Zhu J. Efficacy and adverse reactions of methotrexate in the treatment of ocular cicatricial pemphigoid: A case series study. Medicine (Baltimore) 2018; 97:e12338. [PMID: 30235689 PMCID: PMC6160102 DOI: 10.1097/md.0000000000012338] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The application of methotrexate (MTX) in the treatment of autoimmune diseases has been gradually increasing, but reports of MTX treatment for advanced ocular cicatricial pemphigoid (OCP) are extremely rare. This study investigated the efficacy and adverse reactions of low-dose MTX in patients with OCP.This was a retrospective, noncontrolled, case series study. Eleven patients diagnosed with advanced OCP (4 cases in stage III and 7 cases in stage IV) were enrolled. Treatment by oral administration of MTX (7.5 ± 2.5 mg) alone was performed. Visual acuity of the patients, conjunctival inflammation, cicatrization, ocular surface keratinization, and toxic side effects of drugs were evaluated.All patients enrolled in this study were females aged 32 to 83 years. Patients were followed up for 4 to 33 months. Low-dose MTX improved visual acuity of 3 cases (6 eyes, 27.3%). Conjunctival inflammation of 5 patients (10 eyes) rested after treatment, and conjunctival inflammation of 3 cases (6 eyes, 27.3%) was decreased with an effective rate of 72.7%. Cicatrices of 8 cases (15 eyes) showed degeneration after treatment with an effective rate of 71.4% (15/21). Ocular surface keratinization receded in 4 cases with an effective rate of 66.7%. None of the patients discontinued the treatment due to severe toxic side effects. All patients tolerated mild drug-induced gastrointestinal reactions. Three patients terminated the treatment in advance after 4 to 6 months due to no improvement in the disease condition.Observation of clinical efficacy and safety findings demonstrated that low-dose MTX can be used to treat patients with advanced OCP.
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Affiliation(s)
- Yewen Shi
- Department of Otorhinolaryngology, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an
- Department of Ophthalmology, The Affiliated Guangren Hospital of Xi’an Jiaotong University
| | - Chen Xie
- The Fourth Clinical College, School of Medicine, Nanchang University, Nanchang
| | - Yuan He
- Department of Ophthalmology, The Second Affiliated Hospital of Xi’an Medicine University, Xi’an, China
| | - Huifeng Liu
- Department of Ophthalmology, The Second Affiliated Hospital of Xi’an Medicine University, Xi’an, China
| | - Binliang Zhu
- Department of Ophthalmology, The Second Affiliated Hospital of Xi’an Medicine University, Xi’an, China
| | - Jiang Zhu
- Department of Ophthalmology, The Affiliated Guangren Hospital of Xi’an Jiaotong University
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Abstract
PURPOSE To evaluate the presence of atopy in patients with ocular cicatricial pemphigoid (OCP). METHOD Patient encounters between August 2005 and November 2016 at the Massachusetts Eye Research and Surgery Institute (MERSI) were searched to identify those with biopsy-proven OCP who had concurrent evidence of atopy. RESULTS There were 230 patients with biopsy-proven OCP. Thirty-three of them were found to have clinical symptoms of atopy (asthma, hay fever, and eczema) and of these, 23 had evidence of atopy in their conjunctival biopsy specimens. All patients were administered immunomodulatory therapy for treatment of their OCP with 20 patients requiring additional antiallergy treatment to control residual atopic ocular symptoms. Among patients who used antiallergy medications, 80% showed improvement in residual symptoms. Rituximab and/or intravenous immunoglobulin is a preferred OCP medication for patients with OCP with some evidence of atopy. CONCLUSIONS Clinicians should consider the coexistence of atopy in patients with OCP, especially in those with persistent symptoms after initiation of immunomodulatory therapy.
