Primary hypertrophic osteoarthropathy presenting with ptosis and floppy eyelids: a review of ophthalmic manifestations, histopathology, and pathophysiology.

PURPOSE: To review ophthalmic manifestations, histopathological features, and pathophysiology of primary hypertrophic osteoarthropathy (PHOA).

METHODS

A comprehensive PubMed/Medline search was conducted to identify all articles reporting ophthalmic manifestations in PHOA. The authors highlight an additional case presenting with severe blepharoptosis, floppy and lax eyelids, and meibomian gland dysfunction (MGD).

RESULTS

Twenty-six cases of PHOA with ophthalmic manifestations were evaluated. All cases were in males with a higher prevalence in Indians (23%), Hispanics (19%), and those of African descent (19%). The most common ocular manifestation was blepharoptosis (96%), followed by papillary conjunctivitis (46%), floppy eyelids (38%), eyelid imbrication (35%), enlarged tarsal plates (27%), lid laxity (23%), eyelid ectropion (23%), and meibomian gland dysfunction (15%). Histologically, sebaceous gland hyperplasia was most commonly described (72%), followed by inflammatory infiltrates (50%), tarsal plate fibrosis or thickening (44%), mucin deposition (28%), and alterations in elastin fibers (11%). The clinical histological features of PHOA are due to pathogenic elevation of PGE2 due to mutations in the HPGD and SLCO2A1 genes leading to upregulation of matrix metalloproteinase (MMP) and vascular endothelial growth factor (VEGF). In this review, two patients carried a homogenous mutation in the SLCO2A1 gene. Management is surgical, but tetracyclines in the peri-operative period can reduce tissue inflammation.

CONCLUSIONS

Hormonal, inflammatory, and mechanical factors related to prostaglandin-E2 overexpression, and its influence on various cytokines are at the center of disease pathogenesis in PHOA, manifesting with hypertrophic, lax, floppy eyelids. Further studies targeting disease specific cytokines, VEGF and MMP are needed to explore additional medical therapies.