Polyethylene glycol sensitization in patients with recurrent urticaria: Something to consider before the administration of the mRNA COVID-19 vaccine

Background: Polyethylene glycol (PEG) and polysorbate are two commonly used excipients in cosmetics, therapeutics, and processed foods. They are used not just to stabilize and preserve but also to influence the pharmacokinetics and bioavailability of the active ingredients of these products. Numerous reports have described patients with recurrent urticaria self-reporting multiple unrelated products hypersensitivities. We aim to describe a case series of sensitization to PEG in patients with recurrent urticaria and its implications to the currently available COVID-19 vaccines in Malaysia. Method(s): Data of all patients during the peak vaccination period (March 2021 -May 2021) who had positive intradermal test to surrogate PEG and polysorbate 80 were retrieved and analyzed. They were tested with PEG 4000 (macrogol), PEG 400 (Systane Ultra eye drop) and polysorbate 80 (Tween 80). Result(s): A total of eight patients were skin test positive to PEG and/ or polysorbate 80. The mean age was 35.1 +/- 10.5 years. Only one patient was male. Everyone reported history of multiple product reactions with recurrent urticaria as the major symptom. Majority (75%) had multiple unrelated products hypersensitivities. Four of them had urticarial reactions after the first dose of mRNA vaccine. Two patients were skin test negative to the lower molecular weight PEG 400. Cross sensitization between PEG 4000 and polysorbate 80 was 100%. All patients were subsequently inoculated with two doses of inactivated virus COVID-19 vaccine without any serious sequalae. Conclusion(s): The validity of skin testing towards PEG is not yet clear. Nonetheless it is a promising tool in diagnosing PEG sensitization in selected patients reporting recurrent urticaria with multiple unrelated products. Pretesting of this select group may be considered before the inoculation of PEG-containing COVID-19 vaccine.

Guillain-Barre syndrome: An autoimmune disorder post-COVID-19 vaccination?

SARS-CoV-2 causes Coronavirus Disease 2019 (COVID-19), an infectious condition that can present none or one or more of these symptoms: fever, cough, headache, sore throat, loss of taste and smell, aches, fatigue and musculoskeletal pain. For the prevention of COVID-19, there are vaccines available including those developed by Pfizer, Moderna, Sinovac, Janssen, and AstraZeneca. Recent evidence has shown that some COVID-19-vaccinated individuals can occasionally develop as a potential side effect Guillain-Barre syndrome (GBS), a severe neurological autoimmune condition in which the immune response against the peripheral nerve system (PNS) can result in significant morbidity. GBS had been linked previously to several viral or bacterial infections, and the finding of GBS after vaccination with certain COVID-19, while rare, should alert medical practitioners for an early diagnosis and targeted treatment. Here we review five cases of GBS that developed in different countries after COVID-19 vaccination.Copyright © 2021

A Review Study on Associated Factors Ofmyopia Amongschool Goingchildren

Myopia is a prevalent yet confusingocular disorder. Myopia,formerlyconsidered abenignrefractivecondition, is nowassociatedwithanincreasedriskofdevelopingseveraloculardisorders,evenatmodestlevels.Myopiaisaglobalproblemthatexpe rts have documented. Despite the fact that the specific cause of myopia remains a mystery, it appears to be a combinationof genetic and environmental factors, making the prevention and treatment of the condition difficult and highly personalised.Myopia can have a positive impact on both the quality of life and the health of the eyes if it is prevented. Progressive additionlenses (PAL), topical atropine, ortho-k (orthokeratology) lenses and multifocal contact lenses are some of the most commoncontrol options currently available. Myopia has gained prominence in optometry studies as a result of its high prevalence. It ismore common for children to suffer from problems, such as extreme myopia and myopic macular degeneration, if they begindevelopingmyopiaatanearlyage.Thepurposeofthisstudywillbetoconductaninquiryintotheepidemiologyandriskfactorsfor myopiainschool-agedchildren(aged 6-19years)aroundtheworld.Copyright © 2022, Anka Publishers. All rights reserved.

iConDet2: An Improved Conjunctivitis Detection Portable Healthcare App Powered by Artificial Intelligence

Conjunctivitis is one of the common and contagious ocular diseases which affects the conjunctiva of the human eye. Both the bacterial and viral types of it can be treated with eye drops and other medicines. It is important to diagnose the disease at its early stage to realise the connection between it and other diseases, especially COVID-19. Mobile applications like iConDet is such a solution that performs well for the initial screening of Conjunctivitis. In this work, we present with iConDet2 which provides an advanced solution than the earlier version of it. It is faster with a higher accuracy level (95%) than the previously released iConDet. © 2022, The Author(s), under exclusive license to Springer Nature Switzerland AG.

