Successful nonsurgical management of corneal perforation in a patient with autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy

Limbal stem cell defficiency associated with primary adrenocortical insufficiency

Objective: To report a female patient with bilateral limbal stem cell deficiency (LSCD) due to primary adrenocortical insufficiency (PAI).

Methods: Case report

Results: A 40-year-old female patient had blurry vision, foreign body sensation, tearing, and photophobia for several years. On examination, corneal epithelial haze, surface irregularity, and superficial neovascularization were observed. There was a dull and irregular reflex from the conjunctivalized corneal surface. Medical history revealed that she had a diagnosis of PAI for 11 years and received hormone replacement (fludrocortisone acetate) therapy. With the clinical presentation and examination, the diagnosis was compatible with LSCD. Frequent ocular lubricant and topical steroid drops were initially started and topical cyclosporine treatment was planned for the long term. After 3 weeks, there was no corneal superficial neovascularization and epithelial haze, peripheral stromal haze was still observed.

Conclusion: LSCD may rarely be associated with PAI. In patients with LSCD, systemic evaluation should be made to rule out PAI.

Topical tacrolimus solution in autoimmune polyglandular syndrome-1-associated keratitis

PURPOSE

To evaluate the efficacy of topical tacrloimus eye drops in the treatment of keratitis associated with autoimmune polyglandular syndrome (APS)-1.

METHODS

This is a retrospective review of 10 patients with APS-1. The patients were treated with topical tacrolimus 0.01% solution at The Eye Center, between 1 March 2012 and 30 April 2016. The outcome measures included improvement in visual acuity, photophobia and keratitis following treatment. Clinical assessment was carried out before, during and on the last visit following initiation of therapy.

RESULTS

A total of 10 patients were included. There were five male and five female patients. The mean age was 11 years with age range of 3-42 years. The mean duration of treatment with topical tacrolimus was 26 months (range 8-46 months). There was improvement of photophobia in 7 out of 10 patients following therapy with topical tacrolimus. In three patients, the photophobia was persistent. There was no clinically detectable improvement in the severity of keratitis in all patients. The mean best corrected visual acuity was 0.1 before and following therapy.

CONCLUSION

Topical tacrolimus is effective in reducing the photophobia in patients with APS-1-associated keratitis, but showed no effects on the severity of keratitis.

Spontaneous T cell mediated keratoconjunctivitis in Aire-deficient mice

BACKGROUND/AIMS

Patients with autoimmune polyendocrinopathy-candiasis-ectodermal dystrophy (APECED) develop severe keratoconjunctivitis, corneal scarring and visual loss, but the precise pathogenesis is unknown. This study evaluated the ocular surface immune cell environment, conjunctival goblet cell density and response to desiccating environmental stress of the autoimmune regulatory (Aire) gene knockout murine model of APECED.

METHODS

Aire-deficient and wild type (WT) mice were subjected to desiccating stress from a drafty, low-humidity environment and pharmacological inhibition of tear secretion for 5 days. Immune cell populations (CD4(+), CD8(+), CD11b(+), CD45(+)) and goblet cell density were measured in ocular surface tissues and meibomian glands, and compared with baseline values.

RESULTS

Greater CD4(+) T cell populations were observed in the conjunctival epithelium of Aire-deficient mice (p<0.001) compared with WT. Aire-deficient mice also had greater numbers of CD4(+), CD8(+), and CD11b(+) cells in the peripheral cornea at baseline and following desiccating stress. The meibomian glands of Aire-deficient mice demonstrated greater CD4(+), CD8(+), CD45(+) and CD11b(+) cells at baseline (p<0.001) and following desiccating stress. Conjunctival goblet cell density was lower at baseline and following desiccating stress in Aire-deficient compared with WT mice (p<0.001).

CONCLUSION

Aire-deficiency leads to infiltration of CD4(+) and CD8(+) T cells on the ocular surface and meibomian glands, which is accompanied by goblet cell loss. Desiccating stress promotes this proinflammatory milieu. Immune-mediated mechanisms play a role in the severe blepharitis and keratoconjunctivitis in the murine model of APECED.