Ocular Surface Complications Research Articles

Trichloroacetic acid 10% injection for treatment of conjunctival inclusion cysts

ABSTRACTPurpose: To evaluate the effect of intra-lesional injection of Trichloroacetic acid (TCA) 10% in patients with conjunctival inclusion cysts.Methods: This prospective case series study included all patients with conjunctival inclusion cyst who were referred to our referral center from August 2016 to August 2018. All patients received TCA 10% injection into the conjunctival cyst, and outcomes of the intervention were evaluated at least 6 months later.Results: Ten patients with mean age of 24 ± 17.6 (range 6–65) years including three children received TCA 10% injection into the conjunctival cyst. We included 6 anophthalmic and 4 ophthalmic cases. All patients were treated successfully and no recurrence of the lesion was observed in any case. Mean follow up duration was 18.1 ± 8.3 (range 6–28) months.Conclusion: Intra-lesional injection of TCA 10% is a safe, simple, and effective treatment in patients with conjunctival inclusion cysts including ophthalmic cases and anophthalmic cases, both in adults and in children. This concentration may avoid ocular surface complications.

Gene expression analysis of conjunctival epithelium of patients with Stevens-Johnson syndrome in the chronic stage

ObjectiveTo investigate the pathology underlying the ocular surface complications of patients with Stevens-Johnson syndrome (SJS) in the chronic stage.Methods and analysisUsing oligonucleotide microarrays, we performed comprehensive gene expression analysis of...

Conjunctival Retention Cysts: Outcomes of Aspiration and Sclerotherapy With Sodium Tetradecyl Sulfate

To assess the outcome of aspiration and sclerotherapy with sodium tetradecyl sulfate in the management of conjunctival inclusion cysts. Retrospective interventional case series of 6 patients with clinical diagnosis of conjunctival inclusion cysts treated with cyst aspiration and foam sclerotherapy with 3% sodium tetradecyl sulfate. The volume of the sclerosant was 20% of the aspirated cyst volume. Four patients had an inclusion cyst in anophthalmic sockets and 2 patients in sighted eyes. Average time lag between primary surgery and cyst formation was 14.6 months (range 2-30 months). Average amount of fluid aspirated from cyst was 3.07 ml (range 1-9 ml). Average volume of sclerosant injected was (20% of the aspirated volume) 0.55 ml (range 0.2-1.1 ml). All 6 patients showed complete resolution of cyst at a mean follow-up period of 15.6 months (range 9-24 months). All but one showed complete resolution of cyst with single injection sclerosant. Only 1 patient required a second sclerosant injection. There was no ocular surface or implant-related complications in this cohort. Cyst aspiration and sodium tetradecyl sulfate foam sclerotherapy is a minimally invasive procedure for the management of conjunctival inclusion cysts in anophthalmic sockets and sighted eyes. The injection of sodium tetradecyl sulfate in a dose of 20% of the aspirate is effective in the management of conjunctival inclusion cysts over a follow-up period of 13 months. The procedure is safe, with insignificant inflammation and without ocular surface or implant complications.

Influence of diabetes mellitus on anterior segment of the eye.

Diabetes mellitus (DM) has been emerging as one of the most serious health problems worldwide. Ocular complications of DM are currently one of the major causes of blindness in developed countries, among which diabetic retinopathy is relatively well studied and understood. However, although ocular surface complications of DM are common, diabetic complications of anterior segment of the eye, such as, cornea, conjunctiva, and lacrimal glands, are often overlooked. DM is associated with progressive damage to corneal nerves and epithelial cells, which increases the risk of anterior segment disorders including dry eye disease, corneal erosion, persistent epithelial defects, and even sight-threatening corneal ulcer. In this review, the authors will discuss the association of DM with disorders of anterior segment of the eye. Studies indicating the value of corneal nerve assessment as a sensitive, noninvasive, and repeatable biomarker for diabetic neuropathy will also be introduced. In addition, treatment modalities of anterior segment disorders associated with DM is discussed. The studies introduced in this review suggest that early and periodic screening of the anterior segment of the eye, as well as the retina, is important for the optimal treatment of DM.

Brown Mc Lean Syndrome: A Case Report

Purpose: The aim of this study was to report a case of Brown-McLean syndrome (BMS). Method: A complete ophthalmic evaluation and follow up for a 77 year old patient with BMS. Result: BMS is a rare condition with corneal edema involving the peripheral cornea with orange-brown pigment deposition underlying the edematous area. The edema typically starts inferiorly and advances circumferentially to superior cornea. Central cornea remains clear in most patients. It requires no further treatment and annual follow-ups are adequate. Conclusion: Patients with BMS can rarely progress to corneal decompensation; however, they should be periodically monitored and made aware of early clinical symptoms and signs of ocular surface complications.

