Systemic and local immunological features of atopic dermatitis patients with ocular complications

Long-Term Observation of Prognostic Factors and Clinical Outcome of Vernal Keratoconjunctivitis in Childhood

Purpose

Vernal keratoconjunctivitis (VKC) is a refractory ocular allergic disorder that mainly affects boys. Long-term follow-up has been rarely reported for VKC. We investigated the long-term clinical outcome of VKC to identify relevant clinical features of prognostic value based on follow-up for a median of 70 months.

Methods

In total, 45 consecutive patients clinically diagnosed with VKC aged 4 to 12 years at onset at the Department of Ophthalmology of Fukuoka University Hospital were included. Patients were treated with immunosuppressive eye drops without simultaneous corticosteroid eye drops, except for the occurrence of exacerbations. Collated variables were gender, age at onset, clinical score of ocular lesions (conjunctival giant papillae, limbal edema and corneal epithelial lesions) at the first visit, and clinical score of atopic dermatitis (AD) at baseline. Cumulative cure rate was estimated using Kaplan-Meier method. A binomial logistic predictive model was used to determine the most reliable clinical predictors of VKC outcome.

Results

The observation period ranged from 24 to 188 months, with median of 70 months. Among the 45 cases enrolled, all non-cured cases (14 cases) observed clinically were complicated by AD. Cumulative cure rate was 74.5% and 84.9% at eight- and ten-year follow-up, respectively. Ten-year cumulative cure rates of cases with and without AD were 50.5% and 100%, respectively, and a significant difference was found between these cumulative cure curves. Binomial regression analysis revealed that AD and gender were significantly related to worse outcome, and this binomial regression model had high sensitivity and specificity.

Conclusion

This study demonstrated that th eclinical outcomeof VKC might be predicted by several factors that can beobtained in the early clinical phase. Information on the long-term prognosis of VKC patients might play an important role for precision medicine for VKC in childhood.

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.

A risk-scoring system to predict dupilumab-associated ocular surface disease in patients with atopic dermatitis

Introduction

Dupilumab is the first biological treatment for atopic dermatitis (AD). Dupilumab-associated ocular surface disease (DAOSD) is one of the most commonly reported side effects in patients with AD during dupilumab treatment. This study aimed to identify risk factors for DAOSD in a real-world setting and construct a risk-scoring system for predicting DAOSD risk.

Methods

A retrospective analysis was conducted for dupilumab-treated adult patients with AD between April 2019 and September 2023 at Yeouido St. Mary's Hospital in Korea. Patients aged ≥18 years who received dupilumab to treat AD were included. Univariate and multivariable logistic regression analyses were performed to determine independent risk factors for DAOSD. A risk scoring system was constructed to predict DAOSD risk based on the adjusted odd ratios of significant variables.

Results

Of the 97 dupilumab-treated patients, 28 (28.9%) developed DAOSD. Among them, three (10.7%) patients discontinued dupilumab due to ocular side effects. In the multivariable analysis, older age, history of conjunctivitis, and a baseline Eczema Area and Severity Index (EASI) score ≥28 were independent risk factors for developing DAOSD. Using these variables, a risk-scoring system was constructed. The predicted DAOSD risks for AD patients with 0, 1, 2, 3, 4, and 5 points were 5.8%, 14.2%, 30.7%, 54.3%, 76.2%, and 89.6%, respectively.

Conclusion

In this study, the patient's age, history of conjunctivitis, and higher baseline EASI score were significantly associated with DAOSD. This risk-scoring system would help identify high-risk patients requiring more caution when initiating dupilumab treatment.

Classification of Subtypes of Vernal Keratoconjunctivitis by Cluster Analysis Based on Clinical Features

Background

Vernal keratoconjunctivitis (VKC) is a refractory ocular allergic disorder that mainly affects boys. A few studies have attempted to develop a classification of subtypes of VKC. In this study, we investigated a computational approach called cluster analysis to separate VKC cases into groups based on clinically relevant characteristics.

Methods

In total, 41 consecutive patients clinically diagnosed with VKC at the Department of Ophthalmology of Fukuoka University Hospital were included. Patients were treated with immunosuppressive eye drops without simultaneous corticosteroid eye drops, except for the occurrence of exacerbations. Collated variables were age at onset, clinical score of ocular lesions at baseline, clinical score of ocular lesions at final visit, clinical score of atopic dermatitis (AD) at baseline, frequency of exacerbations of VKC, serum total IgE level and peripheral blood eosinophil count.

Results

VKC patients were grouped into three clusters by cluster analysis, and cluster 1, 2, and 3 comprised 25, 9 and 7 cases, respectively. There were differences in the incidence of complications of AD and age at onset among the clusters; therefore, we named the three clusters for better understanding as traditional VKC (cluster 1), early-onset atopic keratoconjunctivitis (AKC)/VKC (cluster 2) and puberty-onset AKC (cluster 3).

Conclusion

We found in this study that VKC in childhood has three phenotypes which were previously unknown. Our findings may help to establish precision medicine by focusing on the phenotype of each case to develop individualized medicine to prevent exacerbations.

