Ocular involvement in epidermolysis bullosa acquisita with long-term follow-up

Pemphigus and pemphigoids: Clinical presentation, diagnosis and therapy

Pemphigus and pemphigoid are two potentially life-threatening groups of autoimmune diseases, characterized by autoantibodies targeting structural components of desmosomes or hemidesmosomes, respectively. Affected patients typically show itchy/painful plaques or blistering skin lesions and/or impairing mucosal blistering and erosions, which may strongly impact their quality of life. Since the milestone work of Walter Lever in 1953, who differentiated these two groups of diseases by histopathological analysis of the level of antibody-mediated skin cleavage, enormous progresses occurred. Achievements made in laboratory diagnostics now allow to identify antigen specific structural proteins of the skin that are targeted by pathogenic autoantibodies. These progresses were accompanied by an increased understanding of the pathogenesis of these diseases thanks to the establishment of animal models reproducing disease and on studies on skin and blood of affected individuals, which have been leading to novel and disease-specific treatments. Yet, given their phenotypical overlap with more common dermatological diseases, correct diagnosis and appropriate treatment are often delayed, in some cases leading to irreversible sequelae, including organ dysfunction (i.e., loss of vision in mucous membrane pemphigoid). Here, we provide a concise overview of the clinical appearance, diagnosis and therapeutic management of pemphigus and pemphigoid diseases.

Pemphigus- und Pemphigoid-Erkrankungen: Klinik, Diagnostik und Therapie: Pemphigus and pemphigoids: Clinical presentation, diagnosis and therapy

Pemphigus und Pemphigoid sind seltene Autoimmunkrankheiten der Haut mit potenziell lebensbedrohlichem Verlauf. Autoantikörper gegen epidermale und junktionale Strukturproteine (Desmosomen sowie Hemidesmosomen) führen bei Betroffenen typischerweise zu juckenden, schmerzhaften Plaques oder Blasen an der Haut und/oder Blasenbildung und Erosionen der Schleimhäute mit möglicher Einschränkung der Lebensqualität. Seit der bahnbrechenden Arbeit von Walter Lever im Jahr 1953, dem es gelang, mittels histopathologischer Untersuchung diese beiden Krankheitsgruppen anhand des Musters der Antikörper‐vermittelten Blasenbildung zu differenzieren, wurden enorme Fortschritte im Verständnis der Erkrankungen erzielt. Die Errungenschaften in der Labordiagnostik ermöglichten die Identifikation von Zielstrukturen zur präzisen Unterscheidung verschiedener Varianten der bullösen Autoimmunerkrankungen. Diese Fortschritte gingen dank der Entwicklung von Tiermodellen mit einem besseren Verständnis der Pathogenese einher. Außerdem haben Studien an Haut und Blut betroffener Patienten zu neuen und krankheitsspezifischen Behandlungen geführt. Aufgrund ihrer Seltenheit und der klinischen Ähnlichkeit mit anderen dermatologischen Erkrankungen verzögern sich die korrekte Diagnosestellung und die Einleitung einer entsprechenden Therapie häufig, was in einigen Fällen zu irreversiblen Folgeerscheinungen, einschließlich Funktionsstörungen von Organen (zum Beispiel Verlust des Sehvermögens beim Schleimhautpemphigoid) führt. Wir geben hier einen Überblick über das klinische Erscheinungsbild, den Diagnosealgorithmus und das therapeutische Management von Pemphigus‐ und Pemphigoid‐Erkrankungen.

Ocular involvement in autoimmune bullous diseases

Autoimmune bullous diseases represent a heterogenous group of disorders caused by autoantibodies against adhesion molecules; the location of the target protein determines the level of cleft formation. The spectrum of ocular lesions in autoimmune bullous diseases can range from mild symptoms to severe involvement with sight impairment and even, in some cases, blindness. In pemphigus vulgaris, the prevalence of ocular involvement has been reported to be between 7% and 26%. The most common clinical sign of ocular pemphigus vulgaris is bilateral conjunctivitis with hyperemia. Ocular involvement also occurs in 41% to 70% of patients with paraneoplastic pemphigus. The main ocular manifestations are bilateral cicatrizing conjunctivitis with symblepharon formation, and shortening of the fornices. In mucous membrane pemphigoid, ocular involvement is seen in 61% to 70% of patients; the most frequent ocular finding is cicatricial conjunctivitis. Patients with autoimmune bullous diseases having common ocular involvement should be assessed by an ophthalmologist to avoid serious complications. Diagnostic procedures and treatment require multidisciplinary care based on the close cooperation between dermatologists and ophthalmologists.

