Conjunctival keratinisation, an abnormal reaction to an ocular beta-blocker

Drug induced cicatrizing conjunctivitis: A case series with review of etiopathogenesis, diagnosis and management

Drug induced cicatrizing conjunctivitis (DICC) is defined as a disease in which conjunctival cicatrization develops as a response to the chronic use of inciting topical and, rarely, systemic medications. DICC accounts for up to one third of cases of pseudopemphigoid, a large group of cicatrizing conjunctival diseases sharing similar clinical features to those of mucous membrane pemphigoid (MMP) but generally without the morbidity of progressive scarring or the need for systemic immunosuppression. The preservatives in topical anti-glaucoma medications (AGM) are the most frequently implicated inciting causes of DICC although topical antivirals, vasoconstrictors and mydriatics and some systemic drugs have been implicated. The literature review summarizes the classification, epidemiology, etiopathogenesis, histopathology, clinical presentation, diagnosis, management, and treatment outcomes of DICC in the context of a case series of 23 patients (42 eyes) with AGM induced DICC, from India and the UK. In this series all subjects reacted to preserved AGM with one exception, who also reacted to non-preserved AGM. At diagnosis >70% of eyes showed punctal scarring, inflammation, and forniceal shortening. Pemphigoid studies were negative in the 19/23 patients in whom they were carried out. DICC can be classified as non-progressive, progressive with positive pemphigoid immunopathology or progressive with negative pemphigoid immunopathology. It is unclear whether progressive DICC is a stand-alone disease, or concurrent (or drug induced) ocular MMP. Progressive cases should currently be treated as ocular MMP. The diagnosis can be made clinically when there is rapid resolution of symptoms and inflammation, usually within 1-16 weeks, after withdrawal of suspected inciting medications, ideally by temporary substitution of oral carbonic anhydrase inhibitors. If the response to withdrawal is uncertain, or the progression of inflammation and scarring continues then patients must be evaluated to exclude concurrent (or drug induced) MMP, and other potential causes of CC, for which the treatment and prognosis is different. Management, in addition to withdrawing inciting medications, may require short-term treatment of conjunctival inflammation with steroids, treatment of associated corneal disease with contact lenses or surface reconstructive surgery, control of intra-ocular pressure with non-preserved AGM and, in some, surgery for glaucoma or for trichiasis and entropion.

Timolol 0.1% in Glaucomatous Patients: Efficacy, Tolerance, and Quality of Life

Glaucoma is a progressive, chronic optic neuropathy characterized by a typical visual field defects. Four main classes of topical medication are actually available on the market: beta-blockers, prostaglandins, alpha2-agonists, and topical carbonic anhydrase inhibitor to treat intraocular pressure (IOP). The aim of this review is to outline the efficacy of timolol and to evaluate the impact of this treatment on patients' quality of life. Among beta-blockers, timolol is most used at three different concentrations: 0.1%, 0.25%, and 0.5%. While the first one is a gel, the other two products are solution. Timolol has few topical side effects, while it has some important systemic side effects on the cardiac and respiratory systems. The balance between efficacy and safety is always the main aspect to care patients. Because of the less efficacy of timolol 0.1% solution, the possibility to use carbomers as vehicle in the gel drops helped timolol 0.1 to be used in clinics, extending the time contact between the active ingredient and the surface of the cornea. Using preservative-free timolol 0.1 for treatment, IOP was at the same level of the other beta-blockers at higher concentration, but it was better tolerated. Preservative-free treatment improved the quality of life reducing dry-eye like symptoms; furthermore, the presence of an artificial tear in the medication bottle could help adherence. The once daily dosing improves compliance.

Pseudopemphigoid as caused by topical drugs and pemphigus disease

Pseudopemphigoid can cause a chronic cicatricial conjunctivitis that is clinically identical to the manifestations seen in mucous membrane pemphigoid, a disorder with a common clinical phenotype and multiple autoimmune links. For the purpose of this review, we will describe pseudopemphigoid as caused by topical drugs, the most common etiology with ocular manifestations, and as caused by the pemphigus disease, a more rare etiology. Specifically, we will discuss the ophthalmological features of drug-induced cicatricial conjunctivitis, pemphigus vulgaris, and paraneoplastic pemphigus. Other etiologies of pseudopemphigoid exist that will not be described in this review including autoimmune or inflammatory conditions such as lichen planus, sarcoidosis, granulomatosis with polyangiitis (Wegener’s granulomatosis), erythema multiforme (minor, major, and Stevens-Johnson syndrome), bullous pemphigoid, skin-dominated linear IgA bullous dermatosis, and skin-dominated epidermolysis bullosa acquisita. Prompt diagnosis of the underlying etiology in pseudopemphigoid is paramount to the patient’s outcome as certain diseases are associated with a more severe clinical course, increased ocular involvement, and differential response to treatment. A complete history and ocular examination may find early cicatricial changes in the conjunctiva that are important to note and evaluate to avoid progression to more severe disease manifestations. When such cicatricial changes are noted, proper diagnostic techniques are needed to help elucidate a diagnosis. Lastly, collaboration between ophthalmologists and subspecialists such as dermatologists, pathologists, immunologists, and others involved in the care of the patient is needed to ensure optimal management of disease.

