A case report of a 31-year-old woman who developed anterior subacapsular cataracts, and associated dermatological signs, after exposure to black mold. While atopic illness is commonly seen in childhood, a growing body of literature supports adult onset atopic dermatitis. Anterior subcapsular cataracts are pathognomonic for atopic illness, and can support a definitive and expedited dermatologic diagnosis of adult onset disease

Lynch, Katherine B, OD

Teitelbaum, Bruce A., OD

English

University of the Incarnate Word

Optometric Clinical Practice Volume 1 Issue 1 2019 Anterior Subcapsular Cataract Secondary to Black Mold Exposure Katherine B. Lynch OD Illinois College of Optometry, kalynch@ico.edu Bruce A. Teitelbaum OD Illinois College of Optometry, bteitelb@ico.edu Follow this and additional works at: https://athenaeum.uiw.edu/optometric_clinical_practice  Part of the Dermatology Commons, Ophthalmology Commons, and the Optometry Commons The Athenaeum provides a publication platform for fully open access journals, which means that all articles are available on the Internet to all users immediately upon publication. However, the opinions and sentiments expressed by the authors of articles published in our journal does not necessarily indicate the endorsement or reflect the views of the University of the Incarnate Word and its employees. The authors are solely responsible for the content of their work. Please address questions to athenaeum@uiwtx.edu. Recommended Citation Lynch KB, Teitelbaum BA. Anterior Subcapsular Cataract Secondary to Black Mold Exposure. Optometric Clinical Practice. 2019; 1(1):7. This Article is brought to you for free and open access by The Athenaeum. It has been accepted for inclusion in Optometric Clinical Practice by an authorized editor of The Athenaeum. For more information, please contact athenaeum@uiwtx.edu. Anterior Subcapsular Cataract Secondary to Black Mold Exposure Abstract A case report of a 31-year-old woman who developed anterior subacapsular cataracts, and associated dermatological signs, after exposure to black mold. While atopic illness is commonly seen in childhood, a growing body of literature supports adult onset atopic dermatitis. Anterior subcapsular cataracts are pathognomonic for atopic illness, and can support a definitive and expedited dermatologic diagnosis of adult onset disease. Keywords cataract, atopic dermatitis, mold Creative Commons License This work is licensed under a Creative Commons Attribution-Noncommercial 4.0 License This article is available in Optometric Clinical Practice: https://athenaeum.uiw.edu/optometric_clinical_practice/vol1/iss1/3 Introduction   Adult onset atopic dermatitis is a newly recognized subtype of atopic dermatitis, first described in 2000. In most patients, atopic dermatitis is a disease originating in childhood, and most will have an episode before the age of five. Nevertheless, an increasing number of adults presenting with atopic disease de novo are emerging in the literature. While the criteria for a diagnosis is not well defined, as it is in children, many providers choose to use the Hanifin and Rajka criteria for diagnosis.1 However, these criteria have limitations in practical application. The literature suggests that classic patterns seen in children are not always exhibited in adults, delaying or precluding the diagnosis of atopic disease. Because the condition is reliant on clinical examination, another consideration for a confident diagnosis is the presence of ocular findings. Anterior subcapsular cataracts are a highly suggestive sequela of this condition. We report an adult woman with exposure to black mold developing atopic dermatitis with an anterior subcapsular cataracts.  Report and Discussion    A 31-year-old African American female presented to an urban eye clinic with complaints of blurry vision. The patient reported a primary dermatological hypersensitivity reaction at age 28 to black mold in her apartment precipitating a change in vision and a subsequent diagnosis of cataract. Prior to this episode there was no history of allergy or atopic disease. Recent re-exposure to black mold triggered another severe dermatological reaction (Fig 1) associated with worsening visual acuity. 7Lynch and Teitelbaum: Anterior Subcapsular CataractPublished by The Athenaeum, 2019 Figure 1: Dermatological appearance of the patient after black mold exposure.   Upon examination, the previously noted bilateral anterior subcapsular cataracts had progressed in both eyes (Fig 2), more so in the right eye to 3+ and the patient was reduced to 20/30. 8Optometric Clinical Practice, Vol. 1 [2019], Iss. 1, Art. 3https://athenaeum.uiw.edu/optometric_clinical_practice/vol1/iss1/3         Figure 2: Anterior subscapular cataract  Intraocular pressure was 20 OD and OS. Dilated fundus examination was unremarkable OU. Allergy testing after the black mold exposure revealed the patient was now highly allergic to grasses, trees, molds, animals and various foods. A dermatology consult resulted in the diagnosis of atopic dermatitis.    