Paediatric ocular rosacea: diagnosis and management with an eyelid-warming device and topical azithromycin 1.5.

BACKGROUND: Ocular rosacea is a chronic inflammatory disorder with periods of exacerbation and remission, often underdiagnosed in children. When diagnosed, its management is challenging because of a lack of effective long-term treatment options. OBJECTIVE: To report our experience in cases of pediatric ocular rosacea treated with moist heat therapy and topical azithromycin 1.5%. METHODS: The medical records of six children diagnosed with ocular rosacea based on a careful medical history and slit-lamp examination of the eyelids and ocular surface were reviewed. Previous treatments were discontinued, and children/parents were instructed to use the eyelid-warming device for 1 or 2 sessions of 10minutes each day, followed by eyelid massage and cleansing, in combination with azithromycin 1.5% eye drops. RESULTS: The diagnosis of ocular rosacea in these children was delayed for several months or years from the first identifiable clinical sign or symptom. All the children presented with corneal sequelae and decreased vision. Ocular manifestations included meibomian gland disease, recurrent chalazia, and phlyctenular keratoconjunctivitis. Cutaneous signs were not always associated with the condition. Ocular rosacea was usually resistant to initial treatments with antibiotics and topical corticosteroids. Treatment with the eyelid-warming device in combination with azithromycin 1.5% led to a rapid improvement in the clinical signs and was well tolerated by all patients. CONCLUSIONS: Childhood ocular rosacea is potentially sight threatening. Practitioners should consider this condition in order to minimise diagnostic delay and subsequent complications. Combined therapy of eyelid hygiene (including an eyelid warming device) and azithromycin 1.5% eye drops was effective in treating ocular rosacea in children.

[Dupilumab-related blepharoconjunctivitis: Recommendations of the CEDRE group. Atopic dermatitis, conjunctivitis and dupilumab: Which management approach?] / Blépharo-conjonctivites sous dupilumab : recommandations du groupe CEDRE. Dermatite atopique, conjonctivites et dupilumab : quelle prise en charge ?

Dupilumab is a recombinant monoclonal IgG4 type antibody which inhibits IL4 and IL13 signaling. It is indicated in moderate to severe atopic dermatitis (AD) in adults and adolescents over 12 years of age. Its side effects include conjunctivitis and blepharoconjunctivitis, affecting between 4.7% and 28% of patients depending on the study. The incidence of conjunctivitis in patients treated with dupilumab for AD appears to be higher than placebo in clinical studies. This increase was not observed in patients treated with dupilumab for asthma or sinonasal polyposis. The risk factors for conjunctivitis in patients with AD are disease severity, pre-existence of conjunctivitis and low concentrations of dupilumab, but the pathophysiology of this disease is poorly understood. A literature search carried out in April and May 2020 showed an increase in the number of publications on the subject, but there are currently no official joint dermatologist-ophthalmologist recommendations for prevention and management. The objective of this article is to provide an overview of the status of this subject, to address the main questions raised by this type of conjunctivitis and to suggest a course of action for starting and continuing treatment with dupilumab in patients with AD, according to the recommendations of the French Ophthalmologist/Dermatologist group CEDRE.

[Efficacy of intense pulsed light therapy in the treatment of Meibomian gland dysfunction-related severe dry eye]. / Efficacité de la lumière pulsée dans le traitement des sécheresses oculaires sévères par dysfonctionnement meibomien.

INTRODUCTION: Dry eye syndrome caused by Meibomian gland dysfunction (MGD) is a common disease in the general population and impairs quality of life. Intense Pulsed Light (IPL) has mainly been used in dermatology for the treatment of skin disorders, and more recently for MGD-related dry eye. The objective of our study is to evaluate the efficacy and tolerability of IPL with the E-Eye® device (E-Swin, Houdan, France) in severe MGD-related dry eye patients. MATERIALS AND METHODS: This non-comparative study included 20 patients with MGD-related dry eye with a Break-Up Time (BUT)<10seconds, dry eye symptoms >30mm on a Visual Analog Scale (VAS), and failure of lid hygiene and artificial tears. Treatment consisted of 3 sessions of IPL on D0, D15, and D45 (5 flashes of 13J/cm2 per eye). The following parameters were assessed at each visit and at D75 : symptoms graded with a VAS and the Standard Patient Assessment of Eye Dryness questionnaire (SPEED), BUT, corneal fluorescein staining, Meibomian gland expression score, meibography, tear film lipid layer thickness by interferometry and the ocular scattering index by double-pass aberrometry (OQAS). Statistical analysis was performed on the eye most affected at baseline. RESULTS: We included 40 eyes of 20 patients, 15 female and 5 male, mean age 47±15 years (24 to 74 years). The symptoms rated by VAS were severe, averaging 69±25mm. After treatment, there was a statistically significant decrease in symptoms, with a 14mm VAS decrease (55±29mm at D75 versus 69mm at D0, P=0.048) and SPEED score of 3.4 (19.0±6mm versus 22.4±4.6, P=0.03). The number of expressible Meibomian gland ducts increased significantly (from 5.9 to 8.1, P=0.04), lid redness decreased (from 1.4 to 0.6, P=NS) and BUT improved (from 4.2 to 5.9, P=NS). Other parameters remained unchanged. Three patients (15%) complained of transient ocular burning after each treatment. CONCLUSION: IPL appears to be effective in improving signs and symptoms in patients with severe MGD-related dry eye, with a good safety profile. Its exact mechanism of action remains to be elucidated.