Betaine- and L-Carnitine-Based Ionic Liquids as Solubilising and Stabilising Agents for the Formulation of Antimicrobial Eye Drops Containing Diacerein.

The therapeutic efficacy of topically administered drugs, however powerful, is largely affected by their bioavailability and, thus, ultimately, on their aqueous solubility and stability. The aim of this study was to evaluate the use of ionic liquids (ILs) as functional excipients to solubilise, stabilise, and prolong the ocular residence time of diacerein (DIA) in eye drop formulations. DIA is a poorly soluble and unstable anthraquinone prodrug, rapidly hydrolysed to rhein (Rhe), for the treatment of osteoarthritis. DIA has recently been evaluated as an antimicrobial agent for bacterial keratitis. Two ILs based on natural zwitterionic compounds were investigated: L-carnitine C6 alkyl ester bromide (Carn6), and betaine C6 alkyl ester bromide (Bet6). The stabilising, solubilising, and mucoadhesive properties of ILs were investigated, as well as their cytotoxicity to the murine fibroblast BALB/3T3 clone A31 cell line. Two IL-DIA-based eye drop formulations were prepared, and their efficacy against both Staphylococcus aureus and Pseudomonas aeruginosa was determined. Finally, the eye drops were administered in vivo on New Zealand albino rabbits, testing their tolerability as well as their elimination and degradation kinetics. Both Bet6 and Carn6 have good potential as functional excipients, showing solubilising, stabilising, mucoadhesive, and antimicrobial properties; their in vitro cytotoxicity and in vivo ocular tolerability pave the way for their future use in ophthalmic applications.

Robotic Telepresence Consults in Underserved Community-Based Vision Threatening Disease Screenings During COVID-19

Purpose : Vision Threatening Diseases (VTDs) (age-related macular degeneration, cataracts, diabetic retinopathy, glaucoma) affect 36 million individuals in the United States. 50% are unaware they have a VTD, disproportionally affecting minorities and lowincome groups with less access to eye care. While screening programs in underserved communities result in early detection, less than half of subjects with findings follow up with a specialist. This number is four times lower during COVID-19. Methods : Robotic Telepresence (RT) was implemented in this pilot study during COVID19 to increase real-time access to specialist care. 58 subjects (age 56, 45% male) underwent a non-mydriatic screening protocol over five screenings. They were divided into three groups for consult: In Person (IP) followed by RT (N = 21), RT followed by IP (N = 19), and IP only (N = 18). IP consult was done by an on-site certified reader. RT consult was done by an off-site glaucoma or retina specialist with access to blood pressure, visual acuity, intraocular pressure, 45° retinal images, and ocular coherence tomography Bscans via cloud-based software. Video connection for RT was established via HIPAAcompliant mobile hotspot. Subject demographics and preferences were collected afterwards via survey. Results : Of 40 RT consults, 26 were second opinion for VTD suspect and 14 were wellness encounters. 24 reported their last eye care visit >3 years ago or never. Following RT consult, 18 subjects received one or multiple VTD diagnosis and 3 with glaucoma were referred for pressure-lowering eye drops. In the group with IP consult first, preferences were 5% RT, 52% IP, and 43% none. In the group with RT consult first, preferences were 5% RT, 58% IP, and 37% none. There was no significant difference in number of questions asked, wait time, or encounter length between IP and RT consults. Conclusions : RT consults proved valuable in community-based VTD screenings, particularly during COVID-19 when access to eye care is further limited. Most subjects preferred IP. However subjects with VTD that face socioeconomic barriers benefit from immediate RT consult and management directives from remote subspecialists. Further studies should incorporate consults from additional specialties (endocrinologists, general practitioners, social workers) and include telehealth CPT code for reimbursement.

