What is the management of conjunctival lichen planus?

Management of Conjunctival Lichen Planus

Conjunctival lichen planus requires systemic immunosuppression as the cornerstone of treatment, with topical cyclosporine 2% eye drops serving as the most effective topical adjunct to control inflammation and prevent cicatrization. 1, 2

Initial Assessment and Diagnosis

• Urgent ophthalmology consultation is mandatory for any suspected conjunctival lichen planus, with daily ophthalmologic review during active disease 3
• Conjunctival biopsy should demonstrate irregular, thickened basement membrane with reduplications and heavy linear fibrinogen deposits along the basement membrane without IgG, IgA, IgM, or C3 deposition to confirm the diagnosis 1, 4
• Rule out ocular mucous membrane pemphigoid (OMMP) through immunofluorescence studies, as management differs significantly 3, 1
• Screen for systemic lichen planus involvement including oral mucosa, skin, and genitalia, though isolated conjunctival disease can occur 4

Treatment Algorithm

First-Line Systemic Therapy

Systemic immunosuppression is required to inhibit inflammation and prevent progression of conjunctival scarring, as topical therapy alone is insufficient. 3, 5

• Oral prednisone 1 mg/kg daily should be initiated for active disease with peripheral ulcerative keratitis or severe inflammation 5, 2
• For moderate disease without corneal involvement, consider starting with oral methotrexate combined with low-dose oral steroids 4
• Taper oral corticosteroids slowly over months to prevent relapse of ocular surface inflammation 5

Essential Topical Therapy

• Topical cyclosporine 2% eye drops are the most effective topical agent and should be started immediately to control inflammation and stop cicatrization 1, 2
• Topical cyclosporine can successfully maintain long-term disease control after systemic therapy is tapered, with sustained remission documented for 12 months 1, 5
• Topical corticosteroid drops (dexamethasone 0.1% preservative-free) should be added during acute phases, applied four times daily 3, 5
• Taper and discontinue topical steroids after 3-5 months once inflammation is controlled, but continue topical cyclosporine indefinitely 5

Adjunctive Ocular Care

• Apply preservative-free lubricants (hyaluronate or carmellose) every 2 hours to address associated dry eye 3, 2
• Daily ocular hygiene with gentle saline irrigation to remove mucous and debris, performed by an ophthalmologist or trained nurse 3
• Daily removal of pseudomembranes and breakdown of conjunctival adhesions using forceps and squint hook to prevent symblepharon formation 3, 4
• Broad-spectrum topical antibiotic prophylaxis (moxifloxacin or levofloxacin four times daily) if corneal epithelial defects are present 3

Refractory Disease Management

For cases unresponsive to initial therapy:

• Add oral cyclosporine to the systemic regimen in combination with methotrexate and low-dose steroids 4
• Consider amniotic membrane transplantation as an adjunctive procedure for refractory keratoconjunctivitis with persistent epithelial defects 2
• Mycophenolate mofetil, azathioprine, or other systemic immunosuppressants may be considered, similar to OMMP management 3, 6

Critical Pitfalls to Avoid

• Never rely on topical therapy alone—systemic immunosuppression is mandatory to prevent progressive cicatrization and vision loss 3, 5
• Topical corticosteroids can mask signs of corneal infection; maintain high suspicion and culture any suspected infectious keratitis 3, 5
• Avoid abrupt discontinuation of systemic steroids, as this leads to rebound inflammation and disease progression 5
• Do not perform ocular surgery (including cataract extraction) during active disease, as this can worsen inflammation; perioperative immunosuppression is required if surgery is necessary 3
• Blind sweeping of fornices with cotton buds is contraindicated and may cause additional damage 3

Monitoring Protocol

• Daily ophthalmologic examination during acute phase, including fluorescein staining to assess corneal and conjunctival epithelial integrity 3
• Document extent of conjunctival scarring photographically at each visit to accurately gauge disease progression 3
• Monitor for complications including symblepharon formation, corneal ulceration, keratouveitis, and infectious keratitis 4, 2
• Long-term follow-up is essential as disease may require years of topical cyclosporine to maintain remission 1, 5
• Coordinate care with a physician experienced in systemic immunosuppressive therapy to manage and minimize side effects 3