[Demodex and ocular surface disease]. / Demodex et pathologies de la surface oculaire.

Demodex is a saprophytic mite of the ocular adnexa, which can in certain circumstances proliferate on the skin of the face and on the eyelid margins. It is involved in facial rosacea (especially in the papulopustular form) and in the development or aggravation of anterior and/or posterior blepharitis or even keratoconjunctivitis, often in association with cutaneous lesions ; the pathophysiology is often multifactorial. Symptoms are non-specific, but the presence of cylindrical sleeves on the eyelashes is very suggestive of infestation, and certain techniques of biomicroscopic examination or imaging, such as confocal microscopy in vivo, allow direct visualization of the parasite. Parasitological examination of the eyelashes can confirm the diagnosis and can be improved by good sampling technique. Eyelid hygiene and oil-based ointments are the cornerstone of treatment. New specific treatments, in particular topical treatments based on tea tree oil, ivermectin, as well as pulsed light therapy and micro-exfoliation of the eyelid margin, can help to reduce the parasitic load and improve symptoms.

Diagnostic tools in ocular allergy.

Ocular allergy (OA) includes a group of common and less frequent hypersensitivity disorders frequently misdiagnosed and not properly managed. The diagnosis of OA is usually based on clinical history and signs and symptoms, with the support of in vivo and in vitro tests when identification of the specific allergen is required. To date, no specific test is available for the diagnosis of the whole spectrum of the different forms of OA. The lack of recommendations on diagnosis of OA is considered a medical need not only for allergists but also for ophthalmologists. This position paper aims to provide a comprehensive overview of the currently available tools for diagnosing OA to promote a common nomenclature and procedures to be used by different specialists. Questionnaires, sign and symptom grading scales, tests, and potential biomarkers for OA are reviewed. We also identified several unmet needs in the diagnostic tools to generate interest, increase understanding, and inspire further investigations. Tools, recommendations, and algorithms for the diagnosis of OA are proposed for use by both allergists and ophthalmologists. Several unmet needs in the diagnostic tools should be further improved by specific clinical research in OA.

Conjunctival allergen provocation test : guidelines for daily practice.

Conjunctival allergen provocation test (CAPT) reproduces the events occurring by instilling an allergen on the ocular surface. This paper is the compilation of a task force focussed on practical aspects of this technique based on the analysis of 131 papers. Main mechanisms involved are reviewed. Indications are diagnosing the allergen(s)-triggering symptoms in IgE-mediated ocular allergy in seasonal, acute or perennial forms of allergic conjunctivitis, especially when the relevance of the allergen is not obvious or in polysensitized patients. Contraindications are limited to ongoing systemic severe pathology, asthma and eye diseases. CAPT should be delayed if receiving systemic steroids or antihistamines. Local treatment should be interrupted according to the half-life of each drug. Prerequisites are as follows: obtaining informed consent; evidencing of an allergen by skin prick tests and/or serum-specific IgE dosages; being able to deal with an unlikely event such as acute asthma exacerbation, urticaria or anaphylaxis, or an exacerbation of allergic conjunctivitis. Allergen extracts should be diluted locally prior to administration. Positive criteria are based on itching or quoted according to a composite score. An alternative scoring is based on itching. CAPT remains underused in daily practice, although it is a safe and simple procedure which can provide valuable clinical information.

[Gas-permeable scleral lens for management of severe keratoconjunctivitis sicca secondary to chronic graft-versus-host disease]. / Traitement des sécheresses oculaires sévères secondaires à la maladie du greffon contre l'hôte chronique par lentilles sclérales perméables à l'oxygène.

