Eyelid excoriation and erythema with nepafenac eye drop.

Sir,

Periocular contact dermatitis has been known to occur after usage of topical ocular anti-inflammatory medications, mydriatics, antiglaucoma, and even antiallergic medications.[1] Among anti-inflammatory drugs, diclofenac sodium and ketorolac tromethamine have been reported to cause eyelid eczema in the past.[23] However, no such adverse reaction has been found in the literature following the use of nepafenac. Nepafenac is primarily used for macular edema postcataract surgery as well as due to other retinal diseases. We report the first case of contact dermatitis with use of topical nepafenac. A 55-year-old female presented to us with branch retinal vein occlusion with macular edema in her right eye. Optical coherence tomography showed cystoid macular edema in her right eye. She was advised to undergo intravitreal Anti-Vascular Endothelial Growth Factor injection in her right eye; however, she was unwilling for intravitreal injection and wanted only topical medication. After explaining the pros and cons of her decision, she was prescribed nepafenac 0.1% (Nevanac™; Alcon Labs, Fort Worth, TX, USA) eye drops three times a day for one month. The patient reported in the emergency department three days later with pain and redness over her right eye. She had developed the symptoms on the same day of starting the eye drop. She had excoriation and erythema in her right eyelid. The left eye was normal [Figure 1]. There was no history of insect bite or similar ailment in family members. She was suspected to have developed contact dermatitis due to nepafenac eye drops and was asked to discontinue the medicine. She was advised to use petroleum jelly over the right eyelid. A skin patch test was planned but the patient did not give consent for the same.

Figure 1

External photograph of both eyes showing eyelid excoriation and erythema after use of topical nepafenac in right eye and normal left eye

One week later, the patient reported with relief from the eyelid symptoms. Examination revealed resolution of eyelid erythema and healing of the excoriation [Figure 2].

Figure 2

External photograph of both eyes showing resolution of excoriation and erythema in right eye after one week of discontinuing topical nepafenac

Nepafenac 0.1% is a suspension of a nonsteroidal anti-inflammatory prodrug (NSAID). It is converted into its active ingredient amfenac by intraocular hydrolases.[4] Nepafenac has been known to cause sterile corneal ulceration and corneal melt.[56] In our patient the adverse effect was limited to the skin around the eye and may not be associated with active ingredient of nepafenac and might be caused by the inactive ingredients such as sodium hydroxide, which is known to cause skin burns.[7] However, it can also be a hypersensitivity reaction to nepafenac. Ideally a challenge–rechallenge test would confirm the causal association between eyelid excoriation and nepafenac, but that was not possible due to ethical and logistic reasons. Skin patch test would have conclusively proven the causal association of nepafenac with the eyelid excoriation; however, that could not be performed due to lack of consent from the patient. Corazza et al. have noted that conventional patch tests are poor predictors of contact allergy to ophthalmic products.[8] Therefore a negative patch test may not always rule out allergy to ophthalmic medicines.[89] Onset of eyelid symptoms immediately after starting nepafenac and prompt relief after its discontinuation incriminates nepafenac as the causative agent.

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Conflicts of interest

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