Efficacy and safety of ustekinumab in a group of 22 elderly patients with psoriasis over a 2‐year period

Oral isotretinoin is known to cause ocular side effects, most commonly dry eyes and very rarely, corneal opacity and keratitis. We describe what we believe is the first case of recurrent corneal epithelial erosion (RCES) precipitated by the commencement of isotretinoin therapy for acne vulgaris. A 38-year-old woman presented to her optometrist with severe, spontaneous, sudden-onset pain, along with photophobia, watering and redness of her left eye. She had persistent excoriated acne, which had been treated successfully over the previous 18 months with oral isotretinoin 20 mg daily. On physical examination, an area of corneal epithelial loss was detected, and standard treatment with topical antibiotic ointment was commenced. One month later, the patient re-presented to the ophthalmology clinic with the same symptoms in the same eye. Corneal examination revealed epithelial microcysts, typical of recurrent corneal erosion syndrome, as well as a corneal epithelial defect. Long-term prophylactic ocular lubrication was prescribed. On further enquiry, the patient described minor trauma to her left eye 2 years previously, for which she had received treatment at a different centre. It was deemed probable that the isotretinoin was having an exacerbating effect on the ocular surface environment, and thus the dose was reduced. The patient continued to use regular lubrication and had no further episodes of recurrent corneal erosion over a follow-up period of 6 months. Recurrent corneal epithelial erosion is an acutely painful relapsing ocular condition caused by defective attachment of the basal cells of the corneal epithelium to their basement membrane, and is typically associated with a history of previous traumatic corneal abrasion. In the months/years following an abrasion, episodes of corneal epithelial breakdown (erosions) are experienced by an affected individual, usually overnight or on waking, when the ocular surface is less well lubricated by the blink mechanism. Salient clinical features include pain, photophobia and epiphora. Long-term ocular lubrication is the mainstay of prophylaxis in order to maintain tear film stability and ensure corneal protection. A stable tear film is essential for normal vision, ocular comfort and maintenance of a healthy ocular surface environment. The meibomian glands secrete the lipid layer of the tears, and are essential to reduce tear evaporation and maintain tear film stability. Isotretinoin has a direct effect on the function of these glands, causing atrophy and hypoplasia. In a study of 1741 adverse drug reactions related to isotretinoin, there were no reports of RCES. Any cause of tear film instability or meibomian gland dysfunction could precipitate or exacerbate RCES in vulnerable patients, and we believe that isotretinoin should be considered a risk factor for RCES in such cases. We advise that clinicians commencing patients on isotretinoin should ask about previous ocular conditions, including previous trauma and corneal abrasions. For patients with such conditions, the low-risk prophylactic intervention of commencing ocular lubricants should be suggested, as well as making the patient aware of the symptoms of RCES.