1.

25
A CME Publication
Accreditation
Vindico Medical Education is accredited
by the Accreditation Council for Continuing
Medical Education to provide continuing
medical education for physicians.
Credit Designation
Vindico Medical Education designates
this enduring material for a maximum of
1.25 AMA PRA Category 1 Credit(s)™. Volume 5 • Number 3 • October 2019
Physicians should claim only the credit
commensurate with the extent of their

Corneal Complications of
participation in the activity.

This enduring material is approved for

1 year from the date of original release,
October 10, 2019 to October 10, 2020.
How to Participate in This Activity and
Aesthetic Procedures
Obtain CME Credit
To participate in this CME activity, you must Cynthia Matossian, MD, FACS
read the objectives and articles, complete
the CME posttest, and fill in and return the
registration form and evaluation in their
entirety. Provide only one (1) correct answer
for each question. A satisfactory score is
defined as answering 70% of the posttest
questions correctly. Upon receipt of the
T hroughout
women and men have
history,

used various minerals and

care providers may not always consider that
ingredients or other factors related to these
cosmetic products and procedures may exac-
completed materials, if a satisfactory score
on the posttest is achieved, Vindico Medical dyes to enhance their looks, erbate dry eye disease.3 According to O’Dell et
Education will issue an AMA PRA Category and this interest in looking al,3 ophthalmologists rarely ask about beauty
1 Credit(s) TM certificate within 4-6 weeks.
one’s best continues today. Cynthia Matossian, regimens used by patients.
Disclosures MD, FACS
In accordance with the Accreditation The global beauty business is This article will address a variety of cos-
Council for Continuing Medical Education’s a $445 billion industry, with women dispropor- metic procedures that can affect the ocular
Standards for Commercial Support, all
CME providers are required to disclose to tionately spending billions of dollars more on surface, including lash beauty, makeup, and
the activity audience the relevant financial aesthetic products and procedures than men.1 conjunctival or corneal embellishments.
relationships of the planners, reviewers,
teachers, and authors involved in the In addition, women are more likely to suffer
development of CME content. An individual from dry eye disease than men.2 Some beauty Lash Beauty
has a relevant financial relationship if he
or she has a financial relationship in any products and procedures used on or near the Eyelashes help to protect the corneal sur-
amount occurring in the past 12 months with
a commercial interest whose products or
eye may have a negative impact on the ocular face by repelling micropollutants and debris.
services are discussed in the CME activity surface.3 Unfortunately, patients and their eye continued on page 3
content over which the individual has control.
Editorial Board and Faculty Members
report the following relationship(s):
Brandon D. Ayres, MD
Consulting Fee: Alcon, Allergan,
Bausch + Lomb, Gore, MicroSurgical
Technology, Omeros, Shire, Sight Sciences
Episcleritis and Scleritis
Speakers Bureau: Alcon, Allergan, Shire
Sanjay Kedhar, MD
Kenneth A. Beckman, MD, FACS
Royalty: EyeXpress
Consulting Fee: Alcon, Allergan, Avedro,
Bausch + Lomb, Bruder, Dompè, EyePoint,
Eyevance, J&J Vision, Kala, Mallinckrodt,
Ocular Therapeutix, ReFocus, Sun, Takeda,
E piscleritis is an acute,
self-limited inflamma-
tion of the episclera, which
anastomotic network of vessels. The vessels
of the superficial layer are straight and ori-
ented in a radial fashion, giving episcleritis
TearLab, Zeiss
Speakers Bureau: Alcon, Allergan, Avedro, is a highly vascularized its characteristic appearance.1
Bausch + Lomb, Takeda
Contracted Research: Avedro, ICare, Kala layer of connective tissue Episcleritis occurrence is relatively com-
Ownership Interest: Avedro, eyeXpress, between Tenon’s capsule mon and affects all age groups, although
Sanjay Kedhar,
Eyevance, Ocular Science, RPS, RxSight
and the sclera. The episclera MD it is rare in children.2 Young and middle-
Marjan Farid, MD
Consulting Fee: Allergan, CorneaGen, consists of a parietal layer containing the su- aged adults are most often affected, with
Dompé, EyePoint, Eyevance,
Johnson & Johnson Vision, Kala, Takeda perficial episcleral capillary vascular plexus a gender predominance toward women.3
Laura K. Green, MD and a deeper visceral layer containing an continued on page 9
No relevant financial relationships to disclose.
Preeya K. Gupta, MD
Consulting Fee: Alcon, Allergan, Aurea,
Bausch + Lomb, J&J Vision, Kala, NovaBay,
This continuing medical education Educational Partner This activity is supported by an
Novartis, Ocular Science, Omeros, Shire,
activity is provided by educational grant from
TearLab, TearScience, Zeiss
Shire.
VINDICO
medical education
Volume 5 • Number 3 • October 2019

Chief Medical Editor Julie Schallhorn, MD, MS Laura M. Periman, MD

Inside this Issue Assistant Professor of Clinical Ophthalmology
Associate Program Director
Consulting Fee: Allergan, Shire/Takeda, Sun
Speakers Bureau: Allergan, Shire/Takeda, Sun
Terry Kim, MD
1 Corneal Complications of Professor of Ophthalmology
Duke University School of Medicine
University of California, San Francisco
San Francisco, CA
Contracted Research: Lumenis,
Olympic Ophthalmics
Aesthetic Procedures Chief, Cornea and External Disease Division
Brede A. Skillings, MD Julie Schallhorn, MD, MS
Director, Refractive Surgery Service
Cynthia Matossian, MD, FACS Duke University Eye Center Krieger Eye Institute Consulting Fee: Avedro, J&J Vision, Zeiss
Durham, NC Baltimore, MD
Brede A. Skillings, MD
1 Episcleritis and Scleritis No relevant financial relationships to disclose.
Sanjay Kedhar, MD Associate Medical Editor Reviewers
Christopher E. Starr, MD, FACS
Paul M. Karpecki, OD, FAAO Ashay Bhatwadekar, MPharm, PhD Consulting Fee: Alcon/Novartis, Allergan,
6 Immunologic Peripheral Director, Cornea Services Ronald A. Codario, MD, EMBA, FACP, FNLA, BlephEx, Bruder, Dompé, EyePoint, Eyevance,
Kala, Quidel, Shire, Sun, TearLab
Corneal Disorders Kentucky Eye Institute
Lexington, KY
RPVI, CHCP
Contracted Research: Shire
Julie Schallhorn, MD, MS Ownership Interest: TearLab
Medical Writer
Editorial Board Reviewers report the following
14 Expert Interview: Valerie Zimmerman, PhD
relationship(s):
Dupilumab-Induced Ocular Brandon D. Ayres, MD
Cornea Service Editorial Board and Faculty Members
Surface Disease Co-Director of Cornea Fellowship report the following relationship(s) Ashay Bhatwadekar, MPharm, PhD
Wills Eye Hospital (continued from cover): No relevant financial relationships to disclose.
Kenneth A. Beckman, MD, FACS Philadelphia, PA
Paul M. Karpecki, OD, FAAO Ronald A. Codario, MD, EMBA, FACP, FNLA,
Marjan Farid, MD
16 Case Presentation: Associate Professor of Ophthalmology Consulting Fee: Aerie, Alcon, Allergan, Akorn, RPVI, CHCP
No relevant financial relationships to disclose.
Dupilumab-Induced Ocular Director of Cornea, Cataract, and Anthem, Avellino, Bausch + Lomb, Bio-Tissue,
Refractive Surgery BlephEx, Bruder Healthcare, Cambium, Medical Writer reports the
Surface Disease Gavin Herbert Eye Institute DGH Technology, Essilor, eyeBrain, EyeGate,
University of California, Irvine EyePoint, Eyevance, Focus Labs, Icare,
following relationship(s):
Laura M. Periman, MD;
Irvine, CA Imprimis, Ivantis, Jobson Healthcare,
Laura K. Green, MD; Valerie Zimmerman, PhD
Preeya K. Gupta, MD J&J Vision, Konan, Lentechs, Maculogix,
No relevant financial relationships to disclose.
Brede A. Skillings, MD Associate Professor of Ophthalmology Nevakar, Notal Vision, Novaliq, Novartis,
Duke University School of Medicine Oasis Medical, Ocular Sciences, Oculus, Purdue University and Vindico Medical
18 CME Posttest Cornea and Refractive Surgery
Clinical Director, Duke Eye Center
OcuMedic, OCuSOFT, Oyster Point, PECAA,
Quark, Refocus Group, Reichert, Rendia, Education staff report the following
Durham, NC RxSight, ScienceBased Health, Sentiss, Shire, relationship(s):
19 CME Registration Form Christopher E. Starr, MD, FACS Sight Sciences, Sun, TLC, Topcon, Vmax, Zeiss
Contracted Research: Novartis, Shire, No relevant financial relationships to disclose.
Associate Professor of Ophthalmology
Director, Refractive Surgery Sight Sciences Signed disclosures are on file at Purdue
Director, Cornea Fellowship Ownership Interest: Bruder Healthcare,
Vindico Medical Education Director, Ophthalmic Education Ophthalmic Resources,
University and Vindico Medical Education.
Optometric Medical Solutions,
Medical Director Weill Cornell Medicine
New York Presbyterian Hospital Silk Technologies, Tarsus Medical, TearLab
Target Audience
Ronald A. Codario, MD, EMBA, FACP, New York, NY The intended audience for this activity is
Sanjay Kedhar, MD
FNLA, RPVI, CHCP Consulting Fee: Aldeyra Therapeutics, ophthalmologists, optometrists, and other health
care professionals involved in the treatment of
Scientific Director Guest Contributors J&J Vision, RxSight
patients with ocular surface disease.
Simon J. Cooper, PhD Contracted Research: Aldeyra Therapeutics,
Kenneth A. Beckman, MD, FACS jCyte, Santen
Senior Medical Editor Director, Corneal Service Overview
Betti Bandura, ELS Comprehensive EyeCare of Central Ohio Terry Kim, MD Early identification and prompt management
Clinical Assistant Professor Consulting Fee: Aerie, Alcon/Novartis, of patients with ocular surface disease (OSD)
Program Manager The Ohio State University Allergan/Actavis, Avedro, Avellino Labs, can lessen disease severity and achieve earlier
Arielle Garbarino Westerville, OH Bausch + Lomb/Valeant, BlephEx, resolution. However, OSD continues to be
Laura K. Green, MD CoDa/Ocunexus Therapeutics, Kala, NovaBay, challenging to differentially diagnose and therefore
Ophthalmology Residing Program Director Ocular Therapeutix, Omeros, PowerVision, is frequently undertreated. Consequences of
Krieger Eye Institute Presbyopia Therapies, Shire, Simple Contacts, delayed identification and treatment of OSD have
CME Questions? Sinai Hospital of Baltimore TearLab, Zeiss detrimental effects, but the continued assessment
Baltimore, MD Ownership Interest: Avellino Labs, CorneaGen, and refinement of diagnostic and management
Contact us at: Kala, NovaBay, Ocular Therapeutix, Omeros, algorithms, along with advances in ocular imaging
Sanjay Kedhar, MD and therapeutic modalities, have the potential to
Purdue University: cmemda@purdue.edu Clinical Professor of Ophthalmology Simple Contacts
enhance visual acuity outcomes and quality of life in
or 765-496-1306. Director, Ocular Immunology Service Cynthia Matossian, MD, FACS patients with OSD. In this publication series, Ocular
University of California Consulting Fee: Aerie, Alcon, Allergan, Surface Diseases, Disorders, & Dysfunctions®,
Vindico Medical Education: cme@vindicocme.com Irvine, CA Volume 5, expert clinicians will review and evaluate
or 856-994-9400, ext. 504. Bausch + Lomb, Bio-Tissue, Bruder,
pertinent advances for the diagnosis, treatment,
Cynthia Matossian, MD, FACS Checked-Up, Conclusn, Dompé, EyePoint, and management of patients with OSD, as well as
Adjunct Clinical Assistant Professor Eyevance, Guardion Health Sciences, offer clinical guidance for the optimal management
of Ophthalmology Imprimis, J&J Vision, Kala, Lenstec, Marco, of challenging case presentations.
Temple University School of Medicine MDbackline, Ocular Science,
Learning Objectives Philadelphia, PA
Upon successful completion of the Clinical Instructor
Ocular Therapeutix, Omeros, Physician Unlabeled and
Recommended Nutriceuticals, Quidel, Shire,
publication series, participants should be Robert Wood Johnson Medical School Sun, TearLab, TearScience, Zeiss Investigational Usage
better able to: Rutgers University Speakers Bureau: Alcon, Allergan,
New Brunswick, NJ The audience is advised that this continuing medical
Bausch + Lomb, BioTissue, EyePoint, Guardion education activity may contain references to
• Evaluate new methods and modalities Founder, CEO, and Chief Medical Officer Health Sciences, Imprimis, J&J Vision,
Matossian Eye Associates unlabeled uses of US Food and Drug Administration
that assist in the diagnosis of ocular Physician Recommended Nutriceuticals, Shire, (FDA)-approved products or to products not
surface and dry eye disease. Pennington, NJ Sun, TearLab, TearScience, Zeiss approved by the FDA for use in the United States.
• Investigate the use of dry eye Laura M. Periman, MD Ownership Interest: CheckedUp, The faculty members have been made aware of
Director of Dry Eye Services and Physician Recommended Nutriceuticals, their obligation to disclose such usage. All activity
therapies in specific patient Clinical Research Progressive Tech Training, Strathspey Crown, participants will be informed if any speakers/
populations to better understand Evergreen Eye Center Veterinarian Recommended Solutions authors intend to discuss either non–FDA-approved
the attributes and limitations of Seattle, WA Grant Support: Shire or investigational use of products/devices.
monotherapy and combination
therapy in these patients.
Created and published by Vindico Medical Education, 6900 Grove Road, Building 100, Thorofare, NJ 08086-9447. Telephone: 856-994-9400; Fax: 856-384-6680.
• Assess the management of dry Printed in the USA. Copyright © 2019 Vindico Medical Education. All rights reserved. No part of this publication may be reproduced without written permission
eye disease and ocular surface from the publisher. The material presented at or in any of Purdue University and Vindico Medical Education continuing education activities does not necessarily
disorders both preoperatively and reflect the views and opinions of Purdue University and Vindico Medical Education. Neither Purdue University and Vindico Medical Education nor the faculty
postoperatively to improve endorse or recommend any techniques, commercial products, or manufacturers. The faculty/authors may discuss the use of materials and/or products
surgical outcomes. that have not yet been approved by the US Food and Drug Administration. All readers and continuing education participants should verify all information
before treating patients or utilizing any product.
 Ocular Surface Diseases, Disorders, & Dysfunctions ® 3