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Hong GH, Khan IR, Shifera AS, Okeagu C, Thorne JE. Incidence and Clinical Characteristics of Ocular Involvement in Mucous Membrane Pemphigoid. Ocul Immunol Inflamm 2018; 27:821-825. [DOI: 10.1080/09273948.2018.1455879] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Gloria H. Hong
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Irfan R. Khan
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Amde Selassie Shifera
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Chinwenwa Okeagu
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jennifer E. Thorne
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Adrenocorticotropic hormone analogue as novel treatment regimen in ocular cicatricial pemphigoid. Am J Ophthalmol Case Rep 2018; 10:264-267. [PMID: 29780948 PMCID: PMC5956726 DOI: 10.1016/j.ajoc.2018.03.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 03/12/2018] [Accepted: 03/19/2018] [Indexed: 11/22/2022] Open
Abstract
Purpose To report the clinical outcome of a patient with ocular cicatricial pemphigoid, treated with adrenocorticotropic hormone gel. Observations A 75-year-old female with a biopsy proven ocular cicatricial pemphigoid (OCP) presented with bilateral conjunctival inflammation, fornix shortening, subepithelial fibrosis and corneal scarring. The patient was previously treated with topical steroids, topical cyclosporine and lubricating drops, and had undergone several amniotic membrane transplants due to recurrent corneal erosions. Once OCP diagnosis was established, the patient was started on oral corticosteroids (60 mg daily). In order to wean the patient off from systemic steroids, other immunomodulatory agents had been tried, including mycophenolate mofetil (1000 mg twice daily) and methotrexate (up to 25 mg weekly). However, none of these agents adequately controlled the ocular surface inflammation, and the patient experienced bilateral progressive cicatrization and corneal decompensation, as well as the development of side effects from the systemic corticosteroids, methotrexate and mycophenolate mofetil therapies. Treatment with twice weekly subcutaneous adrenocorticotropic hormone (ACTH) gel was initiated, along with tapering of systemic corticosteroids. During the 19 months treatment period, the patient demonstrated significant improvement in the ocular surface inflammation, visual acuity was stable and no significant adverse effects were observed. Systemic corticosteroids dosage was successfully reduced from 10 mg/day to none at last follow up. Conclusions and importance ACTH gel has shown to be an effective and safe treatment option for chronic, refractory and progressive ocular inflammatory disease. To the best of our knowledge, this is the first case report of a patient with OCP, treated successfully with ACTH gel. This case report may encourage ophthalmologists to employ ACTH gel in the management of OCP.
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Clinical Implications of Direct Immunofluorescence Findings in Patients With Ocular Mucous Membrane Pemphigoid. Am J Ophthalmol 2017; 183:48-55. [PMID: 28860044 DOI: 10.1016/j.ajo.2017.08.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 08/15/2017] [Accepted: 08/17/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE To examine the clinical implications of positive or negative direct immunofluorescence biopsies (DIF) in patients with clinically typical ocular mucous membrane pemphigoid (MMP). DESIGN Retrospective cohort study. METHODS The study population was patients with clinically typical ocular MMP disease with documented DIF results who were followed for at least 1 year at the Duke University multidisciplinary ocular MMP clinic. Data were collected by chart review and included patient demographics, clinical examination findings, and history of autoimmune disease and/or malignancy, as well as topical, systemic, and surgical treatments received. Main outcome measures included MMP Disease Area Index, Foster stages, proportion legally blind, duration of follow-up, and use of systemic immunosuppression and ocular procedures in treatment. RESULTS In multivariable analysis restricted to 55 patients, patients with negative and positive biopsies were similar in the outcome measures; however, positive-biopsy patients were more likely to be treated with systemic immunosuppression and were followed for longer at our clinic. Patients with isolated ocular disease were also more likely to have negative biopsies compared to those who also had extraocular disease. Patients who had conjunctival biopsies were more likely to have a negative direct immunofluorescence result than patients with biopsies from other sites. CONCLUSIONS We encourage clinicians and patients to consider treatment with systemic immunosuppression even in the absence of diagnosis confirmation by DIF. Furthermore, this study supports current standard of care to pursue a nonocular biopsy of normal-appearing, perilesional skin or oral mucosa when possible.
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Abstract
Autoimmune blistering diseases (AIBD) are a group of chronic diseases affecting the skin and mucous membranes, with different presentation, clinical course, histologic and immunopathologic findings, and different therapeutic approach. Blisters develop as a result of autoantibodies directed against distinct adhesion structures within desmosomes or within the basement membrane zone. The most common AIBD that develops in the elderly is bullous pemphigoid (previously also named "pemphigoid senilis"), but mature patients can also present with other AIBD as mucous membrane pemphigoid, epidermolysis bullosa acquisita, paraneoplastic pemphigus, pemphigus vulgaris, pemphigus foliaceus, linear IgA dermatosis, and dermatitis herpetiformis. There are no differences in treatment approach to mature patients with AIBD, but due to more common comorbidities, systemic therapy should be given with more caution and control, and due to distorted skin integrity in the aged skin, the safety concerns are increased with the long-term use of any topical medication.
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Affiliation(s)
- Ines Lakoš Jukić
- Department of Dermatovenereology, University Hospital Center Zagreb and University of Zagreb School of Medicine, Zagreb, Croatia
| | - Sandra Jerković Gulin
- Department of Infectious Diseases and Dermatovenereology, General Hospital Šibenik, Šibenik, Croatia
| | - Branka Marinović
- Department of Dermatovenereology, University Hospital Center Zagreb and University of Zagreb School of Medicine, Zagreb, Croatia.
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