Challenges in the management of pediatric blepharokeratoconjunctivis / ocular rosacea

Pediatric blepharokeratoconjunctivitis: A challenging ocular surface disease

Pediatric blepharokeratoconjunctivitis (PBKC) is a chronic and recurrent ocular surface inflammatory disorder affecting children in early life. It is frequently under- or late- diagnosed, representing a potential cause of severe visual morbidity worldwide. An expert panel consensus recently agreed on its definition and proposed diagnostic criteria for suspected and definitive PBKC to reduce confusion and avoid varied terminology previously used in the literature, improving early and precise diagnosis. Previous evidence has pointed to the role of the adaptive immune system in recognizing and handling antigenic eyelid bacterial products, particularly from the cell wall, and the direct toxic and inflammatory effects of their cytolytic exotoxins on the ocular surface. PBKC is a frequent referral in pediatric and cornea clinics characterized by a history of recurrent chalazia, blepharitis, meibomian gland dysfunction, conjunctival hyperemia, phlyctenules formation, and corneal infiltrates with vascularization and scarring. The latter is a major cause of significant visual loss and amblyopia. Current treatment strategies aim to control inflammation on the ocular surface, halt disease progression, and avoid corneal involvement. Further research on pathogenic mechanisms will shed light on novel potential therapeutic strategies. Awareness of PBKC should enhance early diagnosis, prompt adequate treatment, and improve outcomes. We compile current evidence on epidemiology, pathophysiology, clinical spectrum of disease, diagnostic criteria, and management strategies for PBKC.

Ocular Rosacea: An Updated Review

PURPOSE

Ocular rosacea is a chronic inflammatory disorder affecting the ocular surface, often associated with cutaneous rosacea. This review aims to explore its pathogenesis, treatment approaches, and future directions for management.

METHODS

A review of current literature on the pathophysiology, clinical features, and treatment strategies of ocular rosacea in adults and children (pediatric blepharokeratoconjunctivitis) was conducted. Emerging research on immune dysregulation, microbiome alterations, and potential therapeutic targets was analyzed.

RESULTS

Ocular rosacea involves dysregulation of the immune and neurovascular systems, with toll-like receptor activation and complement system involvement leading to chronic ocular surface inflammation. Alterations in the ocular microbiome have been implicated in disease progression. Treatment strategies emphasize a stepwise approach, incorporating ocular and skin hygiene, lifestyle modifications, and pharmacological interventions. Recent advancements in understanding the disease mechanisms have led to the exploration of targeted therapies, including biologics and small-molecule inhibitors.

CONCLUSIONS

Ocular rosacea remains challenging to diagnose and treat, particularly in children (pediatric blepharokeratoconjunctivitis), often leading to delayed intervention and poor outcomes. A multidisciplinary approach, including new therapeutic options, holds promise for improving patient care. Further research into the genetic and molecular basis of ocular rosacea may enable more personalized treatments.

Quantum Molecular Resonance Electrotherapy for the Treatment of Pediatric Ocular Rosacea

PURPOSE

The purpose of this study was to report the outcomes of quantum molecular resonance (QMR) electrotherapy in the management of refractory pediatric ocular rosacea.

METHODS

This is a retrospective case series on 3 female pediatric patients (ages 12, 15, 14 years) with ocular rosacea. Two patients presented with corneal stromal neovascularization and punctate epithelial erosions while 1 patient presented with corneal scarring and paracentral stromal thinning. After failing conservative management, the patients were treated with 4 consecutive QMR electrotherapy sessions with the intensity set at 5 corresponding on average to a power of 12 W, with 60 V voltage and 200 mA current. Informed consent was obtained for off-label use. Patients were assessed for changes in vision, foreign body sensation, tearing, photophobia, and redness at each visit to determine symptomatic improvement. Outcome measures include best-corrected visual acuity, use of supplemental therapies (eg topical steroids) for symptom relief, extent of corneal neovascularization via serial slitlamp photography, and corneal scar remodeling via high resolution anterior segment optical coherence tomography.

RESULTS

Two of the 3 patients experienced improvement in visual acuity after QMR electrotherapy. Corneal neovascularization and scarring regressed significantly in all 3 patients. Two months post-QMR electrotherapy, corneal remodeling was evident on optical coherence tomography in 2 patients. All 3 patients were able to discontinue topical immunosuppressants and remain symptom-free at 1.5 years of follow-up.

CONCLUSIONS

QMR electrotherapy is a promising alternative in the treatment of refractory ocular rosacea in childhood and puberty, and it may potentiate corneal remodeling.