Dupilumab-associated ocular manifestations: A review of clinical presentations and management

Dupilumab is a first-in-class biologic approved by the European Medicines Agency (EMA) and the US Food and Drug Administration (US FDA) for the treatment of multiple atopic diseases, including atopic dermatitis, asthma, and chronic rhinosinusitis with nasal polyposis. Since gaining traction as an effective treatment modality, multiple reports have highlighted the many ocular side effects associated with dupilumab usage. These range from mild diseases such as conjunctivitis, dry eyes, and blepharitis, to more severe manifestations such as intraocular inflammation and cicatrising conjunctivitis. The pathogenesis behind these manifestations remains controversial but are likely multi-factorial. We review the current evidence surrounding ocular manifestations of dupilumab-associated disease and proposed treatments to provide an overview of this unique disease entity. With increasing usage of dupilumab, formal recommendations regarding the treatment of dupilumab-associated ocular disease are warranted to provide standardised clinical guidance. Furthermore, it is important for healthcare practitioners to remain abreast with existing literature to adequately counsel and empower patients with the knowledge surrounding contemporary treatments for atopic diseases and their associated side-effects.

A 52 weeks dupilumab treatment for moderate to severe atopic dermatitis in Korea: long-term efficacy and safety in real world

Previously, we have reported short term effectiveness and safety of dupilumab in Korea. In this study, we are trying to report the long-term effectiveness and safety of dupilumab in Korea. Ninety-nine patients with moderate to severe AD were analyzed. They were evaluated using Eczema Area and Severity Index (EASI), Numerical Rating Scale (NRS), Patient Oriented Eczema Measure (POEM), and Dermatology Quality of Life Index (DLQI) at baseline, week 16, 32 and 52. Efficacy outcomes showed higher improvement at 52 weeks compared with 16 weeks; high percentual reductions in EASI (88.1%), peak pruritus NRS (65.6%), POEM (67.2%), and DLQI (69.0%) compared to baseline. Proportion of patients achieving EASI 75 and 90 were 90.2% and 53.7%. POEM and DLQI had high correlation with clinical measured outcomes. In the analysis for the factors affecting achievement of EASI 90, female gender (OR 2.5), eosinophilia (OR 0.2) and elevated LDH (OR 0.07) were significantly associated. Most frequent adverse events included facial erythema (19.2%) and conjunctivitis (17.2%), which were mild/moderate and resolved during treatment. In conclusion, dupilumab treatment for 52 weeks in Korean patients with moderate-to-severe AD confirmed long term effectiveness and safety.

Factors associated with ocular surface disease and severity in adults with atopic dermatitis: a nationwide survey

BACKGROUND

Ocular surface diseases (OSDs), including conjunctivitis and blepharitis, are common in atopic dermatitis (AD) patients, but the magnitude and patient characteristics are unclear.

OBJECTIVES

To examine the prevalence of OSDs in adults with AD and identify patient characteristics and risk factors.

METHODS

We designed a cross-sectional questionnaire-based survey and sent it via a secure public mail to all adult Danes with a hospital diagnosis of AD (ICD-10 code L20.x) registered in the National Patient Register (n = 16 718) between 2000 and 2019 and 7044 (42%) participated. Primary outcomes were OSDs and severity according to Ocular Surface Disease Index (OSDI). Adjusted odds ratios (aOR) were calculated with 95% confidence intervals (CIs) using logistic regression models.

RESULTS

Respondents were mostly females and middle-aged (67.4%, mean [SD] age, 39.0 [15.5] years). Based on Patient-Oriented SCORing Atopic Dermatitis 49% had mild AD, 35% moderate, 10% severe and in 6% AD was inactive; 44.3% reported physician-diagnosed asthma bronchiale and 55.8% rhinitis. The lifetime prevalence of OSDs was 66.6% for conjunctivitis, 63.5% for hordeolum, 11.0% for blepharitis, 9.7% for keratitis, 2.0% for pterygium, 1.5% for symblepharon, 1.1% for keratoconus and 12.7% reported current conjunctivitis. Factors associated with lifetime occurrence of conjunctivitis included mild, moderate, and severe AD (aOR = 1.48 [95% CI, 1.02-2.14], aOR = 1.73 [95% CI, 1.19-2.53], aOR = 2.17 [95% CI, 1.42-3.21]), asthma bronchiale and rhinitis (aOR = 1.76 [95% CI, 1.49-2.07]), childhood-onset of AD (aOR = 1.34 [95% CI, 1.16-1.56]) and systemic AD treatment (aOR = 1.27 [95% CI, 1.08-1.50]). Use of soft and hard contact lenses (aOR = 2.15 [95% CI, 1.65-2.80], aOR = 3.35 [95% CI, 1.62-6.92]) were associated with lifetime occurrence of keratitis. Moderate and severe AD, asthma bronchiale and rhinitis were also associated with a higher OSDI level.

CONCLUSIONS

This study identified important patient factors associated with OSDs. Clinicians should be attentive of ocular signs and symptoms in AD patients and ask about these.

Keratoconus, allergy, itch, eye‐rubbing and hand‐dominance

BACKGROUND

One hypothesis for the pathogenesis of keratoconus includes teenage allergy, ocular itch and associated eye-rubbing.

METHODS

This study examined the prevalence of these factors for teenage and adult patients. The results for a sample of 53 subjects with bilateral keratoconus were compared with those for a control sample of non-keratoconus subjects, who also routinely wore RGP contact lenses. The strongest dominant hand and the eye with more advanced keratoconus were also determined, to examine for a relationship between them.

