Dry eye syndrome associated with meibomian gland dysfunction in the context of isotretinoin use: a clinical case

Introduction. Acne is a chronic, recurrent, and inflammatory skin disease that that can have significant aesthetic and psychological impacts on patients. The first-line treatment for acne is isotretinoin, which exerts systemic effect, reducing sebum production and alleviating inflammation However, one of the most common complications associated with prolonged systemic retinoid use is dry eye syndrome, linked to meibomian gland dysfunction, warranting special attention from ophthalmologists. Purpose: to present a clinical case of a patient who underwent four months of systemic isotretinoin therapy for acne and subsequently developed ocular complaints. Methods. Comprehensive ophthalmological diagnostics were conducted, including patient history, biomicroscopy, and corneal staining with fluorescein. Additional assessment included non-invasive tear film breakup time, measurement of tear meniscus height, evaluation of the lipid layer thickness of the tear film, meibography, eyelid margin photography, conjunctival hyperemia analysis, and corneal fluorescein staining. Treatment included various groups drug classes such as moisturizing drops, reparative gels, corneal protectors, and glucocorticosteroids. A therapeutic eyelid massage was also performed. Results. After three months of active therapy, the patient exhibited significant improvement, with a marked reduction in subjective complaints, no corneal epithelial defects, and an increase in tear film breakup time. Long-term symptom remission was achieved after five months of therapy. Conclusion. This case highlights the importance of interdisciplinary collaboration between ophthalmologists and dermatologists in managing patients undergoing long-term systemic retinoid therapy for acne. Comprehensive ophthal- mological assessment using specialized diagnostic methods is essential for accurately evaluating the clinical picture of ocular conditions and administering timely, multi-faceted therapy. This approach enhances patients’ quality of life and helps prevent severe complications.

1. Matushevskaya EV, Antonova LA, Matushevskaya YuI, Petrova KS. Clinical experience with systemic isotretinoin in the treatment of severe acne. RMZh. 2018;8(II):109–112. (In Russ.)

2. Cunliffe WJ, Van De Kerkhof PCM, Caputo R, et al. Roaccutane treatment guidelines: results of an international survey. Der matology.1997;194(4):351–357. doi: 10.1159/000246134

3. Anisimova MYu. Acne (Acne vulgaris) from the perspective of evidence-based medicine. Bulletin of Reproductive Health. 2010;3–4:14–23. (In Russ.) doi: 10.14341/brh20103-414-23

4. Masiukova SA, Mordovtseva VV, Kakhishvili NN, et al. Lowdose isotretinoin treatment of acne. Russian Journal of Clinical Dermatology and Venereology. 2013;11(6):7–12. (In Russ.)

5. Lvov AN, Kornyat MS, Igoshina AV, Nazarenko AR. Perspectives in acne therapy: an analytical review. Russian Journal of Clinical Dermatology and Venereology. 2019;18(2):115–128. (In Russ.) doi: 10.17116/klinderma201918021115

6. Oon HH, Wong SN, Aw DCW, et al. Acne management guidelines by the dermatological society of singapore. J Clin Aesthet Dermatol. 2019;12(7):34–50.

7. Fallah H, Rademaker M. Isotretinoin for acne vulgaris – an update on adverse effects and laboratory monitoring. J Dermatolog Treat. 2022;33(5):2414–2424. doi: 10.1080/09546634.2021.1967269

8. Brzezinski P, Borowska K, Chiriac A, Smigielski J. Adverse effects of isotretinoin: A large, retrospective review. Dermatol Ther. 2017;30(4). doi: 10.1111/dth.12483

9. Düzgün E, Özkur E. The effect of oral isotretinoin therapy on meibomian gland morphology and dry eye tests. J Dermatolog Treat. 2022;33(2):762–768. doi: 10.1080/09546634.2020.1774041

10. Ruiz-Lozano RE, Hernández-Camarena JC, Garza-Garza LA, et al. Isotretinoin and the eye: A review for the dermatologist. Dermatol Ther. 2020;33(6):e14029. doi: 10.1111/dth.14029

11. Caglar C, Senel E, Sabancilar E, Durmus M. Reduced ocular surface disease index (OSDI) scores in patients with isotretinoin treatment. Int Ophthalmol. 2017;37(1):197–202. doi: 10.1007/s10792-016-0263-y

12. Alfouzan YA, Al-Hammad RA, Alkhuzayem FA, et al. Isotretinoin-related eye dryness in acne patients in Qassim, Saudi Arabia. Cureus. 2023;15(12):e49904. doi: 10.7759/cureus.49904

