Ocular toxicity of systemic asthma and allergy treatments

Ocular manifestations of common pulmonary diseases: a narrative review

Several pulmonary disorders can cause ocular involvement. Understanding these manifestations is critical for early diagnosis and treatment. Hence, we set out to examine the most common ocular manifestations of asthma, chronic obstructive pulmonary disease (COPD), sarcoidosis, obstructive sleep apnea (OSA), and lung cancer. Allergic keratoconjunctivitis and dry eye are two ocular manifestations of bronchial asthma. The inhaled corticosteroids used to treat asthma can cause cataract formation. COPD is associated with ocular microvascular changes as a result of chronic hypoxia and systemic inflammation spillover into the eyes. Its clinical significance, however, is unknown. Ocular involvement is common in sarcoidosis, occurring in 20% of cases of pulmonary sarcoidosis. It can affect nearly any anatomical structure of the eye. Obstructive sleep apnea has been linked to floppy eye syndrome, glaucoma, non-arteritic anterior ischemic optic neuropathy, keratoconus, retinal vein occlusion, and central serous retinopathy, according to research. However, while an association has been established, causality has yet to be established. The effect of positive airway pressure (PAP) therapy used to treat OSA on the aforementioned ocular conditions is unknown. PAP therapy can cause eye irritation and dryness. Lung cancer can affect the eyes through direct nerve invasion, ocular metastasis, or as part of a paraneoplastic syndrome. The goal of this narrative review is to raise awareness about the link between ocular and pulmonary disorders in order to aid in the early detection and treatment of these conditions.

Identified risk factors for dry eye syndrome: A systematic review and meta-analysis

A meta-analytic approach was used to identify potential risk factors for dry eye syndrome. PubMed, Embase, and the Cochrane library were systematically searched for studies investigated the risk factors for dry eye syndrome from their inception until September 2021. The odds ratio (OR) with 95% confidence interval (CI) was calculated using the random-effects model. Forty-eight studies comprising 493,630 individuals were included. Older age (OR: 1.82; P<0.001), female sex (OR: 1.56; P<0.001), other race (OR: 1.27; P<0.001), visual display terminal use (OR: 1.32; P<0.001), cataract surgery (OR: 1.80; P<0.001), contact lens wear (OR: 1.74; P<0.001), pterygium (OR: 1.85; P = 0.014), glaucoma (OR: 1.77; P = 0.007), eye surgery (OR: 1.65; P<0.001), depression (OR: 1.83; P<0.001), post-traumatic stress disorder (OR: 1.65; P<0.001), sleep apnea (OR: 1.57; P = 0.003), asthma (OR: 1.43; P<0.001), allergy (OR: 1.38; P<0.001), hypertension (OR: 1.12; P = 0.004), diabetes mellitus (OR: 1.15; P = 0.019), cardiovascular disease (OR: 1.20; P<0.001), stroke (OR: 1.32; P<0.001), rosacea (OR: 1.99; P = 0.001), thyroid disease (OR: 1.60; P<0.001), gout (OR: 1.40; P<0.001), migraines (OR: 1.53; P<0.001), arthritis (OR: 1.76; P<0.001), osteoporosis (OR: 1.36; P = 0.030), tumor (OR: 1.46; P<0.001), eczema (OR: 1.30; P<0.001), and systemic disease (OR: 1.45; P = 0.007) were associated with an increased risk of dry eye syndrome. This study reported risk factors for dry eye syndrome, and identified patients at high risk for dry eye syndrome.

Association between asthma and dry eye disease: a meta-analysis based on observational studies

OBJECTIVE

This study aimed to systematically review the relationship between dry eye disease (DED) and asthma based on published population-based studies.

DATA SOURCES

PubMed, EMBASE and ISI Web of Science from their inception were searched up to October 2019.

STUDY SELECTION

Observational studies addressing the association between asthma and DED will be eligible.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently conducted the data extraction and quality assessment. We used a random-effects model for all analyses. Subgroup analysis according to ethnicity was performed to test the influence of ethnicity on the association.