continued from page 1 Although special cleaners are avail- perming, especially for those in
Lash extensions are a popular trend, able for lash extensions, many of the whom lash extensions have become
but they can damage the natural lashes ingredients in the cleaners are toxic to problematic.10 Perming involves curl-
if applied incorrectly, potentially the corneal surface, the lashes, and the ing the lashes upwards by breaking
causing ocular surface problems.4 skin in the periorbital area.10 the sulfur bonds in the lash follicles
Although consumers undergoing eye- to recreate them in a bent fashion,
lash extensions should use a licensed Lash Strips resulting in curly lashes.10 However,
professional who is certified to apply When consumers become intol- the process of perming typically in-
the lashes, most eyelash applications erant of lash extensions or develop volves several ingredients, some of
are performed at beauty/nail salons allergic reactions to their key com- which can lead to blepharokerati-
where employees are not certified ponents, they may try an at-home tis or a chemical burn if the perm-
to perform the task.4 The glues used process of gluing a strip of artificial ing chemical seeps onto the corneal
with these individually applied lashes lashes onto their eyelids. The glue surface.8,10,12 Ingredients frequently
often contain latex and formalde- used with these at-home false lashes used in lash perming include AMP-
hyde, which can negatively affect the is typically applied 1 to 2 mm above acrylates/allyl methacrylate copo-
tear film in patients allergic to these the natural lash line, where new lash lymer, carbomer, glycerin, sodium
substances,5 leading to periorbital growth occurs.10 Consumers are sup- hydroxide, phenoxyethanol, hydro-
erythema, chemosis, and permanent posed to remove the false eyelashes lyzed collagen, panthenol, tocoph-
lash loss.5 If a consumer is allergic to every night.10 However, this step eryl acetate, benzoic acid, dehydro-
latex and the person applying the lash concurrently strips away new lash acetic acid, potassium sorbate, and
extensions is unaware of this fact, the growth, thins the natural lashes, and sodium benzoate.10
latex in the fixative could lead to al- interferes with their protective pur-
lergic blepharoconjunctivitis.6,7 Simi- pose against surface irritants.6,10 Lash Dying
larly, the gel pads used during the lash Lash dying or tinting is another
application process may contain latex Lash Embellishment beauty option that consumers use to
and a variety of adhesives, which can Lash embellishment is a beauty darken their lashes to make them ap-
potentially lead to ocular irritation trend whereby users apply rhine- pear more prominent. This coloring
and allergic dermatitis.6-8 Eyelashes stones, feathers, and other adornments process is often performed in salons
that are excessively long or thick may to the lashes with fine wires or glues.5 by hair and nail technicians who are
alter the air dynamics as well as fun- These can create trauma to the natu- not familiar with orbital anatomy.8
nel pollen and pollution onto the cor- ral lash and lash root, leading to per- Many dyes have harsh components,
neal surface instead of repelling these manent lash loss due to the weight of including hydrogen peroxide, syn-
environmental elements.9 the objects attached as well as to the thetic coal tar, and histamine.8,10 Ul-
The interest in obtaining longer tugging and manipulation.10 If a user timately, these coloring agents may
lashes with extensions creates a vi- attaches decorative feathers to their lead to an allergic reaction in patients
cious cycle—persons must return to a eyelashes and they have an allergy to sensitive to these components.8,10 To
salon every few weeks for a “refill,” as feathers, this may create the perfect perform eyelash tinting properly,
20% to 30% of human lashes are lost venue for allergic conjunctivitis.10 the dye should first be tested on the
during that period due to natural turn- Similarly, the use of trendy glued-on skin,8 and then the consumer should
over.7,10 This not only creates a cost LED lights to the upper eyelid margin be seated at a 45-degree angle after
burden, but it may exacerbate dry eye can affect the growth of new lashes.10 the dye is applied to the lashes to
disease, blepharitis, and meibomian The weight of these lights can lead to avoid getting colorant into the eye.10
gland dysfunction.6,7,10 As patients aim traction alopecia, particularly because Unfortunately, these 2 steps are fre-
to retain their lash extensions, they be- users must apply a copious amount quently not performed.
come hesitant to wash their eyelids.10 of glue to keep them on.10,11 Stripping
Consequently, debris accumulates at off the lights can remove natural, new Makeup and Ocular
the base of the lashes, which can lead eyelash growth.10 Surface Disease
to blepharitis, foreign body sensation, The use of makeup, with its many
or a Demodex folliculorum infestation, Lash Perming ingredients, may lead to exacerbation
with progressive worsening of the per- Another lash trend toward which of OSD and overall eye discomfort.3
son's ocular surface disease (OSD).10 consumers are gravitating is lash Most patients do not link the use of
 4 Volume 5 • Number 3 • October 2019

