Dupilumab-associated ocular surface disease: presentation, management and long-term sequelae.

OBJECTIVES: To determine the presenting features of ocular surface disease in patients with atopic dermatitis (AD) treated with dupilumab at a tertiary, university hospital. To establish the need for treatment of dupilumab-associated ocular surface disease and report any long-term effects on the ocular surface. METHODS: A retrospective analysis of consecutive patients treated with dupilumab for AD between January 2017 and August 2019 was undertaken. Data were collected on demographics, incidence and type of ocular disease features, natural history and treatment. RESULTS: A total of 50% (14/28) patients developed ocular symptoms with a mean time of onset of 6.75 (±6.1) weeks from starting dupilumab. Of these, 69% (9/13) were diagnosed with conjunctivitis associated with cicatrisation in two patients and periorbital skin changes in four. Of these nine, four had prior history of atopic keratoconjunctivitis. All were treated with topical steroids; two required additional ciclosporin drops. In all, 67% (6/9) patients went on to have on-going ocular inflammation requiring maintenance drops at a mean of 16 (±6.9) months of follow-up. All patients had improvement in their AD severity; only one patient discontinued dupilumab due to ocular side effects. CONCLUSION: The rate of dupilumab-associated ocular surface disease was 32%. Periorbital skin changes and conjunctival cicatrisation were noted in association with conjunctivitis. Ocular surface disease improved on topical steroids and ciclosporin but 67% of patients needed on-going treatment. Close liaison with an ophthalmologist should be considered in those patients who develop conjunctivitis or have a past history of severe ocular surface disease.

Is the severity of refractive error dependent on the quantity and extent of retinal laser ablation for retinopathy of prematurity?

BACKGROUND/AIM: To test the hypothesis severity of acquired refractive error in Retinopathy of Prematurity (ROP) is dependent on the quantity of laser treatment delivered. METHODS: Two groups (treated and untreated infants) were age and weight matched. Data on the number of laser burns and Retcam II retinal images were analysed using computer aided design software to determine the proportion of area treated. Data were collected until the age of 6 years. RESULTS: The study comprises 43 infants (86 eyes). Twenty-one infants (42 eyes) in the treated group, mean gestational age (GA) was 26.40 (±2.5) weeks versus 27.30 (±1.7) weeks in the matched untreated group (P = 0.650). Birth weight (BW) in the treated group was 812 g (±86) and 804 g (±135) (P = 0.185) in the untreated group. Mean refractive error at 72 months was -2.23 (±4.06) in the treated group and +2.04 (±0.90) in the untreated group (P < 0.005). At 72 months 50% of treated eyes were myopic versus 19% of controls (P = 0.013). Mean laser burns applied were 1855 (±659), mean proportion of retina treated 45% (±10). Myopic eyes had a mean treatment area of 49% (±13) versus 43% (±10) hypermetropia and 42% (±5) emmetropia (P = 0.030). A larger treatment area was associated with a higher degree of myopia and anisometropia at 72 months (P < 0.050). These associations were not found for hypermetropia. CONCLUSIONS: The extent of myopia after retinal laser ablation for ROP is higher if a greater number of laser burns or a larger proportion of the retina is treated.

Factors influencing pupil behaviour during femtosecond laser assisted cataract surgery.

AIM: Femtosecond laser assisted cataract surgery is associated with pupillary constriction. This study aims to look at patient and surgical factors predisposing to abnormal pupil behaviour during FLACS. METHODS: This prospective observational study included all patients undergoing FLACS in the Princess of Wales Hospital, Bridgend, UK between February and June 2017. Pupils were measured at three time points; immediately before and after laser pre-treatment, and at the start of surgery. Pupil behaviour during surgery was noted in descriptive terms, patient demographic, co-morbidities, eye measurements, suction on time, shifting time and laser energy levels were recorded. RESULTS: Seventy-three eyes were included. Average patient age was 74.84 ±â€¯9.1 years. Mean horizontal pupil sizes immediately before and after femto pre-treatment were 7.87 ±â€¯0.87 mm and 7.7 ±â€¯0.89 mm respectively (P < 0.0005). Mean horizontal pupil size at the start of surgery was 6.83 ±â€¯1.43 mm (P < 0.0005). Short capsulotomy-pupil distance (P = 0.01), shallower anterior chamber (P = 0.0012), smaller pre-operative pupil size (P = 0.045) and longer suction on time (P = 0.0019) were significantly associated with intra-operative miosis during FLACS. Sustained mydriasis was observed in eyes in whom topical diclofenac was used within 2 h of surgery. CONCLUSIONS: FLACS can result in significant pupil miosis. Eyes particularly at risk are ones with smaller pre-operative pupils and shallower anterior chambers and those subjected to longer suction on time. Well-timed NSAIDs application could be protective against this phenomenon.