Long-term, Low-Dose Oral Azithromycin Treatment for Chronic Severe Bilateral Blepharokeratoconjunctivitis in Pediatric Patients

PURPOSE

To evaluate the efficacy and safety of oral azithromycin treatment combined with topical antibiotic and anti-inflammatory agents in pediatric patients with chronic severe bilateral blepharokeratoconjunctivitis.

METHODS

Patients younger than 14 years with chronic and severe bilateral blepharokeratoconjunctivitis were reviewed retrospectively. Consecutive patients receiving oral azithromycin treatment were included. All patients received oral azithromycin (5 mg/kg/single dose daily) for at least 4 weeks combined with topical antibiotic and anti-inflammatory agents. Before and after the treatment, clinical symptoms were noted, and corneal and conjunctival fluorescein staining and corneal neovascularization were graded. Meibomian gland secretion and meibomian gland plugging were also assessed. All patients completed at least 3 months of follow-up after completion of the oral azithromycin treatment. Patients' clinical data at the time of diagnosis and last follow-up visit were statistically compared.

RESULTS

Twenty-nine children (58 eyes, mean age of 6.51 years) were included. The mean time of oral azithromycin use was 5.87 weeks (range: 4 to 10 weeks). Clinical symptoms and signs and visual acuity were significantly improved after treatment. The mean fluorescein staining and corneal neovascularization grades and meibomian gland secretion and meibomian gland plugging scores also improved after treatment (P < .001). Eyelid distortion or fornix shortening was not observed. At the last follow-up visit, all patients were stable with treatment only with daily eyelid hygiene, topical cyclosporine, and artificial tears.

CONCLUSIONS

Long-term, low-dose oral azithromycin combined with topical antibiotic and anti-inflammatory agents is an effective treatment option for pediatric patients with chronic severe bilateral blepharokeratoconjunctivitis. [J Pediatr Ophthalmol Strabismus. 2024;61(5):358-364.].

Definition and Diagnostic Criteria for Pediatric Blepharokeratoconjunctivitis

Importance

Pediatric blepharokeratoconjunctivitis (PBKC) is a chronic, sight-threatening inflammatory ocular surface disease. Due to the lack of unified terminology and diagnostic criteria, nonspecific symptoms and signs, and the challenge of differentiation from similar ocular surface disorders, PBKC may be frequently unrecognized or diagnosed late.

Objective

To establish a consensus on the nomenclature, definition, and diagnostic criteria of PBKC.

Design, Setting, and Participants

This quality improvement study used expert panel and agreement applying the non-RAND modified Delphi method and open discussions to identify unified nomenclature, definition, and definitive diagnostic criteria for PBKC. The study was conducted between September 1, 2021, and August 14, 2022. Consensus activities were carried out through electronic surveys via email and online virtual meetings.

Results

Of 16 expert international panelists (pediatric ophthalmologists or cornea and external diseases specialists) chosen by specific inclusion criteria, including their contribution to scientific leadership and research in PBKC, 14 (87.5%) participated in the consensus. The name proposed was "pediatric blepharokeratoconjunctivitis," and the agreed-on definition was "Pediatric blepharokeratoconjunctivitis is a frequently underdiagnosed, sight-threatening, chronic, and recurrent inflammatory eyelid margin disease associated with ocular surface involvement affecting children and adolescents. Its clinical spectrum includes chronic blepharitis, meibomitis, conjunctivitis, and corneal involvement ranging from superficial punctate keratitis to corneal infiltrates with vascularization and scarring." The diagnostic criteria included 1 or more suggestive symptoms accompanied by clinical signs from 3 anatomical regions: the eyelid margin, conjunctiva, and cornea. For PBKC suspect, the same criteria were included except for corneal involvement.

Conclusions and Relevance

The agreements on the name, definition, and proposed diagnostic criteria of PBKC may help ophthalmologists avoid diagnostic confusion and recognize the disease early to establish adequate therapy and avoid sight-threatening complications. The diagnostic criteria rely on published evidence, analysis of simulated clinical cases, and the expert panel's clinical experience, requiring further validation with real patient data analysis.

Topical cyclosporine A 1 mg/ml for atopic keratoconjunctivitis: Five-year case series of 99 children and young people

PURPOSE

To explore the effects of cyclosporine A (CsA) in the management of atopic keratoconjunctivitis (AKC).

METHODS

Open single-group interventional consecutive cohort study (case series) at a single eye care facility in the UK. We reviewed the electronic patient records of 99 children and young people (CYP) aged 3.4-18 years with AKC treated with topical CsA 1 mg/ml. Main outcome measures were number of prescriptions and hospital clinic visits over 12 months before and after the start of CsA and the proportion of CYP affected by adverse effects.

