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• Bullous pemphigoid antigen II (BP180) and its soluble domains - as possible autoantigen
• Autoantibodies deposited along the basement membrane zone (BMZ) at the epithelial–
subepithelial junction of mucous membranes and occasionally skin
• OCP can begin at least as early as the third decade of life, generally seen in 60-70 years age.
• OCP has a slight but definite preponderance for women at a rate of 2–3 : 1.
• Conjunctival involvement - occur as early as 10 years before other mucosal or skin lesions
develop, or it may occur as much as 20 years following the onset of other lesions
PATHOGENESIS
• Classically described as an autoimmune disease with a “genetic predisposition” & “second hit”
environmental requirement to trigger the onset of the disease.
• Exhibits a type II immune reaction : deposition of immuno-reactants (IgG, IgA, IgM, and/or
complement C 3) along the epithelial BMZ.
• The target auto-antigen is the β4 peptide of α6β4 integrin & epiligrin (α3 subunit of laminin 5)
The binding of the autoantibody to the autoantigen at the
epithelial basement membrane
• Early stages – fine white perivascular lines in inferior & superior tarsal conjunctiva
• Symptoms – burning, FB sensation, tearing, photophobia, itchiness, pain & mucoid discharge
STAGE 2 PEMPHIGOID
Inferior Forniceal shortening
STAGE 3 PEMPHIGOID
Symblepharon formation
STAGE 4 PEMPHIGOID
Total obliteration of the inferior
fornix, the ankyloblepharon
formation, and keratinization of
the corneal surface.
MODIFIED FOSTER GRADING (1992 TAUBER
ET AL. )
• STAGE I : Chronic conjunctivitis, subconjunctival fibrosis
• STAGE II : Inferior forniceal shortening
• IIa : 0-25%
• IIb : 25-50%
• IIc : 50-75%
• IId : 75-100%
• STAGE III : Presence & extent of horizontal symblepharon
• IIIa : 0-25%
• IIIb : 25-50%
• IIIc : 50-75%
• IIId : >75%
• STAGE IV : Ankyloblepharon imobilize the globe
OTHER MUCOSAL TISSUES/ SKIN
INVOLVEMENT
• Scarring ( Brusting-Perry) dermatitis may occur in approximately 25% of cases
• Involvement of other mucosa may lead to scarring of the soft palate and oral
and nasal mucosa
• The esophageal scarring can lead to asphyxiation if a food bolus lodges during
attempted swallowing
DIAGNOSIS
• Extremely important to prevent the inevitable blinding sequalae of OCP, Since the initial symptoms of
OCP are nonspecific and easily misdiagnosed
• Too often, patients present during the later stages of the disease
• A High level of clinical suspicion in cases of unexplained chronic, recurrent conjunctivitis, especially
when there is any evidence of subepithelial scarring.
DIAGNOSIS
DIRECT IMMUNOFLUORESCENCE
• Gold standard for diagnosis of OCP is a conjunctival MICROSCOPY
biopsy using immunofluorescent or immuno-
peroxidase techniques of fresh specimen
• Homogeneous linear deposition of immuno- Note the bright apple-green linear pattern of fluorescence
reactants, such as IgG, IgA, IgM, and Complement 3 at the conjunctival epithelial basement membrane zone,
component (C3) along the BMZ of inflamed indicating the deposition of IgG, IgA, IgM at the
conjunctiva, is diagnostic of OCP basement membrane, providing immuno-histopathologic
confirmation of the suspected clinical diagnosis.
