Atopic Dermatitis and Ocular Surface Diseases
Adults with atopic dermatitis (AD) are at increased risk for eye diseases.1 Therefore, it is important for dermatologists to screen for the ocular manifestations of AD and work with their ophthalmology partners to diagnose and treat AD-related ocular disorders.
To better understand the connection between AD and ocular surface diseases, The Dermatologist spoke to Raj Chovatiya, MD, PhD, assistant professor of dermatology and director for the center of eczema and itch at Northwestern University Feinberg School of Medicine in Chicago, IL. He also presented this topic at the Diversity in Dermatology 2022 Conference.
The Dermatologist: Can you give us a brief overview of your session on ocular surface diseases and their association with AD?
Dr Chovatiya: In this session, we first discussed the signs and symptoms associated with periorbital or periocular AD, with a focus on appropriate terminology and visual recognition.2 We then took a closer look at ocular anatomy and talked about different categories of ocular disease associated with AD, including chronic conjunctivitis, corneal ectasia, cataracts, infectious diseases, and drug-related disease. We examined each of these categories closely, with a focus on inflammatory mechanisms, treatment options, and the role of multidisciplinary management with an ophthalmologist.3
The Dermatologist: Which ocular diseases are most often associated with AD?
Dr Chovatiya: Chronic (atopic) conjunctivitis is the most common category of ocular surface disease that we see as dermatologists.4 This includes seasonal and perennial allergic conjunctivitis, vernal keratoconjunctivitis, and atopic keratoconjunctivitis. The former 2 diseases have prevalent etiologies of itching, tearing, and burning in patients with AD and are not typically associated with vision loss. The latter 2 conditions are less common but associated with similar symptoms, along with pain and mucus discharge, and they can be associated with vision loss in the long run because of additional corneal inflammation. Corneal ectasias (noninflammatory thinning and protrusion of the cornea) associated with AD includes keratoconus5 and pellucid marginal corneal degeneration. Cataracts include both anterior and posterior subcapsular cataracts, which are generally uncommon. Bacterial blepharoconjunctivitis and herpetic eye disease are 2 important causes of infectious eye disease in this population, with the latter requiring prompt recognition and treatment because of the risk of vision loss. Finally, dupilumab is a recently described etiology of drug-induced conjunctivitis, and studies on its underlying pathogenesis are ongoing.6
The Dermatologist: What is the mechanism of action of ocular disorders in AD?
Dr Chovatiya: The mechanism of ocular disorders in AD is multifactorial. We know that ocular disease is associated with increased AD disease severity and, thus, is more common in individuals with moderate to severe disease. Chronic, uncontrolled, type 2 inflammation driven by type 2 T-helper cells is likely an important part of this risk. However, there are other inflammatory pathways involved in ocular inflammation, including type 1 hypersensitivity mediated by mast cells and IgE. We also know that chronic rubbing, scratching, or physical manipulation of the eyes is another important risk factor for certain ocular comorbidities.5 Finally, specific (such as allergens) and nonspecific (such as wind, temperature, sun, humidity, and climate) environmental triggers can also exacerbate and drive inflammation in ocular disease.
The Dermatologist: What is the key take-home message from your session?
Dr Chovatiya: The 4 main points are: (1) Do not forget to examine the periocular region and eyes in your patients with AD; (2) Become comfortable with eye anatomy to better understand the potential ocular complications of AD; (3) Dermatologists can intervene early with conservative measures; and (4) Get to know your ophthalmologist because the diagnosis and treatment of ocular disease in AD are limited without them.
References
1. Adults with AD at greater risk for eye disease. News release. National Eczema Association. November 6, 2017. Updated July 15, 2021. Accessed February 17, 2022. https://nationaleczema.org/ad-risk-eye-disease
2. Eczema around the eyes. National Eczema Society. Accessed February 17, 2022. https://eczema.org/information-and-advice/types-of-eczema/eczema-around-the-eyes
3. Sumers A. How do you medically treat eyelid eczema? American Academy of Ophthalmology. February 21, 2014. Accessed February 17, 2022. https://www.aao.org/eye-health/ask-ophthalmologist-q/eczema-treatment
4. Pietruszynska M, Zawadzka-Krajewska A, Duda P, Rogowska M, Grabska-Liberek I, Kulus M. Ophthalmic manifestations of atopic dermatitis. Postepy Dermatol Alergol. 2020;37(2):174-179. doi:10.5114/ada.2018.79445
5. The eye condition that people with eczema need to know about. News release. National Eczema Association. March 1, 2021. Updated May 5, 2021. Accessed February 17, 2022. https://nationaleczema.org/the-eye-condition-that-peoplewith-eczema-need-to-know-about
6. Aszodi N, Thurau S, Seegräber M, de Bruin-Weller M, Wollenberg A. Management of dupilumab-associated conjunctivitis in atopic dermatitis. J Dtsch Dermatol Ges. 2019;17(5):488-491. doi:10.1111/ddg.13809