INTRODUCTION: Graft-versus-host disease is a major complication of allogeneic hematopoietic stem cell transplantation. Severe keratoconjunctivitis sicca is common in patients with chronic GVH disease. The goal of this study was to evaluate the safety and efficacy of a gas-permeable scleral lens in the management of severe dry eye disease associated with chronic GVH. PATIENTS AND METHODS: This is a retrospective study from June 2009 to November 2013. Patients fitted with scleral lenses for severe keratoconjunctivitis sicca associated with chronic GVH were included. The main outcomes measured were best-corrected visual acuity and quality of life (OSDI and NEI-VFQ25) composite scores before and six months after scleral lens fitting. RESULTS: Sixteen patients were included. The mean age was 52 years (19-69 years). Mean follow-up was 20 months (3-48 months). All patients reported improvement of their ocular symptoms. Best corrected visual acuity improved from 0.21 ± 0.26 to 0.1 ± 0.14 logMAR (P = 0.002), OSDI score improved from 92.1 ± 11.3 to 23.5 ± 11.2 (P = 0.002) and NEI-VFQ25 improved from 41.3 ± 7 to 83.1 ± 15.9 (P = 0.003), 6 months after scleral lens fitting. No serious adverse events, infectious, hypoxemic or allergic complications attributable to the scleral lens occurred. CONCLUSION: Gas-permeable scleral lens use appears to be safe and effective in patients with severe dry eye related to chronic GVH.

Evaluation of an eyelid warming device (Blephasteam) for the management of ocular surface diseases in France: the ESPOIR study.

INTRODUCTION: Eyelid hygiene, including massage and warm compresses, is an important part of the treatment and prevention of Meibomian gland dysfunction (MGD). Although effective, it requires active participation of the patient and lacks standardisation. Blephasteam is a medical device designed to warm and humidify the eyelid with heating glasses, in order to liquify meibum, thus relieving symptoms and preventing relapse. MATERIALS AND METHODS: The ESPOIR study (Evaluation of the Satisfaction of Patients with Management of Ocular Surface Diseases) presented herein was designed to evaluate the safety and efficacy of this medical device in patients with MGD. A total of 28 French centers participated in the study. One hundred and two patients presenting with symptomatic dysfunction or Meibomian-related dry eye underwent two sessions per day with the eyelid warming device and recorded diary entries on a number of parameters every 2 days for the first week and then weekly for the remaining 2 weeks. Patients were assessed on days 0 and 21. RESULTS: Symptomatology, as recorded on a visual analogue scale (VAS) by the investigator (the primary efficacy variable) was significantly (P<0.001) improved at the end of the study (59.97, 95% CI 55.64-64.30 vs. 39.71, 95% CI 34.78-44.65 on Days 0 and 21 respectively), as was the mean symptoms score (mean decrease of 19.93 ± 22.15 VAS units; P<0.001), hyperemia score (-1.57 ± 1.96 and -1.45 ± 1.85; P<0.001, in the worse and contralateral eye respectively), and quality of meibum (mean -4.03 ± 3.08; P<0.001 and -3.32 ± 3.20; P<0.01, in the worse and contralateral eye respectively). More than twice as many reported their symptoms had improved or disappeared compared with those whose symptoms had not changed or had worsened. Global symptomatology, as assessed by the patients, declined throughout the study, and a large majority of patients were satisfied or very satisfied with the treatment. Clear vision and blinking were not impaired during use of the eyelid warming device, which insures proper spreading of the tear film, and patients were able to continue daily activities such as reading and watching television. No adverse events were reported, and there were no changes in intraocular pressure or visual acuity. Safety was rated as satisfactory or very satisfactory by more than 95% of the investigators. CONCLUSION: The study suggests that the eyelid warming device is safe and effective in reducing ocular discomfort and symptoms in MGD.

[The biological characteristics of dominated agents of acute enteric infections].

In 2003-2012 the rate of increase of morbidity of acute enteric infections caused by opportunistic microorganisms came to 3.6%. In the etiologic structure prevailed Klebsiella pneumoniae, Staphylococcus aureus and Enterobacter cloacae. Their percentage varied from 70.5% to 81.6%. The opportunistic microorganisms isolated from feces of patients with acute enteric infections and individuals from control group characterized by presence of pathogenic factors of broad spectrum. The adhesive characteristics were manifested by 50.8±4.4% of analyzed cultures isolated from patients with symptoms of diarrhea infection and by 19.5±3.5% in control group. The anti-lysozyme activity was manifested correspondingly in 86.2±3.0% and 61.7±4.3% of strains. The anti-complement activity was manifested in 70.8±3.9% and 61.7±4.3% of strains. The anti-interferon activity was manifested in 100% and 95.3±1.9% of strains correspondingly. The level of adhesive activity in E. cloacae (35.0±7.5%) and anti-complement and adhesive activity in K. pneumoniae consisted 100% and 85.0±5.6% of strains isolated from feces of patients with acute enteric infections reliably (p<0.05) exceeded values in individuals from control group.