MAIN OUTCOMES AND MEASURES

Six independent studies (a total of 45 215 patients with asthma and 232 864 control subjects) were included in this review and had an average of seven stars by the Newcastle-Ottawa Scale. Our current findings suggest that the prevalence of DED was higher in the asthma group than in the control group (Z=7.42, p<0.00001; OR 1.29, 95% CI 1.20 to 1.38). In the subgroup analysis by ethnicity, Australian, Caucasian and Asian patients with asthma showed an increased risk of DED.

Exposure to Ambient NO2 Increases the Risk of Dry Eye Syndrome in Females: An 11-Year Population-Based Study

Previous studies have indicated that women suffer from dry eye syndrome (DES) more significantly than men. Therefore, we specifically explore the associations between air pollutant levels and the risks of DES for women. The study obtained 27,605 participants from the 29 recruitment centers of the Taiwan Biobank, which was established in October 2012. A large scale cross-sectional study involving DES sufferers and age- and education-matched control groups without DES was designed. Based on the municipality of residence, the predicted concentration levels of various air pollutants, including PM_2.5, sulfur dioxide (SO₂), ozone (O₃), and nitrogen dioxide (NO₂) were estimated by using hybrid kriging/LUR model. Multiple logistic regressions were applied to estimate the prevalence ratios (PR) of DES and 95% confidence interval. Hormone supplementations, DBP, allergies, and arthritis were considered as important comorbidities for increased PR risk of DES. In addition, with each standard deviation (SD) increment of PM_2.5 and temperature, women had significant increases in PRs of DES of 1.09- and 1.07-fold, respectively; conversely, each SD increment of relative humidity (RH) had a protective effect against the risk of DES. After considering hormone supplementation, arthritis, and allergy, the SD increment of NO₂ and temperature were associated with the PRs of DES. In conclusion, significant associations of ambient NO₂ concentration, RH and temperature with DES indicated the importance of increased environmental protection in the female population. Female exposure to high levels of NO₂ when receiving hormone supplementation, or suffering with allergies or arthritis, had significantly increased risk of DES.

Association between asthma with dry eye disease: A protocol for systematic review and meta-analysis

BACKGOUN

Asthma and dry eye disease are common clinical diseases. Studies have shown that asthma is related to dry eye, but there is no high-quality evidence-based medical evidence.

METHOD

This protocol and final study will be conducted in accordance with the Preferred Reporting Items for Systematic review and Meta-Analysis Protocols 2015 statement. We will search PubMed, EMBASE, ISI Web of Science, China National Knowledge Infrastructure for all relevant literature published from their inception up to August 1, 2020. Literature search, data extraction, and quality assessment will be carried out independently by two researchers, and a third researcher will resolve differences when necessary. The association between dry eye disease and asthma will indicate as odds ratio with 95% confidence interval and statistically analyzed using RevMan 5.3 software. If the studies included have high heterogeneity, we will conduct sensitivity analysis and subgroup analysis.

RESULTS

The protocol is intended to guide a meta-analysis aimed at identifying and quantifying the association between asthma and dry eye disease.