Connective tissue disorders and eye: A review and recent updates

Collagen vascular disorders (CVDs), also known as connective tissue diseases (CTDs), are a heterogeneous group of entities that affect the connective tissues and are capable of causing end-organ damage to multiple systems, primarily cardiopulmonary and musculoskeletal. However, the occurrence and severity are highly variable among patients. Ocular involvement occurs in a significant number of these disorders and may precede the onset of other extraocular features, thereby serving as an important marker in the diagnosis of these diseases. A timely and accurate diagnosis enables the management of complications. CTDs are primarily immune-mediated inflammatory diseases; however, classifications have encompassed heritable disorders affecting collagen-containing structures and disorders of vascular development. A review of literature published until 25 January 2022 and collected from various databases using the relevant keywords was conducted. All publications (original articles, review articles, as well as case reports) describing the ocular features in CTDs were studied in detail. The objective of this review is to recognize the common ophthalmic presentations of various autoimmune and heritable CTDs, distinguish them from overlapping diseases, elaborate on the prognosis and management of these varied eye presentations, and deliberate on their impact on other ophthalmic surgeries.

The conjunctival extracellular matrix, related disorders and development of substrates for conjunctival restoration

The conjunctiva can be damaged by numerous diseases with scarring, loss of tissue and dysfunction. Depending on extent of damage, restoration of function may require a conjunctival graft. A wide variety of biological and synthetic substrates have been tested in the search for optimal conditions for ex vivo culture of conjunctival epithelial cells as a route toward tissue grafts. Each substrate has specific advantages but also disadvantages related to their unique physical and biological characteristics, and identification and development of an improved substrate remains a priority. To achieve the goal of mimicking and restoring a biological material, requires information from the material. Specifically, extracellular matrix (ECM) derived from conjunctival tissue. Knowledge of the composition and structure of native ECM and identifying contributions of individual components to its function would enable using or mimicking those components to develop improved biological substrates. ECM is comprised of two components: basement membrane secreted predominantly by epithelial cells containing laminins and type IV collagens, which directly support epithelial and goblet cell adhesion differentiation and growth and, interstitial matrix secreted by fibroblasts in lamina propria, which provides mechanical and structural support. This review presents current knowledge on anatomy, composition of conjunctival ECM and related conjunctival disorders. Requirements of potential substrates for conjunctival tissue engineering and transplantation are discussed. Biological and synthetic substrates and their components are described in an accompanying review.

Eye Involvement and Management in Inherited Epidermolysis Bullosa

Inherited epidermolysis bullosa (EB) is a group of genetic rare diseases associated with skin fragility, which leads to the formation of blisters, erosions, and scars on the skin and mucous membranes. Epidermolysis bullosa includes four main types and some several clinical subtypes including EB simplex, junctional EB, dystrophic EB, and Kindler's EB. Ocular involvement ranged from 51 to 68% in EB and can cause irreversible damages if not properly managed. Corneal erosions are the most common finding among series, including our cohort. We review here clinical and pathological features of ocular involvement in EB and the main keys for management, with a focus on recent innovative therapies.

Systemic diseases and the cornea

There is a number of systemic diseases affecting the cornea. These include endocrine disorders (diabetes, Graves' disease, Addison's disease, hyperparathyroidism), infections with viruses (SARS-CoV-2, herpes simplex, varicella zoster, HTLV-1, Epstein-Barr virus) and bacteria (tuberculosis, syphilis and Pseudomonas aeruginosa), autoimmune and inflammatory diseases (rheumatoid arthritis, Sjögren's syndrome, lupus erythematosus, gout, atopic and vernal keratoconjunctivitis, multiple sclerosis, granulomatosis with polyangiitis, sarcoidosis, Cogan's syndrome, immunobullous diseases), corneal deposit disorders (Wilson's disease, cystinosis, Fabry disease, Meretoja's syndrome, mucopolysaccharidosis, hyperlipoproteinemia), and genetic disorders (aniridia, Ehlers-Danlos syndromes, Marfan syndrome). Corneal manifestations often provide an insight to underlying systemic diseases and can act as the first indicator of an undiagnosed systemic condition. Routine eye exams can bring attention to potentially life-threatening illnesses. In this review, we provide a fairly detailed overview of the pathologic changes in the cornea described in various systemic diseases and also discuss underlying molecular mechanisms, as well as current and emerging treatments.