RESULTS

The keratoconic sample reported significantly higher levels of allergy, itch and rubbing as teenagers and as adults. However, all distributions were bimodal, consistent with the hypothesis that allergy, itch and rubbing are relevant in the pathogenesis of keratoconus only when the highest levels of these factors are present. For example, a significant relationship between the stronger dominant hand and the more advanced eye was evident only in subjects who reported the most severe rubbing.

CONCLUSIONS

This finding adds weight to the circumstantial evidence that rubbing contributes to the pathogenesis of keratoconus. Low levels of teenage rubbing by some keratoconic subjects suggest a non-rubbing pathogenesis and that emphasis on rubbing management is not warranted in these cases. However, high levels of adult rubbing reported by many keratoconic subjects indicate that the standard advice to avoid vigorous and prolonged rubbing is often not effective, even when repeated. There appears to be an indication for the need to improve the management of eye-rubbing for some patients with keratoconus or at risk of developing this disease.

Conjunctivitis in Dupilumab Clinical Trials for Adolescents with Atopic Dermatitis or Asthma

BACKGROUND

Conjunctivitis is a known comorbidity of atopic dermatitis. Dupilumab clinical trials for moderate-to-severe atopic dermatitis in adults showed a higher conjunctivitis incidence for dupilumab-treated patients than placebo-treated patients, whereas trials for uncontrolled asthma reported lower rates for both dupilumab and placebo.

OBJECTIVE

The objective of this study was to evaluate the incidence and severity of conjunctivitis in dupilumab clinical trials in adolescents with moderate-to-severe atopic dermatitis or uncontrolled asthma.

METHODS

We evaluated the incidence of conjunctivitis in adolescents (aged 12 to < 18 years) in three phase III trials. Ocular events were diagnosed and treated based on patient-reported symptoms and an external eye examination by study investigators, in most cases without an ophthalmologic referral. In LIBERTY AD ADOL (16-week, randomized, placebo-controlled, double-blinded trial), adolescents with moderate-to-severe atopic dermatitis were randomized to subcutaneous placebo, dupilumab 300 mg every 4 weeks, or dupilumab every 2 weeks (200 mg, patients < 60 kg at baseline; 300 mg, ≥ 60 kg at baseline). In LIBERTY AD PED-OLE (open-label extension), pediatric patients from previous dupilumab atopic dermatitis trials received dupilumab 2 mg/kg or 4 mg/kg weekly (up to 300 mg) or 300 mg every 4 weeks. In LIBERTY ASTHMA QUEST (randomized, double-blinded, placebo-controlled trial), patients with uncontrolled moderate-to-severe asthma were randomized to 52 weeks of add-on therapy with dupilumab 200 or 300 mg every 2 weeks or matched-volume placebo.

RESULTS

In ADOL, more dupilumab-treated (17/165; 10.3%) than placebo-treated patients (4/85; 4.7%) reported one or more conjunctivitis event. All events were mild to moderate in severity; 12 (7.3%) dupilumab-treated and 4 (4.7%) placebo-treated patients received treatment. Most patients with conjunctivitis (dupilumab, 12/17; placebo, 4/4) recovered/resolved during the treatment period. The risk of conjunctivitis showed no relationship with dupilumab serum concentration. In PED-OLE, 12/275 adolescents (4.4%) reported one or more conjunctivitis event. Most conjunctivitis events were mild to moderate. Ten patients received treatment for conjunctivitis. Ten patients recovered/resolved during the study. In QUEST, similar low proportions of dupilumab-treated (2/68, 2.9%) and placebo-treated (1/39, 2.6%) adolescents reported one or more conjunctivitis event. All events were mild to moderate. One dupilumab-treated patient received treatment for conjunctivitis. All cases recovered/resolved during the study. No patients in these trials discontinued study treatment temporarily or permanently because of conjunctivitis. In ADOL, one case of unspecified viral keratitis (specific viral etiology not known) in the dupilumab 300-mg every 4 weeks group and one case of allergic blepharitis in the placebo group were reported; both events resolved during the treatment period, and neither led to treatment discontinuation.

CONCLUSIONS

Dupilumab-treated adolescents in atopic dermatitis trials had a higher incidence of conjunctivitis than placebo-treated patients, whereas overall rates of conjunctivitis among adolescents in the asthma trial were lower than in atopic dermatitis trials and were similar for dupilumab- and placebo-treated patients. Most events were mild to moderate, most recovered/resolved, and none prompted study withdrawal. These results are similar to those reported in adult trials and support a drug-disease interaction. CLINICALTRIALS.

GOV IDENTIFIERS

NCT03054428, NCT02612454, NCT02414854. Conjunctivitis in Dupilumab Clinical Trials for Adolescents with Atopic Dermatitis or Asthma (MP4 18453 kb).

Efficacy and Safety of Multiple Dupilumab Dose Regimens After Initial Successful Treatment in Patients With Atopic Dermatitis: A Randomized Clinical Trial

Question

Do dupilumab regimens less frequent than once weekly or every 2 weeks maintain long-term efficacy and safety?