RESULTS

The median number of inflammatory episodes requiring treatment with topical corticosteroids (tCS) fell from 3 (interquartile range IQR 1-4) during the 12 months prior to CsA to 1 (IQR 0-3) during the 12 months after, excluding tCS prescriptions with the first CsA prescription (Wilcoxon signed ranks test, 2 tailed, p < 0.01). In the 12-month period following initiation of CsA 1 mg/ml with concomitant prescription of tCS (n = 66), daily dosage of steroids was reduced in 62 CYP (93.9%), and they were discontinued in 43 (65.2%). The median number of hospital visits fell from 4 (IQR 3-6) to 3 (IQR 2-5; Wilcoxon p < 0.01). Adverse events leading to discontinuation of CsA were stinging (instillation site pain; 9/99, 9%) and a transient skin rash (1/99, 1%).

CONCLUSIONS

Off-label use of commercial preparations of CsA 1 mg/ml significantly reduces the need for concomitant topical corticosteroids and hospital clinic visits in CYP with AKC. Stinging and skin rash can lead to discontinuation.

Steroid-sparing effect of ciclosporin A 1 mg/mL: 5-year case series of 107 children and young people with vernal keratoconjunctivitis

Background/aims

To explore the steroid-sparing and other therapeutic effects of ciclosporin A (CsA) 1 mg/mL in the management of vernal keratoconjunctivitis (VKC).

Methods

Open retrospective single-group interventional consecutive cohort study (case series) of 107 children and young people (CYP) age 4.4–18 years with severe and/or recurrent VKC who were prescribed CsA 1 mg/mL between November 2015 and May 2021 at one institution. Review of electronic patient records, noting clinical indication for prescribing CsA 1 mg/mL, dosage prescribed at initiation and follow-up, impact on steroid usage before and after commencing CsA as well as adverse events and indications for discontinuation of treatment.

Results

The median number of inflammatory episodes requiring treatment with topical corticosteroids fell from 3 (IQR 2–4) during the 12 months prior to CsA 1 mg/mL to 1 (IQR 0–3) during the 12 months after, excluding steroid prescriptions with the first CsA 1 mg/mL prescription (Wilcoxon signed ranks test, two tailed, p<0.01). In the 12-month period following initiation of CsA 1 mg/mL with concomitant prescription of topical corticosteroids (n=82), daily dosage of steroids was reduced in 79 (96.3%) and discontinued in 67 (81.7%). The median number of hospital clinic visits fell from 4 (IQR 3–5) to 3 (IQR 2–5) (Wilcoxon p<0.01). Adverse events leading to discontinuation of CsA 1 mg/mL within 12 months of starting included stinging (instillation site pain) (6/107, 5.6%) and skinrash (1/107, 0.9%).

Conclusion

Commercial preparations of CsA 1 mg/mL, licensed for severe VKC in CYP, significantly reduce the need for concomitant topical corticosteroids and hospital clinic visits. Adverse events which may lead to discontinuation are stinging and skin rash.

Practical use and prescription of ocular medications in children and infants

Optometrists in Australia employ ophthalmic medicines in their paediatric practice to assist clinical diagnosis and to treat ocular conditions. Prior to employing ocular medicines or initiating treatment, it is important to consider the risks versus benefits of ophthalmic medicines and determine the minimum dose required to safely achieve a diagnostic or therapeutic benefit. Instilling drops in infants and young children may require techniques that do not depend on full cooperation, particularly to maintain appropriate dosing and limit the rate of elimination from the eye. Diagnostic cycloplegic agents are highly recommended for the accurate determination of refractive error in infants and young children. Topical atropine is commonly prescribed in paediatric optometry practice in highly variable concentrations. 1% atropine eye drops are used for pharmacological penalisation in management of amblyopia, and, increasingly, low concentration (< 0.1%) atropine is used to manage the progression of childhood myopia. Doses of topical ocular medicines to treat inflammation, infection or glaucoma are generally identical to those use in adults; however, there is potential for increased ocular and systemic side effects with certain medications. It is, therefore, timely to present, summarise and comment on the use of ophthalmic diagnostic and therapeutic agents in children and reference where practitioners can look for more detailed information. The perspective is set in the Australian context of a collaborative approach between paediatric optometry and ophthalmology eye care practitioners for delivery of best practice care in infants and young children. Inclusion of the more complex spectrum of paediatric eye disease in a tertiary ophthalmological setting is provided to build practitioner knowledge of treatment regimens their patients may be using, even though management of these conditions lies outside their scope of practice.

Ocular Surface Disease in a PICU: Incidence and Outcomes With a Dynamic Eye Care Protocol

OBJECTIVES

Sedated intensive care patients have impaired ocular protective mechanisms putting them at risk for ocular surface disease with potential vision loss. Historically, routine eye care has been limited to critically ill patients receiving neuromuscular blockade. The aim of this project was to determine the occurrence rate of ocular surface disease in sedated and ventilated children, identify risk factors, and determine the progression of injury with routine eye care.

