Ocular Surface Findings in Hallopeau-Siemens Subtype of Dystrophic Epidermolysis Bullosa

Controversy and Consideration of Refractive Surgery in Patients with Heritable Disorders of Connective Tissue

Heritable Disorders of Connective Tissue (HDCTs) are syndromes that disrupt connective tissue integrity. They include Osteogenesis Imperfecta (OI), Ehlers Danlos Syndrome (EDS), Marfan Syndrome (MFS), Loeys-Dietz Syndrome (LDS), Epidermolysis Bullosa (EB), Stickler Syndrome (STL), Wagner Syndrome, and Pseudoxanthoma Elasticum (PXE). Because many patients with HDCTs have ocular symptoms, commonly myopia, they will often present to the clinic seeking refractive surgery. Currently, corrective measures are limited, as the FDA contraindicates laser-assisted in-situ keratomileusis (LASIK) in EDS and discourages the procedure in OI and MFS due to a theoretically increased risk of post-LASIK ectasia, poor wound healing, poor refractive predictability, underlying keratoconus, and globe rupture. While these disorders present with a wide range of ocular manifestations that are associated with an increased risk of post-LASIK complications (e.g., thinned corneas, ocular fragility, keratoconus, glaucoma, ectopia lentis, retinal detachment, angioid streaks, and ocular surface disease), their occurrence and severity are highly variable among patients. Therefore, an HDCT diagnosis should not warrant an immediate disqualification for refractive surgery. Patients with minimal ocular manifestations can consider LASIK. In contrast, those with preoperative signs of corneal thinning and ocular fragility may find the combination of collagen cross-linking (CXL) with either photorefractive keratotomy (PRK), small incision lenticule extraction (SMILE) or a phakic intraocular lens (pIOL) implant to be more suitable options. However, evidence of refractive surgery performed on patients with HDCTs is limited, and surgeons must fully inform patients of the unknown risks and complications before proceeding. This paper serves as a guideline for future studies to evaluate refractive surgery outcomes in patients with HDCTs.

A review of scoring systems for ocular involvement in chronic cutaneous bullous diseases

BACKGROUND

Epidermolysis bullosa (EB) and autoimmune blistering diseases (AIBD) describe a group of rare chronic dermatoses characterized by cutaneous fragility and blistering. Although uncommon, significant ocular surface disease (OSD) may occur in both and require ophthalmological assessment. Disease scoring systems have a critical role in providing objective and accurate assessment of disease severity. The objectives of this report were, firstly, to document the prevalence and severity of ocular involvement in EB/AIBD. Secondly, to review and evaluate existing ocular and systemic scoring systems for EB/AIBD. Finally, to identify areas where further development of ocular specific tools in EB/AIBD could be pursued.

METHODS

A literature search was performed in October 2017 utilising Medline, Embase, and Scopus databases. The results were restricted by date of publication, between 01.01.1950 and 31.10.2017. The reference lists of these articles were then reviewed for additional relevant publications. Articles of all languages were included if an English translation was available. Articles were excluded if they were duplicates, had no reference to ocular involvement in EB/AIBD or described ocular involvement in other diseases.

RESULTS

Descriptions of ocular involvement in EB/AIBD were identified in 88 peer-reviewed journal articles. Findings reported include but are not limited to: cicatrising conjunctivitis, meibomian gland dysfunction, dry eye disease, trichiasis, symblepharon, fornix fibrosis, keratopathy, ectropion/entropion, ankyloblepharon, corneal ulceration, visual impairment and blindness. Although scoring systems exist for assessment of OSD in mucous membrane pemphigoid, no such tools exist for the other AIBD subtypes or for EB. Several systemic scoring systems exist in the dermatological literature that are efficacious in grading overall EB/AIBD severity, but have limited inclusion of ocular features. To the best of our knowledge, there is no recognised or validated scoring systems which comprehensively stages or grades the spectrum of ocular manifestations in EB/AIBD.

CONCLUSIONS

There are a range of ocular complications documented in EB and AIBD. Development of a comprehensive ocular scoring system for EB/AIBD which incorporates the delineation between 'activity' and 'damage' would facilitate more objective patient assessment, improved longitudinal monitoring, comparison of intervention outcomes, and provide commonality for discussion of these patients due to the multidisciplinary nature of their care.

The Frequency of Signs of Meibomian Gland Dysfunction in Children with Epidermolysis Bullosa

PURPOSE

To determine the frequency of meibomian gland dysfunction (MGD) in children with epidermolysis bullosa (EB).

DESIGN

Hospital-based cross-sectional study.

PARTICIPANTS

One hundred five children with different forms of EB.

