EyeWorld Asia-Pacific December 2015 Issue

52 EWAP CORNEA December 2015 Views from Asia-Pacific Jodhbir S. MEHTA, BSc(Hons), MBBS, MRCOphth, FRCOphth, FRCS(Ed), FAMS Head, Corneal and External Eye Disease Service Senior Consultant, Refractive Service Head, Tissue Engineering and Stem Cells Group, Singapore Eye Research Institute Singapore National Eye Centre 11 Third Hospital Avenue, Singapore 169751 Jodhbir.s.mehta@snec.com. s I n this review article the diagnosis and treatment of ocular surface disease are reviewed. The article focuses on dry eye, newer treatments, and limbal stem cell deficiency. Dry Eye and Blepharitis The treatment of dry eye and blepharitis has improved over the last few years. There has been a shift to the recognition of the anti- inflammatory component of dry eye and the importance in its treatment acutely with steroids and long-term with anti-inflammatory agents such as cyclosporine and omega-3 fatty acids. Ocular pain is often undiagnosed but is also difficult to treat since there can be very few signs. It may be linked to a general hypersensitivity of the nervous system. Hence, treatment may be more unconventional, e.g., oral medication such as pregabalin or PROSE. In my practise I do use a lot of anti-inflammatory agents such as omega-3 fatty acids, they have been shown to have a lot of positive benefits for the ocular surface. Newer treatments Topical anakinra, a human interleukin-1 receptor antagonist is undergoing trials for dry eye and allergic conjunctivitis, also lifitegrast is promising. Rebipamide is also an interesting secretagogue. Some of these newer agents, e.g. rebipamide, are very popular in Japan and the clinical results of their use look very interesting. There is certainly a need for newer agents such as these as opposed to conventional lubricants. Pediatric blepharitis is an underdiagnosed condition and frequently misdiagnosed. It can be associated with bacteria such as Staph, acne rosacea or scalp dandruff. It is important to apply aggressive lid hygiene in addition to topical antibiotic therapy and short burst of anti-inflammatory medication. This is often a difficult condition to diagnose since children have very immature meiobomian glands, and hence do not typically display the same phenotype as adults. Also, compliance with lid scrubs in children is not good. I use oral anti-inflammatory agents, e.g. fish oils with flaxseed. They have been shown to alter the disease process and certainly can reduce the anti-inflammatory component of the disease. As the child grows up the inflammation does subside but I have seen several cases of corneal perforation from this condition. Limbal Stem Cell Deficiency Can be caused by chemical injuries and Stevens–Johnson Syndrome. Other causes include congenital condition, e.g. aniridia and contact lens-induced LSCD. When diagnosing LSCD appears as opaque epithelial sheet with superficial neovascularization. Late wavy staining with fluorescein is also a useful sign. To treat LSCD, need to optimize the surface, e.g. stop CL wear or stop use of benzalkonium chloride. Non-prescription drops and treatment of MGD is important as well as anti-inflammatory therapy. More advanced cases need LSC transplantation—conjunctival limbal autograft in unilateral cases, a living-related conjunctival limbal graft or cadaver allograft in bilateral cases. Oral immunosuppression is vital in allogeneic cases. LSCD is difficult to manage especially if permanent. It is important to consider treating the whole ocular surface not just the cornea in such cases. Editors’ note: Dr. Mehta declared no relevant financial interests. Biology and Tissue Engineering Laboratory, Illinois Eye and Ear Infirmary. Other causes include congenital conditions such as aniridia and contact lens-induced LSCD. When diagnosing LSCD, Dr. Djalilian looks for the presence of conjunctival cells over the cornea. “It appears as an opaque epithelial sheet along with superficial neovascularization,” he said. He also recommends that clinicians identify a fluorescein staining pattern. “Conjunctival epithelium can be distinguished from corneal epithelium by its greater fluorescein uptake and a wavy pattern.” To treat LSCD, Dr. Djalilian aims to optimize the health of the ocular surface by having patients discontinue contact lens wear or stop the use of drops with benzalkonium chloride. He advises the use of nonpreserved lubricants and the treatment of meibomian gland disease as well as local anti- inflammatory therapy. More advanced cases require limbal stem cell transplantation, such as conjunctival limbal autograft in unilateral cases. In bilateral cases, a living-related conjunctival limbal graft or cadaver-based keratolimbal allograft is used. “The key to the success of allograft procedures is systemic immunosuppression postoperatively,” Dr. Djalilian said. EWAP Editors’ note: The physicians have no financial interests related to this article. Contact information De la Cruz: jnapoli@hotmail.com Djalilian: adjalili@uic.edu Galor: agalor@med.miami.edu Hammersmith: khammersmith@willseye.org Jacobs: djacobs@bostonsight.org Diagnosing - from page 51