Minimally invasive scleral buckling surgery under operating microscope for the treatment of rhegmatogenous retinal detachment

Objective To evaluate the efficacy of minimally invasive scleral buckling surgery under operating microscope for the treatment of rhegmatogenous retinal detachment (RRD). Methods The data of 74 eyes of 72 patients with RRD from Dec. 2015 to Jun. 2017 were analyzed retrospectively. All cases were treated with minimally invasive scleral buckling under operating microscope. The operation time, postoperative reattachment, ocular surface recovery and complications were observed. Results The average duration of surgery was (26.7±20.2) min. One week after surgery, 68 eyes gained retinal reattachment; subretinal fluid was not absorbed at 3 days after surgery in 3 eyes and they received air tamponade. The retina was successfully reattached in 2 eyes and 1 eye received air tamponade again. One eye with large retinal tear gained retinal reattachment after vitrectomy. During the follow-up period, there were 2 eyes with new retinal redetachment. All retina were reattached after second surgery. The BCVA (LogMAR) was mean 1.32±0.37 before surgery, and BCVA at the last follow-up was 0.12±0.16. The difference was significant between after and before operation (t=16.52, P<0.001). Conclusion Minimally invasive scleral buckling surgery under operating microscope is a safe and efficient surgical method. Key words: Minimal invasive; Scleral buckling; Surgical microscope; Retinal detachment, rehgmatogenous

Outcomes after surgical resection of lower eyelid tumors and reconstruction using a nasal chondromucosal graft and an upper eyelid myocutaneous flap

Surgical excision of large malignant lower eyelid tumors may cause important full-thickness eyelid defects. The reconstruction of such defects must restore the physiologic function of the eyelid and also re-establish an acceptable aesthetic result. We report the outcomes of full-thickness excision of tumors extending over half of the horizontal lid length, followed by reconstruction using a nasal chondromucosal graft (coming from the ipsilateral ala of the nose) and an upper eyelid myocutaneous flap. Histological analysis of the specimen identified the tumor type and surgical margins for each patient. A total of 25 patients were operated using this reconstruction technique between March 2009 and June 2015: 17 basal cell carcinomas, 3 spindle cell carcinomas and 5 conjunctival melanomas (out of which 2 were associated with lentigo maligna). Mean duration of follow-up after surgery was respectively 36, 41 and 17 months for each of these 3 tumor types. We found a single local tumor recurrence and this was a basal cell carcinoma in a xeroderma pigmentosum patient. After surgery, none of the patients had lagophthalmos or ocular surface complications. Only 4 patients had a 1mm scleral show postoperatively; 3 other patients developed a small retraction of the eyelid after adjuvant radiotherapy and a 1mm scleral show occurred. In malignant tumors, complete surgical excision with histological margins adapted to tumor type prevents local recurrence in most cases. Our repair strategy of nasal chondromucosal graft and skin-muscle flap for large inferior eyelid defects provides good functional and aesthetic results.

Plasmapheresis, Intravenous Immunoglobulins, and Autologous Serum Eyedrops in the Acute Eye Complications of Toxic Epidermal Necrolysis.

Toxic epidermal necrolysis (TEN) is a rare, life-threatening, drug-induced, mucocutaneous disease, which can severely affect the ocular surface. The purpose of this study was to investigate the efficacy of plasmapheresis, human IV immunoglobulins (IVIg), and autologous serum (AS) eyedrops in the treatment of the severe acute ocular complications of TEN. A retrospective chart review of all patients admitted to the Burn Unit, Azienda Ospedaliero-Universitaria-Sassari, Sassari, Italy, from 2009 to 2015, identified 9 patients (2 men, 7 women; mean age 63.8 ± 24.7 years) with TEN. Bilateral, acute ocular surface complications were observed in 7 (78%) patients; 3 showed catarrhal conjunctivitis, whereas 4 had severe pseudomembranous conjunctivitis and corneal ulcers. All patients with TEN were immediately treated with plasmapheresis and human IVIg, which produced a marked improvement in the patients' general condition. In the 3 with catarrhal conjunctivitis, preservative-free artificial tears and topical antibiotics were beneficial. In the 4 with severe pseudomembranous conjunctivitis and corneal ulcers, treatment with AS eyedrops resulted in corneal and conjunctival epithelium healing over 3-6 weeks. After a minimum follow-up of at least 12 months, there were minimal/mild residual signs and symptoms of dry eye. Plasmapheresis and IVIg may be life-saving and contribute to reduce ocular surface inflammation in TEN. Autologous serum eyedrops, prepared after plasmapheresis completion and IVIg infusion, may be helpful in the management of the severe acute ocular complications of TEN.