Manicures ingrowth, reactions to the metal in

Figure. Meibomian
Gland Loss One area of makeup use that the flap, and other occurrences that
physicians and consumers alike do may lead to decreased vision.10
not consider as a link to OSD is a Piercings are commonly per-
nail manicure.17 When a person has formed all over the body, including
a manicure, he/she may commonly near the eye. If these are performed
touch the face and area around the at a piercing parlor by workers who
eyes. However, there is a high cor- are not familiar with ocular anato-
relation of certain chemicals in nail my, the result can lead to injury of
polish, especially toluene, that may the ocular surface based on the posi-
Meibomian gland loss in a patient who cause periorbital chemosis due to tion of the piercing.10
has permanent eyeliner tattoos.
Source: Cynthia Matossian, MD, FACS.
an allergic reaction.17,18 In addition,
some metallic nail polishes with Eye Whitening
glitter or shimmer contain nickel, Conjunctivoplasty or a proce-
eye makeup to their ocular problems. which could cause a reaction in per- dure called I-BRITE involves cos-
This can especially occur if makeup sons with a known nickel allergy.17,18 metic conjunctival eye whitening
is not removed properly.3 For exam- I believe that men can also be af- performed by ophthalmologists.21,22
ple, a 50-year-old woman presented fected by this problem if they re- It is used to whiten the conjunc-
to the hospital emergency department ceive a manicure with clear polish tiva through inhibiting blood vessel
for severe pain in 1 of her eyes.13 She or if their spouse had a manicure. growth by excising the conjunctiva
had used mascara for 25 years, but The ocular effects from nail polish and then applying topical mitomy-
she did not remove it or removed may not manifest for days after a cin C or an anti-vascular endothe-
it poorly.13 The buildup of mascara manicure, so it may be challenging lial growth factor medication such
pigment in the macrophages eroded to connect the ocular problem to its as bevacizumab.22 This procedure
through the conjunctival surface, root cause.17,18 has been associated with persis-
leading to multiple corneal abra- tent conjunctival epithelial defects,
sions and multiple darkly pigmented Conjunctival and Corneal limbal stem cell compromise, in-
subconjunctival concretions.13 The Beauty Procedures fectious scleritis, diplopia from
pathology slides revealed a chronic Ocular Jewelry Tenon’s capsule scarring, and scler-
inflammatory infiltrate with pig- Conjunctival jewelry involves the al necrosis with secondary infec-
mented macrophages.13 insertion of small platinum jewelry, tious endophthalmitis.21,22 Despite
such as a heart shape, into a pocket these effects, the procedure is still
Permanent Eyeliner created in the conjunctiva.19 The 3- currently performed.
Eyelid tattoos, also known to 4-mm platinum design is placed
as permanent eyeliner, involve a between the sclera and conjunctiva Tattooing
microneedling procedure that uses during a 5-minute procedure.19 Pa- Much like piercing, tattooing is
an ink with a mineral pigment.14 In tients may change their jewelry by commonly performed on all areas
some Asian cultures, permanent eye- returning to the ophthalmologist. of the body. Conjunctival or scleral
liner and eyebrow tattoos are com- Localized conjunctival hyperemia, tattooing may be performed at tat-
mon.14 The use of permanent eye- as well as a foreign body sensation, too parlors, where the tattoo artist,
liner is becoming more popular in may occur.20 The patient’s blinking who has little or no knowledge of
the United States.15 However, if the mechanism and blink pattern may eye anatomy, injects ink of all col-
eyelid microneedling is performed also be affected, leading to further ors subconjunctivally.10 These types
improperly, it can cause iatrogenic exacerbation of OSD.11 of procedures have been associated
damage to the meibomian glands, Corneal jewelry is also avail- with infections, globe perforations,
with gland dropout and atrophy able, where a fleck of gold is placed and complete loss of vision.10,23
(Figure).16 Consequently, cosmetic inside a femtosecond laser-created
eyeliner tattoos can cause destruc- flap to provide the patient’s eye Clinical Pearls
tion of the meibomian glands due to with a little sparkle.10 However, Ophthalmologists have an ideal
excessive needle penetration and ink these types of corneal procedures opportunity to improve the ocular
pigment migration.8,16 could potentially lead to epithelial health of their patients by asking
 Ocular Surface Diseases, Disorders, & Dysfunctions ® 5

about their use of beauty products 3. O’Dell LE, et al. Poster presented 15. National Environmental Health
and cosmetic procedures. at: ARVO 2017; May 6-11, 2017; Association. https://www.neha.
Baltimore, MD. Poster A0420. org/sites/default/files/publications/
I believe an important pearl is to
https://iovs.arvojournals.org/article. position-papers/NEHA_Policy_
teach patients to read beauty product aspx?articleid=2638663&resultCli Statement_Microblading_FINAL.
ingredient labels as closely as they ck=1. Accessed July 31, 2019. pdf. Accessed August 20, 2019.
may read food ingredient labels. For 4. Mukamal R. https://www.aao.org/ 16. Bussel II, et al Ophthalmol-
example, teaching patients about the eye-health/tips-prevention/eyelash- ogy Times. https://www.
presence of prostaglandins (indicated extension-facts-safety. Accessed ophthalmologytimes.com/modern-
with prost in an ingredient name) can August 19, 2019. medicine-cases/cosmetic-eyeliner-
make them aware of this substance, 5. Avitzur O. https://www.consumer- tattoo-risk-factor-ocular-surface-
which may cause periorbital pigmen- reports.org/cro/2013/05/eyelash- disease. Accessed July 10, 2019.
tation, along with a negative effect on extensions-can-pose-health-risks/ 17. Choi M. https://www.livinghealthy.
index.htm. Accessed July 10, 2019.
meibomian glands.24 In patients with com/articles/itchy-eyes-why-
chronic blepharitis and dry eye, pa- 6. Amano Y, et al. Cornea. your-manicure-is-the-most-likely-
2012;31(2):121-5. culprit. Accessed July 10, 2019.
tients or their ophthalmologists should
7. Whelan C. https://www.healthline. 18. Shanmugam S, et al. Contact Der-
look for products with benzalkonium
com/health/eyelash-extension-side- matitis. 2012;67(5):309-10.
chloride (BAK), which may aggravate effects. Accessed August 20, 2019.
their underlying ocular surface prob- 19. Whitelocks S. https://www.daily-
8. Masud M, et al. Med Hypoth-
lem.24 Patients also should look for mail.co.uk/femail/article-2510576/
esis Discov Innov Ophthalmol.
eye beauty products that are free of Woman-gets-platinum-eye-jewelry-
2019;8(2):96-103.
implanted-optic-membrane.html.
parabens, which are preservatives that 9. Amador GJ, et al. J R Soc Interface. Accessed July 15, 2019.
could irritate the ocular surface.10 2015;12(105):20141294.
20. American Academy of Ophthal-
Ophthalmologists need to keep in 10. Matossian C. Presented at: ASCRS
mology. https://www.aao.org/eye-
mind that beauty-related procedures 2019; May 4, 2019; San Diego, CA.
health/news/eyeball-jewelry. Ac-
and products can be causes, mas- Course #IC-111.
cessed August 20, 2019.
queraders, or exacerbators of OSD. 11. Matossian C, et al. Ophthalmology
Management. 2016;20(April):30-3. 21. Saldanha MJ, et al. Can J Ophthal-
mol. 2016;51(4):e115-e116.
References 12. Cherney K. https://www.healthline.
com/health/lash-lift-side-effects. 22. Leung TG, et al. J Ophthalmic In-
1. Sorvino C. https://www.forbes.com/
Accessed August 20, 2019. flamm Infect. 2013;3(1):39.
sites/chloesorvino/2017/05/18/self-
made-women-wealth-beauty-gold- 13. Robaei D. Ophthalmology. 23. American Academy of Ophthal-
mine/#27d371652a3a. Accessed 2018;125(5):641. mology. https://www.aao.org/
July 10, 2019. 14. Wesley N. https://www.mdedge. eye-health/tips-prevention/eyeball-
2. Starr CE, et al. In: Ocular Surface com/dermatology/article/57216/ tattoos-are-even-worse-than-they-
Diseases, Disorders, & Dysfunc- pigmentation-disorders/cosmetic- sound. Accessed August 20, 2019.
tions. Thorofare, NJ: Vindico Medi- tattooing-and-ethnic-skin. Accessed 24. Mocan MC, et al. J Glaucoma.
cal Education; 2017;3(4):1-6. August 20, 2019. 2016;25(9):770-4.
 6 Volume 5 • Number 3 • October 2019

