A major review on punctal stenosis: Part II: Updated therapeutic interventions, complications, and outcomes

We continue our review of on punctal stenosis by providing a detailed discussion of management modalities, their complications, and outcomes. There is a significant change in the understanding of punctal and peripunctal anatomy, puncto-canalicular junction, and the lacrimal pump mechanisms. While the snip punctoplasty procedures are still practiced, there is an increasing trend toward nonincisional procedures. The nonincisional procedures in select cases appear to be equally effective as the incisional ones. Although simple to use, punctal plugs never became the mainstay of treatment because of design issues and the inability to address the coexisting canalicular stenosis. Placing stents only in the lower punctum in cases of upper and lower punctal stenosis should be discouraged, and management needs to address punctal stenosis and not which punctum is involved. Several types of stents are used in the management of punctal stenosis, mostly based on surgeon's preference. The benefits of adjuvant mitomycin C are uncertain. In view of literature on how stent biofilms can themselves cause chronic inflammation, placing them for prolonged periods should be reviewed and debated. Enhanced understanding of the molecular pathogenesis of punctal stenosis and addressing the current controversies in management would help standardize the therapeutic interventions available in the lacrimal armamentarium.

Eyelid dermatitis in patch-tested adult patients: a systematic review with a meta-analysis

Eyelid dermatitis (ED) affects a cosmetically significant area and leads to patients' distress. Despite ongoing and recent research efforts, ED remains a multidisciplinary problem that needs further characterization. We aimed to evaluate the atopic eyelid dermatitis (AED) frequency in ED patients and to perform their clinical profiling. PubMed databases were searched from 01.01.1980 till 01.02.2024 to PRISMA guidelines using a search strategy: (eyelid OR periorbital OR periocular) AND (dermatitis or eczema). Studies with patch-tested ED patients were included. Proportional meta-analysis was performed using JBI SUMARI software. We included 65 studies across Europe, North America, Asia and Australia, with a total of 21,793 patch-tested ED patients. AED was reported in 27.5% (95% CI 0.177, 0.384) of patch-tested ED patients. Isolated ED was noted in 51.6% (95% CI 0.408, 0.623) of 8453 ED patients with reported lesion distribution, including 430 patients with isolated AED. Our meta-analysis demonstrated that the AED frequency in patch-tested ED patients exceeded the previous estimate of 10%. Isolated AED was noted in adult patients, attending contact allergy clinics. Future studies are needed to elucidate the global prevalence and natural history of isolated AED in adults.

Contact allergy to topical ophthalmic medications: A retrospective single-centre study of three decades

BACKGROUND

The prevalence of contact allergy to various ophthalmic medications appears to be rare; however, data on culprits, clinical relevance of sensitizations, and changes in frequency within recent decades are limited.

OBJECTIVE

This study aimed to investigate the clinical relevance, risk factors, and prevalence of contact allergy to topical ophthalmic medications in patients suspected of allergic contact dermatitis to ophthalmic medication.

METHODS

We retrospectively analysed patch test results and clinical data for 754 patients patch-tested with an ophthalmic medication series at our tertiary referral centre between January 1992 and December 2022.

RESULTS

In total, 37.5% (283/754) of patch-tested patients had a contact allergy to at least one ophthalmic allergen, with 87.3% (247) being clinically relevant sensitization. Phenylephrine (31.8%, 192/604), povidone-iodine (29%, 27/93), and tobramycin (23%, 46/200) were the most important sensitizers. The incidence of contact allergies increased significantly in a linear manner (p = 0.008) from 20% to 44.1% within the study period. Male sex and age above 40 were risk factors for contact allergy to ophthalmic medication.

CONCLUSIONS

One third of patch tested patients had allergic contact dermatitis to ophthalmic medication, particularly phenylephrine. Male sex and age above 40 years were independent risk factors and drove the linear increase in contact allergy to ophthalmic medications within the past 31 years.

Allergic Conjunctivitis Management: Update on Ophthalmic Solutions

PURPOSE OF REVIEW

The aim of this review, is to present an updated revision of topical management of SAC and PAC, based on the available scientific evidence and focused on the impact of ophthalmic solution formulations on eye surface.