DIFFERENTIAL DIAGNOSIS :-
*Ocular Mucous Membrane Pemphigoid: Current State of Pathophysiology, Diagnostics and Treatment Panagiotis Georgoudis . Francesco
Sabatino . Nora Szentmary . Sotiria Palioura . Eszter Fodor . Samer Hamada . Hendrik P. N. Scholl . Zisis Gatzioufas (January 2019)
MANAGEMENT
MEDICAL MANAGEMENT –
A multidisciplinary approach is often required with the
involvement of ophthalmologists, dermatologists, oral
surgeons, primary care physicians and ENT surgeons
C. Recalcitrant infection: -
• Multidrug treatment
• Intravenous immunoglobulin ( IVIG)
• Biologic agents such as Rituximab, infliximab, or Etanercept
THERAPEUTIC AGENTS
THERAPEUTIC AGENTS
Rituximab,
Infliximab,
Etanercept
(23 January 2017)
Purpose :The purpose was to evaluate the effectiveness and safety of rituximab (RTX) for the treatment of
patients with aggressive ocular cicatricial pemphigoid (OCP)
Methods : Sixty-one eyes of 32 patients with symptomatic OCP who received treatment with RTX
monotherapy or RTX in combination with additional immunomodulatory treatment (IMT) were evaluated
EYELIDS/LASHES -
• Epilation, Cryoablation, Electrolysis
• Temporary or permanent punctal occlusion
• Marginal eyelid rotation
• Hard palate and buccal mucosal grafting can be useful in severe cases
CONJUNCTIVA –
• Fornix reconstruction with AMG & 0.04% MMC or autologous oral mucosa
• Limbal Stem Cell Transplant (LSCT)
SURGICAL MANAGEMENT
CORNEA :
• Tarsorrhaphy – in decreased corneal sensations
• PK (with a very guarded prognosis )
• Keratoprosthesis can be used with some success
CATARACT :
• Should be operated for some improvement in VA after disease
control with immuno-suppressive agents
• Small clear corneal incision technique to avoid conjunctival
damage
SUPPORTIVE MANAGEMENT
• Treat the ocular surface disorder
• Preservative free artificial tear drops and ointments, AST ( autologous serum tears)
• Punctal occlusion
• All three conditions are precipitated by reactions to drugs or infectious diseases (eg, herpes
simplex virus, adenovirus) that result from the presentation of major histocompatibility complex
(MHC) class I–restricted antigens, leading to infiltration of the skin with cytotoxic T lymphocytes
and natural killer cells
• Approximately 80% of TEN and 50%–80% of SJS cases are thought to be drug induced
• Erythema multiforme minor primarily involves the
skin. It usually does not involve the eye
• Two American physicians, Stevens and Johnson, reported two classic cases in children &
named the disease eruptive fever with stomatitis and ophthalmia in 1922. Came to be known
as Stevens Johnson syndrome
• Thomas, in 1950, coined the terms erythema multiforme minor and major : EM minor to
what von Hebra described and EM major to SJS
• Males have a higher incidence of erythema multiforme 3 : 1. Peak incidence is in the 2nd & 3rd
decades of life
• Toxic epidermal necrolysis is slightly more common in women, with a ratio 2 : 1.
• The elderly have an increased incidence of toxic epidermal necrolysis and also have a higher rate
of morbidity and mortality
• Sulfonamides main agents causing erythema multiforme in healthy patients as well as in patients with
HIV or AIDS
• Other medications linked to erythema multiforme, including :
• Phenytoin
• Barbiturates
• Phenylbutazone
• Penicillin
• Salicylates
• Ophthalmic drops such as dorzolamide, or tropicamide
• Erythema multiforme can be due to
infections –
• Herpes simplex
• Mycoplasma pneumoniae
• Measles infection
• Mycobacterium
• Group A streptococci
• Epstein-Barr virus
• Yersinia
• Enterovirus
• Keratinocyte death occurs from extensive apoptosis, triggered by drug-specific cytotoxic T lymphocytes
via the perforin–granzyme pathway
• Apoptosis is induced by a suicidal interaction between Fas and Fas ligand (Fas L) which is either
membrane bound on keratinocytes
• Ocular lesions of Stevens-Johnson syndrome have a significantly increased incidence of HLA-B12, HLA-
Aw33, and DRw53
• An increased incidence of HLA-B12 was also seen in white patients with toxic epidermal necrolysis
CLINICAL FINDINGS
• INITIAL PRESENTATION-
• A systemic prodrome of malaise, fever, and headache or symptoms of an upper respiratory tract
infection may precede the ocular and dermatologic manifestations and can begin 1 to 3 weeks after
initial exposure and within hours after re-exposure to an inciting agent.