In vivo confocal microscopy of conjunctiva in preservative-free timolol 0.1% gel formulation therapy for glaucoma

PURPOSE

To evaluate the effects at 1 year of preservative-free timolol gel and preserved timolol eye drops on conjunctiva and tear parameters.

METHODS

Forty patients with primary open-angle glaucoma or ocular hypertension were randomized to the two treatment groups and compared with 20 healthy age-matched controls. Clinical tests (IOP, Schirmer I test, and lacrimal film break-up time BUT) and in vivo conjunctival confocal microscopy (IVCM) were performed in all patients at baseline and after 12 months. IVCM (HRT II Rostock Cornea Module; Heidelberg Engineering GmbH, Heidelberg, Germany) was performed after topical anaesthesia in the four cardinal locations and at the corresponding limbus to analyse conjunctiva cells. The main IVCM outcomes were goblet cell density and epithelial regularity.

RESULTS

IVCM and clinical parameters were similar in the three groups at baseline. After 12 months, intra-epithelial goblet cell density was significantly lower in the preserved (48.25 ± 7.70) than in the preservative-free beta-blocker group (86.83 ± 22.17, p < 0.001) and controls (88.9 ± 18.33, p < 0.001). The epithelial layer was significantly more regular in the preserved beta-blocker medication group than in the preservative-free beta-blocker group (p < 0.001) and the control group (p < 0.001). A significant reduction in both Schirmer I and BUT was found in the group of preserved timolol (respectively, 11.3 ± 2.97 and 8.12 ± 0.99) compared with preservative-free timolol (16.8 ± 1.83 and 11.27 ± 1.27, p < 0.001) and controls (17.8 ± 1.87 and 12.10 ± 1.28, p < 0.001).

CONCLUSIONS

Based on our IVCM data, preservative-free beta-blocker gel induces less changes at ocular surface than preserved beta-blockers, a fact that should be considered to obtain less adverse effects and maximal adherence to treatment in a chronic condition such as glaucoma.

Changes in the morphological and functional patterns of the ocular surface in patients treated with prostaglandin analogues after the use of TSP 0.5%® preservative-free eyedrops: a prospective, multicenter study

AIM

To investigate and compare the effects of topical benzalkonium chloride-preserved prostaglandins (PGAs) on the ocular surface in patients with primary open-angle glaucoma before and after 3 months of treatment with additional 0.5% preservative-free tamarind seed polysaccharide single-dose eyedrops (TSP®, Oftagen, Pisa, Italy).

METHODS

This was a prospective, longitudinal, multicenter study. From 5 different Italian glaucoma centers, 10 glaucomatous patients were recruited in each center. All the patients were treated with a PGA with preservative for at least 1 year. Preservative-free artificial tears 3 times per day were prescribed. The participants were subjected to clinical and instrumental evaluation at baseline, after 1 month and after 3 months of treatment. All patients were examined with a digital corneal confocal laser scanning microscope (HRT II Rostock Cornea Module).

RESULTS

After 3 months of TSP 0.5% treatment, an improvement of some ocular signs and symptoms was found. The percentage of conjunctival hyperemia decreased from 67 to 13%. Schirmer's test and breakup time significantly changed from the baseline after 3 months. Confocal microscopy showed a significant increase in conjunctival goblet cells.

CONCLUSION

Artificial substitutes, in particular TSP 0.5%, might protect the ocular surface hence giving higher compliance, adherence and quality of life to the patients.

Apoptotic effects of topical antiglaucoma medications on conjunctival epithelium in glaucoma patients

PURPOSE

In this study, we aimed to investigate the apoptotic effects of topical antiglaucoma medications on the conjunctival epithelium.

METHODS

A total of 65 patients were included in the study. Thirty patients were included in the first group who had received antiglaucomatous therapy before trabeculectomy. In the second group, 20 patients who had received no drugs before trabeculectomy were included, while the third group underwent only cataract surgery as control. During the surgery, 2 x 4 mm conjunctival samples were harvested from the upper bulbar conjunctiva. The mean apoptosis rate was calculated by determining apoptosis at conjunctival epithelium using the terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL) method.