RECENT FINDINGS

Physicians treating ocular allergy should be aware of tear film and tear film disruption in SAC and PAC, and how eye drop composition and additives affect the physiology of the allergic eye. Seasonal and perennial allergic conjunctivitis (SAC and PAC) are the most frequent causes of ocular allergy (OA), and both conditions are underdiagnosed and undertreated. SAC and PAC are immunoglobulin E (IgE)-mediated hypersensitivity reactions. The additional tear film disruption caused by the release of inflammatory mediators increases and exacerbates the impact of signs and symptoms and may trigger damage of the ocular surface. Comorbidities are frequent, and dry eye disease in particular must be considered. Clinical guidelines for the management of SAC and PAC recommend topical therapy with antihistamines, mast cells stabilizers or dualaction agents as first-line treatment, but care should be taken, as many medications contain other compounds that may contribute to ocular surface damage.

A major review of punctal stenosis: Updated anatomy, epidemiology, etiology, and clinical presentation

We aim to provide a detailed and updated literature review on the epidemiology, etiology, clinical presentations, histopathology, and ultrastructural features of punctal stenosis. There are inconsistencies in the definition and staging of punctal stenosis. While advanced optical coherence tomography imaging techniques have revolutionized the way the punctum and vertical canaliculi are assessed or monitored following treatment, the planes of measurement to characterize punctum anatomy need to evolve further. The current criteria for diagnosing and grading punctal stenosis are inadequate and based on empirical clinical findings. There is increasing evidence of the role of lymphocytes and myofibroblasts in the pathogenesis of punctal stenosis. There is a need for a uniform assessment of punctal stenosis and a uniform reporting of severity that would help standardize the several management options available in the lacrimal armamentarium.

Allergic disorders of the eyelid

Eyelid dermatitis may present with a variety of clinical findings including erythema, pruritus, and edema, and it has a wide differential. Allergic contact dermatitis due to allergen sources in personal care products, cosmetics, and fragrances is a leading cause of eyelid dermatitis and may be challenging to diagnose by clinical examination alone. Expanded patch testing, in addition to careful inspection of the surrounding skin for additional areas of involvement and clinical clues, remains an important tool in differentiating allergic contact dermatitis from other relevant etiologies of eyelid dermatitis including irritant contact dermatitis, atopic dermatitis, seborrheic dermatitis, and rosacea. We present a practical approach to the management of eyelid dermatitis including the use of a topical anti-inflammatory for long-term control of eyelid findings. Further diagnostic workup may be warranted in patients with refractory eyelid dermatitis.

Topical eye medications causing allergic contact dermatitis

BACKGROUND

Allergic contact dermatitis (ACD) in the eye region caused by topical eye medications is difficult to diagnose and may be overlooked.

OBJECTIVE

To study the characteristics and causative agents in patients with ACD caused by topical eye medications in a Danish tertiary dermatology department.

METHODS

A retrospective study of 318 patients, patch tested between 2013 and 2021 due to suspected ACD to topical eye medications. All patients were tested with a locally developed eye medication series, some were additionally tested with suspected eye medications. Medical records were studied in patch test positive patients.

RESULTS

Contact allergy to a topical eye allergen/medication was found in 12.9% (n = 41) of 318 patients, and culprit allergens were phenylephrine (6.9%), timolol (2.5%) and ketotifen (1.6%). Patch test positive patients were often previously diagnosed with cataract (29.3%) or glaucoma (24.4%), and the majority reported more than one previous reaction. Initial symptoms were oedema (56.0%), erythema (48.8%) and dermatitis (31.7%) in the eye region, and facial dermatitis was also seen.

CONCLUSIONS

Patients with symptoms from the eye region who have been using topical eye medications should be patch tested with ingredients from commonly used eye medications supplemented by the products tested 'as is'.

Tolerance and Efficacy of a Dermocosmetic Containing Neurosensine® in Subjects with Eyelid Eczema

Background

Eyelid eczema (EE) is frequently observed in patients with an allergic or atopic diathesis. As for atopic eczema, restoring the skin barrier of the periocular region together with relieving clinical signs and symptoms is important in the management of EE. This study assessed the benefit and tolerance of a dedicated dermocosmetic (DC) in subjects with EE.

Materials and Methods

Open-label study in adults with EE and sensitive skin. The DC was applied twice daily for 28 days. Dermatological signs (eczema, desquamation/dryness, erythema, swelling, roughness) and symptoms (itching, prickling, heat/burning sensation, tightness) on the periorbital region, as well as ophthalmological evaluation were assessed at Day 0, 14 and 28. Subjects assessed quality of life (QOL) using DLQI, the perceived benefit and cosmetic acceptability of the DC.

