Epimax-Related Ocular Surface Toxicity On A Background Of Topical Steroid Withdrawal Syndrome

Periorbital dermatitis presents commonly to ophthalmology departments. In some regions, changes to formularies mean Epimax is now a first-line emollient for use in eczema. There is recent clinical and laboratory evidence to suggest Epimax can cause a chemical injury with inadvertent ocular administration - a condition now termed Epimax Related Ocular Surface Toxicity. Ophthalmologists should have heightened suspicion of this condition. This case was complicated by the patient having a prior history of a condition called steroid-induced dermatitis, also known as topical steroid withdrawal (TSW). TSW is characterised by erythema and pruritus of the skin following discontinuation of prolonged use of mid-to-high potency topical steroid.

Ophthalmic emergency department in Sussex Eye Hospital, National Health Service

A male in his 20s with a background of severe atopic eczema presented with a 24-hour history of intense pain, redness and blurred vision in his left eye. The day before symptom onset, the patient recalls applying Epimax to above the left eyelid. Examination of the left eye revealed findings consistent to a chemical injury, demonstrating a total corneal epithelial defect with associated stromal haze. The patient initially declined topical corticosteroid therapy due to prior complications with steroid-induced dermatitis that had necessitated prolonged hospitalisation. After treatment with intensive lubricant, antibiotic and dexamethasone drops, the patient made a good clinical recovery over 1 week. A modified, time-limited course of steroid drops was prescribed and the patient experienced no recurrence of steroid dermatitis. Healthcare professionals should counsel patients on the risks of periocular application of Epimax and maintain awareness of its potential to cause ocular surface toxicity.

1)  Dermatological emollients, despite their intended safe use on skin, can act as potent ocular surface irritants when inadvertently applied peri-ocularly or introduced to the eye; 

(2)  Extensive corneal epithelial defects warrant diagnostic consideration of chemical injury aetiology even when conventional high-risk chemical exposure history is absent, 

(3)  Patient-centred communication and shared decision-making are essential when recommended therapy conflicts with or is perceived to contradict patients' prior adverse medical experiences.