Lichen Planus in Ocular Surface: Major Presentations and Treatments

Abstract

Ocular lichen planus (LP) is a rare disease which has been increasingly reported in the literature in the last two decades involving conjunctiva, cornea, and lacrimal drainage system. Most reported cases of ocular LP are cicatricial conjunctivitis with subepithelial fibrosis, fornix shortening, and symblepharon formation. It is not clear whether corneal involvement is a primary event or secondary to these changes. Topical cyclosporine and corticosteroid can be considered as first-line therapy in ocular surface involvement, while treatment regimen in more aggravated disease should be boosted with systemic immunosuppressives. After resolving acute inflammation, the patient should be treated with long-term maintenance therapy to halt the chronic progression of the disease. Lacrimal drainage system could also be involved, usually in a bilateral bicanalicular pattern with severe punctal/canalicular stenosis. Because of severity, the surgical outcomes are not favorable but successive treatments with dacryocystorhinostomy + mitomycin C (MMC), Jones tube implantation, and systemic cyclosporine are reported.

Evaluation of corneal densitometry changes in patients with lichen planus

“…13 Whether corneal involvement is an event within the natural course of lichen planus or whether it develops secondary to occurring ocular surface changes is not yet clear, but corneal involvement often accompanies other ocular surface disorders especially conjunctival types. 14 In fact, lichen planus is a systemic disease that can also occur in the form of isolated ocular lichen planus. This very rare condition is usually characterised by eyelid and conjunctival involvement and may cause severe conjunctival scarring.…”

Ocular involvement and complications of lichen planus, lichen planus pigmentosus, and lichen planopilaris: A comprehensive review

“…29 The most common presentation of ocular LP is conjunctivitis, followed by corneal involvement (keratitis) and lacrimal drainage system obstruction, usually punctal and/or canalicular. 10 A rare case of scleritis related to LP was recently reported. 9 Initially, patients refer blurred vision, redness, dry eyes, mild mucous discharge, and foreign body sensation.…”

“…8 Left untreated, subepithelial fibrosis evolves to fornix foreshortening, symblepharon formation (adhesions between the bulbar and palpebral conjunctiva), and keratinization of the OS with or without ankyloblepharon (partial or complete fusing of superior and inferior eyelids). 10 Finally, end-stage disease is characterized by corneal involvement. Corneal microtrauma associated to tarsal fibrosis, along with the chronic inflammatory environment of the entire OS, results in overexpression of matrix metalloproteinases and proinflammatory cytokines that cause both epithelial breakdown and absent epithelial healing.…”

“…13 The latter, results in corneal scarring, observed as an opacified "white eye," neovascularization, stromal melting, ulceration, and an increased risk of perforation. 10,13…”

Cyclosporin in dermatology: A practical compendium

“…Another study done in 2018 evaluated efficacy and safety of methotrexate and CYA concluded that both of them have similar results when tried in lichen planopilaris 32 . Ocular LP although a rare presentation also benefits from topical CYA 33 …”