Findings

In this randomized clinical trial of 422 patients, high-responding patients previously treated for 16 weeks with 300 mg of dupilumab weekly or every 2 weeks who continued those regimens had the most consistent efficacy; patients taking lower-dose regimens (every 4 or 8 weeks) or placebo had a dose-dependent reduction in response and no safety advantage.

Meaning

The approved regimen (every 2 weeks) maintained clinical response and is therefore recommended for long-term treatment.

Importance

The dupilumab regimen of 300 mg every 2 weeks is approved for uncontrolled, moderate to severe atopic dermatitis (AD).

Objective

To assess the efficacy and safety of different dupilumab regimens in maintaining response after 16 weeks of initial treatment.

Design, Setting, and Participants

The Study to Confirm the Efficacy and Safety of Different Dupilumab Dose Regimens in Adults With Atopic Dermatitis (LIBERTY AD SOLO-CONTINUE) was a randomized, double-blind, phase 3 clinical trial conducted from March 25, 2015, to October 18, 2016, at 185 sites in North America, Europe, Asia, and Japan. Patients with moderate to severe AD who received dupilumab treatment and achieved an Investigator’s Global Assessment score of 0 or 1 or 75% improvement in Eczema Area and Severity Index scores (EASI-75) at week 16 in 2 previous dupilumab monotherapy trials (LIBERTY AD SOLO 1 and 2) were rerandomized in SOLO-CONTINUE. After completing SOLO-CONTINUE, patients were followed up for up to 12 weeks or enrolled in an open-label extension. Data were analyzed from December 5 to 12, 2016.

Interventions

High-responding patients treated with dupilumab in SOLO were rerandomized 2:1:1:1 to continue their original regimen of dupilumab, 300 mg, weekly or every 2 weeks or to receive dupilumab, 300 mg, every 4 or 8 weeks or placebo for 36 weeks.

Main Outcomes and Measures

Percentage change in EASI score from baseline during the SOLO-CONTINUE trial, percentage of patients with EASI-75 at week 36, and safety.

Results

Among the 422 patients (mean [SD] age, 38.2 [14.5] years; 227 [53.8%] male), continuing dupilumab treatment once weekly or every 2 weeks maintained optimal efficacy, with negligible change in percent EASI improvement from SOLO 1 and 2 baseline during the SOLO-CONTINUE trial (−0.06%; P < .001 vs placebo); percent change with the other regimens dose-dependently worsened (dupilumab every 4 weeks, −3.84%; dupilumab every 8 weeks, −6.84%; placebo, −21.67%). More patients taking dupilumab weekly or every 2 weeks (116 of 162 [71.6%]; P < .001 vs placebo) maintained EASI-75 response than those taking dupilumab every 4 weeks (49 of 84 [58.3%]) or every 8 weeks (45 of 82 [54.9%]) or those taking placebo (24 of 79 [30.4%]). Overall adverse event incidences were 70.7% in the weekly or every 2 weeks group, 73.6% in the every 4 weeks group, 75.0% in the every 8 weeks group, and 81.7% in the placebo group. Treatment groups had similar conjunctivitis rates. Treatment-emergent antidrug antibody incidence was lower with more frequent dupilumab dose regimens (11.3% in the placebo group and 11.7%, 6.0%, 4.3%, and 1.2% in the dupilumab every 8 weeks, every 4 weeks, every 2 weeks, and weekly groups, respectively).

Conclusions and Relevance

In this trial, continued response over time was most consistently maintained with dupilumab administered weekly or every 2 weeks. Longer dosage intervals and placebo resulted in a diminution of response for both continuous and categorical end points. No new safety signals were observed. The approved regimen of 300 mg of dupilumab every 2 weeks is recommended for long-term treatment.

Trial Registration

ClinicalTrials.gov identifier: NCT02395133

Patient-Reported Ocular Disorders and Symptoms in Adults with Moderate-to-Severe Atopic Dermatitis: Screening and Baseline Survey Data from a Clinical Trial

Introduction

Patients with atopic dermatitis (AD) have a greater risk of conjunctivitis and other ocular surface disorders than the general population. We evaluated the burden of ocular surface disorders and related symptoms prior to treatment initiation in adults with moderate-to-severe AD.

Methods

Patients were enrolled in a randomized, placebo-controlled, double-blinded, phase 3 trial of dupilumab administered with concomitant topical corticosteroids. At the beginning of the screening period, all enrolled patients completed a survey of ocular disorder diagnoses received in the past year; at baseline, patients completed a survey of frequency and severity of ocular symptoms (discomfort, itching, redness, and tearing) experienced in the past month.

Results

A total of 712 of 740 patients enrolled in the trial provided responses to the survey. At screening, 286 of 740 patients (38.6%) reported having at least one ocular disorder in the past year. At baseline, 499 of 712 respondents (70.1%) reported having at least one symptom within the past month. Of these patients, 4.4%, 6.0%, 5.5%, and 4.4%, respectively, reported having discomfort, itching, redness, and tearing all of the time. Mild discomfort, itching, redness, and tearing were reported by 26.1%, 33.7%, 30.8%, and 31.6% of patients, respectively, while 7.3%, 7.7%, 6.2%, and 4.2%, reported severe discomfort, itching, redness, and tearing, respectively.

