Dupilumab-associated ocular surface disease: An interdisciplinary decision framework for prescribers in the Australian setting.

BACKGROUND/OBJECTIVES: Dupilumab-associated ocular surface disease (DAOSD) is of particular relevance in patients with atopic dermatitis (AD). Guidance on DAOSD assessment and management in the Australian setting is needed to reduce its impact and minimise disruption to treatment. METHODS: A systematic review of the literature was undertaken to identify data pertaining to the incidence, pathophysiology, risk factors and management of DAOSD. A critical review of this literature was used to inform a decision framework for dupilumab-prescribers and develop a graded severity scoring tool to guide appropriate management options. RESULTS: DAOSD typically emerges within 4 months of commencing dupilumab and the occurrence of new events diminishes over time. The reported incidence varies widely depending on the nature and source of the data: 8.6-22.1% (clinical trials programme), 0.5-70% (real-world data; differences in study size, duration of follow-up, ophthalmologist intervention, use of prophylaxis). Occurrence increases with AD severity and in patients with prior history of ocular disease; pathophysiology is still to be fully characterised. Management options have evolved over time and include lubricants/artificial tears, corticosteroids, calcineurin inhibitors, antihistamines, anti-inflammatory agents and antimicrobial agents. Current therapies aim to resolve symptoms or reduce severity to levels sufficiently tolerable to enable continuation of dupilumab therapy. CONCLUSIONS: Recommendations for DAOSD assessment and management include identification of high-risk patients, vigilance for red flags (keratoconus, herpetic and bacterial keratitis), regular assessment of symptom severity (before and during dupilumab therapy), conservative management of mild DAOSD by the prescribing physician and ophthalmologist referral for collaborative care of moderate-severe DAOSD and high-risk patients.

Hypophysitis due to IgG4-related disease responding to treatment with azathioprine: an alternative to corticosteroid therapy.

PURPOSE: Fifteen cases of lymphocytic hypophysitis due to IgG4-related disease have been reported demonstrating marked improvement with corticosteroid therapy. This is the first case of IgG4-related hypophysitis demonstrating improvement with azathioprine, where corticosteroids were initially tried but ceased due to concern regarding enlargement of the pituitary infiltrate. METHODS: Case description and review of 15 cases reported in the literature. A 40 year old male was diagnosed with IgG-4 related disease based on pituitary and lacrimal gland biopsies associated with raised serum concentration of IgG4. The patient was commenced on prednisolone 30 mg/day, as rapid response to prednisolone treatment has been described in the literature for other cases of IgG4-related hypophysitis. Over the next 3 months, prednisolone treatment resulted in a reduction of serum IgG4 levels, but repeat MRI scan showed an enlarging pituitary mass with new optic nerve compression. Azathioprine 75 mg twice daily was commenced and in the subsequent 3 months, IgG4 levels normalised (0.58 g/L) and MRI scan showed 50% shrinkage of the pituitary mass. After 10 months of azathioprine treatment the MRI showed a normal sized pituitary but persistence of the infraorbital nerve thickening. CONCLUSIONS: Hypophysitis due to IgG4-related disease usually demonstrates prompt response to corticosteroids. This case highlights the need to image promptly after starting treatment to exclude an enlarging pituitary mass despite corticosteroid treatment. Alternative therapy with azathioprine can result in marked improvement. It should be remembered that IgG-4 related hypophysitis is part of a multi-organ disease.

A Rare Tick Tale: A Novel Case of the Australian Paralysis Tick Causing Multiple Cranial Neuropathies.

The Australian paralysis tick (Ixodes holocyclus) is found along the east coast of Australia. Tick bites may result in paralysis ranging from muscular weakness to ascending paralysis requiring respiratory support. Ocular complications and facial nerve involvement are rare. We present a rare occurrence of tick-bite-associated visual loss, proptosis, and multiple cranial neuropathies not previously reported in the literature. The tick was removed, and the patient's symptoms improved following treatment with steroids and oral doxycycline. The vision and sensory changes are not explained by the Ixodes toxin; thus, we hypothesize this is related to orbital apex inflammation.

Medial tarsal suspension: a method of elevating the medial lower eyelid.

PURPOSE: When attempting to elevate the lower eyelid for any reason, medial elevation is the most difficult to attain. Medial canthal tendon tightening creates mostly horizontal tension and contributes little vertical vector. We present a technique for applying a lifting force to the medial end of the eyelid: medial tarsal suspension. METHODS: The technique to suspend the medial lower eyelid tarsal plate to the superior orbital rim periosteum is described. The procedure, medial tarsal suspension (MTS), was performed on 38 lower lids of 24 patients. Adjunctive procedures, most commonly lateral canthal sling, were performed on 66% of the lids at the time of the initial medial tarsal suspension. The patients ranged in age from 29 years to 84 years. All had medial lower eyelid retraction, with facial nerve palsy, Graves eye disease, involutional lower eyelid retraction, and forms of muscular dystrophy the commonest etiologies. RESULTS: Thirty-one (82%) of the 38 MTS procedures were successful. There was no unifying factor among the seven failed procedures in five lids of five patients. Three of the five patients, including two who were operated on twice, ultimately had a successful MTS. This procedure was not repeated on the other two failed patients. Range of follow-up was 9 months to 5.6 years, with a mean of 3.7 years. The mean elevation of the central lower eyelid was 1.6 mm in the successful cases. CONCLUSIONS: Medial tarsal suspension is an effective way to elevate the medial end of the lower eyelid.