Cataract progression in patients with atopic dermatitis

Cataract progression in patients with atopic dermatitis Yasunori Nagaki, MD, Seiji Hayasaka, MD, Chiharu Kadoi, MD ABSTRACT

.P.UrlOo~: To

evaluate the possible causes of cataract progression in Japanese patients with atopic dermatitis.

Setting: Department of Ophthalmology, Toyama Medical and Pharmaceutical University, Toyama, Japan. Methods: This prospective study comprised 41 patients (81 eyes) with atopic dermatitis. Cataract progression was determined by photographs and visual acuity results. Mean follow-up was 2.5 years (range 1.0 to 3.5 years). Results: Of 41 patients, 10 (24.4%) had progression of cataract. Of 81 eyes, 10 (12.3%) had slow progression and 9 (11.1%), rapid. Cataract progression was not statistically significantly related to patient sex or severity of systemic skin lesions but was to facial skin lesions. Soft contact lens wear and eye rubbing were also correlated with cataract progression. Conclusion: Patients with facial atopic dermatitis, contact lenses, or both may rub their eyes more frequently than those with lesions on other body parts, increasing their risk of cataract progression. J Cataract Refract Surg 1999; 25:96-99

topic dermatitis, one of the most common forms of dermatitis in contemporary Japan, is associated with several ocular complications such as conjunctivitis, blepharitis, keratoconus, cataract, and retinal detachment. '~ Most studies have reported the incidence of cataract in patients with atopic dermatitis, ''2'4'6 with only a few describing the possible factors in cataract formation in these patients2 '5 To our knowledge, the causes of cataract progression in atopic dermatitis are still unclear. In this study, we examined Japanese patients with atopic dermatitis to ascertain the possible causes of cataract progression.

A

Acceptedfor publication August 7, 1998. From the Department of Ophthalmology, ToyamaMedical and Pharmaceutical University, Toyama.Japan. Reprint requeststo YasunoriNagaki, MD, Department of Ophthalmolog~ ToyamaMedical and Pharmaceutical Universi~ 2630 Sugitani, Toyama 930-0194, Japan. 96

Patients and Methods This prospective study comprised patients with atopic dermatitis who were seen at the Department of Ophthalmology clinic from 1993 to 1996. At the initial eye evaluation, patients were also examined by consultant dermatologists and their family histories obtained. The diagnosis of atopic dermatitis was made by dermatologists on the basis of morphology and distribution of skin lesions, clinical course, and family history of eczema. All patients had been treated primarily with topical corticosteroids and antihistamines. All patients had routine ophthalmological examinations and photographs of the anterior segment after instillation of mydriatics at the initial visit and during the follow-up. Follow-up was bimonthly or trimonthly with a mean of 2.5 years (range 1.0 to 3.5 years). Excluded were 6 patients (8 eyes) with atopic dermatitis associated with cataract and retinal detachment, 2 (4 eyes)

J CATARACT REFRACT SURG~VOL 25. JANUARY 1999

CATARACT AND ATOPIC DERMATITIS

Table 1. Age, sex. and cataract progression in patients with atopic dermatitis.

"

11-15

16-20

21-25

26-30

31-35

'.

: "

, '~:'~: ;',:',"~'~,-~. ~ " . : ~ ' ; - , ~ - , ' " ~ - : " : ' : ~ ; ~ ' : ~ , : ~ ? ~ , ' ~ ! ~ X

i~

M

5

(12.2)

10 (12.3)

F

8

(19.5)

16 (19.8)

M

7

(17.1)

14 (17.3)

F

2

(4.9)

4

(4.9)

2

(3.2)

M

1

(2.4)

2

(2.5)

2

F-

7

(17.1)

M

4

(9.8)

8

(9.9)

6

(9.7)

0

2 (22.2)

F

1

(2.4)

2

(2.5)

2

(3.2)

0

0

M

2

(4.9)

4

(4.9)

0

2 (20.0)

2 (22.2)

F

4

(9.8)

8

(9.9)

5

2 (20.0)

1 (11.1)

13 (16.0)

6

(9.7)

2 (20.0)

2 (22.2)

16 (25.8)

0

0

12 (19.4)

2 (20.0)

0

2 (20.0)

0

(3.2)

0

0

11 (17.7)

0

2 (22.2)

(8.1)

*Percentage of eyes within each group

with atopic dermatitis accompanied by keratoconus, 1 (1 eye) with ocular trauma, and 2 (4 eyes) with atopic cataract treated with systemic corticosteroids. Cataract progression was determined by findings of photographs according to the Lens Opacities Classification System III 9 and visual acuity as follows: no progression = lenticular opacities were unchanged and visual acuity was not reduced; slow progression = lenticular opacities increased and visual acuity decreased more than 2 lines in more than 6 months; rapid progression = cataract increased and visual acuity decreased more than 2 lines in fewer than 6 months. Severity of skin lesions was classified by dermatologists, as described by Uehara and coauthors, 5 according to the number of anatomical areas involving the face, neck, upper trunk, upper limbs, lower trunk, and lower limbs during the follow-up: mild = involvement of 2 anatomical areas; moderate = involvement of 3 to 4 areas; severe = involvement of 5 or more areas. All patients were asked whether they rubbed their eyes. Statistical analysis was by the Fisher exact test. A Pvalue <.05 was considered significant.