Bunazosin inhibited axial elongation with an increase of the choroidal blood perfusion in a murine model of myopia

Purpose : The prevalence of myopia is accelerating worldwide possibly because of the decrease in outdoor activity including COVID-19 home confinement. We have reported the effective treatments of suppressing myopia progression, including oral administration of crocetin (Mori K et al. Sci Rep. 2019) and violet light exposure (Jiang X et al. Proc Natl Acad Sci USA. 2021). In this study, we examined the therapeutic effects of bunazosin, known as one of the α1-adrenergic receptor antagonists, in a lens-induced myopia mouse model. Methods : C57BL/6J mice were induced myopia at 3-week-old by a method established in our research group (Jiang X et al. Sci Rep. 2018). For 3 weeks, mice were equipped with lenses in both eyes, a left for 0 D lens as internal control and a right for -30 D lens as myopia induction. During this period, we administered 0.01% bunazosin hydrochloride solution by intraperitoneal injection (IP group) and eye drop (E group) once a day, and PBS as control. Ocular components including refraction error, axial length, and choroidal thickness before and after myopia induction were measured by an infrared photorefractor and an SD-OCT. The choroidal blood flow was evaluated by an SS-OCT angiography. Results : In the eye with -30D lens of control group, significant changes in a myopic shift of refraction (p < 0.01), axial elongation (p < 0.05), and choroidal thinning (p < 0.01) compared to 0D lens were observed. In contrast, IP or E groups showed no significant difference between both eyes, suggesting myopia progression was suppressed by bunazosin treatment. The choroidal blood flow of the eye with -30D in E group (58.9±8.9%) was higher than that of the control group -30D (44.0±6.4%)(p < 0.05). Conclusions : Bunazosin has a preventive effect on myopia progression by suppressing axial elongation and choroidal thinning together with an increase of choroidal blood flow.

REACTIVE INFECTIOUS MUCOCUTANEOUS ERUPTION (RIME) THROUGH REASON: EVALUATING ORAL SWELLING IN A PATIENT WITH COVID-19

CASE: A 22-year-old woman with h/o asthma initially presented to the hospital with lip swelling and sore throat. She tested positive for COVID-19 and received a casirivimab-imdevimab (monoclonal antibody) infusion. She returned a week later with worsening lip swelling, dysphagia and conjunctivitis. Physical exam revealed edematous lips with vesicular lesions, no tongue swelling, tonsillar exudate, 4+ conjunctival injection bilaterally with purulent discharge, and shallow clean based clitoral ulceration. She reports no history of allergic reactions, angioedema or exposure to new medications. Nasopharyngolaryngoscopy showed no laryngeal edema but visualized exudates throughout the supraglottis and glottis. C4, ANA, CMV, EBV, throat and blood cultures were negative. STI testing was trichomonas positive and gonorrhea/chlamydia negative. Respiratory virus panel remained positive for COVID-19. HSV swab of lip lesion, HSV 1/2 IgG and IgM were negative. Mycoplasma pneumoniae IgG was elevated (0.60, negative is ≤0.09), IgM equivocal (0.85, negative is ≤0.76), and nasopharyngeal PCR negative. Conjunctival culture showed rare bacteria (S. Aureus) and no leukocytes. She initially received methylprednisolone IV due to concern for angioedema, acyclovir for empiric HSV treatment and empiric antibacterial moxifloxacin eye drops. Given lack of infectious trigger, her presentation was concerning for reactive infectious mucocutaneous eruption (RIME) associated with SARSCoV-2 or Mycoplasma. Prednisone 1mg/kg daily was initiated followed by improvement in oral mucositis and conjunctivitis within days. IMPACT/DISCUSSION: A broad differential is important when evaluating oral swelling and mucositis. Her lack of cutaneous involvement, medication exposure or family history and negative infectious, autoimmune and inflammatory workup make other causes including Stevens-Johnson syndrome, erythema multiforme, angioedema, and HSV less likely. Our final diagnosis of RIME describes mucocutaneous eruptions likely due to an immune response triggered by bacterial or viral infection. Our patient's RIME may be due to COVID-19 or Mycoplasma given her equivocal Mycoplasma IgM. Eruptions generally involve two or more mucosal sites and occur mostly in children and adolescents. Common presentations include oral erosions and ulcers, purulent bilateral conjunctivitis, or urogenital lesions, which were all seen in our patient. As this is a relatively rare and new condition, no standard of care treatment exists for RIME but systemic steroids have been effective in case reports for initial treatment and subsequent flares. CONCLUSION: RIME is a rare, newly described condition in young patients who develop postinfectious mucocutaneous eruptions of two or more mucosal sites. It has been recently reported in association with COVID-19 and its association with Mycoplasma infection is important to evaluate. This condition is important to recognize and treat given the requirement for higher dose steroids than that used for angioedema.

