Ocular surface disease associated with dupilumab treatment for atopic diseases

Dupilumab is the first US FDA approved biologic for treatment of atopic dermatitis. It is a human monoclonal antibody which blocks the shared receptor component, the interleukin (IL)-4 alpha subunit, of IL-4 and IL-13 signaling pathways. Occurrence of "conjunctivitis", mostly in atopic dermatitis trials, has been the main side effect reported thus far. The etiology of "conjunctivitis" associated with dupilumab treatment is unclear and might be similar to atopic keratoconjunctivitis. There is evidence in the published literature that unlike the Th2-like profile in vernal keratoconjunctivitis, Th1-mediated inflammation is predominant in atopic keratoconjunctivitis. Blocking the Th2 pathway with dupilumab therapy might result in a shift towards Th1, causing the ocular findings associated with dupilumab. In addition, blockage of IL-13 might have implications with regards to mucin production and ocular surface health. This review highlights the clinical manifestations, reviews treatment options and offers explanations for pathogenesis of this ocular surface diseases associated with dupilumab treatment.