Immunologic Peripheral Corneal Disorders

Julie Schallhorn, MD, MS

T he corneal pe-
riphery repre-
sents a unique im-
Marginal keratitis generally pres-
ents with 1 or multiple small infil-
trates, with a small, clear, intervening
Phlyctenular Keratitis
Phlyctenular keratitis is thought
to occur as a response to antigens
munologic zone. space between the limbus and the released by infectious organisms. It
Proximity to sys- infiltrate, which is thought to occur was initially described in children
temic vasculature Julie Schallhorn, because of the diffusion dynamics with tuberculosis, but staphylococcal
on the limbal side MD, MS of the immune complex deposition.8 blepharitis and meibomitis are more
makes this portion of the cornea ac- The infiltrates may occur anywhere, commonly seen today.9-12 It has also
cessible to inflammatory cells, anti- but they are typically found at loca- been reported in the setting of helmin-
bodies, and inflammatory mediators.1 tions of overlap between the eyelid thic infections and rosacea and occurs
Due to the junction between the lim- margin and the limbus.8 There often more commonly in children.13,14
bal blood supply and the avascular is overlying epithelial ulceration, but Phlyctenules can be limited to
central cornea, immune mediators the epithelium may be intact in some the conjunctiva, where they present
and antibodies can collect in the cases.8 Examination of the eyelids as raised nodules on a background
peripheral stroma causing disease, and lashes often reveals blephari- of conjunctival injection, usually in
whereas the central cornea remains tis with scurf, lid margin crusting, the nasal/temporal limbus. The lack
unaffected.1 The limbus also houses or ulceration and may demonstrate of deep episcleral injection and the
a population of antigen-presenting meibomitis.8 Typically, the infiltrates characteristic boring pain separate
cells that are effective at recruiting a are culture-negative (so-called sterile phlyctenular keratitis from scleritis.8
cellular immune response.1 However, infiltrates), but cultures from the eye- When involving the cornea, phlycte-
this can result in the unique inflam- lids and conjunctiva yield high levels nules generally appear as a white foci
matory patterns of crescentic inflam- of Staphylococcus species.8 of inflammation, leading a wedge-
mation that is often seen in peripheral In the setting of ulceration, and shaped patch of injection or vascular-
corneal diseases.2 especially if the patient has a his- ization (Figure 1). There can be ulcer-
tory of contact lens wear, the infil- ation overlying the inflammation, with
Marginal Keratitis trate should be cultured to rule out the lesion requiring a culture to differ-
Marginal keratitis, also called an infectious etiology. After culture, entiate it from infectious keratitis.
staphylococcal marginal keratitis or my patients are started on a broad- Chronic phlyctenular disease can
staphylococcal hypersensitivity kerati- spectrum topical antibiotic, such as have a meandering pattern of vascular-
tis, is thought to arise from the deposi- a fourth-generation fluoroquinolone, ized, scarred cornea leading from the
tion of immune complexes within the 4 times per day. In classic cases limbus to the central cornea.8 This is
peripheral corneal stroma in response without a history of contact lens thought to occur from repeated bouts
to antigens from lid bacteria.3 This wear, some practitioners will also of inflammation at the head of the le-
causes the attraction of inflammatory start a mild topical steroid, such as sion, leading the phlyctenule further
cells, resulting in the appearance of an fluorometholone 0.1%, at the same onto the cornea with each relapse.8
infiltrate.3 As macrophages ingest the time. In atypical cases or those with The clinical sequelae of phlyc-
immune complexes and neutrophils a history of contact lens wear, ste- tenules, particularly in the pediatric
disgorge cytotoxic enzymes, ulcer- roids should not be given prior to population where it is more common,
ation of the overlying epithelium can obtaining culture results.8 Treatment can be severe.15 Significant corneal
form.3,4 Marginal keratitis has also also involves addressing underlying involvement can result in corneal
been reported in the setting of numer- blepharitis. Patients generally bene- scarring and irregular astigmatism,
ous other conditions, including ocular fit from a regimen of lid hygiene and inducing amblyopia in younger chil-
rosacea, syphilis, graft-versus-host warm compresses, although compli- dren.15 If ulceration occurs, treatment
disease, and leukocytoclastic vascu- ance with these measures can often involves obtaining a culture to rule
litis, and atypical or severe cases re- be suboptimal and many patients out infection, and a topical antibi-
quire further investigation.5-7 will experience repeat episodes.8 otic—generally a fourth-generation
 Ocular Surface Diseases, Disorders, & Dysfunctions ® 7

fluoroquinolone or polymyxin/trime-
Figure 1. Corneal Figure 2. Peripheral
thoprim—is used until the epithelium
Phylectenule Ulcerative
is healed, in addition to use of a topi- Keratitis Without
cal steroid.1 Lesions are generally re- Scleritis
sponsive to steroids, requiring appli-
cation no more than 4 times per day.1
Patients with ocular rosacea or mei-
bomitis also benefit from the addition
of an oral macrolide or tetracycline
antibiotic.16 In young children, eryth-
romycin is preferred to the tetracy-
clines.16 In my experience, some pa-
tients require chronic topical steroids Source: Courtesy of Gerami Seitzman, MD. Source: Julie Schallhorn, MD, MS.
to control their disease. In such cases,
topical 0.03% tacrolimus ointment
has been shown to be of benefit.17,18 cornea may be markedly thinned, and there are any positive findings on
Children with phlyctenular disease perforation may occur.2 There may patients’ review of systems, consider
should be followed closely to prevent be associated scleritis in concomitant referral to a rheumatologist for further
scarring, loss of vision, and steroid- systemic vasculitic disease.2 evaluation. Patients presenting with
induced ocular complications.1 Approximately 50% of the oc- what appears to be PUK should also
currences of PUK are associated undergo a laboratory culture to rule
Peripheral Ulcerative with a systemic vasculitic disease.20 out infection. In cases of suspected
Keratitis The most common systemic asso- viral etiology, polymerase chain reac-
Peripheral ulcerative keratitis ciation is rheumatoid arthritis, but tion should be performed.24 Numerous
(PUK) is a severe, vision-threatening numerous other autoimmune etiolo- infectious pathogens, including Acan-
disease in which ulceration of the epi- gies have been implicated, includ- thamoeba and herpes, can masquer-
thelium and progressive keratolysis of ing granulomatosis with polyangiitis ade as PUK, thus differentiation is of
the stroma result in severe peripheral (GPA; formerly known as Wegener’s the utmost importance to provide the
corneal thinning, with a risk of per- granulomatosis), polyarteritis nodosa, proper treatment.19,24,25
foration and secondary infection.1,19 Cogan’s syndrome, systemic lupus The diagnosis of noninfectious
The exact pathogenic mechanisms erythematosus, relapsing polychon- PUK should always prompt a workup
are unknown but are thought to be the dritis, eosinophilic granulomatosis for systemic vasculitic diseases (Ta-
development of an immune response with polyangiitis (formerly known as ble).26 This is essential, given the fre-
against a corneal or epithelial antigen. Churg-Strauss syndrome), Behcet’s quency of concurrent systemic dis-
However, cell-mediated cytotoxicity disease, inflammatory bowel dis- ease and the life-threatening nature
may also play a role.1,19 This results ease, and scleroderma.1,21,22 Infectious of these diseases.26 It is especially
in the deposition of antibody–antigen causes have also been implicated in critical to properly diagnose patients
complexes within the peripheral stro- PUK, including varicella zoster and with GPA as a cause of PUK because
ma, complement activation, and an in- herpes simplex, acanthamoeba, fun- patients with GPA and eye involve-
flux of T cells, macrophages, and neu- gal infections, many bacterial species, ment are at a significantly increased
trophils.1 Neutrophil activation results syphilis, tuberculosis, and others.1,19 risk of mortality—up to 50% at
in the release of cytotoxic enzymes, Patients should undergo a thor- 5 months—without treatment.26
which degrade the epithelium and col- ough review of systems, with special Patients with PUK without associ-
lagen fibers, resulting in ulceration attention focused on the musculoskel- ated scleritis who have a negative sys-
and thinning.1 The associated limbal etal, skin, and respiratory systems to temic workup and no other attributable
vasculature may demonstrate a vaso- evaluate symptoms of any other auto- causes of PUK are usually associated
occlusive vascultitis.2 immune disease.21,23 Specifically for with a diagnosis of Mooren’s ulcer.8
The presenting appearance of PUK relapsing polychondritis, the practitio- An association between Mooren’s
is peripheral crescentic ulceration, ner should inquire about patients’ ten- ulcer and hepatitis C infection has
with thinning in the absence of an derness over cartilaginous processes, been reported.27 Thus, patients with
infectious infiltrate (Figure 2).2 The including the nose and pinna.21,23 If a diagnosis of Mooren’s ulcer should
 8 Volume 5 • Number 3 • October 2019

Table. Targeted Laboratory Workup for Systemic Vasculitic Diseases

Figure 3. Corneal
Laboratory Testa Associated Disease Perforation
Rheumatoid factor Rheumatoid arthritis
Anti-cyclic citrullinated peptide Rheumatoid arthritis
Antineutrophil cytoplasmic antibodies Granulomatosis with polyangiitis
Polyarteritis nodosa
Relapsing polychondritis
Antinuclear antibody Systemic lupus erythematosus
Purified protein derivative or Tuberculosis
interferon-gamma release assay
Fluorescent treponemal antibody Syphilis
absorption, Treponema pallidum
particle agglutination assay,
microhemagglutination assay for
Treponema pallidum antibodies
Chest X-ray Granulomatous diseases Gluing of a corneal perforation with
Urinalysis Renal involvement in cyanoacrylate in a patient with severe
vasculitic diseases seronegative rheumatoid arthritis and
a
recurrent peripheral ulcerative keratitis.
Additional laboratory studies should be considered if the patient’s review of systems reveals concern
Source: Julie Schallhorn, MD, MS.
for any other diseases.
Source: Dana MR, et al1; Krachmer JH, et al8; Galor A, et al21; Messmer EM.23

