Amniotic membrane grafting for conjunctival and lid surface disease in the acute phase of toxic epidermal necrolysis

Sutureless Amniotic Membrane (ProKera®) and Intravenous Immunoglobulin in the Management of Ocular Complications of Stevens-Johnson Syndrome-Toxic Epidermal Necrolysis Overlap

PURPOSE

To report a case of Stevens-Johnson syndrome-toxic epidermal necrolysis (SJS-TEN) overlap, with severe acute ocular manifestations successfully managed with sutureless Amniotic Membrane device ProKera® (Bio-Tissue, Inc., Miami, FL) and topical steroids, followed by late complications that were successfully managed with intravenous immunoglobulin (IVIG) therapy.

OBSERVATIONS

A 24-year-old lady, known case of epilepsy, admitted to the burn unit with SJS-TEN overlap attributed to a recent change of her anti-convulsant therapy, with severe ocular manifestations, inability to open both eyes, and poor visual acuity. Early management included intensive topical steroids and lubrication, in addition to the application of a ProKera® device. Despite achieving full epithelialization within two weeks with the improvement of ocular manifestations, the patient presented three weeks later with recurrence of conjunctival epithelial defects, partial ankyloblepharon, and severely dry corneas. These late sequelae were managed with bandage contact lens (BCL) application, intensive topical steroid, and lubrication in addition to IVIG therapy. After six cycles of IVIG therapy, ocular manifestations improved significantly and the patient achieved uncorrected visual acuity of 6/9 in both eyes. Conclusion and importance: Existing evidence suggests that the use of IVIG in combination with systemic steroids in the early phase of SJS-TEN can reduce mortality, without affecting the final visual outcome in patients with ocular manifestations. This case highlights the possible role of IVIG therapy alone - without systemic steroids - in managing and preventing long-term ocular complications of SJS-TEN.

USA: Ophthalmologic Evaluation and Management of Acute Stevens-Johnson Syndrome

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) can cause significant damage to the ocular surface and eyelids. The sloughing and inflammation of the ocular mucosal epithelium during the acute phase may lead to scarring sequelae of the eyelids and ocular surface, resulting in pain and vision loss. Amniotic membrane transplantation (AMT) to the eyes and eyelids during the initial 1–2 weeks of the disease can decrease the chronic sequelae. The main development in the ophthalmologic treatment of SJS/TEN in the USA over the last 15 years has been the use of AMT on the ocular surface and eyelids during the acute phase. The evolution of AMT techniques, refinement of the evaluation of the eyes in acute SJS, and the efforts to increase the use of AMT in the USA are discussed.

Comparison of the acute ocular manifestations of Stevens-Johnson syndrome and toxic epidermal necrolysis in Chinese eyes: a 15-year retrospective study

BACKGROUND

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare but life-threatening conditions that initially affect the skin and mucous membranes. The aim of this study was to compare the acute ocular manifestations between SJS and TEN.

METHODS

The initial presenting ophthalmic records of patients with either SJS (<30% body surface area involvement) or TEN (> = 30% involvement), who were treated at one tertiary burn center in Hong Kong between 1999 and 2014, were retrospectively analyzed and compared.

RESULTS

A total of 20 SJS and 12 TEN cases were included. All were drug-induced. The patient demographics and treatment received were comparable. Overall, 40% of SJS and 75% of TEN patients had acute ocular surface inflammation. When comparing the two groups, there was a significant difference in the number of cases with mild involvement (5% in SJS, 42% in TEN, p = 0.01), while no statistically significant differences were found (p > 0.05) comparing between the moderate (15% in SJS, 0% in TEN) and severe groups (20% in SJS, 33% in TEN).

CONCLUSIONS

Ocular surface inflammation was common during the acute phase in both SJS and TEN. TEN had a significantly higher number of cases with mild ocular involvement when compared with SJS, but no significant difference between the number of moderate and severe cases between the two groups.

Amniotic Membrane Transplantation in Acute Toxic Epidermal Necrolysis: Histopathologic Changes and Ocular Surface Features after 1-Year follow-up

Purpose

To evaluate ocular features and histopathologic changes in patients with toxic epidermal necrolysis (TEN) treated with amniotic membrane transplantation (AMT) in the acute phase.

Methods

A prospective study of 5 eyes (3 patients) with severe ocular involvement and 4 eyes (2 patients) with moderate involvement treated with AMT in the acute phase of TEN was performed. Patients underwent a complete ophthalmic assessment before the intervention and 3, 6, 9, and 12 months postoperatively. Tear film break-up time (BUT), Schirmer test, fluorescein_staining, corneal and conjunctival epithelial squamous metaplasia, ocular sequelae, and conjunctival retraction were measured.

Results

In patients with severe involvement, 2 eyes (40%) showed mild symblepharon and peripheral corneal neovascularization, and corneal epithelial defects, lid margin malposition, and trichiasis was found in 20% of the eyes; only 1 eye (20%) required surgery for structural defects. We did not find ocular sequelae after 1-year follow-up in the patients with moderate involvement. Only 1 eye (25%) developed mild symblepharon that did not require specific treatment. Amniotic membrane transplantation significantly improved the squamous metaplasia in corneal and conjunctival nonsecretory epithelial cells, and significantly improved the goblet cells density after 1-year follow-up.