DESIGN

Prospective cohort study.

SETTING

A tertiary care medical-surgical PICU.

PATIENTS

All intubated patients admitted from May 2015 to December 2016.

INTERVENTIONS

Staff education regarding corneal examination with fluorescein, and routine eye care as per a PICU eye care protocol.

MEASUREMENTS AND MAIN RESULTS

We evaluated 479 patients (1,242 corneal exams) and found that 15% had ocular surface disease at admission to the PICU: keratopathy 62, abrasion 16. The highest incidence was in trauma patients (39.0%) and those intubated in the emergency department (22.2%) or prehospital setting (42.9%). Of the 245 patients with multiple ocular assessments, 32.2% displayed ocular surface disease at some point during their hospitalization: keratopathy 73, abrasion 24. Ourprotocol dictated increased frequency of eye care if ocular surface disease worsened. As a result, the overall incidence of ocular surface disease decreased to 8.6% by the last examination (keratopathy 19, mild abrasion 2), but more severe ocular abnormalities such as corneal infiltrates, ulcers, or scarring were not observed. Based on multivariate analysis, clinical factors associated with increased risk of ocular surface disease included primary diagnosis, and lagophthalmos (incomplete eyelid closure).

CONCLUSIONS

Ocular surface disease is an under-recognized process in critically ill pediatric patients. A standardized and dynamic protocol may improve corneal health, which in turn may reduce injury, pain, infection, and long-term vision loss.

Meibography and corneal volume optical coherence tomography to quantify damage to ocular structures in children with blepharokeratoconjunctivitis

PURPOSE

To evaluate non-contact infrared meibography and anterior segment optical coherence tomography (AS-OCT) to detect meibomian gland (MG) and corneal changes in children with blepharokeratoconjunctivitis (BKC).

METHODS

We acquired infrared meibography images of upper and lower lids and AS-OCT corneal scans. One masked observer graded meiboscore, full/partial MG dropout, and measured total corneal volume and differential corneal volume per quadrant and central corneal thickness (CCT).

RESULTS

We enrolled 63 children, 31 with BKC and 32 without ocular surface inflammation; median (interquartile range) age BKC 10.6 (7.2-13.9) years, healthy volunteers (HV) 11.4 (9.5-13.8) years. Likert scale scores for meibography and OCT indicate no to low discomfort. Meiboscores for upper and lower lids as well as the total meiboscore were significantly higher in children with BKC than in HV. Subscores for full and partial MG dropout were also significantly higher in children with BKC than in healthy volunteers. There was no statistically significant difference between upper and lower lid for meiboscore nor full/partial MG dropout scores. The corneal volume in the superior quadrant was significantly higher in children with BKC than in HV, whereas the corneal volume in the nasal and inferior quadrants was significantly lower.

CONCLUSIONS

Non-contact imaging technologies objectively demonstrate damage to meibomian glands and changes in corneal volume secondary to BKC. The tests are well tolerated by children with mild/moderate ocular surface inflammation and can detect changes without the requirement for routine eversion of the upper lid. These parameters may be useful both for clinical follow-up and clinical trials.

Medical Management of Blepharokeratoconjunctivitis in Children: A Delphi Consensus

PURPOSE

To describe a pragmatic approach to the medical management of blepharokeratoconjunctivitis in children, based on published evidence and clinical experience.

METHODS

The authors used the Delphi consensus method to explore the preferred management patterns of four senior clinicians at one institution to reach agreement on indications and dosage schedules for commonly used treatments. Four iterations were created, with electronic questionnaires distributed via an online survey platform. Initial questions were based on recent systematic reviews and clinical experience. After each round, a facilitator summarized the responses and fed these back to the expert participants, together with an invitation to complete the next round of questions.

RESULTS

Typical and specific eyelid, corneal, and conjunctival disease features influenced management decisions, and treatments were targeted toward specific findings in these tissues rather than to overall disease severity. Active keratitis was considered the main indication for high potency steroids, systemic antibiotics, and possibly systemic immunomodulators. Other indications for systemic antibiotics were chronic active blepharitis and recurrent troublesome chalazia. Oral antibiotics were used for their anti-inflammatory and antimicrobial properties. There was little agreement on the role of dietary modification, topical lubricants, and preference for oral or topical antibiotics.

CONCLUSIONS

Detailed clinical assessment of eyelids and ocular surface allows targeted treatment. Research is needed to clarify disease mechanisms and to optimize treatment strategies. [J Pediatr Ophthalmol Strabismus. 2017;54(3):156-162.].