• Cicatrization of the lacrimal ducts + destruction of the conjunctival goblet cells - severe dry eye
• Loss of goblet cells and their mucus secretion – unstable tear film, with poor wetting of the cornea
• Entropion, trichiasis, and lid margin keratinization result in chronic irritation of the cornea and
resultant persistent epithelial defects
OCULAR COMPLICATIONS
• In severe cases, acute ocular involvement may cause keratitis, corneal perforation, and
endophthalmitis
• Chronic complications :
• Conjunctival scarring
• Symblepharon
• Entropion
• Dry eye syndrome
MANAGEMENT - SYSTEMIC DISEASE
• Immediate discontinuation of the offending agent
• Careful monitoring of fluid balance, respiratory function, nutritional requirements, and wound care is
crucial - best managed in an intensive burn care unit
• More than half of all deaths occurring in toxic epidermal necrolysis are secondary to SEPSIS, so control of
infection is critical – Silver nitrate solution on the denuded skin
• The use of systemic corticosteroids (prednisolone 1mg/kg/ day for 3 days ) and i.v. immunoglobulins is
helpful in reducing mortality and morbidity
• High-dose corticosteroids may arrest the necrolysis and benefit the patient’s systemic recovery
• Disadvantages of employing systemic steroids - increased susceptibility to infection, masking of the early
signs of sepsis, gastrointestinal haemorrhage, impaired wound healing, and prolonged recovery
• Examples of fluorescein staining patterns in acute Stevens-Johnson
syndrome
• A, Mild: Only mild conjunctival injection with no epithelial sloughing.
Medical treatment recommended
•
• B, Moderate: Less than 1-cm of discrete epithelial sloughing involving
only the bulbar conjunctiva. Medical treatment recommended
• The parameters of 1 cm of conjunctival staining and one-third of the lid margin are relatively easy to
identify at the bedside and act as useful guide to predict the severity of inflammation
• Areas of conjunctival staining less than 1 cm in diameter without coexistent corneal or lid margin staining
may be treated with topical medications
• Staining involving more than one-third of the lid margin also is concerning because of high risk of scarring
of the meibomian gland orifices and subsequent dry eye problems
• Extent of fluorescein staining is crucial because it indicates how much normal tissue remains to repopulate
the damaged areas that slough off
• If AMT is considered necessary, it should be performed as soon as possible
• Using these above guidelines described, we can decide which patients require urgent AMT and
which patients may be observed and treated with more conservative measures
• In extremely severe cases, the need to repeat the AMT in the acute phase is more likely
• Beyond the first week after the onset of symptoms, the effectiveness of AMT begins to
decrease *
• (Cherof AM. Acute StevensJohnson syndrome: the effect the timing of amniotic membrane
transplantation has on the occurrence of significant ocular sequelae. November 16, 2015)
• Purpose: To highlight and compare the outcomes of management for the ocular sequelae of Stevens–
Johnson syndrome (SJS) over 25 years in a tertiary eye care institute.