Results Eighty-one eyes of 41 patients with atopic dermatitis (19 men, 22 women) were examined. Their age, sex, and cataract progression are shown in Table 1. Mean patient age was 23.5 years (range 11 to 35 years).

Of the 41 patients, 10 (24.4%) showed progression of cataract during the follow-up. O f the 81 eyes, 10 (12.3%) showed slow progression of anterior and posterior subcapsular cataract and 9 (11.1%) showed rapid progression (6 anterior and posterior subcapsular cataract; 3 total diffuse opacities). O f the 19 men (38 eyes), 6 (31.6%; 12 eyes) showed progression of cataract. O f the 22 women (43 eyes), 4 (18.2%; 7 eyes) showed progression of cataract. There was no significant difference by sex in predominance of cataract progression (P > .05). Most patients with atopic dermatitis had mild myopia. Cataracts in most patients were bilaterally symmetric. Cataract progression by severity of systemic skin lesions is shown in Table 2. Progression of cataract was not significandy associated with severity of systemic skin lesions (P > .05). Table 2. Cataract progression and severity of systemic skin lesions by patients (N = 41).

None or no cataract

5 (12.2)

Slow

0

Rapid

1

10 (24.4) 1

(2.4)

0

(2.4)

16 (39.0) 4

(9.8)

4

(9.8)

Note: The association between cataract progression and severity of lesions not significant (P > .05) *Number of patients (%)

j CATARACTREFRACTSURG--VOL25, JANUARY1999

97

CATARACT A N D ATOPIC DERMATITIS

T~b|e 3. Cataract progression and facial skin lesions by patients (N = 41).

T s b l e 4. Cataract progression and contact lens and spectacle wear by eyes (N = 81).

;~~- f~: ,~z' :.~,~~ ,'.,- : ;. ~ : J,,.~~~...... ' ;5,,~ ;,~,.~:,,;.%,.~;~ ., ; ' , , None or no cataract

6 (14.6)

25 (100)

Slow

5 (12.2)

0

Rapid

5 (12.2)

0

None or no cataract

2

Slow

0

Rapid

6

(2.7)

12 (14.8) 0

(7.4)

0

48 (59.3) 10 (12.3) 3

(3.7)

Note: Difference between patients with no pi'ogression or cataract and those with slow progression significant (P < .01); between patients with no progression or cataract and those with rapid progression significant (P < .01) *Number of patients (%)

Note: Difference between patients with no progression or no cataract and those with rapid progression significant (P < .001)

Cataract progression and facial skin lesions are shown in Table 3. Progression of cataract was significandy associated with the facial skin lesions (P < .01). Cataract progression with contact lens or spectacle use to correct a refractive error is shown in Table 4. Soft contact lens wear was significantly associated with cataract progression (P < .001). Cataract progression with eye rubbing is shown in Table 5. Eye rubbing was significantly associated with cataract progression (P < .05). All patients with facial skin lesions who wore soft contact lenses rubbed their

Cowan and Klauder * found that the cataracts in patients with atopic dermatitis are usually bilateral and that posterior and anterior pole opacities progress to mature cataract. In our study, most cataracts in patients with atopic dermatitis were also bilateral and showed anterior and posterior subcapsular opacities. Most studies have reported the incidence of cataract in patients with atopic dermatitis. Cowan and Klauder I found cataract in 8 of 100 patients (8.0%) with atopic dermatitis, Brunsting and coauthorF in 136 of 1158 patients (11.7%), Amemiya and coauthors° in 11 of 44 patients (25.0%), Garrity and Liesegang~ in 26 of 200 patients (13.0%), Uehara and coauthors 5 in 19 of 153 patients (12.4%), and Katsushima et al. 6 in 13 of 75 patients (17.3%). In our study, cataract progressed in 10 of 41 patients (24.4%). Amemiya and coauthors 3 found that in 2 patients, lens opacities rapidly progressed to total during exacerbation of the skin lesions. Uehara and coauthors 5 found cataract development had no relationship to the distribution of skin lesions, clinical course of dermatitis, or history of respiratory atopy. In o u r study, cataract progression in atopic dermatitis .was associated with the facial skin lesions, soft contact lens wear, and eye rubbing but not with severity of the systemic skin lesions. We could not determine the dose of topical corticosteroids taken by our patients. Katsushima et al.6 reported that using topical steroids on facial skin lesions was not significandy associated with cataract formation in patients with atopic dermatitis. In our study, all patients with facial skin lesions who wore soft contact lenses rubbed their eyes; thus, it is unlikely that the soft

eyes.