undergo evaluation for hepatitis C.27 Any keratoconjunctivitis sicca or sec- Summary
There have also been reports of asso- ondary Sjogren’s syndrome should With a thorough patient examina-
ciation of Mooren’s ulcer with expo- also be addressed, as this can contrib- tion and history and an understand-
sure to helminths, although the patho- ute to further melting.1 ing of the underlying pathophysiol-
genic mechanisms remain unclear.28 Perforation of the cornea in an ogy of corneal diseases, clinicians
In patients with a negative infec- acute setting can often be managed should be able to differentiate the
tious workup, treatment should be with topical cyanoacrylate glue until numerous peripheral corneal auto-
initiated with high-dose oral cor- the systemic disease can be brought immune diseases and provide the
ticosteroids, generally prednisone under control, which is the preferred appropriate treatment. Proper diag-
1 mg/kg.21,23 Patients taking oral non- method of treating perforations in pa- nosis of these diseases is extremely
steroidal anti-inflammatory drugs or tients with active disease (Figure 3).23 important, as they often are harbin-
aspirin or have a history of peptic Patients with large perforations that gers of severe systemic diseases.
ulcer disease should begin peptic ul- are unresponsive to glue require
cer prophylaxis with an oral proton urgent tectonic grafting.23 In these References
pump inhibitor or H2-blocker.21 In cases, all attempts should be made 1. Dana MR, et al. Cornea.
hyperacute cases, intravenous pulse to get the systemic disease under 2000;19(5):625-43.
steroids may be necessary.21 Patients control as rapidly as possible or 2. Foster CS. J Fr Ophtalmol.
should be transitioned to systemic further melting of the tectonic graft 2013;36(6):526-32.
immunomodulatory therapy from will occur.29 3. Ficker L, et al. Eye (Lond).
oral steroids in most cases.21 Mul- Areas of PUK can induce signifi- 1989;3(Pt 2):190-3.
tidisciplinary care with rheumatol- cant irregular astigmatism.30 When the 4. Jayamanne DG, et al. Eye (Lond).
ogy is essential to ensure appropriate disease has been stabilized, treatment 1997;11(Pt 5):618-21.
patient management. During active with large-diameter scleral lenses can 5. Martinez JA, et al. Am J Ophthal-
disease, topical and systemic anticol- often provide excellent vision as well mol. 1989;107(4):431-3.
lagenase adjuvant measures, includ- as the treatment of concurrent kerato- 6. Dai E, et al. Cornea. 2007;26(6):756-8.
ing oral doxycycline, oral high-dose conjunctivitis sicca.30 Patients who are 7. Li Yim JF, et al. Clin Exp Ophthal-
vitamin C, and topical 20% n-acetyl- not candidates for contact lenses may mol. 2007;35(3):288-90.
cysteine, may be helpful but should undergo tectonic grafting for the treat- 8. Krachmer JH, et al (eds). Cornea.
not be used as a stand-alone therapy.8 ment of astigmatism.29 Philadelphia, PA: Elsevier; 2011.
 Ocular Surface Diseases, Disorders, & Dysfunctions ® 9

9. Lahiri K, et al. Pediatr Infect Dis J. 16. Culbertson WW, et al. Ophthalmol- 23. Messmer EM, et al. Surv Ophthal-
2015;34(6):675. ogy. 1993;100(9):1358-66. mol. 1999;43(5):379-96.
10. Neiberg MN, et al. Optometry. 17. Yoon CH, et al. Cornea. 24. Praidou A, et al. Cornea.
2008;79(3):133-7. 2018;37(2):168-71. 2012;31(5):570-1.
25. Vignesh AP, et al. Taiwan J Oph-
11. Suzuki T. Cornea. 2012;31 Suppl 18. Kymionis GD, et al. Cornea. thalmol. 2016;6(4):204-5.
1:S41-4. 2012;31(8):950-2. 26. Tarabishy AB, et al. Surv Ophthal-
12. Suzuki T, et al. Am J Ophthalmol. 19. Moreira AT, et al. Cornea. mol. 2010;55(5):429-44.
2005;140(1):77-82. 2003;22(6):576-7. 27. Wilson SE, et al. Ophthalmology.
13. Blaustein BH, et al. Optometry. 20. Knox Cartwright NE, et al. Cornea. 1994;101(4):736-45.
2001;72(3):179-84. 2014;33(1):27-31. 28. van der Gaag R, et al. Br J Ophthal-
mol. 1983;67(9):623-8.
14. Doan S, et al. J Ophthalmic In- 21. Galor A, et al. Rheum Dis Clin 29. Lohchab M, et al. Surv Ophthal-
flamm Infect. 2013;3(1):38. North Am. 2007;33(4):835-54, vii. mol. 2019;64(1):67-78.
15. Rodriguez-Garcia A, et al. Eye 22. Shiuey Y, et al. Int Ophthalmol 30. Ding Y, et al. Surv Ophthalmol.
(Lond). 2016;30(3):438-46. Clin. 1998;38(1):21-32. 2019;64(2):162-74.

Episcleritis and Scleritis vessels, whereas the vessels in scle- Patient Workup
continued from page 1 ritis will not blanch.3 Moreover, use If the patient has positive find-
A large cohort study of patients in of the red-free filter on the slit lamp ings on review of systems or frequent
northern California found the in- can be helpful in distinguishing vas- recurrences, a workup for an associ-
cidence to be 41/100,000 person- cular engorgement of the superficial ated systemic disease and possibly a
years and the prevalence to be episcleral layers of the episclera biopsy should be considered.4 Labo-
52.6/100,000 person-years.3 Extrapo- from the involvement of the deeper ratory workup should be directed
lated to the population of the United visceral layer in scleritis (Figure 2).1 and guided by the patient’s history
States, we would expect 120,000 new Episcleritis is usually idiopathic, and review of systems rather than
cases of episcleritis every year in the but it may be associated with sys- a “shotgun” approach to testing.6
United States.3 Because of its self- temic disease in approximately one- For instance, findings of lower back
limiting nature, the true incidence third of patients.4 Jabs et al5 found stiffness or pain that is worse in the
and prevalence may be difficult to an association with rheumatoid morning and gets better with activ-
quantify, as many patients may not arthritis in 11.1% of patients with ity should prompt testing for HLA-
seek attention or may be treated by episcleritis. In another study, atopy B27.6 Laboratory investigations for
their primary care physician.3 (12%) was the most commonly as- episcleritis and scleritis are shown in
sociated systemic disease.4 The the Table.
Classification of Episcleritis study authors found no correlation In addition, nearly half of patients
Episcleritis is classified as sim- between the number of recurrences, with episcleritis will have a concur-
ple or nodular. Simple episcleritis laterality, or type of episcleritis and rent underlying eye disease such as
is most common and characterized the presence of associated systemic rosacea, keratoconjunctivitis sicca, or
by sectoral or diffuse vascular con- disease.4 Of note, 2 patients in the atopic keratoconjunctivitis.4 A thor-
gestion of the episcleral vessels.1 study were found to have previously ough examination of the ocular sur-
Nodular episcleritis presents with a undiagnosed systemic vasculitides, face, including lids as well as palpebral
discrete, elevated area of inflamed including granulomatosis with poly- and bulbar conjunctiva, is essential
episcleral tissue (Figure 1).3 Episcle- angiitis and Cogan’s syndrome.4 because treatment of these conditions
ritis can be distinguished from scle- Thus, obtaining a thorough history will often resolve the episcleritis.4
ritis by the presence of straight ves- and review of systems is important
sels rather than criss-cross vessels for each patient presenting with Treatment
in the deep episcleral plexus, which episcleritis, with a special focus on Because episcleritis is often self-
causes a bluish-red color when vas- symptoms of atopy, inflammatory, limited, treatment may not be required.
cular congestion occurs in scleritis.1 and collagen vascular diseases. Jabs et al5 found that 16.7% of cases
Use of 10% phenylephrine will re- This should be repeated annually, of episcleritis spontaneously remit-
sult in blanching of the episcleral or optimally with each recurrence.4 ted without treatment. However, for
 10 Volume 5 • Number 3 • October 2019

Figure 1. Nodular Figure 2. Slit-Lamp Figure 3. Diffuse Anterior

Episcleritis Examination Scleritis

Use of the red-free filter in slit-lamp

Nodular episcleritis, with a discrete, examination reveals congestion of the Generalized inflammation of the sclera
elevated area of inflamed episcleral tissue. deeper vascular plexus in scleritis. in a patient with diffuse anterior scleritis.
Source: Sanjay Kedhar, MD. Source: Sanjay Kedhar, MD. Source: Sanjay Kedhar, MD.

patients with persistent inflamma- systemic complications.3 The esti- complain about mild to moderate
tion or symptomatic disease, treat- mated annual incidence of scleritis dull pain that can be worse at night
ment may be justified and should in the United States is 10,500 new and can be referred to other parts of
be aimed at any underlying condi- cases per year, with a prevalence of the face, including the cheek, jaw,
tion (eg, removal of allergens or 5.2/100,000 person-years.3 Scleri- and face.9 In my experience, some
treatment of dry eye).4 Iced arti- tis typically affects women in their patients, such as those who are al-
ficial tears and cold compresses fourth to sixth decade of life and is ready taking systemic anti-inflam-
are often the only treatment that rare in children.3 matory medications, may not have
is needed.4 Topical nonsteroidal Structural and vascular character- pain. Keratitis and uveitis can also
anti-inflammatory drugs (NSAIDs) istics of the sclera explain its predis- be present and usually portend a
are not better than artificial tears in position to inflammatory conditions.9 poorer prognosis.10
treating episcleritis.7 In contrast, The sclera is avascular, obtaining
topical corticosteroids resulted in nutrition from the choroid as well Nodular Scleritis
improvement in 50% of cases.5 as episcleral vascular networks, with Nodular anterior scleritis pres-
Topical fluorometholone 0.1% or artery-to-artery anastomoses, where ents with a localized, elevated nod-
prednisolone acetate 1% is gener- blood oscillates rather than circu- ule on the sclera that is immobile
ally effective.5 Less than 20% of pa- lates.9 This leads to reduced circula- and firm, with surrounding inflam-
tients with episcleritis may require tion and clearance of antigens, allow- mation.5 These patients should be
oral NSAIDs for control, and oral ing the inflammation to persist.9 monitored for progression to necro-
corticosteroid use or immunosup- Watson’s and Hayreh’s classifi- tizing anterior scleritis.5
pressive therapy is usually not re- cation of scleritis into anterior and
quired.8 Over-the-counter NSAIDs, posterior forms is useful in deter- Necrotizing Scleritis
such as naproxen and ibuprofen, mining severity as well as choosing In necrotizing anterior scleri-
are effective and well tolerated.6 the appropriate treatment.1 Ante- tis, vasculitis leads to closure of
Both selective and nonselective rior scleritis is further subdivided the deep episcleral plexus, result-
cyclooxygenase inhibitors have into diffuse, nodular, and necrotiz- ing in necrosis of the scleral tissue
demonstrated an 80% success rate ing with inflammation and without (Figure 4).11 This can lead to ex-
in the treatment of episcleritis.8 inflammation (scleromalacia per- posure of the underlying uveal tis-
forans), with diffuse scleritis being sue, causing a blue discoloration to
Scleritis the most common subtype.1 the eye (Figure 5).11 The pain and
Scleritis is an ocular inflamma- tenderness in these patients tend to
tion that involves the opaque outer Diffuse Anterior Scleritis be more severe than in other types
eye wall and may include the epi- Diffuse anterior scleritis is char- of scleritis.11 In addition, patients
sclera, cornea, and underlying uvea.1 acterized by generalized inflamma- may be more likely to experi-
The disease is typically character- tion of the sclera and is typically in- ence ocular complications, such
ized by severe ocular pain and is as- sidious in onset (Figure 3).9 Patients as keratitis, uveitis and elevated
sociated with significant ocular and with anterior scleritis will often intraocular pressure.11
 Ocular Surface Diseases, Disorders, & Dysfunctions ® 11