Distant Ocular Manifestations after New Coronavirus Infection

Purpose. Theoretically substantiate and practically identify ocular manifestations after the transferred SARS-CoV-2 virus. Patients and methods. For the study we were invited patients who had recovered from SARS-CoV-2 at the hospital of V.M. Buyanova, the age from 20 to 65 years old in period from 2020 to 2021. The total number of patients was 68 people. The patients had with them the results of PCR tests or ELISA tests, or an extract from the hospital confirmed COVID-19 case and also a clinical blood test and CT scan of the chest organs for the period of illness. Before the start of the study, the patients were asked to fill out a questionnaire “Questionnaire for patients who have had a new coronavirus infection” (Appendix 1). For a detailed study of this group of people, each underwent visometry, pneumotonometry, B-scan, a slit lamp study and also a slit lamp study with a 60D lens using 0.5 % Mydriacyl eye drops in the absence of contraindications and pupillography. Results. As a result of the work carried out, we concluded that the virus is capable of causing inflammation of the choroid of the eyeball, uveitis. Moreover, in our study, we identified patients with acquired intermittent divergent strabismus, anisocoria, ptosis, and accommodation disorder. And, in this regard, we came to the conclusion that the coronavirus belongs to the group of neurotropic, as it is able to affect the nervous tissue and cause the above clinical picture. In other words, the virus negatively affects the somatic and autonomic innervation of the oculomotor nerve. As a result of these lesions, we get the corresponding tetrad of symptoms: heterotropy, mydriasis, ptosis, accommodation paralysis. Conclusions. One of the extraordinary complications of coronavirus infection is damage effect to the fibers of the oculomotor nerve, the signs include: strabismus, mydriasis, ptosis and accommodation paralysis. Thus, this clinical picture is associated with the affinity of the virus to the nervous tissue. And as a result, this ability of the virus can probably infect various areas of the brain, which will lead to corresponding complications, not only from the oculomotor nerve, but also from other cranial nerves with the manifestation of the corresponding symptoms, which in theory can aggravate the patient's condition, causing deep disturbances of motor and sensory innervation.

CASE REPORT OF BELL’S PALSY FOLLOWING SECOND DOSE OF COVISHIELD VACCINE

Bell’s palsy, also known as acute peripheral facial palsy of unidentified reason, is caused by the acute onset of problems with the facial nerve’s lower motor neuron. Several case reports and series have described peripheral facial nerve palsy associated with COVID-19. In addition, since the US food and drug administration’s (FDA) emergency use authorization of several COVID-19 vaccines, there have been media reports of Bell’s palsy associated with vaccination. This case concerns a 26-year-old female with Bell’s palsy (confirmed by clinical diagnosis – an acute unilateral facial nerve paresis or paralysis with onset in >72 h) after receiving second dose of Covishield vaccine (ChAdOx1 nCoV-19). She experienced decreased sleep, dizziness, and left side eye watering post-vaccination. Next day after vaccination, she noticed muscle weakness on the left side of the face, preventing her from close left eye, drinking fluids, and facial droop accompanied by reduced mobility. The patient was treated with methylprednisolone and eye drops (lubricants).

Ophthalmic Manifestation of COVID-19 disease

A coronavirus is the novel coronavirus known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV2). It's a nonsegmented enveloped positive sense RNA virus with 82 percent genetic similarity to the SARS coronavirus (SARSCoV), which sparked an outbreak in early 2003. Respiratory droplets are assumed to be the primary mechanism of transmission because the virus is found in respiratory secretions. Conjunctival transmission and aerosol transmission have also been proposed, however they are also problematic. Fever, tiredness, and dry mouth are the three most prevalent COVID19 clinical symptoms. In several patients, however, conjunctivitis was the initial symptom. The disease's respiratory complications have been the focus of diagnostic and therapeutic efforts, However, a number of ocular concerns have surfaced. Infected patients' tears have been confirmed to contain SARSCov2 RNA, and studies indicate that the virus is spreading. For viral transmission, the ocular surface could serve as both an entry point and a reservoir. COVID19 has been linked to mild conjunctivitis, which can be the disease's first and only symptom. Ocular symptoms can be treated with observation without therapy, antibacterial eye drops, antiviral eye drops, and antiallergic eye drops, according to clinical trials..As a result, the only recommended treatment for COVID19related ocular manifestations is close observation cough. The motivation behind this examination was to investigate the event of visual appearances in patients who had been determined to have Covid illness 2019 (Coronavirus) because of serious intense respiratory condition. 2(SARS-CoV-2). © The Electrochemical Society

COVID testing kits - A new source of accidental poisoning in the UK?

