Impact of Oral Disulfiram on Aldehyde Dehydrogenase (ALDH) Mediated Ocular Fibrosis in Mucous Membrane Pemphigoid (OcMMP)

结膜瘢痕是由许多疾病引起的。其中包括沙眼，这是一种已知的感染，是全球可预防失明的最大原因。它导致全世界190万人双眼不可逆转的视力丧失。在英国，最常见的原因是一种罕见的自身免疫性疾病，称为眼粘膜类天疱疮（OcMMP），每年发生在百万人口中的0.8人中。OcMMP造成结膜的慢性炎症和瘢痕形成，结膜衬在眼睑内侧并覆盖眼睛的白色。眼睑内层的疤痕会导致睫毛向内转动并刮伤角膜（倒睫）。这和炎症，导致衰弱的症状不断刺激，疼痛和干燥。治疗包括免疫抑制，但这对疤痕几乎没有影响。对于一半的患者，瘢痕形成继续; 20%成为不可逆的blin.Our的研究结膜组织取自患者与OcMMP，同时接受诊断性结膜活检作为其常规临床护理的一部分，并在我们的眼类天疱疮样小鼠模型，已经表明，酶，醛脱氢酶（ALDH），控制结膜瘢痕形成在OcMMP人类组织和类天疱疮小鼠。双硫仑（DSF;一种用于治疗酒精滥用的口服片剂）永久性阻断ALDH的作用。我们发现DSF具有抗炎和抗瘢痕形成的特性，当以眼药水的形式给予类天疱疮样小鼠时（每天一次，持续一周），DSF逆转炎症和瘢痕形成。我们想了解双硫仑是否具有相同的作用机制，如果给予患有OcMMP的患者。由于没有获得许可的双硫仑滴眼液制剂，我们希望以英国许可的安全剂量口服片剂，给OcMMP患者两周，并检查其如何影响结膜中的瘢痕信号。我们将在开始治疗前、治疗一周后、治疗结束时和停止治疗后两周从患者身上采集拭子、泪液和血液样本。以前，我们已经从有和没有OcMMP的患者身上采集了结膜拭子，并表明我们可以使用一种称为nanostring的技术在遗传水平上检测结膜瘢痕形成机制的关键参与者。Nanostring允许我们从一个拭子中检测大量基因。我们已经鉴定了一组已知是瘢痕形成途径的一部分的基因，这些基因在OcMMP患者结膜中是异常的。重要的是，使用我们优化的灵敏测定法，我们已经能够定量泪液中的ALDH水平，并且已经表明，与没有这种疾病的患者相比，OcMMP患者的ALDH活性高出约10倍。这意味着我们可以测试给予OcMMP患者双硫仑片剂是否关闭结膜中的ALDH作用（使用泪液样本确定）以及这是否改变了瘢痕形成过程（使用结膜拭子评估）。由于炎症驱动瘢痕形成，我们知道双硫仑眼药水在类天疱疮小鼠中减少了结膜炎症，我们将分析眼睛表面和结膜表面炎症生物标志物的存在。（用眼泪）和血流（使用血液样本）来观察服用双硫仑片是否也能减少相关的炎症信号。通过这种方式，我们预期我们将产生足够的信息来支持我们的假设，即ALDH是人结膜瘢痕形成途径的关键。由于应避免无限期使用口服双硫仑，这一发现将鼓励开发一种新型双硫仑抗瘢痕眼药水，以在临床试验中进行治疗测试。我们的目标是改善患者与OcMMP的生活体验，并通过减少这种和其他结膜瘢痕疾病的视力丧失负担，在全球范围内改变患者护理。

Conjunctival scarring results from many diseases. These include trachoma, an infection that is known to be the largest cause of preventable blindness worldwide. It causes irreversible sight-loss in both eyes in 1.9 million worldwide. In the UK, the most common cause is a rare autoimmune driven disorder called Ocular Mucous Membrane Pemphigoid (OcMMP) that occurs in 0.8 people in a million population each year. OcMMP creates chronic inflammation and scarring of the conjunctiva which lines the inside of the eyelids and covers the white of the eye. Scarring of the inside lining of the eyelid can cause the lashes to turn inwards and scratch the cornea (trichiasis). This and inflammation, lead to debilitating symptoms of constant irritation, pain, and dryness. Treatments involve immunosuppression but this has little effect on scarring. For half of patients, scar formation continues; 20% become irreversibly blind.Our research on conjunctival tissue taken from patients with OcMMP whilst undergoing diagnostic conjunctival biopsies as part of their routine clinical care, and in our ocular pemphigoid-like mouse model, has shown that the enzyme, aldehyde dehydrogenase (ALDH), controls conjunctival scarring both in OcMMP human tissue and in the pemphigoid mouse. Disulfiram (DSF; a drug used as a tablet given by mouth for alcohol-abuse treatment) permanently blocks ALDH action. We have found that DSF has anti-inflammatory and anti-scarring properties and when given to the pemphigoid-like mouse in an eyedrop form (once daily for one week), DSF reverses inflammation and scarring.We would like to understand whether disulfiram has the same mechanism of action if given to patients with OcMMP. As there is no licensed disulfiram eyedrop formulation, we would like to give tablets by mouth at the UK licensed safe dose, to patients with OcMMP for two weeks and examine how it effects the scarring signals in the conjunctiva. We will do this by taking swabs, tear and blood samples from patients before starting treatment, one week into treatment, at the end of treatment and two weeks after coming off treatment. Previously, we have taken conjunctival swabs from patients with and without OcMMP and have shown that we can detect key players in the mechanisms of conjunctival scarring at a genetic level using a technique called nanostring. Nanostring allows us to detect a large number of genes from one swab. We have identified a cluster of genes known to be part of the scarring pathway that are abnormal in OcMMP patient conjunctiva. Importantly, using a sensitive assay optimised by us, we have been able to quantify ALDH levels in tears and have shown ALDH activity to be around 10 times higher in patients with OcMMP compared to those who do not have the disease. What this means is that we can test whether giving disulfiram tablets to patients with OcMMP switches off ALDH action in the conjunctiva (determined using tear samples) and whether this modifies the scarring process (assessed using conjunctival swabs). As inflammation drives scarring, and we know that the disulfiram eyedrop in the pemphigoid-like mouse reduced conjunctival inflammation, we will analyse the presence of inflammatory biomarkers both on the surface of the eye (using tears) and the bloodstream (using a blood sample) to see if taking disulfiram tablets can also reduce the associated inflammatory signals.In this way, we anticipate we will generate sufficient information to support our hypothesis that ALDH is pivotal to the human conjunctival scarring pathway. As indefinite use of oral disulfiram should be avoided, this finding will encourage development of a novel disulfiram anti-scarring eyedrop to test as a treatment in clinical trials. Our goal is to improve the patient experience of living with OcMMP, and to transform patient care on a global scale by reducing the burden of sight-loss for this and other conjunctival scarring disorders.