• A retrospective study of 798 eyes of 399 patients with SJS evaluated between January 1990 and
December 2004 (group I) and of 847 eyes of 517 patients between January 2005 and December 2014
(group II)
• Groups were subdivided into procedures for ocular surface stabilization (A) and visual rehabilitation (B)
and those managed conservatively (C)
• Following parameters were analyzed for the outcome measures:
• 1. best-corrected visual acuity (BCVA);
• 2. Schirmer I test (graded as 1- <5 mm; 2- 5–10 mm; 3, 11–15 mm; and 4, >15 mm)
• 3. fluorescein corneal staining scores from 0 to 9
• Subgroup A -included procedures for surface stabilization and fornix reconstruction that included-
• Punctal occlusion (collagen or silicone plugs),
• Adnexal corrective procedures,
• Symblepharon release with amniotic membrane grafting in group I and
• Punctal cautery, MMG for lid margin keratinization, prosthetic replacement of ocular surface ecosystem (PROSE)
lenses, symblepharon release with amniotic membrane grafting and MMG , cultivated oral mucosal epithelial
transplantation, and adnexal corrective procedures in group II
• Subgroup B included- limbal allograft with penetrating keratoplasty with systemic azathioprine (2 mg/ kg) for 6
months to 1 year in group I and cataract extraction/ optical iridectomy/keratoprosthesis in group II
• Subgroup C included conservative management that comprised primarily artificial tear substitutes and topical
steroids in group I and artificial tear substitutes in group II
RESULTS
• In 54.3% (434) of eyes in group I, which did not undergo
any surgical intervention and received only medical
treatment, a significant deterioration in BCVA was noted.
• In group II, 114 (13.4%) eyes of 57 patients did not undergo
any intervention
• Limbal status (increase in corneal vascularization)
worsened in 66.9% of eyes treated conservatively and in
60.4% of eyes after intervention in group I
• The limbal status stabilized/improved (decrease in corneal
vascularization) in 96.6% (630/652) of eyes treated by
procedures for surface stabilization (punctal cautery, MMG,
and fornix reconstructive procedures) in group II.
Conclusions: Stabilization procedures show a beneficial role while conservative management can lead to deterioration in
chronic ocular sequelae of SJS.
Keratoprosthesis, specifically the modified osteo-odonto-keratoprosthesis, forms the mainstay for visual rehabilitation in
the end-stage disease
( JUNE 2019)
• Such as use of cyanoacrylate glue, amniotic membrane grafting (AMT), lamellar or full-thickness patch grafts
or keratoplasties
• Visual rehabilitation -
• Optical iridectomy can be attempted to improve vision in eyes with central or paracentral corneal opacities
with a relatively clear zone of the peripheral cornea
• Keratoprosthesis forms the last resort for visual rehabilitation in bilateral end-stage disease
• Modified osteo-odonto keratoprosthesis (MOOKP) forms the first choice of Kpro in eyes with SJS
• Type 2 Boston Kpro or the osteo Kpro can be performed in eyes not suitable for the MOOKP
MANAGEMENT - OPHTHALMIC DISEASE -
ACUTE STAGE
• Ocular surface hygiene should be maintained - frequent conjunctival irrigation and installation
of prophylactic antibiotics to combat secondary infection
• Frequent preservative-free artificial tear supplements should be used to lubricate the corneal
and conjunctival epithelium
• Topical steroids decrease ocular inflammation but can also cause secondary bacterial infection :
so close follow up is required
MANAGEMENT - OPHTHALMIC DISEASE -
ACUTE STAGE
• Bacterial keratitis Rapid corneal perforation
• Trichiasis is a constant and recurring problem – Epilation, cryotherapy, electrolysis to destroy lashes
• Entropion repair, combined with mucous membrane grafting for correcting shortening of the fornices
• Nasolacrimal duct and canalicular obstruction can occur, which sometimes help with DRY EYE state
• In case of dacrocystitis or chronic epiphora occurs, dacryocystorhinostomy and silicone tube insertion
MANAGEMENT - OPHTHALMIC DISEASE -
CHRONIC STAGE
• Frequent artificial tear supplementation to treat the keratoconjunctivitis sicca due to conjunctival scarring
and loss of goblet cells
• Mucolytic agents (10% N-acetylcysteine) used to control filament formation or abnormal mucous discharge
• Bandage soft contact lenses can be used to manage persistent epithelial defects
MANAGEMENT - OPHTHALMIC DISEASE -
CHRONIC STAGE
• Keratoprosthesis have been described for use in patients with Stevens-Johnson syndrome who
have poor epithelial healing
• Once the epithelium has been stabilized by performing the kerato-limbal graft, penetrating
keratoplasty can be performed to improve vision