RESULTS

The mean apoptosis rate was 0.537 ± 0.369 (0.026 ± 0.962) in group 1, 0.139 ± 0.162 (0.005 ± 0.676) in group 2, and 0.078 ± 0.035 (0.035 ± 0.142) in the control group (group 3). The mean apoptosis rate was significantly higher in the first group than the other 2 groups (p = 0.0001).

CONCLUSION

Apoptotic effects of topical antiglaucoma drugs on the conjunctival epithelial cells were found. However, our results revealed that the number of medications, duration of medication, and type of glaucoma had no effect on the apoptotic effect.

Toxic-inflammatory effects of prostoglandin analogs on the ocular surface

PURPOSE

To investigate the toxic-inflammatory effects of prostaglandin analogs on the ocular surface.

MATERIALS AND METHODS

Twenty-three rats were divided into four groups. Bimatoprost 0.03% (I), latanoprost 0.005% (II), and travoprost 0.004% (III) were applied during 6 months; a control group (IV) received no treatment. Dysplasia and keratinization were evaluated on the ocular surface. In the subepithelial area, the number of lymphocytes and mast cells were counted morphologically, and collagen staining densities were compared subjectively in groups.

RESULTS

The ratio of keratinization was 3/12 and 1/10, in groups I and II. The lymphocyte cell counts were 1.4 ± 0.19, 2.2 ± 0.39, 2.27 ± 0.33, and 1.87 ± 0.35 (p > .05). The mast cell counts were 2.58 ± 0.5, 5.4 ± 1.1, 5.7 ± 0.58, and 3.0 ± 0.59. They were significantly higher in groups II and III than in group I (p < .05). Mean collagen density scores were 1.00 ± 0.85, 2.00 ± 0.00, and 1,73 ± 0.70. Group II and III scores were higher than group I scores (p < .05).

CONCLUSION

Latanoprost and travoprost seem to have more toxic-inflammatory effects on the ocular surface than bimatoprost.

Incidence of ocular side effects of topical beta blockers in the Netherlands

BACKGROUND

Several ocular side effects including uveitis, have been reported following topical beta blocker treatment for glaucoma and ocular hypertension. The incidence of these side effects was investigated in the Netherlands.

METHODS

A prospective observational design was used whereby monthly questionnaires were sent to all practising ophthalmologists in the Netherlands during 3 consecutive months. Questionnaires were returned at the end of each month. Any patient whose topical beta blocker therapy was altered because of an ocular reaction was noted on this questionnaire. Ophthalmologists who did not return their questionnaires were interviewed by telephone at the end of the study period. The number of patients using topical beta blockers was derived from drug sales figures.

RESULTS

70% (328/467) of the ophthalmologists in the Netherlands participated in the study. During the 3 month study period 34 cases were reported: 15 patients had periorbital dermatitis, in eight patients eyelids and conjunctiva were affected, in seven patients the conjunctiva was affected, and four patients had punctate keratitis. The calculated incidence of ocular side effects during topical beta blocker therapy was 1.51 cases/1000 patient years.

CONCLUSION

Topical beta blocker therapy is associated with few clinically important ocular side effects. No cases of uveitis were reported.

Adverse effects of topical antiglaucoma drugs on the ocular surface

PURPOSE

This study was designed to determine the effect of long-term antiglaucoma topical medication on the ocular surface; measuring basal Schirmer's and tear break-up time tests using conjunctival impression cytology.

METHODS

The ocular surfaces of 30 control subjects (group 1), 24 primary open-angle glaucoma patients treated with 0.5% betaxolol hydrochloride (group 2), 27 primary open-angle glaucoma patients treated with 0.5% timolol maleate (group 3) and 26 primary open-angle glaucoma patients treated with 0.5% betaxolol and 1% dipivefrin hydrochloride (group 4) were evaluated. Basal Schirmer's and tear break-up time tests were measured and ocular surface changes were determined by impression cytology. Impression cytology specimens of each group were graded and scored in the range 0-3 according to Nelson's method.

RESULTS

Patients in groups 2, 3 and 4 showed statistically significant fewer normal basal Schirmer's tests (wettability) and tear break-up time tests (P < 0.01). Also, the conjunctival impression cytology scores were significantly higher in groups 2, 3 and 4 than in group 1 (P < 0.01).

CONCLUSIONS

The conclusion was that it is possible that conjunctival surface and tear film function change after the long-term use of antiglaucoma medication.

