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Unilateral immunologic corneal affections associated with blepharitis: a report of two cases involving young women

Poster Details

First Author: L.Murad BRAZIL

Co Author(s):    F. Abreu   R. Bueno de Moraes   R. Correia        

Abstract Details



Purpose:

To relate the clinical presentation and the evolution after the start of treatment of corneal affections of an immunologic kind in two young female patients treated at the Cornea Outpatient Center of Policlínica Naval (PNN) in the town of Niterói, State of Rio de Janeiro, Brazil

Setting:

Cornea Outpatient Center of Policlínica Naval (PNN), Niterói, Rio de Janeiro, Brazil. Eyelid margin disease with secondary conjunctival and corneal involvement is well characterised in adults and is termed blepharokeratoconjunctivitis (BKC).1,2 Clinical findings typically consist of inflamed eyelids, anterior lid margin telangiectasia, and accumulations of hard, fibrinous, and crusting scales (collarettes) around the base of the cilia. In chronic cases, ulceration, lid notching (tylosis), thinning or loss of lashes (madarosis), or misdirection of lashes (trichiasis) are common. Conjunctival changes in longstanding cases include mild to moderate papillary and follicular hypertrophy of the palpebral conjunctiva. In acute exacerbations, additional inferior corneal involvement (punctate epithelial erosions, marginal infiltrates, sterile marginal abscesses) is also seen

Methods:

This is the story of two patients treated at the Cornea Center of PNN. All medical visits were documented and the images recorded with the patients’ consent. At each visit, a complete ophthalmologic examination was carried out, including visual acuity, biomicroscopy, applanation tonometry and ophthalmoscopy. During the last visit, made six months after the maintenance phase, the doctor also performed corneal topography and pachymetry. We decided to start the treatment in two phases: the attack phase, aiming at a fast and efficient acute improvement, and the maintenance phase, aiming at avoiding relapse of the inflammatory disease and possible worsening of visual sequels. Both patients are still under care at the facilities. RSV(P1), 21 years old,reported pain and hyperemia of the right eye starting 3 months before. At the first examination, the patient presented corrected visual acuity of 0.9 in the right eye and 1 in the left eye. VT(P2), 24 years old,presenting visual turbidity and pain starting 2 months before. The visual acuity(VA) was 0.4 in the right eye and 1 in the left eye

Results:

The biomicroscopy of the affected eye was rather similar for both patients with blepharitis and meibomitis, keratoconjunctivitis with ciliary injection and corneal lesions coloring with fluorescein, with no signs of infection. Both patients had a good response to the initial therapy (topic dexamethasone 0.005% and metilcellulose 0.5% without preservatives, associated to an attack dosage of oral prednisone). At the evaluation 1 week after both patients reported a complete improvement of the dry eye symptoms and pain however,P2 still reposted a considerable visual turbidity. At that time, the VA was 0.9 in the affected eye of P1 and 0.6 in the affected eye of P2. We started a gradual reduction of the topic and oral corticoid. They were reassessed after a month without symptoms. The VA was 1.0 in both eyes of P1 and 0.7 in the affected eye of P2. We continued reducing the oral and topic corticoid up to its total interruption and at the same time we introduced cyclosporine 0.05% eye drops every 12h for both patients. Henceforth, monthly visits were held up to the sixth month

Conclusions:

The clinical diagnosis was unilateral keratoconjunctivitis associated to blepharitis with an immunological etiology based on the clinical examination. Because they presented a history of frequent relapses, both patients had been given other diagnostic hypotheses, such as herpetic keratitis, recurring erosion, and viral keratoconjunctivitis, and other therapeutic options had been tried unsuccessfully. The choice of an attack treatment with topic medication aimed at minimizing the immunologic stress that often takes place in patients with hypersensitivity to the preservatives of the over-the-counter formulas available in the market. After the disease was stabilized in the initial phase, the choice to go on to a maintenance treatment with topic cyclosporine for an extended period allowed a good adherence to treatment and kept the immunologic balance of the eye surface without any relapse. Furthermore, this therapeutic option presented fewer side effects as compared to the use of corticoid therapy for an extended period. Thus, the diagnostic hypothesis of keratoconjunctivitis with an immunologic etiology should always be considered, even in unusual presentations, such as the ones reported herein, and the earlier the treatment starts, the better the chance to reduce the number of relapses and resulting visual sequels.

Financial Disclosure:

NONE

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