[Assessment of persistent potential dominant pathogens of acute intestinal infections].

To determine the prevalence,and etiological structure of acute intestinal infections, to investigate the dominant agents' persistence factors. According with materials of statistical reports we did the retrospective epidemiological analysis of acute intestinal infections incidence in Sumy region from 2006 till 2011. Biological properties of 40 strains of Klebsiella pneumonia, 40 strains of Enterobacter cloacae and 50 strains of Staphylococcus aureus were investigated. Moderate trend of acute intestinal infections incidence increase was indicated. Bacteria of genera Klebsiella, Enterobacter, Staphylococcus were predominated in etiological structure. Incidence of acute diarrheal infections caused by Klebsiella and Enterobacter was reached the maximum in the spring-summer period. The incidence of staphylococcal etiology was discrete. The strains of Klebsiella pneumonia, Staphylococcus aureus and Enterobacter cloacae were remarkable for different frequency and intensity of persistence factors. Аnti-interferon activity was detected in 100% of clinical isolates of microorganisms, anti-lysozym activity was detected in 87.3 ± 2.9% of clinical isolates of microorganisms, anti-complementary activity was detected in 72.3 ± 3.9% of clinical isolates of microorganisms. Biological properties of opportunistic pathogens that cause acute intestinal infections can be used as epidemiological factors for differentiation of microorganisms pathogenicity.

Oral cyclophosphamide without corticosteroids to treat mucous membrane pemphigoid.

BACKGROUND: Mucous membrane pemphigoid (MMP) still represents a potentially life- and sight-threatening disease. Immunosuppressants, such as cyclophosphamide (CYC), are indicated for patients with severe and/or refractory MMP. OBJECTIVES: To evaluate the efficacy and safety of daily oral CYC without corticosteroids as therapy for severe MMP. METHODS: Thirteen patients with severe refractory MMP, who received oral CYC at an initial dose of 2 mg kg(-1) without corticosteroids, were retained. Previous treatments, for example dapsone, sulfasalazine or topical agents, were maintained during CYC treatment. Initial clinical severity and response to treatment were assessed by scoring. CYC was stopped after complete remission (CR), or when MMP progressed or lymphopenia (< 0·7 × 10(9) cells L(-1) ) occurred. RESULTS: After 52 weeks of CYC treatment, the overall response rate was 69% (9/13 patients) with a median time to disease control of 8 weeks (range 4-52 weeks). Seven patients (54%) entered CR with a median time to CR of 24 weeks (range 16-52 weeks), all remaining in CR at week 52. The mean duration of CYC administration was 12 weeks (range 2-52 weeks). The most common side effect was lymphopenia (10/13 patients), which led to CYC withdrawal for six patients. No sepsis was observed. CONCLUSIONS: CYC without corticosteroids had rapid efficacy in patients with severe refractory MMP and was safe.

Ocular allergy: recognizing and diagnosing hypersensitivity disorders of the ocular surface.

Ocular allergy includes several clinically different conditions that can be considered as hypersensitivity disorders of the ocular surface. The classification of these conditions is complex, and their epidemiology has not been adequately studied because of the lack of unequivocal nomenclature. Ocular allergy symptoms are often, but not always, associated with other allergic manifestations, mostly rhinitis. However, specific ocular allergic diseases need to be recognized and managed by a team that includes both an ophthalmologist and an allergist. The diagnosis of ocular allergy is usually based on clinical history and signs and symptoms, with the support of in vivo and in vitro tests when the identification of the specific allergic sensitization is required for patient management. The aims of this Task Force Report are (i) to unify the nomenclature and classification of ocular allergy, by combining the ophthalmology and allergy Allergic Rhinitis and its Impact on Asthma criteria; (ii) to describe current methods of diagnosis; (iii) to summarize the therapeutic options for the management of ocular allergic inflammation.

[Susac syndrome]. / Syndrome de Susac.

Susac syndrome is a mysterious vasculopathy affecting brain, retina and inner ear in young women. Main features of the disease are increasingly recognized: subacute encephalopathy often mimicking psychosis and frequently heralded with unusual ophthalmic migraine; frequent subclinical meningitis; brain MRI with multiple and bilateral white and gray matter nuclei lesions, with prominent involvement of corpus callosum; bilateral involvement of central retina artery branches, not only with occlusions but also with peculiar leakage of fluorescein through arteriolar walls on late stages of angiography; non-specific bilateral cochleovestibular symptoms with audiogram showing perception hypoacousia that predominates on low frequencies. Outcome, prognosis, pathogenesis and a rational basis for treatment are discussed in this review. A key message for the clinician should be to perform brain MRI, audiogram and retinal angiography whatever the mode of entry, in order not to miss one (or two) features of this syndrome triad.