Management of dupilumab-associated ocular surface diseases in atopic dermatitis patients.

Atopic dermatitis is a chronic inflammatory skin disease characterised by eczematous skin lesions and intense pruritus. It is often associated with other atopic diseases such as allergic rhinitis and conjunctivitis, bronchial asthma and eosinophilic oesophagitis. Dupilumab is the first biologic approved for the treatment of moderate-to-severe atopic dermatitis in Switzerland. Dupilumab targets the interleukin (IL)-4/IL-13 receptor and thus inhibits the signalling of IL-4 and IL-13, two key mediators of type 2 inflammation, resulting in an improvement of clinical signs and symptoms of atopic dermatitis. Patients with atopic dermatitis present more often with ocular surface diseases (OSDs), such as allergic conjunctivitis, blepharitis and keratitis as well as infectious conjunctivitis and keratoconus compared with the general population. Upon dupilumab therapy, increased rates of ocular surface diseases have been reported in clinical trials. Interestingly, dupilumab-associated (da) OSD is restricted to atopic dermatitis patients and has not been observed in asthma and chronic rhinosinusitis trials. Fortunately, most cases of dupilumab-associated OSD are mild-to-moderate and transient. Thus, ocular surface disease presents a particular adverse event of treatment with dupilumab in dermatology. This article aims at providing a practical guide for physicians, with a special focus on dermatologists, allergists and ophthalmologists in Switzerland, to the diagnosis and management of dupilumab-associated OSD in atopic dermatitis patients.For this purpose, an expert group of dermatologists and ophthalmologists from university and cantonal hospitals in Switzerland reviewed data on ocular surface diseases published in clinical trial and real-life reports of dupilumab therapy, published case reports and case series on the management of dupilumab-associated OSD, as well as recent recommendations provided by experts of national and international boards. Based on the observations of dupilumab-associated OSD and practical experiences in identifying and treating OSD, an algorithm has been developed that is specific to the needs in Switzerland. Considering concomitant ocular diseases and differential diagnoses, the clinical presentation of dupilumab-associated OSD and its response to therapeutic measures, a stepwise approach is recommended. Mild dupilumab-associated OSD can be managed by dermatologists and allergists, whereas patients with moderate-to-severe OSD requiring corticosteroid or calcineurin inhibitor therapy should necessarily be referred to an ophthalmologist. The effects of preventive measures, such as artificial tears, are uncertain. The recommendations provided here should guarantee a prompt and effective treatment of OSD for patients under dupilumab therapy in order to prevent that an otherwise potent therapy has to be ceased because of ocular adverse events.

Comparison of Choroidal Thickness Measurements Using Spectral Domain Optical Coherence Tomography in Six Different Settings and With Customized Automated Segmentation Software.

PURPOSE: We investigate which spectral domain-optical coherence tomography (SD-OCT) setting is superior when measuring subfoveal choroidal thickness (CT) and compared results to an automated segmentation software. METHODS: Thirty patients underwent enhanced depth imaging (EDI)-OCT. B-scans were extracted in six different settings (W+N = white background/normal contrast 9; W+H = white background/maximum contrast 16; B+N = black background/normal contrast 12; B+H = black background/maximum contrast 16; C+N = Color-encoded image on black background at predefined contrast of 9, and C+H = Color-encoded image on black background at high/maximal contrast of 16), resulting in 180 images. Subfoveal CT was manually measured by nine graders and by automated segmentation software. Intraclass correlation (ICC) was assessed. RESULTS: ICC was higher in normal than in high contrast images, and better for achromatic black than for white background images. Achromatic images were better than color images. Highest ICC was achieved in B+N (ICC = 0.64), followed by B+H (ICC = 0.54), W+N, and W+H (ICC = 0.5 each). Weakest ICC was obtained with Spectral-color (ICC = 0.47). Mean manual CT versus mean computer estimated CT showed a correlation of r = 0.6 (P = 0.001). CONCLUSION: Black background with white image at normal contrast (B+N) seems the best setting to manually assess subfoveal CT. Automated assessment of CT seems to be a reliable tool for CT assessment. TRANSLATIONAL RELEVANCE: To define optimized OCT analysis settings to improve the evaluation of in vivo imaging.