Conclusions

Amniotic membrane transplantation performed for acute TEN reduced inflammation and ocular surface scarring, improved dry eye and squamous metaplasia. and decreased ocular sequelae in the chronic stage. Although further and prospective studies are needed, AMT may be the optimal treatment for acute TEN with severe or moderate ocular involvement.

Update on amniotic membrane transplantation

Cryopreserved amniotic membrane modulates adult wound healing by promoting epithelialization while suppressing stromal inflammation, angiogenesis and scarring. Such clinical efficacies of amniotic membrane transplantation have been reported in several hundred publications for a wide spectrum of ophthalmic indications. The success of the aforementioned therapeutic actions prompts investigators to use amniotic membrane as a surrogate niche to achieve ex vivo expansion of ocular surface epithelial progenitor cells. Further investigation into the molecular mechanism whereby amniotic membrane exerts its actions will undoubtedly reveal additional applications in the burgeoning field of regenerative medicine. This article will focus on recent advances in amniotic membrane transplantation and expand to cover its clinical uses beyond the ocular surface.

Effect of age and early intervention with a systemic steroid, intravenous immunoglobulin or amniotic membrane transplantation on the ocular outcomes of patients with Stevens-Johnson syndrome

PURPOSE

This retrospective observational case series of fifty-one consecutive patients referred to the eye clinic with acute-stage Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN) from 1995 to 2011 examines the effect of early treatment with a systemic corticosteroid or intravenous immunoglobulin (IVIG) on the ocular outcomes in patients with SJS or TEN.

METHODS

All patients were classified by age (≤18 years vs. >18 years) and analyzed by treatment modality and early intervention with systemic corticosteroids (≤5 days), IVIG (≤6 days), or amniotic membrane graft transplantation (AMT) (≤15 days). The main outcomes were best-corrected visual acuity (BCVA) in logarithm of the minimum angle of resolution (logMAR) and ocular involvement scores (OIS, 0-12), which were calculated based on the presence of superficial punctate keratitis, epithelial defect, conjunctivalization, neovascularization, corneal opacity, keratinization, hyperemia, symblepharon, trichiasis, mucocutaneous junction involvement, meibomian gland involvement, and punctal damage.

RESULTS

The mean logMAR and OIS scores at the initial visit were not significantly different in the pediatric group (logMAR = 0.44, OIS = 2.76, n = 17) or the adult group (logMAR = 0.60, OIS = 2.21, n = 34). At the final follow-up, the logMAR and OIS had improved significantly in the adult group (p = 0.0002, p = 0.023, respectively), but not in the pediatric group. Early intervention with IVIG or corticosteroids significantly improved the mean BCVA and OIS in the adult group (p = 0.043 and p = 0.024, respectively for IVIG; p = 0.002 and p = 0.034, respectively for corticosteroid). AMT was found to be associated with a significantly improved BCVA or OIS in the late treatment group or the group with a better initial OIS (p = 0.043 and p = 0.043, respectively for BCVA; p = 0.042 and p = 0.041, respectively for OIS).

CONCLUSIONS

Our findings suggest that patients with SJS or TEN who are aged 18 years or less have poorer ocular outcomes than older patients and that early treatment with steroid or immunoglobulin therapy improves ocular outcomes.

Current ophthalmologic treatment strategies for acute and chronic Stevens-Johnson syndrome and toxic epidermal necrolysis

PURPOSE OF REVIEW

To review the newer, effective ophthalmologic treatments for acute Stevens-Johnson syndrome (SJS) as well as the emerging treatment options for patients with chronic, severe ocular surface damage from the disease.

RECENT FINDINGS

Amniotic membrane transplantation (AMT) applied to the eyes and eyelids in the acute phase of SJS can prevent the devastating scarring and visual problems that characterize the chronic phase of the disease. The severity of ocular inflammation in the acute phase does not always correlate to the severity of skin and systemic involvement. Thus, it is crucial that all patients with SJS be evaluated by an ophthalmologist familiar with the current management of the disease, the potential urgency of the situation and the option of AMT. Although challenging, the severe, chronic ocular problems of SJS can be at least partially alleviated with autologous serum drops, mucous membrane grafting to replace scarred tarsal conjunctiva, specialized contact lenses (PROSE), conjunctival replacement surgery (COMET), limbal stem cell transplantation and kerotoprostheses.

SUMMARY

Early AMT is an effective treatment of acute SJS. Emerging treatments offer increased hope for those who have already suffered damage from SJS, but emphasis on the prevention of damage in the acute phase is most crucial.

"Triple-TEN" in the treatment of acute ocular complications from toxic epidermal necrolysis

PURPOSE

Toxic epidermal necrolysis (TEN) is a devastating form of Stevens-Johnson syndrome (SJS) with acute and chronic ocular complications. We present a novel aggressive combination strategy, termed "Triple-TEN", for the management of acute ocular TEN designed to minimize the risk of chronic, blinding sequelae.