Objective: Self-testing kits for COVID-19 are available to the public and commonplace in households. Kits consist of nasal/throat swabs, absorbent testing strips (including a desiccant sachet) and bottles of extraction liquid. Once samples are collected swabs are placed in the liquid to create a sample for lateral flow (LFT) or polymerase chain reaction (PCR) testing. The liquid is a mixture of water, transport mediums, buffers, preservatives and animal proteins and although not intended for human contact, is considered to be low toxicity. Our objective was to analyse enquiries to the UK National Poisons Information Service (NPIS) regarding COVID-19 test kits to investigate potential toxicity. Methods: We conducted a retrospective analysis of enquiries from 1 March 2020 until 31 July 2021. Enquiries were identified from the UK Poisons Information Database (UKPID) and filtered to identify those relating specifically to COVID-19 test kits. Results: In the study period 126 enquiries were received about COVID-19 test kits. One enquiry was regarding ingestion of the desiccant (LFT kit) with all others regarding the extraction liquid. The majority of enquiries (86, 68.3%) related to LFT kits with 9 (7.1%) enquiries regarding PCR kits. In 31 enquiries (24.6%) the test type was not specified. NHS telephone services (NHS 111/ Direct/24) accounted for the majority of enquiries (94, 74.6%), with the remaining from hospitals (12, 9.5%), primary care (10, 7.9%), and other sources (10, 7.9%) including ambulance services and nursing homes. Adults accounted for 69 (54.8%) enquiries with 55 (43.7%) regarding children. Age was not specified in 2 (1.6%) enquiries. Most adult exposures were accidental (67, 97.1%) with only 2 (2.9%) intentional exposures. Accidental exposures were due to the liquid being mistaken for eye drops (24, 35.8%), swabs dipped in liquid before taking samples (21, 31.3%), ingestion of liquid (19, 28.4%), spill of liquid onto skin (2, 3%) and liquid mistaken for ear drops (1, 1.5%). Patients were either asymptomatic (48, 69.6%) or reported mild symptoms only (20, 29%). In 1 enquiry the symptoms were unknown. Paediatric exposures were also accidental with only one intentional ingestion. Enquiries included ingestion of liquid or desiccant (45, 83.3%), liquid mistaken for eye drops (6, 11.1%), and swab dipped in liquid before taking sample (3, 5.5%). Patients were asymptomatic (48, 87.3%) or reported mild symptoms only (7, 12.7%). Conclusion: Almost all exposures to COVID-19 test kits were accidental with the extraction liquid most commonly being mistaken for eye drops. Reassuringly, serious toxicity has not been reported.

Comparative Evaluation of Antimicrobial, Antiamoebic, and Antiviral Efficacy of Ophthalmic Formulations.

The extensive use of ophthalmic antibiotics is contributing to the appearance of resistant bacterial strains, which require prolonged and massive treatments with consequent detrimental outcomes and adverse effects. In addition to these issues, antibiotics are not effective against parasites and viruses. In this context, antiseptics could be valuable alternatives. They have nonselective mechanisms of action preventing bacterial resistance and a broad spectrum of action and are also effective against parasites and viruses. Here, we compare the in vitro antibacterial, antiameobic, and antiviral activities of six ophthalmic formulations containing antiseptics such as povidone-iodine, chlorhexidine, and thymol against Gram-positive and Gram-negative bacteria, the amoeba Acanthamoeba castellanii, and two respiratory viruses, HAdV-2 and HCoV-OC43. The results suggest that, among all the tested formulations, Dropsept, consisting of Vitamin E TPGS-based (tocopheryl polyethylene glycol succinate) in combination with the antiseptic chlorhexidine, is the one with the highest range of activities, as it works efficiently against bacteria, amoeba, and viruses. On the other hand, the solution containing PVA (polyvinyl alcohol) and thymol showed a promising inhibitory effect on Pseudomonas aeruginosa, which causes severe keratitis. Given its high efficiency, Dropsept might represent a valuable alternative to the widely used antibiotics for the treatment of ocular infections. In addition to this commercial eye drop solution, thymol-based solutions might be enrolled for their natural antimicrobial and antiamoebic effect.