Conclusions

These data demonstrate a high burden of ocular surface disorders and related symptoms in a population of adults with moderate-to-severe AD. Dermatologists should be aware of increased incidence of these disorders in AD and query their patients for signs and symptoms of eye disease.

ClinicalTrials.gov Registration Number

NCT02260986.

Conjunctivitis in patients with atopic dermatitis treated with dupilumab

Atopic dermatitis (AD) is a common, chronic, inflammatory skin disorder with high physical and emotional burden. Robust evidence suggests that interleukin (IL)-4 and IL-13 are key cytokines in the immunopathogenesis of AD. New emerging agents include dupilumab, a fully human monoclonal antibody directed against the IL-4 receptor a subunit that blocks both IL-4 and IL-13 signaling and has shown significant efficacy in patients with moderate-to-severe AD. Dupilumab is approved for the treatment of moderate-to-severe AD, moderate-to-severe eosinophilic or oral corticosteroid-dependent asthma, and chronic rhinosinusitis with nasal polyps. Data from phase phase 2 and 3 studies have revealed that dupilumab generally has a low rate of adverse events, although an increased incidence of mild-to-moderate conjunctivitis has been reported for dupilumab compared with placebo.

The present paper reviews the data of dupilumab-associated conjunctivitis and risk factors in adults with moderate-to-severe AD and other atopic diseases in dupilumab clinical trials and addresses the characteristics and treatment options available for this clinically highly relevant condition. Additionally, it presents data from ten studies in the real-life setting with dupilumab. Dupilumab-associated conjunctivitis incidence is higher in AD, although most cases are mild-to-moderate and have good response to topical treatment, with no need to suspend dupilumab therapy.

A Clinician's Guide to the Recognition and Management of Dupilumab-Associated Conjunctivitis

Dupilumab, a monoclonal antibody that inhibits both interleukin (IL)-4 and IL-13 signaling, is an effective treatment option in moderate-to-severe atopic dermatitis (AD). Patients with AD are already at increased risk of developing conjunctivitis, and clinical trials and case reports have shown a greater incidence of conjunctivitis in individuals with AD treated with dupilumab. As this is one of the more commonly reported side effects of this biologic agent, it is important that clinicians are aware of this association and advise patients receiving dupilumab to report signs of conjunctivitis. This review summarizes the risk factors, clinical features, and management options for patients with AD presenting with conjunctivitis after receiving dupilumab therapy.

Conjunctivitis in dupilumab clinical trials

BACKGROUND

Dupilumab blocks the shared receptor component for interleukin (IL)-4 and IL-13. It is approved in the U.S.A. for patients aged ≥ 12 years with moderate-to-severe atopic dermatitis (AD) uncontrolled by topical prescription medicines or who cannot use topical medicines, for patients in Japan whose AD is uncontrolled with existing therapies, for patients with moderate-to-severe AD in Europe who are candidates for systemic therapy and for patients aged ≥ 12 years for maintenance treatment of moderate-to-severe asthma uncontrolled with their current medicines. AD trials have reported increased incidence of conjunctivitis for dupilumab vs. placebo.

OBJECTIVES

To characterize further the occurrence and risk factors of conjunctivitis in dupilumab clinical trials.

METHODS

We evaluated randomized placebo-controlled trials of dupilumab in AD (n = 2629), asthma (n = 2876), chronic rhinosinusitis with nasal polyps (CRSwNP) (n = 60) and eosinophilic oesophagitis (EoE) (n = 47).

RESULTS

In most AD trials, dupilumab-treated patients had higher conjunctivitis incidence than placebo controls. Higher baseline AD severity and previous history of conjunctivitis were associated with increased conjunctivitis incidence. Conjunctivitis was mostly mild to moderate. Most cases recovered or resolved during the treatment period; two patients permanently discontinued dupilumab due to conjunctivitis or keratitis. Common treatments included ophthalmic corticosteroids, antibiotics, and antihistamines or mast cell stabilizers. Most cases were diagnosed by the investigators. In asthma and CRSwNP trials, the incidence of conjunctivitis was lower for both dupilumab and placebo than in AD trials; dupilumab did not increase the incidence compared with placebo. In the EoE trial, no patients had conjunctivitis.

CONCLUSIONS

Conjunctivitis was more frequent with dupilumab treatment in most AD trials. In dupilumab trials in other type 2 diseases, incidence of conjunctivitis was overall very low, and was similar for dupilumab and placebo. In AD, the incidence of conjunctivitis was associated with AD severity and prior history of conjunctivitis. The aetiology and treatment of conjunctivitis in dupilumab-treated patients require further study. What's already known about this topic? Ocular disorders, including allergic conjunctivitis, are common in patients with atopic dermatitis (AD). In most dupilumab AD trials, dupilumab-treated patients had higher conjunctivitis incidence than those receiving placebo. Most cases were mild to moderate and recovered or were recovering during study treatment; study treatment discontinuation due to conjunctivitis was rare. Conjunctivitis incidence was very low and similar for dupilumab and placebo in clinical trials in asthma, chronic rhinosinusitis with nasal polyps and eosinophilic oesophagitis. What does this study add? This analysis confirms and extends the results of the individual clinical trials. Baseline disease-related factors, including AD severity, prior conjunctivitis history and certain biomarkers (thymus and activation-regulated chemokine, IgE, eosinophils), were associated with increased incidence of conjunctivitis. Patients who responded well to dupilumab had reduced incidence of conjunctivitis. Further study is needed to elucidate the aetiology and treatment of conjunctivitis in dupilumab-treated patients with AD.