Other Forms of Scleritis Table. Laboratory Testing for Episcleritis And Scleritis
The most severe form of scleri-
Diagnostic Test Purpose
tis—scleromalacia perforans—is
11 Antineutrophil cytoplasmic Can suggest granulomatosis
also the rarest. Typically seen in
antibodies (ANCAs) with polyangiitis
patients with rheumatoid arthritis,
obliterative arteritis in the deep epi- Antinuclear antibodies (ANAs) Can suggest systemic lupus
erythematosus, rheumatoid arthritis,
scleral plexus may cause necrosis mixed connective tissue disease,
without pain, redness, or other signs polymyositis/dermatomyositis, but the
of inflammation.11 positive predictive value is low, so it
Posterior scleritis involves in- has questionable utility)
flammation posterior to the rectus Urinalysis May reveal microscopic hematuria in
muscle insertions and can be diffuse systemic vasculitis; helpful in identifying
or nodular.5 Patients with posterior additional renal abnormalities that
can point to further areas for
scleritis tend to be younger than diagnostic testing
those with anterior scleritis, and dis-
ease is often bilateral.5 Due to the an- Chest X-ray, computed Sarcoidosis
tomography imaging
atomic location of the inflammation,
patients may experience more severe Fluorescent treponemal Syphilis (rapid plasma reagin [RPR] or
antibody absorption test, venereal disease research laboratory
vision loss due to serous retinal de-
enzyme immunoassay test [VDRL] testing should be obtained as
tachments, optic nerve edema, or (EIA), treponema pallidum well for confirmation)
chorioretinal granulomas.12 A B- particle agglutination assay
scan ultrasound can be helpful in (TPPA), microhemagglutination
assay for Treponema pallidum
making the diagnosis, with thick-
antibodies (MHA-TP)
ening of the posterior coats ⬎2 mm
Interferon-gamma-release assay Tuberculosis
and a “T-sign” caused by edema of
Tenon’s space and the optic nerve.12 Lyme serology Should be performed in patients from
endemic areas with a history of tick
bite or rash consistent with disease;
Infectious and Systemic Causes positive results should be confirmed
of Scleritis with Western blot testing
Up to 50% of patients with scle- HLA-B27 Seronegative spondyloarthropathies
ritis will have an associated infec-
tious or rheumatic disease.13 The Complete blood count (CBC) Helpful prior to starting
systemic therapy
most common infectious cause is
herpes zoster, and the most com- Comprehensive metabolic panel Helpful in identifying renal issues
associated with vasculitis and possible
mon rheumatic disease association hepatitis; helpful prior to starting
is rheumatoid arthritis.13 Although systemic therapy
most patients have the systemic dis-
Source: Sanjay Kedhar, MD.
ease before the diagnosis of scleri-
tis, it is important to note that 14% in necrotizing scleritis, with 50% to obtaining a complete blood count,
of patients in one study received a 80% having an underlying systemic comprehensive metabolic panel, an-
diagnosis after initial evaluation for condition.13,14 Because a significant tineutrophil cytoplasmic antibodies
scleritis, and 8% of those undiag- portion of patients with scleritis will (ANCA), syphilis serologies, urinal-
nosed initially developed a systemic have an associated systemic disease ysis, and chest radiograph.14 Mea-
disease during follow-up.13 System- (some life-threatening), a laboratory suring antineutrophil cytoplasmic
ic vasculitides (especially granulo- workup is warranted in all patients antibodies, assessing for granuloma-
matosis with polyangiitis) were 3 who do not carry an established diag- tosis with polyangiitis, is crucial for
times more likely to be diagnosed nosis.14 The workup should be guided the initial workup for scleritis. In ad-
as a result of the initial evaluation by the history, review of systems, dition, cytoplasmic ANCA-positive
than rheumatic diseases.1 The risk and physical examination.14 All pa- patients may be more refractory to
of systemic autoimmune disease in- tients should be tested for systemic treatment and more likely to need
creases with severity and is greatest vasculitis, which should include immunosuppressive therapy, even
 12 Volume 5 • Number 3 • October 2019

scleral thinning, scleral necrosis,

Figure 4. Necrotizing Figure 5. Necrotizing
and melting or perforation.20 How-
Anterior Scleritis Scleritis
ever, subconjunctival injections of
triamcinolone for non-necrotizing
anterior scleritis can be success-
ful, and scleral melting is rare.20 In
one study, two-thirds of patients did
not have recurrence at 2 years after
a single subconjunctival injection
of triamcinolone.21
Systemic treatment with oral
Scleral necrosis (central white area)
corticosteroids is warranted if oral
in a patient with rheumatoid arthritis.
Retained nylon sutures (dark spots) from NSAIDs cannot control the inflam-
an unsuccessful attempt to place a scleral Discoloration due to scleral thinning in an mation. Certain types of scleritis,
patch graft while inflammation was active. eye with necrotizing scleritis. such as necrotizing scleritis, are
Source: Sanjay Kedhar, MD. Source: Sanjay Kedhar, MD.
more likely to require systemic
steroids and immunosuppressive
agents.13 Oral prednisone should be
without findings of a systemic vas- Treatment of Scleritis started at a dose of 1 mg/kg/day,
culitis.1 Because systemic lupus ery- In the management of noninfec- with the dose tapered when com-
thematosus and rheumatoid arthritis tious scleritis, oral NSAIDs and plete resolution of scleral inflam-
are generally diagnosed prior to the corticosteroids are the mainstays of mation is complete.5 Patients with
onset of scleritis, testing for anti- treatment.18 Oral NSAIDs are ef- posterior scleritis may respond more
nuclear antibodies and rheumatoid fective for most cases of anterior variably to NSAIDs, and the use of
factor are not necessary, unless in- scleritis, with an 8% failure rate.18 systemic steroids should be consid-
dicated by review of systems.14 Ad- However, I believe that response to ered earlier in the disease course.5 In
ditional tests commonly ordered in NSAIDs can be idiosyncratic, so a cases of pediatric posterior scleritis,
the workup of scleritis are shown in trial of more than one NSAID may be high-dose oral prednisone (1 mg/kg/
the Table. needed for success. The common oral day) was associated with lower rates
Scleritis that is unresponsive NSAIDs I use include indomethacin, of relapse and use of immunosup-
to treatment should prompt an in- naproxen, flurbiprofen, ibuprofen, pressive therapy than doses below
vestigation into the possibility of and celecoxib. It appears that there is 0.5 mg/kg/day.22 In patients with
infectious scleritis.15 A high index no significant difference in efficacy necrotizing scleritis, oral or intrave-
of suspicion for infection is neces- between selective and nonselective nous steroids should be considered
sary, especially in cases following cyclooxygenase inhibitors.16 Patients as first-line treatment.23 Pulsed intra-
prior ocular surgery, as infectious taking oral NSAIDs should be moni- venous methylprednisolone is effec-
scleritis may have a late presenta- tored for renal toxicity.18 Topical cor- tive at inducing remission.24
tion.15 Cases associated with herpes ticosteroids can be effective in mild Immunosuppressive therapy
zoster may not occur for months to moderate cases of simple, diffuse should be considered when oral
after the initial infection.16 Necro- scleritis. A study by McMullen et al19 prednisone does not resolve scle-
tizing scleritis associated with pte- found a 50% success rate in treat- ritis within 1 month, where sig-
rygium excision had a mean onset of ment with topical steroids. However, nificant adverse effects from oral
95.7 months after surgery and was the study by Jabs et al5 found that no prednisone are noted and where a
most often caused by Pseudomonas diffuse anterior or necrotizing scleri- systemic disease requiring immu-
aeruginosa.15 Cultures, and possi- tis in their cohort responded to topi- nomodulatory therapy is present.25
bly a scleral biopsy, should be per- cal steroids. Both prednisolone ace- The choice of immunosuppressive
formed to confirm the diagnosis. In tate 1% and difluprednate 0.05% can agents is individualized to the pa-
addition to antibiotic therapy, surgi- be effective. tient and physician, but robust data
cal procedures, such as cryotherapy Subconjunctival steroid injec- on the comparative effectiveness of
and lamellar grafting, may improve tions for scleritis are controver- these drugs in scleritis is not avail-
outcomes in infectious scleritis.17 sial due to fear of worsening of able.25 Gangaputra et al26 found
 Ocular Surface Diseases, Disorders, & Dysfunctions ® 13