Results

Overall, 41 subjects were included; 59% were women. The mean age was 52.4±15.8 years; all subjects had periorbital sensitive skin. The DC immediately reduced the intensity of itching, prickling, heat/burning sensation and tightness. Clinical signs and symptoms had all significantly (p<0.001) improved by Day 14 and were sustained to Day 28. The DC significantly (p<0.001) improved the perception of irritation (73%) and swelling (66%) while soothing (59%) the periorbital skin regions at Day 28. QOL had improved at Day 28 (0.82±1.0) compared to Day 0 (4.17±2.23). No local adverse reactions were reported. Ophthalmological examinations paralleled the excellent dermatological tolerance of DC.

Discussion

The tested DC is highly efficacious in reducing clinical signs and symptoms of eyelid eczema and was well tolerated.

ClinicalTrialsgov Identifier

NCT05540496.

A closer look at allergic contact dermatitis caused by topical ophthalmic medications

BACKGROUND

Allergic contact dermatitis caused by topical ophthalmic medications (OftACD) is frequently difficult to confirm with patch testing and, therefore, it is considered uncommon.

METHODS

We collected retrospective data from a cohort of 65 patients with suspected OftACD patch tested in our Dermatology Unit (2005-2021) according to ESCD guidelines, using a series of topical drugs and excipients (Chemotechnique Diagnostics), including betaxolol and timolol 5% pet. kindly supplied by the pharmaceutical industry. Also, frequently used ophthalmic medications as well as patient's own products were also patch tested 'as is' in most patients.

RESULTS

Positive patch tests to ophthalmic medications occurred in 44 patients (67.7%) (38F/6M; mean age 63.1 years), with 102 positive reactions. Most positive reactions were associated with active ingredients (n = 56), especially aminoglycoside antibiotics (n = 27), followed by excipients (n = 24) such as sodium metabisulfite (n = 7). There were also positive reactions to topical products tested 'as is' (n = 22), mostly containing beta-blockers, but only five of these reacted to the active ingredient.

DISCUSSION

This study reinforces previous findings in OftACD, such as older age of onset, and the importance of antibiotics, contrasting with the progressively lower prevalence of excipients. In addition, it helps raising awareness for the sensitization to beta-blockers, which is probably underestimated. Patch test preparations for the diagnosis of OftACD may require protocol optimization.

Immediate and Delayed Hypersensitivity Reactions to Antibiotics: Aminoglycosides, Clindamycin, Linezolid, and Metronidazole

Hypersensitivity reactions including IgE-mediated and delayed cell-mediated reactions to aminoglycosides, clindamycin, linezolid, and metronidazole are rare. For aminoglycosides, allergic contact dermatitis is the most frequent reaction for which patch testing can be a useful step in evaluation. For clindamycin, delayed maculopapular exanthems are the most common reactions. There are case reports of clindamycin associated with drug rash with eosinophilia and systemic symptoms (DRESS), acute generalized exanthematous pustulosis (AGEP), acute febrile neutrophilic dermatosis, and symmetrical drug-related intertriginous and flexural exanthema (SDRIFE). For linezolid, cases of hypersensitivity were exceedingly rare and included urticaria, angioedema, anaphylaxis, delayed rashes, and DRESS. For metronidazole, only rare cases were found across a broad spectrum of reactions including allergic contact dermatitis, fixed drug eruption, angioedema, anaphylaxis, serum sickness-like reaction, SJS/TEN, AGEP, SDRIFE, and a possible case of DRESS. IgE-mediated reactions and anaphylaxis to these types of antibiotics are uncommon, and reports of skin testing concentrations and desensitization protocols are largely limited to case reports and series. Non-irritating skin testing concentrations have been reported for gentamycin, tobramycin, and clindamycin. Published desensitization protocols for intravenous and inhaled tobramycin, oral clindamycin, intravenous linezolid, and oral and intravenous metronidazole have also been reported and are reviewed.

Punctal Congestion Syndrome: A Reversible, Functional Punctal Stenosis Causing Epiphora in the Setting of Chronic Pretarsal Conjunctivitis

PURPOSE

To describe a reversible syndrome of epiphora, functional punctal stenosis, and chronic pretarsal conjunctivitis associated with corticosteroid or corticosteroid-antibiotic eyedrop use.

METHODS

This is an Institutional Review Board-approved retrospective review of patients diagnosed with epiphora, punctal stenosis, and chronic conjunctivitis by a single surgeon (B.J.W.). These patients were subsequently invited to participate in a prospective study involving allergy skin patch testing for ophthalmic drops, common excipients, and active ingredients.