Acute keratoconjunctivitis due to contamination of contact lens care solution with histamine-producing Raoultella species: A case report

RATIONALE

Contact lens storage cases are known to be contaminated by a significant number of bacteria. However, histamine-producing Raoultella species has not been reported to contaminate contact lens storage case.

PATIENT CONCERNS

A 27-year-old woman with keratoconjunctivitis that developed in the left eye owing to a cosmetic contact lens and poor hygiene was referred to our hospital. The corrected visual acuity was hand motion.

DIAGNOSES

Corneal infection other than Acanthamoeba keratitis (AK) and corneal hypoxia were excluded.

INTERVENTIONS

We initiated empirical therapy for AK, although no cysts or trophozoites were detected in the cornea and in the lens care solution. Analysis of 16S rDNA sequences from the lens care solution yielded the highest homology with Raoultella species, which are histamine-producing bacteria. Histamine was estimated to be 492 ng/mL in the lens care solution.

OUTCOMES

Her clinical course was distinct from that of usual AK cases. The corrected visual acuity increased up to (1.2) only 5 days after initiating empirical therapy.

LESSONS

To our knowledge, this is the first report to indicate an association between histamine-producing bacteria and keratoconjunctivitis. We should pay an attention to the microbial contamination of contact lens storage cases by histamine producing bacteria.

Protective effects of Cassia tora leaves in experimental cataract by modulating intracellular communication, membrane co-transporters, energy metabolism and the ubiquitin-proteasome pathway

CONTEXT

Cataract is the clouding of eye lens which causes impairment in vision and accounts for the leading factor of global blindness. Functional food-based prevention of cataract finds application in vision research because of its availability and easy access to all classes of the society. Cassia tora Linn. (Caesalpinaceae) is an edible plant mentioned in the traditional systems of medicine for whole body health, especially to the eyes.

OBJECTIVE

The present study evaluates the potential of ethyl acetate fraction of Cassia tora leaves (ECT) on experimental cataract.

MATERIALS AND METHODS

Cataract was induced by a single subcutaneous injection of sodium selenite (4 μg/g body weight) on 10th day. ECT was supplemented orally from 8th day up to 12th day at a concentration of 5 μg/g body weight and marker parameters were evaluated after 30 days.

RESULTS

The production of MPO and the activation of calpain were reduced 52.17% and 36.67% by ECT in lens tissue, respectively. It modulated the energy status by significantly increasing the activity of CCO 1 (55.56%) and ATP production (41.88%). ECT maintained the ionic balance in the lens by reducing the level of sodium (50%) and increasing the level of potassium (42.5%). It also reduced cell junction modifications and preserved a functional ubiquitin-proteasome pathway.

DISCUSSION AND CONCLUSION

The results reinforce the growing attention on wild plant food resources for preventive protection against cataract. The data suggest the value of Cassia tora leaves as a functional food for ameliorating cataract pathology.

MMF and Eye Disease

Immunosuppressive treatment has shown to be effective in various ocular inflammatory disorders. Factors limiting their use are the individual response and the rate of side effects. This report summarizes our knowledge about the use of mycophenolate mofetil (MMF) in the treatment of ocular cicatricial pemphigoid (OCP), uveitis, atopic keratoconjunctivitis (AKC), prevention of graft rejection after penetrating keratoplasty (PK) and scleritis. Controlled studies have been performed for prevention of graft rejection after PK, showing MMF as effective in the prevention of graft rejection as cyclosporine A. In experimental uveitis, MMF has been demonstrated to be highly effective in prevention of retinal destruction. A number of studies have now shown that MMF also seems effective in uveitis. There are also studies with smaller patient groups which point out the effectiveness of MMF in OCP, AKC, and scleritis. In most of the studies, the spectrum of side effects was small, compared to other immunosuppressives.

Epigenetic mechanisms might help explain environmental contributions to the pathogenesis of keratoconus

The etiology of keratoconus (KC) seems to involve genetic and/or environmental factors such as rubbing and/or contact lens trauma and/or exposure to ultraviolet radiation. An examination of the possibility that epigenetic mechanisms could contribute to the tissue changes in KC has been considered in this review. The tissue changes in KC result in thinning and/or other forms of mechanical weakening of the cornea, which cause it to become more susceptible to the distending forces of intraocular pressure with associated development of a cone. Rather than being caused by a single gene mutation, a complex or multifactorial disease such as KC involves multiple genes plus lifestyle and environmental factors. The epigenome of a cell is highly dynamic, being governed by a complex interplay of genetic and environmental factors. The full range of epigenetic marks is currently unknown but is potentially enormous. Although further elucidation of the genetic determinants of KC is important, there is now increasing interest in exploring how non-genetic variants, such as epigenetic factors, could influence complex disease etiology. Studies of epigenetic processes in KC may help explain the relationship between the genome and the environment and provide new clues for modifying these processes with the possibility of preventing the development of KC or stabilizing its progress. Epigenetic linking may be relevant to other complex ocular diseases that involve environmental factors including those that involve exposure to ultraviolet radiation.

