Brimonidine-induced unilateral ocular lichen planus: a case report / Líquen plano ocular unilateral induzido por brimonidina: relato de caso

ABSTRACT This report was written to describe a case of unilateral brimonidine-induced conjunctival lichen planus. Because the ophthalmic examination indicated chronic conjunctivitis or drug-induced pseudopemphigoid, the patient underwent thorough ophthalmic and systemic examinations, as well as conjunctival biopsy and direct immunofluorescence studies. A 71-year-old woman with unilateral left eye findings of chronic conjunctivitis was referred to our Ophthalmology Department. The patient reported that chronic conjunctivitis began shortly after she initiated use of topical brimonidine. Ophthalmic examination revealed foreshortening of the inferior fornix and symblepharon. Conjunctival biopsy revealed submucous lymphocytes and shaggy distribution of fibrinogen on direct immunofluorescence; this was suggestive of ocular lichen planus. No other systemic lesions were found that were consistent with the presentation of lichen planus. A good response was observed to topical cyclosporine treatment. To our knowledge, this may be the first report of unilateral ocular lichen planus without systemic findings. The correlation with the initiation of topical brimonidine suggests that this might be the first case of biopsy-confirmed brimonidine-induced ocular lichen planus.

RESUMO Este relato é para descrever um caso de líquen plano conjuntival unilateral induzido por brimonidina. Como o exame oftalmológico indicava conjuntivite crônica ou pseudopenfigóide induzido por medicamento, o paciente foi submetido a exames oftalmológicos e sistémicos completos, além de biópsia conjuntival e estudos de imunofluorescência direta. Uma mulher de 71 anos de idade com achados unilaterais do olho esquerdo de conjuntivite crônica foi encaminhada ao nosso departamento de Oftalmologia. A paciente relatou que a conjuntivite crônica começou logo após o início do uso da brimonidina tópica. O exame oftalmológico revelou encurtamento do fórnice inferior e do symblepharon. A biópsia conjuntival revelou linfócitos submucosos e distribuição felpuda de fibrinogênio na imunofluorescência direta; isso era sugestivo de líquen plano ocular. Não foram encontradas outras lesões sistêmicas compatíveis com a apresentação do líquen plano. Uma boa resposta foi observada no tratamento tópico com ciclosporina. Pelo nosso conhecimento, este pode ser o primeiro relato de líquen plano ocular unilateral sem achados sistêmicos. A correlação com o início da brimonidina tópica sugere que este pode ser o primeiro caso de líquen plano ocular induzido por brimonidina confirmado por biópsia.

Brimonidine-induced unilateral ocular lichen planus: a case report.

This report was written to describe a case of unilateral brimonidine-induced conjunctival lichen planus. Because the ophthalmic examination indicated chronic conjunctivitis or drug-induced pseudopemphigoid, the patient underwent thorough ophthalmic and systemic examinations, as well as conjunctival biopsy and direct immunofluorescence studies. A 71-year-old woman with unilateral left eye findings of chronic conjunctivitis was referred to our Ophthalmology Department. The patient reported that chronic conjunctivitis began shortly after she initiated use of topical brimonidine. Ophthalmic examination revealed foreshortening of the inferior fornix and symblepharon. Conjunctival biopsy revealed submucous lymphocytes and shaggy distribution of fibrinogen on direct immunofluorescence; this was suggestive of ocular lichen planus. No other systemic lesions were found that were consistent with the presentation of lichen planus. A good response was observed to topical cyclosporine treatment. To our knowledge, this may be the first report of unilateral ocular lichen planus without systemic findings. The correlation with the initiation of topical brimonidine suggests that this might be the first case of biopsy-confirmed brimonidine-induced ocular lichen planus.

Optical Coherence Tomography Thickness Measurements of the Extraocular Rectus Muscle Tendons in Graves' Ophthalmopathy.