TFOS DEWS II iatrogenic report

Dry eye can be caused by a variety of iatrogenic interventions. The increasing number of patients looking for eye care or cosmetic procedures involving the eyes, together with a better understanding of the pathophysiological mechanisms of dry eye disease (DED), have led to the need for a specific report about iatrogenic dry eye within the TFOS DEWS II. Topical medications can cause DED due to their allergic, toxic and immuno-inflammatory effects on the ocular surface. Preservatives, such as benzalkonium chloride, may further aggravate DED. A variety of systemic drugs can also induce DED secondary to multiple mechanisms. Moreover, the use of contact lens induces or is associated with DED. However, one of the most emblematic situations is DED caused by surgical procedures such as corneal refractive surgery as in laser-assisted in situ keratomileusis (LASIK) and keratoplasty due to mechanisms intrinsic to the procedure (i.e. corneal nerve cutting) or even by the use of postoperative topical drugs. Cataract surgery, lid surgeries, botulinum toxin application and cosmetic procedures are also considered risk factors to iatrogenic DED, which can cause patient dissatisfaction, visual disturbance and poor surgical outcomes. This report also presents future directions to address iatrogenic DED, including the need for more in-depth epidemiological studies about the risk factors, development of less toxic medications and preservatives, as well as new techniques for less invasive eye surgeries. Novel research into detection of early dry eye prior to surgeries, efforts to establish appropriate therapeutics and a greater attempt to regulate and oversee medications, preservatives and procedures should be considered.

Dry eye disease and allergic conditions: A Korean nationwide population-based study

BACKGROUND

Dry eye disease (DED) is a multifactorial disease of the tears and ocular surface. No epidemiologic reports have yet been published about the relationship between DED and allergic rhinitis or sensitization to allergens.

OBJECTIVE

To investigate the association between DED and allergic conditions in the general adult Korean population.

METHODS

This population-based cross-sectional study included 17,542 individuals (ages ≥ 19 years) who participated in the Korea National Health and Nutrition Examination Survey (KNHANES) from 2010 to 2012. Data for total serum immunoglobulin E (IgE) and allergen-specific IgE levels were available for 1857 subjects. Data were analyzed by using logistic regression to determine the association of DED with allergy or allergic conditions, including allergic rhinitis, atopic dermatitis, asthma, increased total serum IgE, and sensitization to house-dust mite (Dermatophagoides farinae), dog, and cockroach allergens.

RESULTS

The prevalence of DED, allergic rhinitis, atopic dermatitis, and asthma was 10.4, 13.1, 2.2, and 3.3%, respectively. The prevalence of the increased total serum IgE level and sensitization to D. farinae, dog, and cockroach allergens was 34.6, 15.7, 1.0, and 2.8%, respectively. After adjusting for general characteristics, DED was significantly associated with allergic rhinitis (odds ratio 1.58 [95% confidence interval, 1.38-1.81]) and D. farinae sensitization (odds ratio 1.80 [95% confidence interval, 1.17-2.79]).

CONCLUSION

This study demonstrated a close association between DED and both allergic rhinitis and D. farinae sensitization in Korean adults. Further studies are warranted to establish temporal relationships between DED and allergic rhinitis.

Safety and efficacy of inhaled corticosteroids (ICS) in children with asthma

Inhaled corticosteroids (ICS) are the guideline-preferred preventative therapy for persistent asthma of all severity levels and for all ages, including children. While these drugs are unquestionably efficacious, concerns of adverse systemic effects limit patient compliance with treatment regimens and thus the attainable benefits. Suppression of bone growth, bone density, and HPA axis function, in addition to cataract formation and elevated intraocular pressure/glaucoma, have been associated with ICS use. This review will focus on recent developments in the safety and efficacy of ICS as compared to oral CS corticosteroids and the achievement of a balance between risk and benefit in optimizing ICS therapy.

Resolvin D1 and aspirin-triggered resolvin D1 regulate histamine-stimulated conjunctival goblet cell secretion

Resolution of inflammation is an active process mediated by pro-resolution lipid mediators. As resolvin (Rv) D1 is produced in the cornea, pro-resolution mediators could be effective in regulating inflammatory responses to histamine in allergic conjunctivitis. Two key mediators of resolution are the D-series resolvins RvD1 or aspirin-triggered RvD1 (AT-RvD1). We used cultured conjunctival goblet cells to determine whether histamine actions can be terminated during allergic responses. We found cross-talk between two types of G protein-coupled receptors (GPRs), as RvD1 interacts with its receptor GPR32 to block histamine-stimulated H1 receptor increases in intracellular [Ca(2+)] ([Ca(2+)]i) preventing H1 receptor-mediated responses. In human and rat conjunctival goblet cells, RvD1 and AT-RvD1 each block histamine-stimulated secretion by preventing its increase in [Ca(2+)]i and activation of extracellular regulated-protein kinase (ERK)1/2. We suggest that D-series resolvins regulate histamine responses in the eye and offer new treatment approaches for allergic conjunctivitis or other histamine-dependent pathologies.