methotrexate to be effective for con- importance because prognosis, as- 12. McCluskey PJ, et al. Ophthalmol-
trolling scleritis in approximately sociation with systemic disease, ogy. 1999;106(12):2380-6.
50% of patients. In another study, and treatment will differ. Episcle- 13. Akpek EK, et al. Ophthalmology.
azathioprine was found to be ap- ritis is benign, self-limited, and 2004;111(3):501-6.
proximately 20% less effective.27 rarely associated with systemic 14. Sainz de la Maza M, et al. Ophthal-
mology. 2012;119(1):43-50.
Mycophenolate mofetil success- disease.4 Scleritis carries signifi-
15. Doshi RR, et al. Surv Ophthalmol.
fully controlled inflammation in cant ocular and systemic morbidity
2013;58(6):620-33.
49% of patients with scleritis within and should always be investigated,
16. Liesegang TJ. Ophthalmology.
6 months of treatment, tracking with special attention to systemic
1991;98(8):1216-29.
closely to the overall effectiveness vasculitis. A high index of suspi-
17. Reynolds MG, et al. Am J Ophthal-
in other ocular inflammatory diseas- cion is necessary for the recogni- mol. 1991;112(5):543-7.
es.28 Tumor necrosis alpha inhibi- tion of posterior scleritis as well as 18. Sainz de la Maza M, et al. Ophthal-
tors have been shown to be effective performing a complete evaluation mology. 2012;119(1):51-8.
in the treatment of active anterior of patients for infection or systemic 19. McMullen M, et al. Can J Ophthal-
scleritis, with infliximab achieving autoimmune disease. mol. 1999;34(4):217-21.
quiescence in 80% of patients, with 20. Albini TA, et al. Ophthalmology.
60% being able to taper oral predni- References 2005;112(10):1814-20.
sone down to 10 mg or less per day.29 1. Watson PG, et al. Br J Ophthalmol. 21. Sohn EH, et al. Ophthalmology.
Adalimumab may also be effective, 1976;60(3):163-91. 2011;118(10) 1932-7.
but etanercept should be avoided 2. Read RW, et al. Ophthalmology. 22. Cheung CM, et al. Ophthalmology.
because it has been shown to be 1999;106(12) 2377-9. 2012;119(1):59-65.
less effective for ocular inflamma- 3. Honik G, et al. Cornea. 23. Beardsley RM, et al. Expert Opin
tion.30 Rituximab holds promise for 2013;32(12):1562-6. Pharmacother. 2013;14(4)411-24.
cases of refractory scleritis, with 9 4. Akpek EK, et al. Ophthalmology. 24. McCluskey PJ, et al. Arch Ophthal-
of 12 patients achieving a reduction 1999;106(4):729-31. mol. 1987;105(6):793-7.
in inflammation or 50% reduction in 5. Jabs DA, et al. Am J Ophthalmol. 25. Jabs DA, et al. Am J Ophthalmol.
2000;130(4):469-76. 2000;130(4):492-513.
steroid use in one study.31 Alkylating
6. Sieper J, et al. Ann Rheum Dis. 26. Gangaputra S, et al. Ophthalmol-
agents, such as cyclophosphamide
2002;61 Suppl 3:iii8-18. ogy. 2009;116(11):2188-98.e1.
and chlorambucil have also been
7. Lyons CJ, et al. Eye (Lond). 27. Prasadhika S, et al. Am J Ophthal-
used successfully in severe cases.32
1990;4(Pt 3):521-5. mol. 2009;148(4):500-9.e2.
I believe that the surgical man-
8. Kolomeyer AM, et al. Ocul Immu- 28. Daniel E, et al. Am J Ophthalmol.
agement of patients with scleritis is 2010;149(3):423-32.
nol Inflamm. 2012;20(4):293-9.
not common. However, surgery may 29. Sen HN, et al. Can J Ophthalmol.
9. Watson PG, et al. Exp Eye Res.
be necessary for the repair of scleral 2004;78(3):609-23. 2009;44(3):e9-12.
or corneal defects or to aid in diag- 30. Levy-Clarke G, et al. Ophthalmol-
10. Sainz de la Maza M, et al. Ophthal-
nosis via biopsy. mology. 1997;104(1):58-63. ogy. 2014;121(3):785-96.e3.
11. Watson PG. In: Duane’s Clinical 31. Suhler EB, et al. Ophthalmology.
Summary Ophthalmology. Rev ed. Philadel- 2014;121(10):1885-91.
Distinguishing between episcle- phia, PA: Lippincott Williams & 32. Pujari SS, et al. Ophthalmology.
ritis and scleritis is of paramount Wilkins; 1992:1-43. 2010;117(2):356-65.
EXPERT INTERVIEW

Dupilumab-Induced Ocular Surface Disease

Kenneth A. Beckman, MD, FACS

Recent reports indicated that ocular events.3 In clinical trials of dupilumab for AD, in
dupilumab therapy for patients with addition to having a previous history of conjunctivitis,
moderate to severe atopic dermatitis a greater baseline AD severity was associated with in-
can be associated with ocular side creased incidence of conjunctivitis.3 In a real world cohort
effects. What are these side effects? of 142 dupilumab-treated patients, 7 of 12 (58%) who de-
veloped conjunctivitis had other atopic conditions.5 Nine
Kenneth A.
Ocular side effects are common in pa- Beckman, MD, (75%) had severe baseline AD.5 Three of these patients
tients treated with dupilumab for atopic FACS developed severe conjunctivitis, whereas the 3 patients
dermatitis (AD), which received US Food and Drug Ad- with less than severe AD at baseline developed mild (n=1)
ministration approval for AD in 2017.1,2 Conjunctivitis or moderate (n=2) conjunctivitis.5 In another series of
incidence was similar in dupilumab and placebo groups 13 patients with conjunctivitis, 8 (62%) had severe AD at
in clinical trials for other indications.3 In addition to con- baseline and 4 (31%) had a history of conjunctivitis.8 On-
junctivitis, blepharitis, dry eye, photophobia, and keratitis treatment conjunctivitis was severe in 3 of the 8 (38%)
have also been observed following dupilumab treatment patients with severe baseline AD, but no patient with mod-
for patients with AD.4-6 Flare-ups of existing ocular sur- erate baseline AD developed conjunctivitis, although 1 de-
face conditions have also been reported, including poten- veloped severe blepharitis.8 More research is needed, and
tial recurrence of herpes virus infections.4 Case reports all patients taking dupilumab should be considered at risk
have noted goblet cell scarcity in affected patients.7 The for OSD until more evidence is acquired.4
term dupilumab-induced ocular surface disease has been
proposed to accommodate the spectrum of ocular surface What steps should be taken to manage ocular
manifestations that may be observed.6 events associated with dupilumab therapy?

Is the initial presentation of these patients different Clinicians managing patients with AD should be
from those with ocular surface disease who are not aware of the increased risk for OSD associated with this
being treated with dupilumab? disease.6 Referral for an eye examination before starting
treatment can help confirm that timely therapy is pro-
Many of these patients already have ocular surface vided.3 Eye care specialists must ensure that complete
disease (OSD) due to the severity of their AD.3 In my health and medication histories are acquired.3 Education
practice, most patients with AD have lid margin disease, is as important for the clinicians as it is for the patients.
dry eye, and severe allergic conjunctivitis before dupil- A baseline eye examination is warranted before starting
umab treatment. Those conditions tend to worsen after dupilumab therapy.3 Lid margin disease treatments, such
starting dupilumab therapy. I initially investigate patients as lid hygiene, warm compresses, and artificial tears, can
with AD as I would for any other patient with OSD. Also, be helpful.3,6 However, when OSD flares, it is difficult
when dermatologists want to know their patient’s ocular to treat and usually requires several medications.6 Anti-
surface status before starting dupilumab therapy, a full inflammatory agents, including steroids, cyclosporine,
dry eye workup is also performed. and lifitegrast, may be used to treat OSD.6
In my experience, patients with AD do not want to stop
Are there any patient factors associated with the dupilumab therapy, despite the development of OSD, be-
development of ocular events in those treated with cause dupilumab is effective in treating AD. Many of these
dupilumab for atopic dermatitis? patients are young. In addition to being miserable from
dermatitis, they are self-conscious of their appearance.
Persons with underlying OSD at the time of treat- Most patients are willing to adhere to any ocular therapy
ment initiation may be more vulnerable to subsequent regimen rather than discontinue dupilumab treatment.
 Ocular Surface Diseases, Disorders, & Dysfunctions ® 15

One patient referred to my clinic who developed se- References

vere conjunctivitis 3 months after starting dupilumab 1. Dupilumab [Prescribing information]. https://
treatment achieved some symptom relief—but not res- www.accessdata.fda.gov/drugsatfda_docs/
olution—with steroids and cyclosporine.6 Lifitegrast label/2019/761055s014lbl.pdf. Accessed July 12, 2019.
was added, and symptoms resolved completely within 2. Raedler L. http://www.ahdbonline.com/issues/2018/april-
6 weeks. In this combination therapy setting, the poten- 2018-vol-11-ninth-annual-payers-guide/2542-dupixent-
tial effectiveness of lifitegrast as a monotherapy could dupilumab-first-biologic-drug-approved-for-patients-
not be determined. However, the patient was able to re- with-moderate-to-severe-atopic-dermatitis. Accessed
duce loteprednol dosing to once per day. June 24, 2019.
Currently, I treat patients with OSD at baseline with 3. Akinlade B, et al. Br J Dermatol. 2019;181(3):459-73.
lifitegrast initially to stabilize their ocular surface. Lifite- 4. Ivert LU, et al. Acta Derm Venereol. 2019;99(4):375-8.
grast monotherapy has been successful at maintaining
5. Treister AD, et al. JAMA Dermatol. 2018;154(10):1208-11.
the ocular surface in my patients. A steroid or cyclospo-
rine can be added later if needed. These patients should 6. Zirwas MJ, et al. JAAD Case Rep. 2019;5(1):34-6.
be closely monitored to ensure that therapy modifica- 7. Bakker DS, et al. Br J Dermatol. 2019;180(5):1248-9.
tions are implemented before the increased severity of 8. Wollenberg A, et al. J Allergy Clin Immunol Pract.
their disease makes treatment difficult. 2018;6(5):1778-80.