Impact of diabetes mellitus on the ocular surface: a review.

Although diabetes mellitus is reaching epidemic proportions worldwide, ocular surface complications are still largely believed to be uncommon. Although these complications are not often sight threatening, the general well-being of patients and the cost of their health care can be respectively compromised and added by them. Over the last decade, an association of ocular surface complications (in particular reduced corneal sub-basal nerve density and corneal sensitivity) with peripheral neuropathy has emerged, which could help recognize the development of peripheral complications at an earlier stage and also provide research opportunities for examining new treatment modalities of diabetic neuropathies. The ocular surface complications of diabetes mellitus and their association with peripheral neuropathy are reviewed by this report.

Transplant related ocular surface disorders: Advanced techniques for ocular surface rehabilitation after ocular complications secondary to hematopoietic stem cell transplantation.

HSCT has been linked to the development of an assortment of ocular surface complications with the potential to lead to permanent visual impairment if left untreated or if not treated early in the course of disease. Strategies for therapy include maintenance of lubrication and tear preservation, prevention of evaporation, decreasing inflammation, and providing epithelial support. The ultimate aim of treatment is to prevent permanent ocular sequelae through prompt ophthalmology consultation and the use of advanced techniques for ocular surface rehabilitation. We describe several rehabilitation options of ocular surface complications occurring secondarily during the post-HSCT course.

Infectious Keratitis in Limbal Stem Cell Deficiency: Stevens-Johnson Syndrome Versus Chemical Burn.

To investigate the incidence, clinical and microbiological characteristics, risk factors, and therapeutic outcome of infectious keratitis in patients with limbal stem cell deficiency (LSCD) related to Stevens-Johnson syndrome (SJS) and corneal chemical burn. Medical records of 90 eyes of 59 patients who were diagnosed with LSCD resulting from SJS (52 eyes of 29 patients) or corneal chemical burn (38 eyes of 30 patients) were reviewed. Infectious keratitis developed in 35% of LSCD patients with SJS (18 eyes, 14 patients) and in 18% of those with chemical burn (7 eyes, 7 patients). The development of infectious keratitis in SJS was significantly associated with the severity of chronic ocular surface complications in the cornea, conjunctiva, and eyelids and with the use of topical corticosteroids during the disease course. All cases of infectious keratitis following chemical burn occurred in patients with grade III or IV burn by Roper-Hall classification. Approximately 83% of culture-proven cases of infectious keratitis were bacterial infection, most of which (80%) were caused by Gram-positive bacteria. For resolution of infection, 17 eyes (68%) received surgery in addition to medical treatment, whereas 8 eyes (32%) received medical treatment alone. After infection resolution, the final visual acuity was decreased in 10 eyes (40%) compared with before infection. Infectious keratitis is a common complication of LSCD associated with SJS or severe chemical burn to the cornea. Despite medical and surgical treatments, the visual outcome is poor.

Genetic Predisposition to Stevens-Johnson Syndrome With Severe Ocular Surface Complications.

Stevens-Johnson syndrome (SJS) is an acute inflammatory vesiculobullous reaction of the skin and mucosa, including the ocular surface, oral cavity, and genitals. In patients with extensive skin detachment and a poor prognosis, the condition is termed toxic epidermal necrolysis (TEN). This review covers 4 topics: (1) ophthalmic SJS, (2) human leukocyte antigen (HLA) analysis, (3) genome-wide association studies, and (4) other pathogenic factors. Severe ocular complications (SOCs) develop in some SJS/TEN patients diagnosed by dermatologists. Cold medicine-related SJS/TEN (CM-SJS/TEN) with SOCs is associated with HLA-A*02:06 in Japanese and Koreans and HLA-B*44:03 in Japanese, Indians, and Brazilian whites. We conducted a genome-wide association study for CM-SJS/TEN with SOCs and found that IKZF1 single-nucleotide polymorphisms (SNPs) were significantly associated with CM-SJS/TEN with SOCs, and that the ratio of the Ik2/Ik1 isoforms might be influenced by these IKZF1 SNPs. Moreover, HLA-A*02:06 with TLR3 polymorphisms and HLA-A*02:06 with EP3 polymorphisms exerted additive effects in SJS/TEN with SOCs. EP3 is strongly downregulated in the conjunctival epithelium of SJS/TEN. Cold medicines including nonsteroidal antiinflammatory drugs, which are the main causative drugs for SJS/TEN with SOCs, downregulate the production of prostanoids, including PGE2. Because the PGE2-EP3 pathway suppresses the inflammation of the ocular surface, skin, and respiratory tract, downregulation of PGE2 by nonsteroidal antiinflammatory drugs or acetaminophen might significantly contribute to the onset of CM-SJS/TEN with SOCs. Cold medicines and infectious agents such as viruses or other microbes are both important in triggering the onset of SJS/TEN with SOCs.