Ocular complications associated with systemic medications used in allergy/immunology practice

The repertoire of treatment options available to allergists and immunologists is ever increasing and with this comes the increased potential for these treatments to cause adverse ocular side effects. Corticosteroids remain the first line of treatment for most immunological disorders and physicians should be alerted to their extensive ocular morbidity profile. Patients requiring longer-term therapy may often receive immune modulators or newer biologic agents. While effective, these medications may have additional ocular side effects; as newer agents are more frequently used, some of these may not be previously documented. A number of patients will seek alternative or herbal remedies for these long-term conditions, often unknown to the treating physician; these too can cause harmful ocular morbidity. We review the latest information about the potential ocular side effects that may be encountered in treating patients with medications used in allergic and immunological disorders.

Pharmaceutical and herbal products that may contribute to dry eyes

BACKGROUND

Symptomatic dryness of the eyes is a most common blepharoplasty complication. The authors reviewed the medications and herbal products that may potentiate this complication.

METHODS

The MEDLINE and PubMed databases were searched for the years 1991 to 2011. Search terms included "dry eye syndrome," "keratitis sicca," "keratoconjunctivitis sicca," "ocular side effects," "herbal supplements," "herbals and dry eye," "dry eye risk factors," "etiology of dry eye," "drugs side effects," "drugs and dry eye," "dietary supplements," "ocular toxicity," and "tear film." References from herbal product reviews and eligible medication reports were searched for additional articles. A manual search was also conducted based on citations in the published literature.

RESULTS

Of 232 articles found to be related to dry eye syndrome and possible risk factors, 196 were excluded because they did not discuss medications or herbal products as risk factors in dry eye syndrome. Thirty-six articles that examined the pathophysiology and risk factors of dry eye were included. Nine books were reviewed that contained some information regarding the association of medications and herbal products with dry eye. These agents were then categorized based on mechanism of action and usage. Medications listed include antihistamines, decongestants, antidepressants, anticonvulsants, antipsychotics, antiparkinson drugs, beta-blockers, and hormone replacement therapy. The three main herbal products that contribute to dry eye are niacin, echinacea, and kava. There was a strong association between anticholinergic alkaloids and dry eye.

CONCLUSION

This study identifies the medications and herbal products that should be considered when a patient undergoes blepharoplasty and complains of symptoms associated with dryness of the eyes.

Glaucoma

Most medical practitioners have regular contact with adults who have one of the two forms of glaucoma: open-angle glaucoma or angle-closure glaucoma. Data from population-based surveys indicate that one in 40 adults older than 40 years has glaucoma with loss of visual function, which equates to 60 million people worldwide being affected and 8·4 million being bilaterally blind. Even in developed countries, half of glaucoma cases are undiagnosed. Glaucoma is mostly asymptomatic until late in the disease when visual problems arise. Vision loss from glaucoma cannot be recovered, and improved case-detection methods for glaucoma are needed. Glaucoma is commonly treated with daily eye-drop drugs, but adherence to treatment is often unsatisfactory. As a usually asymptomatic and chronic disease, glaucoma has similar treatment challenges to chronic systemic diseases. Similarities to the pathogenesis of common CNS diseases mean that common neuroprotective strategies might exist. Successful gene therapy, which has been used for other eye diseases might be possible for the treatment of glaucoma in the future.