METHODS

Prospective ophthalmic examination of children with EB presenting over seventeen months including meibomian gland assessment using a recognized classification.

MAIN OUTCOME MEASURES

Frequency of MGD.

RESULTS

One hundred five children were recruited, 8.6% with junctional EB, 34.3% with simplex EB, 34.3% with autosomal recessive dystrophic EB, and 22.9% autosomal dominant dystrophic EB. Mean age was 7.42 years (range, 0.08-17.75 years). Ninety-two children (87.62%) demonstrated 1 or more features of MGD.

CONCLUSIONS

Most children with EB exhibit signs of MGD. To the best of our knowledge, this is the first prospective ocular surface evaluation in children with EB to include lid margin evaluation using a recognized classification system. Our findings help explain some of the ocular surface anomalies seen in children with EB.

Ocular manifestations of genetic skin disorders

Genetic skin diseases, or genodermatoses, often have extracutaneous manifestations. Ocular manifestations in particular can have significant clinical implications, like blindness. Other manifestations, such as the corneal opacities that occur in X-linked ichthyosis, are asymptomatic but characteristic of a particular genodermatosis. Ophthalmologic examination can aid in diagnosis when characteristic findings are seen. The genodermatoses with ocular manifestations will be reviewed, but neurocutaneous, syndromes, genetic pigmentary disorders, and genetic metabolic diseases are not included because they are covered elsewhere in this issue.

Assessment of Consistency in Assignment of Severe (Grade 3) Squamous Metaplasia to Human Bulbar Conjunctiva Impression Cytology Cell Samples

Nucleus-to-cytoplasm (N:C) characteristics of published images of human bulbar conjunctival cells designated as showing severe (grade 3) squamous metaplasia were retrospectively assessed. From publications over a 40-year period, measurements were made from images of cell and nucleus size (based on areas and dimensions) and four different calculations were made for nucleo-cytoplasmic (N:C) ratios. From 54 published images, the mean nucleus-to-cytoplasm area ratio (NU/CYT AREA ratio) was 0.145 +/- 0.077 (range 0.052 to 0.346), compared to two different reference set values of 0.069 +/- 0.017 and 0.080 +/- 0.021. Similarly, a nucleus-to-cytoplasm length ratio (as LNLONG) was 0.308 +/- 0.080 (range 0.191 to 0.475) compared to reference values of 0.226 +/- 0.032 and 0.236 +/- 0.034. Similar differences in reference values were obtained using two other N:C ratio calculations. A wide range of values was found for morphometric N:C indices from published images, especially those without a scale bar, indicating a high incidence of inconsistent grading assignments. Overall, only about 30% of the published images showed morphological features consistent with severe squamous metaplasia (i.e., with the rest neither enlarged nor showing substantially changed N:C ratios) with no substantial pictorial evidence indicating that cells from the human bulbar conjunctiva have pyknotic nuclei. Current evidence indicates that grade 3 squamous metaplasia cells should be substantially enlarged.

Case report: rapidly healing epidermolysis bullosa wound after ablative fractional resurfacing

Recessive dystrophic epidermolysis bullosa (RDEB) is a devastating genodermatosis characterized by generalized skin fragility, severe blistering, and wounding that heals with mutilating scarring. Patients are in constant need of effective wound therapies as they often succumb to aggressive metastatic squamous cell carcinomas or to sepsis that may develop from their chronic wounds. Herein, we demonstrate accelerated wound healing with use of a fractionated CO2 laser protocol in a 22-year-old man with RDEB. His 9-month-old, non-healing wound decreased from 7 cm in diameter to 2 cm in diameter (a 92% reduction in wound surface area) within 4 weeks of a single laser treatment, and he had near-complete re-epithelialization within 4 weeks of his second laser treatment without blistering or other adverse effects. This novel intervention of using fractionated CO2 for photo-microdebridement could help revolutionize wound care for patients who have RDEB and whose chronic wounds serve as one of their greatest sources of morbidity and mortality. Dissemination to a pediatric audience is critical so that laser protocols might be more thoroughly investigated and incorporated into wound management strategies for this uniquely vulnerable population.

Ocular surface reconstruction with cultivated limbal epithelium in a patient with unilateral stem cell deficiency caused by Epidermolysis bullosa dystrophica hallopeau-Siemens

PURPOSE

To report a case of partial limbal stem cell deficiency (LSCD) caused by epidermolysis bullosa dystrophica mutilans Hallopeau-Siemens treated by transplantation of autologous ex vivo expanded limbal epithelium.