13. Lamberg O, Strome A, Jones F, et al. Ocular side effects of systemic isotretinoin – a systematic review and summary of case reports. Journal of Dermatological Treatment. 2023;34(1):2213364. doi: 10.1080/09546634.2023.2213364

14. Acar Eser N, Kocabeyoğlu S, Atakan N, Irkec M. The effects of the systemic isotretinoin treatment on ocular surface and meibomian glands: a prospective longitudinal study. Cutan Ocul Toxicol. 2022;41(2):155–161. doi: 10.1080/15569527.2022.2077749

15. Zakrzewska A, Wiącek MP, Słuczanowska-Głąbowska S, et al. The effect of oral isotretinoin therapy on meibomian gland characteristics in patients with acne vulgaris. Ophthalmol Ther. 2023;12(4):2187–2197. doi: 10.1007/s40123-023-00737-6

16. Moy A, McNamara NA, Lin MC. Effects of isotretinoin on meibomian glands. Optometry and Vision Science. 2015;92(9):925– 930. doi: 10.1097/OPX.0000000000000656

17. Elubous KA, Toubasi AA, Elubous A, et al. Ocular manifestations of systemic isotretinoin in patients with acne: a systemic review and meta-analysis. Cutan Ocul Toxicol. 2022;41(2):113–122. doi: 10.1080/15569527.2022.2050747

18. Gurlevik U, Kemeriz F, Yasar E. The effect of isotretinoin on meibomian glands in eyes: a pilot study. Int Ophthalmol. 2022;42(7):2071–2078. doi: 10.1007/s10792-021-02205-1

19. Riks IA, Trufanov SV, Boutaba R. Modern approaches to the treatment of meibomian gland dysfunction. Russian Annals of Ophthalmology. 2021;137(1):130136. (In Russ.) doi: 10.17116/oftalma2021137011130

20. Medvedev IB, Trubilin VN, Poluninа EG, et al. Modern possibilities of physiotherapeutic treatment for meibomian gland dysfunction. Ophthalmology in Russia. 2022;19(2):235–241. (In Russ.) doi: 10.18008/1816-5095-2022-2-235-241

21. Trubilin VN, Poluninа EG, Kurenkov VV, et al. Therapeutic eyelid hygiene in the algorithms for prevention and treatment of ocular surface diseases. Ophthalmology in Russia. 2016;13(2):122–127. (In Russ.) doi: 10.18008/1816-5095-2016-2-122-127

22. Bilgic AA, Sabur H, Acar M, Canpolat F. Effects of li pidcontaining eye drops on the ocular surface and in vivo confocal microscopy findings in patients using syste mic isotretinoin. Cutan Ocul Toxicol. 2023;42(1):25–31. doi: 10.1080/15569527.2023.2166523

23. Acet Y, Bilik L. Instability of tear film and loss of meibomian glands in patients with acne vulgaris. Arq Bras Oftalmol. 2022;87(2):0038. doi: 10.5935/0004-2749.2021-0038

24. Maуchuk DYu, Loshkareva AO, Tsvetkova TV. Complex treatment algorithm for dry eye syndrome with meibomian gland dysfunction: combination of intense pulsed light (IPL) with eyelid hygiene and artificial tears. Ophthalmology in Russia. 2020;17(3s):640–647. (In Russ.) doi: 10.18008/1816-5095-2020-3S-640-647

25. Toyos R, Toyos M, Willcox J, et al. Evaluation of the safety and efficacy of intense pulsed light treatment with meibomian gland expression of the upper eyelids for dry eye disease. Photobiomodul Photomed Laser Surg. 2019;37(9):527–531. doi: 10.1089/photob.2018.4599

26. Liu R, Rong B, Tu P, et al. Analysis of cytokine levels in tears and clinical correlations after intense pulsed light treating meibomian gland dysfunction. Am J Ophthalmol. 2017;183:81–90. doi: 10.1016/j.ajo.2017.08.021

27. Zhang L, Wang J, Gao Y. Eyelid cleaning: Methods, tools, and clinical applications. Indian J Ophthalmol. 2023;71(12):3607– 3614. doi: 10.4103/IJO.IJO_1457_23

28. Zainab Z, Malik NA, Obaid S, et al. Effectiveness of oral Omega 3 in reducing mucocutaneous side effects of oral isotretinoin in patients with acne vulgaris. J Ayub Med Coll Abbottabad. 2021;33(1):60–63.