The effects of long-term topical glaucoma medication on conjunctival impression cytology

Long-term use of topical drugs can induce changes in the conjunctiva and ocular surface. To determine the conjunctival changes resulting from topical glaucoma medication, patients with glaucoma were selected and classified into seven groups, according to the medication received: 24 eyes were treated with betaxolol, 20 eyes with levobunolol, 32 eyes with timolol maleate, 22 eyes with pilocarpine, 52 eyes with beta-blocker and pilocarpine, 34 eyes with beta-blocker and dipivefrin, and 32 eyes with maximum therapy. Patients who were under 18 were excluded, as were those with any history of ocular surgery and other interventions, long-term use of any topically administered medication except glaucoma drugs, and any history or slit-lamp examination evidence of ocular surface disorders. The changes in the conjunctiva of 216 eyes were evaluated by means of ocular surface impression cytology. The medication group showed statistically significant degrees of conjunctival metaplasia when compared to the control group (p < 0.01). The cytological grading was not correlated with age, sex, type of medication, duration of topical treatment or the number of drugs (p > 0.05). Duration of treatment exceeding three months was not correlated with cytological grading. Thus, as far as surgical treatment was concerned, it was concluded that intervention within the first three months after the diagnosis would be most beneficial in the management of glaucoma. The fact that the presence of the preservative benzalkonium chloride was the same in all preparations suggests that it may be the major factor in conjunctival metaplasia.

The effects of antiglaucomatous agents on conjunctiva used for various durations

PURPOSE

The effect of antiglaucomatous agents on conjunctiva used for various durations evaluated histopathologically.

METHODS

Conjunctiva biopsies were taken in 19 Mayis University Faculty of Medicine Ophthalmology Department from 31 eyes of 30 patients who underwent filtration surgery after a period of antiglaucomatous agent use and examined under light microscope. The results were compared with the results of conjunctival biopsies from 10 similar aged patients undergoing retinal detachment of cataract surgery and with no other ocular pathology.

RESULTS

Five of the cases were using antiglaucomatous treatment for two months (Group A), four cases for two to 12 months (Group B) and 22 cases for more than 12 months (Group C) before the surgery. Four cases were using a beta blocker only, eight cases beta blocker + sympathomimetic or beta blocker + myotic and the remaining 19 cases were using a combination of beta blocker + sympathomimetic + myotic. Histopathologic evaluation with light microscope showed no pathologic change in group A, but, subepithelial increase of lymphocytes, mast cells, macrophages and fibroblasts in group C.

CONCLUSIONS

It was detected that subconjunctival inflammatory reaction increases as the number of antiglaucomatous agents and the treatment duration increase. These changes might be considered as risk factors that decrease the success rate of filtration surgery.

Adverse effects of topical antiglaucomatous medications on the conjunctiva

Images

Conjunctival impression cytology in patients with glaucoma using long-term topical medication

Increasing evidence indicates that long-term use of topically administered medications can induce changes in the conjunctiva and ocular surface. We used the technique of conjunctival impression cytology to evaluate the conjunctival changes that develop with long-term use of topically administered antiglaucoma medications. Patients with glaucoma who were on a stable regimen of one, two, or three topically administered medications were recruited for study; glaucoma suspects who were not using topically administered medications served as controls. Eyes with clinical or historical evidence of external eye disease or conjunctival surgery were excluded. Impression cytology specimens, collected from the bulbar and palpebral conjunctiva, were coded and subsequently graded by a masked observer. We examined specimens from 72 eyes by using this technique. Aggregate scores for the bulbar conjunctiva were compiled, using a previously described grading system with a range of 0 (normal) to 3 (diffuse, severe metaplasia). The results show statistically significant degrees of conjunctival metaplasia associated with the number of glaucoma medications used. These results suggest that the long-term use of antiglaucoma medications induces changes in the conjunctival surface. These changes may be related to the medications themselves, the preservatives in the commercial preparations, or the duration of topical treatment. The clinical relevance of these changes remains unknown.

Metipranolol-associated granulomatous anterior uveitis

This paper presents for the first time documented evidence, clinical details, and photographic illustrations of metipranolol-associated granulomatous anterior uveitis in 26 eyes of 15 patients being treated for glaucoma. There were 56 episodes of granulomatous anterior uveitis, all associated with large (mutton-fat) keratic precipitates, flare, cells, and 'white eyes' (except in seven episodes). In 30 (53.6%) of these episodes there was loss of control of intraocular pressure. Metipranolol 0.6% was implicated in 54 of the 56 episodes and metipranolol 0.3% in the remaining two. Fifty-one other cases of metipranolol-associated granulomatous anterior uveitis have so far been reported from other parts of the country to the Committee on Safety of Medicines. As a result multidose metipranolol in 0.1%, 0.3%, and 0.6% strengths has been withdrawn from clinical use in the United Kingdom. The pathogenesis of this adverse drug reaction is uncertain.