EYE DROP INSTILLATION BY PARENTS AT HOME TO FACILITATE OUTPATIENT EYE EXAMINATION FOR RETINOPATHY OF PREMATURITY

Purpose of Study Retinopathy of prematurity (ROP) is the abnormal development of retinal vessels in preterm infants which can lead to severe visual impairment or blindness. Many premature infants require ophthalmology follow-up if the retinae have not fully matured at the time of discharge. Ophthalmology follow-up is crucial as these infants are at risk for poor visual development, especially if changes that require intervention are not detected in a timely manner. Adequate pupillary dilation is necessary for an optimal eye exam and requires installation of eye drops at least 1 hour prior to the exam in the doctor's office. This wait time increases the likelihood of exposure to other people and infection. During the COVID-19 pandemic, our NICU adopted a discharge policy of teaching parents how to instill eyes drops to their infants at home before leaving for the eye appointment, with the goal of reducing the wait time in the office prior to the examination. The goal of this study is to evaluate if instillation of eye drops by parents at home before going to the office will provide adequate pupillary dilation for optimal ROP exam of premature infants in the outpatient setting and reduce wait time in the ophthalmology office. Methods Used Parents of all preterm infants needing follow-up ROP exam were provided with and taught how to instill eye drops at home before leaving for the ophthalmology appointment. Parents were given a paper log and documented the time and number of eye drops instilled. The ophthalmology office then documented check-in time, time of exam and adequacy of pupillary dilatation. A sample log is included (figure 1). Summary of Results Of the 14 individual eyes that were dilated, 10 were adequately dilated when eye drops were instilled by parents. 2 eyes received only one eye drop but were adequately dilated. 2 eyes did not adequately dilate with two drops in each eye and required three drops prior to the subsequent follow-up. 2 eyes received two drops but did not dilate adequately. The average time from check-in to eye exam was 38 minutes. Conclusions As premature infants are at higher risk for infection, a process to allow for efficient outpatient evaluation is necessary. 71% of eyes were adequately dilated when parents instilled the eye drops prior to the first follow-up appointment. Of the eyes that were not adequately dilated, when parents were instructed to increase the number of drops prior to the second follow-up, both eyes were adequately dilated. Our study shows that parents are capable of instilling eye drops to provide optimal dilation for the ROP exam, thus decreasing the time spent in the outpatient office. (Table Presented).

Patient Experiences and Insights on Chronic Ocular Pain from a Social Media Listening Study

Objective: To identify the perceived causes for chronic ocular pain (COP) (≥3 months pain duration), its impact on quality of life (QoL) and understand the patient journey from social media posts. Methods: In this retrospective study, publicly available social media conversations were identified from searches triaged by a combination of automated relevancy keyword algorithm and manual review, and subsequently analyzed post anonymizing for COP content. Twitter, forums, and other (Facebook, Blogs, etc.) platforms were leveraged for the time period February 2020 to February 2021. Results: A total of 464 (UK=208, US=175, Canada=65 and Australia=16) patient/caregiver conversations on COP were identified. Top discussion points were symptoms (62%) and causes of COP (58%). Ocular factors (including dry eye disease, thyroid/Graves’ disease, and ocular surgeries) contributed to ∼46% of causes identified, while non-ocular factors (including migraine, COVID, and side-effects/withdrawal of medications) contributed to ∼54%. The most commonly mentioned symptoms (555) were headache/head pressures (96), dry/gritty eyes (67), light sensitivity (34), insomnia (29), and redness/pink eyes (28). Symptoms impacted all aspects of patients’ QoL: physical day-to-day activities such as reading, driving, and sleeping;emotional wellbeing such as depression/hopelessness, frustration/anger, fear, and suicidal thoughts;functional wellbeing such as difficulty at work/study place, reduced productivity or having to quit their job;social impacts such as being irritated around people, and having a less active social life. Eye drops (58/140 mentions) are the most commonly mentioned treatment option. Common coping strategies mentioned were blue-light filter glasses/eyeglasses (17), and hot compresses (11). Key unmet needs mentioned by patients were failed, improper, delayed diagnosis (62), and lack of effective treatments or appropriate management (30). Conclusion: Insights from this study reported patients’ experiences, concerns, and the adverse impact on overall QoL. The results can help in better understanding the patients’ perspective, which can be considered during drug development.

Primary sjögren's syndrome VS MS: Overlap or misdiagnosis?