Discussion In this study, cataract progression was determined clinically using the Lens Opacities Classification System III. 9 We also used photographs and visual acuity results to determine cataract progression.

"ra~lo 5. Cataract progression and eye rubbing by patients (N = 41). • ":,:~5.~.. •

.

:.. . . . .

~, .

~: -

.

2.. . . . .:

:!',

•

~-

T~

,

•

" ~

:~ . . . . .

"

*~T;.:C-C:&,

. . E ~ , : R u b b i n g , , ~

None or no cataract

6 (14,6)

Slow

5 (12,2)

0

Rhpid

4

1

(9,8)

'.."

........

25 (61.1)

(2.4)

Note: Difference between patients with no progression or cataract and those with slow progression significant (P < .01); difference between those with no progression or cataract and rapid progression significant (P < .05) *Number of patients (%) 98

J CATARACTREFRACTSURG---VOL25, JANUARY1999

CATARACT AND ATOPIC DERMATITIS

contact lens wear alone causes cataract progression. It is possible that people wearing soft contact lenses could rub or touch their eyes more frequently. Matsuo and coauthors 8 found that cataract in patients with atopic dermatitis is significandy associated with higher levels of aqueous flare. They also suggested that long-term subde inflammation around the eye caused by atopic dermatitis, as well as blunt trauma by eye rubbing, may break down the bloodaqueous barrier. 8 0 k a et al. 7 believe that self-inflicted ocular contusion produced by tapping the eyes can cause retinal detachment in those with atopic dermatitis. It is possible that patients with facial skin lesions rub or touch their eyes, causing cataract and retinal detachment. We believe that eye rubbing should be avoided in patients with atopic dermatitis. Niwa and Iizawa ~° reported that serum levels of chylomicrons, very-low-density lipoprotein, and lipid peroxide levels were increased and superoxide dismutase activity was less in atopic patients with cataract than in atopic patients without cataract and in healthy study participants. They suggest that the high levels of serum lipids and decreased superoxide dismutase may accelerate the worsening of atopic dermatitis, leading to cataract) ° In our study, however, serum lipids and leukocyte superoxide dismutase levels were not examined in all patients; thus, we cannot comment on the relationship between these substances and cataract formation.

Refel'ellC~ 1. Cowan A, Klauder JV. Frequency of occurrence of cataract in atopic dermatitis. Arch Ophthalmol 1950; 43:759-768 2. Brunsting LA, Reed WB, Bair HL. Occurrence of cataracts and keratoconus with atopic dermatitis. Arch Dermarol 1955; 72:237-241 3. Amemiya T, Matsuda H, Uehara M. Ocular findings in atopic dermatitis with special reference to the dinical features of atopic cataract. Ophthaimologica 1980; 180:129-132 4. GartityJA, LiesegangTJ. Ocular complications ofatopic dermatitis. Can J Ophthalmol 1984; 19:21-24 5. Uehara M, Amemiya T, Arai M. Atopic cataracts in a Japanese population with special reference to factors possibly relevant to cataract formation. Dermatologica 1985; 170:180-184 6. Katsushima H, Miyazaki I, Sekine N, et al. [Incidence of cataract and retinal detachment associated with atopic dermatitis.] [In Japanese] Nippon Ganka Gakkai Zasshi 1994; 98:495-500 7. Oka C, Ideta H, Nagasaki H, et al. Retinal detachment with atopic dermatitis similar to traumatic retinal detachment. Ophthalmology 1994; 101:1050-1054 8. Matsuo T, Saito H, Matsuo N. Cataract and aqueous flare levels in patients with atopic dermatitis. Am J Ophtha]mol 1997; 124:36-39 9. Chylack LT Jr, Wolfe JK, Singer DM, et al. The Lens Opacities Classification System III. Longitudinal Study of Cataract Group. Arch Ophthalmol 1993; 111:831-836 10. Niwa Y, Iizawa O. Abnormalities in serum lipids and leukocyte superoxide dismutase and associated cataract formation in patients with atopic dermatitis. Arch Dermatol 1994; 130;1387-1392

j CATARACTREFRACTSURG---VOL25, JANUARY1999

99"