RESULTS

Thirteen patients received a diagnosis of punctal congestion syndrome. The average age was 63 years (range, 41-93) and 69.2% were female. Findings were bilateral in 61.5%. All had used preserved drops in the affected eye(s). Various antecedent diagnoses resulted in treatment with preserved drops. Patients experienced epiphora for an average of 3.8 months (median, 3 months; mode, 3 months; range, 1-8 months) prior to presentation. Two patients had undergone punctoplasty which failed to resolve symptoms. 92.3% of patients had been taking tobramycin-dexamethasone drops, loteprednol drops, or a combination of both prior to presentation. All were taken off preserved drops. 69.2% were also treated with a preservative-free loteprednol etabonate 0.5% ophthalmic ointment taper. All improved. Partial relief of symptoms was achieved by an average of 1.6 months (median, 2 months; mode, 2 months; standard deviation, ±0.7 months) and resolution of symptoms by 2.5 months (median, 2 months; mode, 2 months; standard deviation, ±1.7 months). One patient underwent patch testing with strong positive reactions to formaldehyde and neomycin and a weak positive reaction to gentamicin.

CONCLUSIONS

Functional punctal stenosis is associated with topical ophthalmic preparations, especially preserved corticosteroids and antibiotic-corticosteroid combinations. Treatment consists of removal of all preserved eyedrops. Symptoms often improve over several months.

In Vivo Efficacy of Contact Lens Drug-Delivery Systems in Glaucoma Management. A Systematic Review

Adherence is crucial in medical glaucoma therapy, although half of the patients skip eyedrops. In recent years alternative drug-delivery systems have been developed. One of the most promising seems the contact lens (CL). This systematic review aims to present the in vivo efficacy of different CL drug-delivery systems. A total of 126 studies were identified following a literature search adhering to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. After full-text evaluation, 19 studies about CL drug-delivery systems were included. To date, the following drug-delivery systems have been investigated in vivo: drug-soaked CL, CL with physical barriers (vitamin E), molecularly imprinted CL, CL with implants, and nanoparticle-loaded CL. Nanoparticle-loaded CL and CL with implants seem the most promising drug-delivery systems, although initial burst drug release and patient acceptance may limit their widespread use in current practice. Clinical trials are warranted to understand the role of CL as a drug-delivery system in improving glaucomatous patient care.

Topical preservative-free ophthalmic treatments: an unmet clinical need

Introduction: The main role of preservatives in eyedrops is to ensure sterility and microbiological integrity of the drug, and to facilitate the penetration of active compounds into the eye. However, several studies documented significant toxic effects induced by preservatives, especially on the ocular surface. Consequently, most of the ophthalmic medications became progressively available in preservative-free (PF) formulations.Areas covered: We analyzed pre-clinical and clinical studies on PF eyedrops with particular attention to common chronic diseases such as dry eye and glaucoma. We discussed about the pros and cons of using PF eyedrops, in terms of efficacy, safety, and social-economic aspects.Expert opinion: There are still unresolved issues that make hard for PF medications to definitively conquer the drug market. Despite robust pre-clinical evidences of less toxicity, the low number of randomized clinical trials does not permit to state that PF eyedrops have, in clinical practice, a similar efficacy or a higher safety compared to preserved forms. These aspects limit their use to chronic diseases requiring long-term therapies with multiple daily instillations, especially in the presence of concomitant ophthalmic diseases that expose to a risk of ocular surface worsening.

Contact Allergy-Emerging Allergens and Public Health Impact

Contact allergy (sensitisation) and allergic contact dermatitis (ACD) resulting from it have a considerable public health impact. For the present review, all pertinent articles were systematically searched via Medline and Web of Science™; additionally, all available issues of the journals "Contact Dermatitis" and "Dermatitis" were manually searched, covering the years 2018-2019, thereby extending and re-focusing a previous similar review. New allergens, or previously described allergens found in a new exposure context or of other current importance, are described in sections according to substance classes, e.g., metals, preservatives, fragrances. As a common finding in many investigations, a lack of information on product composition has been noted, for instance, regarding a newly described allergen in canvas shoes (dimethylthiocarbamylbenzothiazole sulfide) and, most notably, absence of co-operation from manufacturers of glucose-monitoring devices and insulin pumps, respectively. These latter devices have been shown to cause severe ACD in a considerable number of diabetic patients caused by the liberation of isobornyl acrylate and N,N'-dimethylacrylamide, respectively, as demonstrated by an international collaboration between dermatologists and chemists. Improved and complete ingredient labelling for all types of products, and not just cosmetics, must be put on the legislative agenda.