METHODS

Review of the clinical findings of an 11.5-year-old boy with unilateral LSCD and epidermolysis bullosa dystrophica who underwent ocular surface reconstruction in the right eye with autologous on intact human amniotic membrane cultivated limbal epithelial cells.

RESULTS

Twenty-eight months after reconstruction, the corneal surface is clear, smooth, and stable showing no signs of LSCD recurrence. Three subconjunctival bevacizumab (Avastin) injections reduced the recurrent growth of symblepharon and corneal vascularization. The visual acuity has increased from hand motion to 20/50.

CONCLUSION

Autologous transplantation of cultivated human limbal epithelial cells on intact human amniotic membrane can be a safe and effective method for corneal surface reconstruction in LSCD caused by recessive epidermolysis bullosa dystrophica.

Inherited epidermolysis bullosa: recent basic and clinical advances

PURPOSE OF REVIEW

This review highlights key findings, both clinical and basic, that have been published in the field of inherited epidermolysis bullosa within the past few years.

RECENT FINDINGS

New epidermolysis bullosa phenotypes, genotypes and modes of transmission have been identified, resulting in a revised classification system. Detailed evidence-based data are now available on the risk of extracutaneous complications in each of the major epidermolysis bullosa subtypes. Studies are now underway to try to better explain the biological aggressiveness of squamous cell carcinomas arising in epidermolysis bullosa skin. Cell and animal models have been refined and used to ascertain the feasibility of gene replacement therapy, stem cell transplantation, and treatment with injected allogeneic fibroblasts or recombinant type VII collagen. As a result, clinical trials are now being pursued to test each of these in humans.

SUMMARY

Epidermolysis bullosa is caused by mutations in at least 14 genes, leading to a broad spectrum of entities, each of which has its own relative risk for the development of specific extracutaneous complications and/or premature death. Intensive research, both basic and clinical, is bringing us closer to more effective treatments and possibly even a cure.

Co-factors of LIM domains (Clims/Ldb/Nli) regulate corneal homeostasis and maintenance of hair follicle stem cells

The homeostasis of both cornea and hair follicles depends on a constant supply of progeny cells produced by populations of keratin (K) 14-expressing stem cells localized in specific niches. To investigate the potential role of Co-factors of LIM domains (Clims) in epithelial tissues, we generated transgenic mice expressing a dominant-negative Clim molecule (DN-Clim) under the control of the K14 promoter. As expected, the K14 promoter directed high level expression of the transgene to the basal cells of cornea and epidermis, as well as the outer root sheath of hair follicles. In corneal epithelium, the transgene expression causes decreased expression of adhesion molecule BP180 and defective hemidesmosomes, leading to detachment of corneal epithelium from the underlying stroma, which in turn causes blisters, wounds and an inflammatory response. After a period of epithelial thinning, the corneal epithelium undergoes differentiation to an epidermis-like structure. The K14-DN-Clim mice also develop progressive hair loss due to dysfunctional hair follicles that fail to generate hair shafts. The number of hair follicle stem cells is decreased by at least 60% in K14-DN-Clim mice, indicating that Clims are required for hair follicle stem cell maintenance. In addition, Clim2 interacts with Lhx2 in vivo, suggesting that Clim2 is an essential co-factor for the LIM homeodomain factor Lhx2, which was previously shown to play a role in hair follicle stem cell maintenance. Together, these data indicate that Clim proteins play important roles in the homeostasis of corneal epithelium and hair follicles.

Amniotic membrane transplantation for treatment of symblepharon in a patient with recessive dystrophic epidermolysis bullosa

PURPOSE

To report the surgical treatment of a case with epidermolysis bullosa.

METHODS

A 12-year-old girl with dystrophic epidermolysis bullosa presented to our clinic with a symblepharon connecting the lateral half of the left upper lid to the upper temporal quadrant of the cornea. The central cornea exhibited diffuse opacity and vascularization.

RESULTS

During surgery, the symblepharon was lysed, and lamellar keratectomy was performed. The operated portion of cornea and palpebral conjunctiva was covered with amniotic membrane to promote healing. Fourteen months later, the operated eyelid margin was normal and the eye was fully mobile. The temporal portion of the corneal stroma was still thinner than normal and showed mild superficial vascularization and opacification.

CONCLUSION

We believe that amniotic membrane transplantation is a valuable way to treat symblepharon in cases of epidermolysis bullosa.

Corneal ulcer in a young child with autosomal recessive epidermolysis bullosa

Ocular manifestations of epidermolysis bullosa typically occur in patients with severe skin findings and are more likely with increasing age. An 18-month-old boy with relatively mild dermatologic epidermolysis bullosa developed corneal ulceration and scarring.