PURPOSE: To examine extraocular rectus muscle tendons in patients with Graves' ophthalmopathy using optical coherence tomography (OCT). METHODS: This was a cross-sectional observational study conducted with 55 healthy controls, 45 patients with clinically inactive Graves' ophthalmopathy, and 12 patients with clinically active Graves' ophthalmopathy. Scanning was performed at the 3- and 9-o'clock positions. The medial rectus tendon thickness was measured at 7.2 and 9.2 mm from the limbus and the lateral rectus tendon thickness was measured at 8.5 and 10.5 mm from the limbus. RESULTS: The 9.2-mm medial rectus, 8.5-mm lateral rectus, and 10.5-mm lateral rectus tendons were thicker in the inactive Graves' ophthalmopathy group than the control group (240 ± 70, 231 ± 63, and 228 ± 54 µm vs 201 ± 71, 199 ± 53, and 200 ± 32 µm, respectively; P ≤ .011), whereas the 8.5-mm lateral rectus and 9.2-mm medial rectus tendons were thicker in patients with active Graves' ophthalmopathy than patients with inactive Graves' ophthalmopathy (274 ± 77 and 283 ± 68 µm vs 231 ± 63 and 240 ± 70 µm, respectively; P ≤ .048). A correlation was detected between lateral rectus and medial rectus tendon thicknesses and the Graves' ophthalmopathy clinical activity score (R = 0.252, P = .035; and R = 0.291, P = .013, respectively). CONCLUSIONS: OCT emerged as an accurate method for measuring medial rectus and lateral rectus tendon thicknesses in patients with Graves' ophthalmopathy. The imaging tool was able to detect thicker horizontal rectus tendons in patients with inactive Graves' ophthalmopathy than in controls, and in patients with active compared to inactive disease. [J Pediatr Ophthalmol Strabismus. 2018;55(6):356-362.].

Efficacy of Tocilizumab in Patients With Moderate-to-Severe Corticosteroid-Resistant Graves Orbitopathy: A Randomized Clinical Trial.

OBJECTIVE: To demonstrate the efficacy of the anti-interleukin-6 receptor monoclonal antibody tocilizumab in patients with moderate-to-severe corticosteroid-resistant Graves orbitopathy (GO). DESIGN: Double-masked randomized clinical trial. METHODS: Setting and Participants: Thirty-two adults with moderate-to-severe corticosteroid-resistant GO from 10 medical centers in Spain were randomized (1:1). INTERVENTION: Randomization to either 8 mg/kg body weight tocilizumab or placebo administered intravenously at weeks 0, 4, 8, and 12, and follow-up for an additional 28 weeks. Main Outcomes and Measures: The primary outcome was the proportion of patients with a change from baseline to week 16 of at least 2 in the clinical activity score (CAS). RESULTS: The primary outcome was met by 93.3% (95% confidence interval [CI] 70.1%-98.8%) of the patients receiving tocilizumab and 58.8% (36%-78.3%) receiving placebo (P = .04; odds ratio, 9.8 [CI 1.3-73.2]). A significant difference was also observed in the proportion of patients achieving a CAS < 3 (86.7% [CI 62.1%-96.2%] vs 35.2% [CI 17.3%-58.7%], P = .005; OR 11.9 [CI 2.1-63.1]) at week 16. Additionally, a larger proportion of patients with improvement in the European Group on GO-proposed composite ophthalmic score at week 16 (73.3% [CI 48%-89.1%] vs 29.4% [CI 13.2%-53.1%]; P = .03), and exophthalmos size change from baseline to week 16 (-1.5 [-2.0 to 0.5] mm vs 0.0 [-1.0 to 0.5] mm; P = .01) were seen with tocilizumab. One patient experienced a moderate increase in transaminases at week 8; another had an acute pyelonephritis at week 32 in the tocilizumab-treated group. CONCLUSION: Tocilizumab offers a meaningful improvement in activity and severity in corticosteroid-resistant GO. This trial justifies further studies to characterize the role of tocilizumab in GO.

Epiphora after Uncomplicated Phacoemulsification: Study of Prevalence and Associated Factors.

PURPOSE: To describe the prevalence of epiphora and associated factors after uncomplicated phacoemulsification. METHODS: Prospective and descriptive design. A group of 125 patients was asked about tearing one to two weeks after cataract surgery. A comprehensive examination was performed on the patients who answered affirmatively. All patients were re-interviewed by phone after three months and those who complained of epiphora were explored again. RESULTS: Two weeks after surgery, prevalence of epiphora was 10.4%, but only 3.2% appeared after surgery. In patients with preoperative epiphora, the most frequently associated factors were ocular surface alterations (89%) and unctual and canalicular stenosis (56%). In patients with "new onset" epiphora (4 patients), these factors were: blepharitis (2/4), low tear break-up time (2/4), high tear meniscus (2/4), partial nasolacrimal duct obstruction (2/4), and unctual stenosis (1/4). Three months after surgery, the prevalence of epiphora was 13%, but only 7% appeared after surgery (6 patients). Of those 6 patients, 4 were re-examined: nasolacrimal duct obstruction (2/4), ocular surface problems (3/4), and unctual stenosis (1/4). CONCLUSIONS: Presence of epiphora two weeks after phacoemulsification was infrequent, despite being present in a high proportion of patients before surgery. There was not a noticeable increase in epiphora at three months. The most frequently related factors were mixed disorders of the ocular surface and lacrimal system, without an important incidence of unctual and canalicular stenosis. We consider that our perception about complaints from patients after phacoemulsification may be biased due to those who had previously suffered from epiphora.