Dupilumab-Associated Symblepharon Case Report – Should We Be Monitoring These Patients?

Dupilumab is a recombinant human monoclonal antibody that is most commonly used in the treatment of severe atopic eczema. There have been reports of Dupilumab causing ocular cicatrisation. Symblepharon are pathological adhesions between the palpebral and bulbar conjunctiva that can lead to devastating ocular complications. We present a case report of Dupilumab-associated symblepharon and question whether patients on Dupilumab should have regular ophthalmic screening if they have ever developed Dupilumab-associated conjunctivitis.

A 31-year-old patient on Dupilumab for severe atopic dermatitis was reviewed in the eye casualty at Royal United Hospital Bath in October 2019. He was diagnosed with profound Dupilumab-associated conjunctivitis secondary to his biologic treatment. 

He had already been taking topical lubricating drops and Olopatadine with little symptomatic improvement. He was therefore prescribed a course of Dexamethasone drops (preservative free) twice daily to both eyes over a number of weeks. His symptoms markedly improved. Unfortunately, he continued to have symptomatic flare ups of Dupilumab-associated conjunctivitis over the next few months. These episodes responded to topical steroids but his symptoms soon recurred upon finishing the course. It was decided to keep him on a low dose steroid drop long-term.

When he was reviewed in December 2023, he was noted to have bilateral symblepharon in the inferior fornix. There were no systemic features of mucous membrane pemphigoid. The symblepharon were considered a more severe form of Dupilumab-associated conjunctivitis. He previously had issues taking oral Ciclosporin and topical Ikervis was therefore avoided. Instead, he was given another course of topical steroid (Softacort) with Olopatadine. Literature review showed previous cases of ocular cicatrisation secondary to Dupilumab. The dermatology team were informed and an alternative treatment for his eczema was started (Tralokinumab).

A common, recognised side effect (>1/100 to <1/10) of Dupilumab is an inflammatory conjunctivitis. It is possible that repeated episodes can lead to symblepharon formation. Based on our reported case, we propose that patients who develop Dupilumab-associated conjunctivitis should be monitored in the eye clinic regularly to monitor for symblepharon formation, with early therapy substitution if appropriate.