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CASE PRESENTATION
Dupilumab-Induced Ocular Surface Disease
Laura M. Periman, MD; Laura K. Green, MD; Brede A. Skillings, MD

A 41-year-old man
with a history
of atopic dermatitis,
tears. The oral prednisone was de-
creased to 10 mg daily. At the 4-week
follow-up, the patient noted moderate
for which he is treat- improvement in his ocular and eyelid
ed with dupilumab, symptoms. There was significant im-
presented with com- provement in examination findings,
Laura M. Periman, Laura K. Green, MD Brede A. Skillings,
plaints of bilateral eye MD MD specifically regarding dermatitis, ec-
irritation, mucoid dis- tropion, erythema, and injection of the
charge, photophobia, and tearing approximately 6 weeks tarsal conjunctiva (Figure 4). He was then started on
after starting dupilumab. He described his pain level as a oral doxycycline 100 mg daily (which was decreased to
9 out of 10 in severity. He had been treated with topical 50 mg daily due to gastrointestinal issues), as well as
and oral steroids, artificial tears, and warm compresses prednisolone acetate 1% twice daily in both eyes, and
for the past 2 years. He was taking oral prednisone con- continued on the previous regimen. After 6 weeks, the
tinuously for the past 9 months, with a dosage of 13 mg patient reported continued improvement and was as-
daily at the time of visit. Due to his severe atopic der- ymptomatic. The oral steroids, followed by the topical
matitis, multiple attempts to taper the oral prednisone steroids, were then tapered. The patient was continued
failed. While taking oral prednisone, he developed ste- on a regimen of pimecrolimus 1% cream twice daily,
roid-induced diabetes mellitus. desonide 0.5% cream once daily, and petroleum jelly
administered to the lateral canthus.
Examination
The patient’s best-corrected visual acuity was 20/20 Discussion
in both eyes. His pupils, intraocular pressure, and con- Atopic dermatitis is a T-cell–mediated, chronic in-
frontational visual fields were within normal limits. The flammatory skin disease.1 Dupilumab was US Food and
eyelid examination was notable for bilateral dermatitis Drug Administration-approved in 2017 for the treatment
of the periocular skin, erythema, 3+ meibomian gland of moderate to severe atopic dermatitis and has since
dysfunction, vascularization of the lid margins, and ec- been approved for moderate to severe asthma and chronic
tropion of the lower lids (Figures 1-3). There also was rhinosinusitis with nasal polyposis.2 Clinical trials re-
a right upper lid chalazion, which the patient reports as ported conjunctivitis as an adverse event more frequently
being present for 2 months. The conjunctiva showed 1+ in patients treated with dupilumab compared with pla-
chemosis, 1+ injection, 3+ papillary conjunctivitis, and cebo.3 Since then, articles describing the risk factors;
keratinization of the lower lid tarsal surface bilaterally. varying presentations, including periocular dermatitis;
The corneal examination was notable for trace superfi- and possible treatment options have been published.4,5
cial punctate keratitis. The remainder of the examination Dupilumab blocks interleukin (IL)-4 and IL-13.1
was within normal limits. A Schirmer’s test with anes- Interleukin-4 is an important cytokine involved in the
thesia was normal at 18 mm and 19 mm in the right and allergic TH2 cell response, whereas IL-13 plays a key
left eyes, respectively, at 5 minutes. role in goblet cell differentiation.1 The mechanism of
ocular inflammation related to dupilumab is poorly un-
Treatment derstood, and further research is needed to elucidate
The patient insisted on maintaining the dupilum- the immunopathophysiology. However, given that IL-
ab because it had significantly improved eczema on 13 blockade may result in decreased goblet cell den-
the rest of his body, so he was initiated on desonide sity, the immunoregulatory capacity of the ocular sur-
0.5% cream and pimecrolimus 1% cream twice daily face may also decrease, resulting in more aggressive
to the eyelids as well as frequent warm compresses, Th1 and Th17 inflammation, which is more typical of
lid hygiene, and frequent preservative-free artificial dry eye disease.6,7 Immunosuppressive medications
 Ocular Surface Diseases, Disorders, & Dysfunctions ® 17

Figure 1. Patient With Atopic Dermatitis Figure 2. Patient With Atopic Dermatitis

The patient has atopic dermatitis, with significant eyelid erythema, Close-up photograph of the patient in Figure 1, with significant
thickening, keratinization, and ectropion. eyelid erythema, thickening, keratinization, and ectropion.
Source: Laura K. Green, MD. Source: Laura K. Green, MD.

Figure 3. Conjunctival Injection Figure 4. Four-Week Follow-up

Photograph shows the patient with palpebral conjunctival injection The patient’s external findings improved after antibiotic, steroid,
and inflammation. and nonsteroidal interventions as described.
Source: Laura K. Green, MD. Source: Laura K. Green, MD.

with mechanisms targeting T cells, such as lifitegrast,8 References

cyclosporine,9 and tacrolimus,9 have been reported to be 1. Boothe WD, et al. Adv Exp Med Biol. 2017;1027:21-37.
viable, steroid-sparing treatment options. Dupilumab- 2. Dupilumab injection [Prescribing information].
induced ocular surface disease (DIOSD) has also been https://www.accessdata.fda.gov/drugsatfda_docs/
described.8 Zirwas et al8 reported a patient in which label/2019/761055s014lbl.pdf. Accessed August 8, 2019.
lifitegrast (a specific lymphocyte function-associated 3. Simpson EL, et al. N Engl J Med. 2016;375(24):2335-48.
doi:10.1056/NEJMoa1610020.
antigen 1 antagonist) was effective for treating DIOSD.
4. Treister AD, et al. JAMA Dermatol. 2018;154(10):1208-
In our patient, pimecrolimus 1% cream was used
11. doi:10.1001/jamadermatol.2018.2690.
due to the severity of his periocular dermatitis to ob-
5. Yamane MLM, et al. Orbit. 2019 January 10 [Epub ahead
tain adequate control while limiting steroid exposure. of print]. doi:10.1080/01676830.2018.1553190.
Although some cases of DIOSD are mild, severe cases 6. Stadnikova A, et al. PLoS One. 2019;14(2):e0211861.
necessitate discontinuing the dupilumab or, as in our 7. Contreras-Ruiz L, et al. PLoS One. 2015;10(3):e0120284.
case, chronic corticosteroid use. Therefore, it is impor- 8. Zirwas M, et al. JAAD Case Rep. 2019;5(1):34-6.
tant for ophthalmologists to recognize the side effects doi:10.1016/j.jdcr.2018.10.016.
of dupilumab and work closely with patients and their 9. Aszodi, N, et al. J Dtsch Dermatol Ges. 2019;17(5):488-
dermatologists to limit the patients’ disease burden. 91. doi:10.1111/ddg.13809.
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CME Posttest
1. Which of the following statements is false regarding 6. All the following are effective treatments for adults suffering from
lash extensions? infected phlyctenules with ulceration except:
A. They are a popular trend. A. Fourth-generation fluoroquinolone
B. The glues used often contain latex and formaldehyde. B. Polymyxin/trimethoprim
C. The latex in the fixative could lead to allergic blepharoconjunctivitis C. Topical steroid
in allergic individuals. D. Oral erythromycin
D. Even if applied incorrectly, they do not damage the
natural eyelashes. 7. The most common systemic association of peripheral ulcerative
keratitis is _________.
2. Which of the following statements is true regarding lash strips? A. Scleroderma
A. The glue used with at-home false lashes is typically applied B. Lupus erythematosus
1 to 2 mm above the natural lash line. C. Rheumatoid arthritis
B. Consumers are not supposed to remove the false eyelashes D. Polyarteritis nodosa
every night.
C. Using false eyelashes on a regular basis has no effect on new 8. All the following are side effects that can occur with dupilumab
lash growth. therapy for atopic dermatitis except:
D. Regular use of false eyelashes enhances the protection against A. Conjunctivitis
surface irritants.
B. Blepharitis
3. Which of the following statements is true regarding the treatment C. Glaucoma
of episcleritis? D. Dry eye
A. 86.7% of cases spontaneously resolve without treatment.
9. When ocular surface disease flares in patients taking dupilumab
B. Topical nonsteroidal anti-inflammatory drugs are not better than
for atopic dermatitis, which of the following is likely to be
artificial tears in treating episcleritis.
least effective?
C. Use of topical corticosteroids has resulted in improvement in
肁90% of cases. A. Steroids
D. Oral corticosteroid use or immunosuppressive therapy is B. Artificial tears
usually required. C. Cyclosporine
D. Lifitegrast
4. What is the therapeutic failure rate for oral NSAIDs in patients with
noninfectious anterior scleritis? 10. A 43-year-old woman with a history of atopic dermatitis, which
A. 8% is treated with dupilumab, presents with complaints of bilateral
eye irritation, mucoid discharge, photophobia, and tearing
B. 18%
approximately 4 weeks after starting dupilumab. She described
C. 28% her pain level as 9 out of 10 in severity. She had been treated with
D. 38% topical and oral steroids, artificial tears, and warm compresses
for the past 3 years. She has been taking oral prednisone 15 mg
5. Tumor necrosis alpha inhibitors have been shown to be effective in for the past 7 months. Best-corrected visual acuity was 20/20 in
the treatment of active anterior scleritis, with infliximab achieving both eyes. Her pupils, intraocular pressure, and confrontational
quiescence in __% of patients. visual fields were within normal limits. The eyelid examination
A. 90 was notable for bilateral dermatitis of the periocular skin,
erythema, 3+ meibomian gland dysfunction, vascularization of
B. 80
the lid margins, and ectropion of the lower lids. The conjunctiva
C. 70 showed 1+ chemosis, 1+ injection, 3+ papillary conjunctivitis, and
D. 60 keratinization of the lower lid tarsal surface bilaterally. The corneal
examination was notable for trace superficial punctate keratitis.
Schirmer’s test was normal bilaterally. Your treatment regimen
should include all the following except:
A. Desonide 0.5% cream and pimecrolimus 1% cream twice daily
B. Warm compresses and lid hygiene
C. Frequent preservative-free artificial tears
D. Increase prednisone to 30 mg daily

18
Volume 5 • Number 3

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