Atopic dermatitis and keratoconjunctivitis

Atopic dermatitis, a chronic disease seen by allergist-immunologists, has both dermatologic and ocular manifestations. The ocular component is often disproportionately higher than the dermatologic disease. Even if skin abnormalities seem well controlled, these patients require ophthalmic evaluation. Atopic keratoconjunctivitis in atopic dermatitis patients is characterized by acute exacerbations and requires maintenance therapy for long-term control. Future studies will continue to emphasize the use of steroid-sparing, immunomodulating agents that have the potential to provide long-lasting anti-inflammatory control with a more favorable side-effect profile.

Practical approach to diagnosis and treatment of ocular allergy: a 1-year systematic review

PURPOSE OF REVIEW

A 1-year systematic review in the field of ocular allergy was carried out to select new information which may be useful for a practical approach to allergic conjunctivitis.

RECENT FINDINGS

Out of the 56 articles listed by PubMed, 27 papers were included in the review following a consensus achieved among the authors who had independently reviewed all abstracts. Selected articles were classified according to their main focus: antihistamines, omalizumab, new treatments for vernal keratoconjunctivitis and inflammatory ocular disorders, and sublingual immunotherapy.

SUMMARY

The data reviewed are discussed with the aim of underlining unmet needs and making recommendations for future studies on diagnosis and treatment of ocular allergy which may better guide clinical practice in this important area of allergy and clinical immunology.

An open-label, investigator-masked, crossover study of the ocular drying effects of two antihistamines, topical epinastine and systemic loratadine, in adult volunteers with seasonal allergic conjunctivitis

BACKGROUND

Systemic antihistamines such as loratadine are efficacious in the treatment of many allergic conditions. However, their use has been associated with drying effects, particularly of the ocular surface.

OBJECTIVE

The purpose of this study was to compare the ocular drying effects of topical treatment with epinastine hydrochloride ophthalmic solution 0.05 % twice daily and systemic treatment with loratadine 10 mg once daily in patients with seasonal allergic conjunctivitis through the use of several standard clinical tests for dry eye.

METHODS

This was a single-center, 4-visit, open-label, investigator-masked crossover study in healthy adult volunteers with a history of seasonal allergic conjunctivitis. Participants received 4 days of treatment with topical epinastine administered as 1 drop per eye twice daily and 4 days of treatment with systemic loratadine once daily, with a 10-day washout between treatments. Fluorophotometry was conducted at the baseline visit, at the crossover visit, and after 4 days of each treatment to assess tear volume, tear flow, and tear turnover rate. Decreases from baseline in tear volume, tear flow, or tear turnover rate were considered indicative of a drying effect. Keratitis, global (corneal and conjunctival) fluorescein staining (scale from 0-20 points), and tear film break-up time (TFBUT) were assessed after fluorophotometry at each visit. An increase in keratitis (as measured by global fluorescein staining) and conjunctival lissamine green staining, and a decrease in TFBUT were considered further evidence of a drying effect.

RESULTS

Eighteen subjects were enrolled in and completed the study (78% female; 94% white; age range, 18-55 years). After 4 days of twice-daily use, topical epinastine was associated with no significant changes in tear volume, tear flow, or global fluorescein staining. After 4 days of once-daily use, systemic loratadine was associated with a 33.7% reduction in tear volume (mean reduction, 4.5 microL; range, -7.53 to 22.36 microL; P < 0.05), a 35.0% reduction in tear flow (mean reduction, 0.93 microL/min; range, -2.57 to 2.73 microL/min; P < 0.05), and a 21.7% increase in global fluorescein staining (mean increase, 0.74 point; range, -2.5 to 6.5 points; P < 0.05). No significant change in TFBUT was observed with either treatment.

CONCLUSIONS

These healthy adult volunteers with a history of seasonal allergic conjunctivitis had no clinical signs of ocular drying after 4 days of twice-daily treatment with topical epinastine. After 4 days of once-daily dosing, systemic loratadine was associated with clinical signs of ocular dryness, including decreased tear volume and tear flow. Use of loratadine was also associated with an increase in global fluorescein staining, indicating an increase in ocular surface damage.