It is estimated that atopic disease affects between 2 to 15% of adults.1,2 Traditionally, a diagnosis is made based on clinical signs1 and is commonly characterized as an atopic triad including atopic dermatitis, allergic rhinitis, and asthma when examining children. Clinical diagnosis of atopic dermatitis is made based on the appearance and pattern of the eczema, the waxing and waning of skin inflammation, and medical history3 – all guided by the Hanifin and Rajka criteria.  However, diagnostic criteria for adult onset atopic dermatitis may not fit traditional models and is still heavily weighted on clinical examination, rather than strict adherence to particular criteria. Differentials of atopic dermatitis in adults include a wide array of conditions, notably allergic dermatitis, seborrheic dermatitis, psoriasis, as well as many other inflammatory and infectious processes.1, 3 Atopic dermatitis remains uncommon; however, other clinical signs thought to be minor diagnostic criteria may support atopic etiology.   Ocular manifestations have long been considered minor criteria in the diagnosis of atopic disease. Ocular involvement in atopic disease may be as high at 42%.1 9Lynch and Teitelbaum: Anterior Subcapsular CataractPublished by The Athenaeum, 2019Patients with atopic disease are reported to have a higher incidence of recurrent conjunctivitis, keratoconus, and retinal detachment. 1,4,5,6 Cataract formation is also widely reported.   Cataract formation may occur in up to half of patients with atopic dermatitis.5 This includes both anterior subcapsular (ASC) and posterior subcapsular cataracts (PSC), the two forms of cataract most commonly encountered in this patient population. While corticosteroid use is linked to the development of PSC, the incidence of PSC in the steroid naïve AD group is similar to patients with a known history of steroid use2,4, suggesting that cataract formation cannot be explained by steroid use alone. The presence of ASC is even more specific to the diagnosis of atopic dermatitis. Anterior subcapsular cataract formation is uncommon, and rarely seen outside of an atopic patient population.    Anterior subcapsular cataract formation is typically rapid4 and appears as a central gray-white plaque.2  Commonly encountered cataracts with a similar appearance include cortical, polar or traumatic cataracts and can be easily differentiated on slit lamp exam using an optic section. Clinically, ASC chronologically follows dermatological signs.4 These cataracts are more common in young patients and their formation is more likely in severe atopic presentations.2,6 The pathophysiology behind the development of these cataracts is poorly understood. Oxidative stress, elevated IgE, compromised blood aqueous barrier, elevated protein in the aqueous humor, epithelial-mesenchymal transition, and eye rubbing have all be postulated, but none proven.2,4,5   While adult onset atopic dermatitis is difficult to definitively diagnose, ocular signs may give confidence to the diagnosis.  Cataracts, and more specifically anterior subcapsular cataracts, are a known manifestation of atopic dermatitis.  The formation of anterior subcapsular cataracts may strengthen the diagnosis for adult onset atopic dermatitis and ensure that proper treatment and management options are available.  Images used with permission.  References 1. de Bruin Weller MS, Rockmann H, Knulst AC, Bruijnzeel-Koomen CAFM.          Evaluation of the Adult Patient with Atopic Dermatitis. Clin Exp Allergy      2012;43(3):279-91.  doi:10.1111/cea.12030. 2. Shu DY, Ong K, Lovicu FJ. Histopathology of Subcapsular Cartaract in a      Patient with Atopic Dermatitis. Optom Vis Sci 2017 February; 94(2):270-6.      doi: 10.1097/OPX.0000000000001011. 10Optometric Clinical Practice, Vol. 1 [2019], Iss. 1, Art. 3https://athenaeum.uiw.edu/optometric_clinical_practice/vol1/iss1/3 3. Silvestre Salvador JF, Romero-Pérez D, Encabo-Dúran B. Atopic Dermatitis in      Adults: A Diagnostic Challenge. J Investig Allergol Clin Immunol      2017;27(2):78-88. doi: 10.18176/jiaci.0138. 4. Bair B, Dodd J, Heidelberg K, Krach K. Cataracts in Atopic Dermatitis: A Case      Presentation and Review of the Literature. Arch Dermatol 2011;147(5):585-8.     doi:10.1001/archdermatol.2010.411. 5. Tatham A. Atopic Dermatitis, Cutaneous Steroid and Cataracts in Children:      Two Case Reports. J Med Case Rep 2008;2:124. doi: 10.1186/1752-1947-2-     124. 6. Thyssen JP, Toft PB, Halling-Overgaard AS, et al. Incidence, Prevalence, and      Risk of Selected Ocular Disease in Adults with Atopic Dermatitis. J Am Acad      Dermatol 2017;77(2):280-6. doi:10.1016/j.jaad.2017.03.003.              11Lynch and Teitelbaum: Anterior Subcapsular CataractPublished by The Athenaeum, 2019

Anterior Subcapsular Cataract Secondary to Black Mold Exposure

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Anterior Subcapsular Cataract Secondary to Black Mold Exposure

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