Case report-IntroductionPrimary Sjögren's syndrome (PSS) is a systemic autoimmune disease that mainly affects exocrine glands. Central nervous system (CNS) involvement in primary SS is extremely rare. In 10-20% of patients diagnosed with PSS, there are lesions in the central nervous system analogous to those presented in multiple sclerosis. We report a case of a 58-year-old female, diagnosed as PSS and multiple sclerosis (MS) (2007), but later, all neurological manifestations turned out to be related to PSS rather MS. This case illustrates how difficult it could be, distinguishing Sjögren's with CNS involvement from MS, even to an expert clinician.Case report-Case descriptionA 58-year-old lady presented to Rheumatology clinic in 2010 with polyarthralgia, sicca symptoms and Raynaud's. Immunology tests (positive anti-RO &anti-LA antibodies) and lymph node biopsy were highly suggestive of primary Sjögren's. She was commenced initially on HCQ and prednisolone. Then Methotrexate was added in because she continued to struggle with inflammatory arthritis.Her Sicca symptoms got gradually worse despite being on Acetylcysteine, Hylo Forte, cyclosporine and Dexamethasone eye drop. Therefore, autologous serum eye drops were tried with good response.Her past medical history included Hypertension and knee OA. She has been under Neurology since 2007 for MS. Her original neurological symptoms were imbalance, dizziness, headaches, and tremor of the right arm which seem to be persistent with no definite relapses. MRI brain and spine were reported as normal with a few non-specific white matter areas, but the lumbar puncture result was positive for unmatched bands in the CSF.Clinical examination revealed action tremor in the right upper limb. She had diminished vibration, pinprick, and cold temperature perception in a stocking distribution.InvestigationsWBC 2.0, lymphocyte 0.62, DsDNA 1, C3 0.061, C4 0.01. CRP <5, PV 1.63, APS screen was negative NCS: evidence of sensory and axonal neuropathy predominantly affecting lower limbs. CTCAP 2018-showed calcification of parotid. No evidence of lymphoproliferative disorder.The latest MRI 2019 showed two new lesions (right corpus &right striatum lesion) which according to Neuro-radiology MDT discussion were not typical of MS and more likely related to underlying CTD.Based on these MRI findings and the recent history of skin vasculitis, the deterioration in her neurological condition was put down to primary Sjögren's. Therefore, her treatment was escalated to cyclophosphamide during the COVID-19 pandemic with a particularly good outcome. She was then switched to MMF and her condition remained stable.Case report-DiscussionNeurological disorders are one of the rare manifestations of primary Sjögren's. The first reports regarding the involvement of the nervous system in PSS were published in 1980. Distinguishing between multiple sclerosis and CNS-SS is not easy.Not only because of similarities of the MRI findings, but also the course of the disease can be like MS, either chronic or relapsing and remitting. This usually leads to missing or delaying in the diagnosis as shown in this case.However, Peripheral neuropathy is far much common in PSS rather MS which can help in differentiating these two conditions. Distal axonal sensory polyneuropathy is the most usual form of neuropathy in PSS as illustrated in this case. Furthermore, up to 75% of patients with SS and active CNS disease have been shown to have concomitant active peripheral vasculitis affecting the skin, muscles, and nerves. Our patient later developed skin vasculitis and peripheral neuropathy which made us think that all the neurological findings including the lesions on the brain are more likely to be related to PSS rather MS.Cognitive disorders are common manifestations of CNS-SS such as attention disorder and memory deficit. Dementia-related to CNS-SS seems to be reversible after immunosuppressive treatment. A second MDT discussion took place and after considering the risk-benefit ratio, the decision was made to give cyclophospham de. Patient was given all the information to make an informed decision. Patient asked for more time to think and discuss with her partner, but eventually, she had decided to have cyclophosphamide despite all the risks and uncertainties around the COVID-19 pandemic. Our patient has noticed significant improvement regarding cognition after completing cyclophosphamide treatment and she was pleased with this outcome.Case report-Key learning points1/Distinguishing between multiple sclerosis and CNS-SS is difficult2/neurophysiological tests should be considered even in asymptomatic patients as they contribute to the detection of early and subtle damage to the nervous system. 3/Successful outcome being achieved with intensive immunosuppression despite all the uncertainties around the COVID-19-19 pandemic.4/This case highlights the importance of communication and openness in shared decisions, especially while confronting uncertainties such as in COVID-19 pandemic.