Ocular surface disease in patients with diabetic peripheral neuropathy

PurposeTo analyse clinical signs and symptoms of ocular surface disease in patients with diabetes mellitus (DM), based on severity of diabetic peripheral neuropathy (DPN).MethodsThis cross-sectional study included participants who were...

Management of Dry Eye in Sjögren’s Syndrome

The treatment of dry eye in Sjogren’s syndrome varies based on the severity of the disease. First-line therapy usually includes environmental changes and lubrication of the ocular surface with the use of artificial tears and/or ointments. Punctal occlusion may also help by extending available lubrication via natural or artificial tears. However, the occlusion of the puncta is usually recommended after ocular inflammation is addressed by topical medications. The main anti-inflammatory topical treatment for Sjogren’s syndrome-related dry eye is topical cyclosporine A. Cyclosporine A 0.05 % is the only commercially available ophthalmic emulsion approved by the US Food and Drug Administration to be used in the treatment of dry eye. In severe cases, a 1 % compounded preparation of the cyclosporine or more frequent instillation of 0.05 % cyclosporine may be more efficient. Topical steroids can be considered as a short-term “pulse treatment” for inflammatory exacerbations of the disease given the high risk of complications with chronic use. In refractory cases, other anti-inflammatory treatments including autologous serum and topical tacrolimus may be considered. Contact lenses may help with the healing of the superficial keratitis or sterile ulcers. For the proper management of Sjogren’s syndrome-related dry eye, it is important to diagnose the disease in its early stages and start topical or local anti-inflammatory treatment before irreversible damage occurs in the lacrimal glands and on the ocular surface. The ocular surface complications of such as sterile corneal ulcers, opacification, and perforation may necessitate extensive surgeries, including corneal transplantation or keratoprosthesis implantation for the restoration of vision.

The Role of Systemic Immunomodulatory Treatment and Prognostic Factors on Chronic Ocular Complications in Stevens–Johnson Syndrome

To compare the effect of early systemic immunomodulatory treatment and to identify prognostic factors of chronic ocular complications in Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) patients. Retrospective, comparative, multicenter study. Forty-three patients admitted to 1 of 3 University Hospitals (Seoul National University Hospital, Chonnam National University Hospital, and Yonsei University Hospital) with a diagnosis of SJS or TEN who were followed up for at least 6 months in Korea. Patients were divided into 5 groups according to systemic immunomodulatory treatment received: systemic steroids (S), intravenous immunoglobulin (IVIG), combined S plus IVIG, systemic pulse steroids (PS), and supportive care only (C). Best-corrected visual acuity (BCVA) and chronic ocular surface complications score (COCS; range, 0-15) at final follow-up were compared among the 5 groups. Prognostic factors at onset (age, gender, causative drugs, initial visual acuities, acute ocular involvement score [range, 0-3], acute systemic involvement score [range, 0-16], systemic steroid dose, IVIG dose, and amniotic membrane transplantation [AMT]) were analyzed to predict final BCVA or COCS using logistic regression or linear regression analysis. Best-corrected visual acuity and COCS at final follow-up. The mean age and follow-up period of the patients was 30.5±21.0 years and 29.1±30.4 months, respectively. The acute systemic involvement score in the IVIG, S plus IVIG, and PS groups was significantly higher than that in the S and C groups (P < 0.001). However, final BCVA and COCS were not significantly different between groups, even after statistical adjustment. High COCS (≥8 points) was associated with female gender (P= 0.012) and AMT at the acute stage (P= 0.040). High acute ocular and systemic involvement scores wereassociated with worse COCS (P < 0.001), and COCS showed good correlation with final BCVA (R(2)=0.7101; P < 0.0001). There were no therapeutic benefits of systemic immunomodulatory treatments in final visual outcome and COCS in SJS and TEN patients. Female gender and acute ocular and systemic involvement scores may be prognostic factors predicting chronic ocular complications.

