Eyeworld

77 EW FEATURE September 2015 World Cornea Congress highlights populations. So, we have agents available that might work for some but not all patients," she said. Some chronic graft-versus-host- disease patients have responded favorably to topical anakinra, a human interleukin-1 receptor an- tagonist related to the drug EBI-005 (Eleven Biopharmaceuticals, Cam- bridge, Mass.), the latter of which is in trials for dry eye disease and allergic conjunctivitis. Dr. Jacobs would also like to learn more about lifitegrast (Shire, Lexington, Mass.), another drug un- dergoing trials for dry eye treatment. "Regardless of the approved indica- tion, any new drug such as lifitegrast or EBI-005 is likely to be useful in a subset of patients," she said. Colleagues in Japan have described their effective use of rebipamide for some types of OSD. Rebipamide is a secretagogue approved and available there, Dr. Jacobs added. "The barriers to U.S. approval seem to preclude introduction of that drug or other secretagogues here," Dr. Jacobs said. "It is disap- pointing in the current environ- ment; the quest for broad indi- cations means that patients with moderate to severe disease related to specific etiologies don't have access to drugs from which they might benefit," she said. Blepharokeratoconjunctivitis in children Blepharitis in the pediatric popu- lation tends to be underrecognized and frequently misdiagnosed as allergic conjunctivitis or chronic conjunctivitis by the child's primary care provider, said Jose de La Cruz, MD, assistant professor of ophthal- mology, cornea service, Illinois Eye and Ear Infirmary, Chicago. "Only after a more thorough slit lamp examination can the findings of lid inflammation, meibomian gland inspissation, and/or findings of lid rosacea be discovered," he said. Causes of blepharokerato- conjunctivitis in children include bacteria such as Staphylococcus, acne rosacea, or scalp dandruff. Aggressive lid hygiene with baby shampoo is the first line of defense to counteract the inflamma- tory response, Dr. de la Cruz said. "In the pediatric population, the expectation that the child will use a warm compress daily for at least 20 minutes is perhaps unrealistic," he said. Because of this, medica- tions to help with acute irritation and discomfort are often used. This includes a short burst of low concentration corticosteroid in an ointment or drop applied directly to the lid margin. Another helpful agent is an azi- thromycin ophthalmic drop directly applied to the lid margin twice a day for 7 to 10 days. "The combination of both provides a fast track to sta- bilizing the irritation to the ocular surface," Dr. de la Cruz said. It is also important for physi- cians to treat seborrheic blepharitis and acne rosacea, Dr. de la Cruz said. However, he advises great care with the use of systemic medications such as doxycycline in children and recommends consulting the child's pediatrician or dermatologist to as- sess any associated long-term risks. Limbal stem cell deficiency Chemical injuries and severe im- munologic disease such as Stevens- Johnson syndrome are some of the most common causes of LSCD as seen by Ali Djalilian, MD, associate professor of ophthalmology, cornea service, and director, Corneal Epithe- lial Biology and Tissue Engineering Laboratory, Illinois Eye and Ear Infir- mary. Other causes include congen- ital conditions such as aniridia and contact lens-induced LSCD. When diagnosing LSCD, Dr. Djalilian looks for the presence of conjunctival cells over the cornea. "It appears as an opaque epithelial sheet along with superficial neovas- cularization," he said. He also recommends that clini- cians identify a fluorescein staining pattern. "Conjunctival epithelium can be distinguished from corneal epithelium by its greater fluorescein uptake and a wavy pattern." To treat LSCD, Dr. Djalilian aims to optimize the health of the ocular surface by having patients discontin- ue contact lens wear or stop the use of drops with benzalkonium chlo- ride. He advises the use of nonpre- served lubricants and the treatment of meibomian gland disease as well as local anti-inflammatory therapy. More advanced cases require limbal stem cell transplantation, such as conjunctival limbal auto- graft in unilateral cases. In bilateral cases, a living-related conjunctival limbal graft or cadaver-based kerato- limbal allograft is used. "The key to the success of allograft procedures is systemic immunosuppression post- operatively," Dr. Djalilian said. EW Editors' note: The physicians have no financial interests related to this article. Contact information de la Cruz: jnapoli@hotmail.com Djalilian: adjalili@uic.edu Galor: agalor@med.miami.edu Hammersmith: khammersmith@willseye.org Jacobs: djacobs@bostonsight.org Patient with bilateral chemical injury who successfully underwent combined keratolimbal allograft and penetrating keratoplasty with systemic immunosuppression using the Cincinnati protocol Patient with unilateral chemical injury at 5 years after conjunctival limbal autograft from the contralateral uninjured eye Source: Ali Djalilian, MD

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