Ocular cicatricial disease requires a step-wise approach to secure the best results.
This article was reviewed by Clara C. Chan, MD, FRCSC, FACS
Patients with severe cases of ocular surface disease can be some of the most challenging in ophthalmology, and cannot be treated with a cookbook approach.
Often, these patients require a physician to pull out all of the stops in the treatment armamentarium.
The first step is keeping the inflammation under control. Without that control, the patient can slide down a path filled with hurdles to improving their ocular health.
According to Clara C. Chan, MD, FRCSC, FACS, assistant professor of ophthalmology, University of Toronto, department of ophthalmology, and medical director, Eye Bank of Canada, Ontario Division, the importance of the conjunctiva cannot be overemphasized.
“The tissue allows for monitoring of inflammation,” she said. “The goblet cells, the secrete the mucin layer of the tears, are a hallmark of healthy conjunctival tissue. When goblet cells are identified on the corneal surface it is diagnostic of limbal stem cell deficiency (LSCD).”
In addition to LSCD, other sequelae of conjunctival inflammation are goblet cell loss, mucin deficiency, symblephara formation, loss of the fornices, and end-stage surface keratinization, Dr. Chan pointed out.
The salvage options are very difficult once patients have run the gantlet of these ocular insults.
Dr. Chan explained that eyes with chronic conjunctival inflammation and total LSCD have the worst prognosis with any surgical intervention.
“The sequelae of LSCD are daunting, and include conjunctivalization, visual loss, chronic pain with persistent epithelial defects, photophobia, red eye, and corneal transplant failure,” she said.
Patients with more than 50% LSCD and active conjunctival inflammation such as those with Stevens-Johnson syndrome, mucous membrane pemphigoid (MMP), and recent chemical or thermal injury, can expect the worst outcomes.
Good history-taking is mandatory for identifying the some of the ocular offenders in plain sight that can be overlooked, such as topical formulations with preservatives and glaucoma medications that can damage the ocular surface with chronic use.
In addition, a medical history of atopy, graft-versus-host disease, and Stevens-Johnson syndrome can create cicatricial changes on the ocular surface. The physician should also be alert to a history of infections, i.e., herpes simplex virus, and adenovirus; trauma from chemical/thermal injury, or radiation; and inflammation from rosacea and chronically treated refractory blepharitis.
The presence of a disease such as MMP with ocular involvement is not always evident initially and the condition of the ocular surface—the persistence of inflammation—can escape the control of the treating physicians. Determining the etiology of the inflammation clearly is important to keep it in check.