Transpalpebral proton beam radiotherapy of choroidal melanoma

BackgroundCollateral damage to upper eyelid margin during proton beam radiotherapy (PBR) for choroidal melanoma may cause squamous metaplasia of the tarsal conjunctiva with keratinisation, corneal irritation, discomfort and, rarely, corneal...

Trans-ethnic study confirmed independent associations of HLA-A*02:06 and HLA-B*44:03 with cold medicine-related Stevens-Johnson syndrome with severe ocular surface complications.

Stevens-Johnson syndrome (SJS) and its severe variant, toxic epidermal necrolysis (TEN), are acute inflammatory vesiculobullous reactions of the skin and mucous membranes. Cold medicines including non-steroidal anti-inflammatory drugs and multi-ingredient cold medications are reported to be important inciting drugs. Recently, we reported that cold medicine related SJS/TEN (CM-SJS/TEN) with severe mucosal involvement including severe ocular surface complications (SOC) is associated with HLA-A*02:06 and HLA-B*44:03 in the Japanese. In this study, to determine whether HLA-B*44:03 is a common risk factor for CM-SJS/TEN with SOC in different ethnic groups we used samples from Indian, Brazilian, and Korean patients with CM-SJS/TEN with SOC, and investigated the association between CM-SJS/TEN with SOC and HLA-B*44:03 and/or HLA-A*02:06. We found that HLA-B*44:03 was significantly associated with CM-SJS/TEN with SOC in the Indian and Brazilian but not the Korean population, and that HLA-A*02:06 might be weakly associated in the Korean- but not the Indian and Brazilian population.

HLA association with antipyretic analgesics‐induced Stevens‐Johnson Syndrome/toxic epidermal necrolysis with severe ocular surface complications in japanese patients

Background Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), are severe adverse drug reactions which are very rare, acute, serious, and potentially fatal. They exhibit characteristic symptoms not only in the skin, but also in the mucosal tissues such as ocular surface, oral cavity, and genitals. Although antipyretic analgesics (AAs) are some of the most frequent causative drugs of SJS/TEN, there has been no HLA association studies on these drugs-induced SJS/TEN. The scope of this study is to investigate HLA-type association with AA-related SJS/TEN with severe ocular surface complications (SOCs). Method

Medication tendencies for inducing severe ocular surface symptoms in Japanese Stevens‐Johnson Syndrome / toxic epidermal necrolysis patients

Background Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), are severe cutaneous adverse drug reactions that often induces the mucosal tissue impairments. These symptoms in ocular surface sometimes suffer the patients with pseudomembrane formation leading to vision loss as a sequela. The purpose of this study to reveal the medication tendencies for inducing severe ocular surface complications in SJS/TEN of Japanese populations.

Strong association between hla‐a*02:06 and acetaminophen‐related stevens‐johnson syndrome with severe mucosal involvements in the Japanese

Background Stevens-Johnson syndrome (SJS) and its severe variant, toxic epidermal necrolysis (TEN), are acute inflammatory vesiculobullous reactions of the skin and mucous membranes of, for example, the ocular surface, oral cavity, and genitals. They are rare but often associated with inciting drugs. Cold medicines including non-steroidal antiinflammatory drugs (NSAIDs) and multi-ingredient cold medications are reported to be important inciting drugs. We investigated the association between HLA genotypes and cold medicine-related SJS/TEN (CM-SJS/TEN) with severe mucosal involvement such as severe ocular surface complications (SOC). We also investigated the association between HLA genotypes and acetaminophen-related SJS/ TEN in patients with CM-SJS/TEN with SOC. Methods Japanese acetaminophen-related SJS/TEN patients consist of 59 patients, they were among the 131 CM-SJS/TEN with SOC. While the specific drugs were not named by all 131 patients, 59 (45.0%) were known to have taken medicines containing acetaminophen. The diagnosis of SJS/TEN with SOC was based on a confirmed history of acute-onset high fever, serious mucocutaneous illness with skin eruptions, and the involvement of at least 2 mucosal sites including the oral cavity and ocular surface. We analyzed HLA-A, -B, and -C of 131 CM-SJS/TEN patients and 419 Japanese controls. Results