Generation of transgenic rice with reduced content of major and novel high molecular weight allergens

BACKGROUND

Rice seed proteins contain antigens that provoke allergic responses in some individuals with food allergy, particularly in those with cereal allergy, and these antigens can elicit clinical symptoms such as eczema and dermatitis. We previously generated transgenic rice with reduced accumulation of the three major allergens, which dramatically reduced the level of IgE binding from patients' sera. However, the transgenic rice still possesses allergenic reactivity. Recently, two globulin-like proteins were identified as candidates of novel high molecular weight (HMW) IgE-binding proteins that cause rice allergy.

RESULTS

We identified a glucosidase family encoded by four genes as novel HMW rice allergens based on IgE antibody reactivity from individuals with allergy to rice. To further reduce allergenicity, we generated transgenic rice with reduced accumulation of these HMW allergens. We crossed the rice with reduced HMW allergens and with reduced major allergens, and all major and HMW allergens were substantially reduced in the progeny of the crossed rice. Allergen suppression did not significantly alter accumulation patterns of seed storage proteins and protein folding enzymes. The sera of a portion of patients showed low IgE-binding to the crossed line, suggesting that the crossed line is effective for a portion of patients who are allergic to proteins other than major allergens.

CONCLUSIONS

The transgenic rice with reduced levels of all major and HMW allergens is thought to be an option for a portion of allergy patients with hypersensitive responses to various kinds of rice allergens.

The association between cataract surgery and atypical antipsychotic use: a nested case-control study

PURPOSE

To investigate cataract risk associated with the use of atypical antipsychotics.

DESIGN

Retrospective, nested case-control study.

METHODS

A large health claims database (The British Columbia Ministry of Health Databases) from British Columbia, Canada, was used from January 2000 through December 2007. Cases were defined as clinically significant cataracts requiring surgery and were identified using cataract surgery procedure codes. For each case, 4 to 10 controls were selected randomly using a density-based sampling approach and were matched to cases by age and calendar time. Rate ratios were calculated for users of atypical and typical antipsychotics adjusting for known cataractogenic factors.

RESULTS

One hundred sixty-two thousand five hundred one cases of cataract surgery and 650 004 controls were included. The adjusted rate ratio for current users of atypical antipsychotics was 0.84 (95% confidence interval, 0.80 to 0.89) compared with nonusers. A greater number of prescriptions filled in the year before cataract surgery compared with the median number of filled prescriptions was associated with a lower cataract surgery rate (adjusted rate ratio, 0.70; 95% confidence interval, 0.65 to 0.75) than those with fewer prescriptions filled (adjusted rate ratio, 0.85; 95% confidence interval, 0.79 to 0.91).

CONCLUSIONS

A protective association between the use of atypical antipsychotics and risk of clinically significant cataracts requiring surgery was established. Potential biochemical and neurochemical mechanisms for this protective effect are discussed.

Mometasone furoate nasal spray relieves the ocular symptoms of seasonal allergic rhinoconjunctivitis

BACKGROUND

Recent studies have examined the effects of intranasal corticosteroids (INSs) in relieving the ocular symptoms of seasonal allergic rhinoconjunctivitis (SAR) and perennial allergic rhinitis. However, because most of these studies were based on subjective assessments by patients, the associated factors and mechanism of action are unknown.

METHODS

A single-center, randomized, double-blind, parallel-group study was carried out in which patients with SAR were randomly assigned to an INS mometasone furoate nasal spray (MFNS) group or to a placebo group and treated once daily for 4 weeks. Substance P concentrations in tears were measured, ocular and nasal symptoms were recorded by patients in an allergy diary, and findings were recorded by an ophthalmologist.

RESULTS

There was no significant difference between treatment groups in the mean change from baseline of substance P concentration in tears after 4 weeks of treatment, but the mean change tended to increase in the placebo group and tended to decrease in the MFNS group (P = 0.089). All ocular and nasal symptom scores, except eye tearing, were significantly lower in the MFNS group than in the placebo group. Furthermore, substance P concentrations were strongly correlated with ocular and nasal symptom scores.

CONCLUSIONS

In patients with SAR, INSs tend to decrease the substance P concentration in tears, which is correlated with the severity of ocular and nasal symptoms.

Atopic dermatitis and keratoconjunctivitis

Atopic dermatitis, a chronic disease seen by allergist-immunologists, has both dermatologic and ocular manifestations. The ocular component is often disproportionately higher than the dermatologic disease. Even if skin abnormalities seem well controlled, these patients require ophthalmic evaluation. Atopic keratoconjunctivitis in atopic dermatitis patients is characterized by acute exacerbations and requires maintenance therapy for long-term control. Future studies will continue to emphasize the use of steroid-sparing, immunomodulating agents that have the potential to provide long-lasting anti-inflammatory control with a more favorable side-effect profile.

Topical Bromfenac Sodium for Long-Term Management of Vernal Keratoconjunctivitis

BACKGROUND/AIMS

We evaluated the efficacy and safety of long-term management of patients with vernal keratoconjunctivitis (VKC) with bromfenac sodium eye drops in combination with corticosteroids and anti-allergic eye drops.