Demographics of older keratoconics in Wales and their mortality rates-Where are the older keratoconics?

AIM: The aim of this study was to identify keratoconics at least 40 years of age attending Welsh optometric hospital services, look at their demographics and mortality rates, and test the hypothesis that they die earlier than the general population. METHODS: Keratoconic patients born before 1972 were identified retrospectively through contact lens services across 5 hospitals in Wales, United Kingdom. Patients' notes were reviewed to confirm the diagnosis and collect demographic data. The Exeter patient registration system was used to trace if patients were deceased or alive. General population data was obtained from the Office for National Statistics. RESULTS: A total of 202 keratoconics at least 40years of age were identified. The mean age was 50.8years, 62% of patients were male and 97% Caucasian. Mean age at diagnosis was 28.7 years. Two patients were deceased, one died in 2012 and one in 2013. In 2012 mortality rates for studied patients and the general populations were 0.005 and 0.019, respectively (p 0.03). CONCLUSIONS: Mortality rates for the identified keratoconics were found to be significantly lower than the mortality rates for the general population in 2012. Collected data represents 52% of expected keratoconics over the age of 40, calculated based on disease prevalence, study inclusion criteria and population numbers within the regions included in the study. Thus suggesting the reason for lack of older keratoconics in the National Health Service optometric clinics could be non-attendance rather than higher mortality rates.

Bilateral papilloedema in Camurati-Engelmann disease.

A 23-year-old woman presented with bilateral papilloedema in a setting of Camurati-Engelmann disease (CED). She was investigated with neuroimaging showing no optic nerve canal stenosis or jugular vein canal compromise. Her MRI venogram was normal. Her opening pressure at lumbar puncture and serum alkaline phosphatase were raised. Her papilloedema resolved with long-term use of acetazolamide. We believe that our patient suffered from raised intracranial pressure directly as a result of decreasing intracranial volume secondary to CED.

'The nodule that disappeared' spontaneous regression of an eyelid noduloulcerative lesion mimicking the features of a basal cell carcinoma.

We describe a case of a clinically apparent basal cell carcinoma (BCC) with spontaneous regression. Histological confirmation of the diagnosis was not possible, and an immunological basis for regression is presumed. The understanding of such immunologically mediated regression of BCCs could provide future therapeutic targeting and research is ongoing.

Corneal calcification and phosphates: do you need to prescribe phosphate free?

PURPOSE: Both superficial band keratopathy and deeper calcareous calcification have been linked to the presence of phosphate excipients in topical ophthalmic medicines. (1-3) The European Medicines Agency (EMA) has concluded that patients with ocular surface disease are at greatest risk. This potential side effect should be highlighted to both prescribers and patients. (4) We aimed to review the excipients of commonly prescribed ophthalmic medicines to prepare a list of phosphate-containing drugs and also to investigate where to find this information. METHODS: We reviewed 78 commonly used ophthalmic drops and ointments for the information about their excipients. We reviewed the information written on drug boxes, bottles, patient leaflets, and in the electronic Medicines Compendium (EMC), which contains up-to-date details of all medicines licensed for use in the United Kingdom. The British National Formulary (BNF) was also reviewed. RESULTS: We found 22 phosphate-containing, 13 unbuffered, and 43 ophthalmic drugs containing buffers other than phosphate based. Most displayed the list of their excipients on their boxes and in patient leaflets. This information was also available on the EMC website but not in the BNF. Despite the EMA recommendation, none of the phosphate-containing medicines mentions corneal calcification as a potential side effect. CONCLUSIONS: We present a reference list of phosphate-based ophthalmic drugs to be used with caution for patients with a compromised ocular surface. We found the EMC to be a reliable and easily accessible source of information about drug components. This information will also be included in the new editions of the BNF.

Cytomegalovirus retinitis in Good syndrome: case report and review of literature.

This report describes the case of a 59-year-old woman diagnosed with cytomegalovirus (CMV) retinitis. The diagnosis was suggested by a typical fundus appearance, and confirmed by a positive PCR for CMV of both serum and vitreous biopsy. HIV status was negative. The patient's medical history included thymoma followed by a thymectomy, recent multiple oral thrush infections, lower respiratory tract infections, urinary tract infections and severe weight loss. She had previously been treated for toxoplasma chorioretinitis and had vitrectomies for retinal detachment in the right eye. Immunological investigations revealed low T cells, almost absent B cells with reduced immunoglobulins consistent with the diagnosis of Good syndrome. The patient received treatment with intravenous ganciclovir, followed by maintenance valganciclovir, resulting in resolution of the ocular pathology. Immunoglobulin replacement therapy to boost the humoral immunity has been commenced.