METHODS

Twenty-two patients with VKC were randomly assigned to receive two test eye drops, either bromfenac sodium 0.1% (group A) or placebo eye drops (normal saline; group B) for a mean observation period of 20.9 months. Topical corticosteroids and mast cell stabilizers were continued during the observation period.

RESULTS

The mean 2-year recurrence rate was 90.9% in group A and 11.3% in group B, with a significant difference. No serious side effect was observed in group A.

CONCLUSION

These results suggest that bromfenac sodium eye drops can be used as baseline local treatment in patients with VKC.

MMF and eye disease

Immunosuppressive treatment has shown to be effective in various ocular inflammatory disorders. Factors limiting their use are the individual response and the rate of side effects. This report summarizes our knowledge about the use of mycophenolate mofetil (MMF) in the treatment of ocular cicatricial pemphigoid (OCP), uveitis, atopic keratoconjunctivitis (AKC), prevention of graft rejection after penetrating keratoplasty (PK) and scleritis. Controlled studies have been performed for prevention of graft rejection after PK, showing MMF as effective in the prevention of graft rejection as cyclosporine A. In experimental uveitis, MMF has been demonstrated to be highly effective in prevention of retinal destruction. A number of studies have now shown that MMF also seems effective in uveitis. There are also studies with smaller patient groups which point out the effectiveness of MMF in OCP, AKC, and scleritis. In most of the studies, the spectrum of side effects was small, compared to other immunosuppressives.

Nitric oxide participates in cataract development in selenite-treated rats

PURPOSE

The role of nitric oxide in the development of selenite-induced cataracts in rats was examined using nitric oxide synthase (NOS) inhibitors.

METHODS

Subcutaneous injection of sodium selenite was used to induce cataracts in rats, with or without pretreatment with NOS inhibitors. The anterior eye segment analysis system (EAS-1000, Nidek) was used to measure lens opacity. The glutathione content of the lenses was determined by an HPLC method and the Ca2+ content by atomic absorption spectrometry. Nitrite, a stable metabolite of nitric oxide, was determined fluorometrically. NADPH-diaphorase activity staining and Western blot analysis were used to determine NOS levels.

RESULTS

Administration of the NOS inhibitor, NG-nitro-L-arginine methyl ester (L-NAME), inhibited lens opacification in selenite-treated rats. NG-nitro-d-arginine methyl ester, an inactive enantiomer of l-NAME, had no effect. Aminoguanidine, another NOS inhibitor, also inhibited the development of cataracts in a dose-dependent manner. On the other hand, L-arginine, a substrate of NOS, accelerated the development of cataracts. Although the opacification of the lenses was apparent approximately 3 days after selenite injection, the nitrite level was increased within one day. In addition, NOS was induced in the eye within one day of selenite injection.

CONCLUSIONS

The present study demonstrated that NOS inhibitors prevented the development of cataracts in selenite-treated rats. The results also suggest that nitric oxide had an important role in the development of selenite-induced cataracts.

Allergic and immunologic disorders of the eye. Part II: ocular allergy

Allergy affects more than 15% of the world population, and some studies have shown that up 30% of the US population has some form of allergy. Most of these patients have various target organs for their allergies, and most have ocular involvement. The ocular component may be the most prominent and sometimes disabling feature of their allergy. Some are affected for only a few weeks to months, whereas others have symptoms that last throughout the year. The seasonal forms may present to clinical allergists, whereas the more chronic forms may present to ophthalmologists. Thus, in the second of this 2-part review series (Part I: Ocular Immunology appeared in the November issue of the Journal), an overview is provided of the spectrum of ocular allergy that ranges from acute seasonal allergic conjunctivitis to chronic variants of atopic keratoconjunctivitis. With a better understanding of the immunologic mechanisms, we now can develop better treatment approaches and design further research in intervention of allergic eye diseases.

Serum levels of soluble intercellular adhesion molecule-1, vascular cell adhesion molecule-1, and interleukin-2 receptor in patients with vernal keratoconjunctivitis and allergic conjunctivitis

BACKGROUND

Vernal keratoconjunctivitis (VKC) is characterized by severe ocular allergic inflammation that may have a poor visual prognosis. Due to the high frequency of the presence of atopic dermatitis (AD) in VKC, most systemic parameters are dependent on the clinical severity of AD.

METHODS

Serum levels of sICAM-1, sVCAM-1, and sIL-2R were measured by enzyme-linked immunoassay using samples from 30 VKC patients, 30 allergic conjunctivitis (AC) patients, and 20 normal subjects, to determine whether the concentrations of these molecules are elevated.

RESULTS

Circulating sICAM-1 and sIL-2R levels were increased in patients with VKC with AD compared with those in VKC without AD, AC, and normal controls. Serum levels of sVCAM-1 in VKC patients with and without AD were significantly higher than those in controls. No significant difference was found in the levels of sVCAM-1 between patients with VKC with and without AD. In VKC patients with AD, the sIL-2R level correlated significantly with severity of AD, whereas no such correlation was found for sICAM-1 and sVCAM-1.

CONCLUSIONS

These results suggest that serum sVCAM-1 can be used as a marker to differentiate VKC from nonproliferative ocular allergic diseases, and specific immunologic features of VKC may underlie the upregulation of serum sVCAM-1.