METHODS

Two patients with life-threatening TEN accompanied by severe ocular surface defects and fulminant symblephara formation underwent "Triple-TEN" management of their acute ocular disease under aseptic techniques in the critical care setting, after failed treatment with intensive topical therapy and surgical division of symblephara. The Triple-TEN protocol comprises (1) subconjunctival triamcinolone (Kenalog 20 mg) administered into each of the fornices to curb the local inflammatory response without compromising systemic immunity, (2) placement of amniotic membrane tissue mounted on a polycarbonate skirt (ProKera) over the corneal and limbal regions to facilitate reepithelialization of the ocular surface, and (3) insertion of a steeply curved acrylic scleral shell spacer (Technovent, SC21) to vault the lids away from the globe providing a barrier to symblephara formation.

RESULTS

In both cases, ocular surface inflammation resolved within 4 weeks with no progression of conjunctival cicatrization or evidence of limbal epithelial stem cell failure at 1 year follow-up. There were no long-term complications of the Triple-TEN regimen.

CONCLUSIONS

Aggressive treatment with the Triple-TEN protocol for acute ocular TEN resistant to first-line therapy, may help prevent long-term blinding sequelae.

Prompt versus delayed amniotic membrane application in a patient with acute Stevens-Johnson syndrome

Background

Stevens-Johnson syndrome is often associated with blinding ocular surface cicatricial sequelae. Recent reports have described markedly improved clinical outcomes with the application of amniotic membrane to the ocular surface during the acute phase. Here we describe the clinical outcome of a patient with acute Stevens-Johnson syndrome and severe ocular surface involvement in whom the evolving medical condition and family consent resulted in amniotic membrane application to each eye at differing intervals from disease onset.

Methods

We undertook a retrospective chart review of a woman with Stevens-Johnson syndrome who presented within hours of disease onset. She underwent application of amniotic membrane to the ocular surface of the left eye during the hyperacute phase (<72 hours after disease onset) and to the right eye at a later time point during the acute phase (six days after disease onset). The clinical outcomes of the two eyes, as well as associated ocular symptoms, were compared over a one-year postoperative period.

Results

The right eye, treated later in the course of the disease, required additional surgical procedures and ultimately exhibited significantly more advanced ocular surface pathology than the left. Further, the patient reported more pronounced issues of chronic eye pain and visual difficulties in the right eye.

Conclusion

Earlier intervention with application of amniotic membrane to the ocular surface in this patient with severe ocular involvement secondary to Stevens-Johnson syndrome proved superior. Application of amniotic membrane as soon as possible after disease onset, preferably in the hyperacute phase, appears to result in a significantly better clinical outcome than application later in the disease course.

Toxic epidermal necrolysis in a 15-month-old girl successfully treated with amniotic membrane transplantation

A 15-month-old girl presented with rash, fever, and vesicles around the mouth that worsened after erythromycin was administered. Subsequently, she was diagnosed with toxic epidermal necrolysis. Ocular involvement was treated with repeated complete corneal, conjunctival, and lid margin coverage with amniotic membrane. She recovered with minimal ocular sequelae despite persistent systemic symptoms.

Treatment of acute Stevens-Johnson syndrome and toxic epidermal necrolysis using amniotic membrane: a review of 10 consecutive cases

PURPOSE

To describe the clinical course, treatments, and outcomes of 10 consecutive patients treated with amniotic membrane transplantation (AMT) applied to the eyelid margins, palpebral conjunctiva, and ocular surface during the acute phase of Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN).

DESIGN

Prospective case series of 10 consecutive patients treated by 1 surgeon.

PARTICIPANTS

Ten consecutive patients with severe ocular surface and eyelid inflammation treated with AMT during the acute phase of SJS or TEN.

INTERVENTION

Cryopreserved amniotic membrane was applied to the eyelids and ocular surface of each patient during the first 10 days of illness. Repeat AMT was performed every 10-14 days as long as severe ocular surface inflammation and epithelial sloughing persisted.

MAIN OUTCOME MEASURES

Visual acuity, dry eye severity, and scarring of the ocular surface and eyelids were assessed after a follow-up of ≥6 months.

RESULTS

All patients had best-corrected visual acuity of ≥20/30, with 9 of the 10 seeing 20/20. Dry eye severity was moderate or less in all patients. Overall ocular surface and eyelid scarring was mild to moderate in all patients.

CONCLUSIONS

In acute SJS and TEN, AMT is an effective treatment for severe ocular surface and eyelid inflammation, greatly decreasing the risk of significant ocular and visual sequelae.

Efficacy and limitation of sutureless amniotic membrane transplantation for acute toxic epidermal necrolysis

PURPOSE

The purpose of this case report is to describe the efficacy and limitation of ProKera, a sutureless medical device containing amniotic membrane, for treating acute ocular manifestations of toxic epidermal necrolysis (TEN).

METHODS

ProKera was inserted in both eyes at day 10 after onset of ocular symptoms in a 5-year-old boy suffering from acute TEN, manifesting conjunctival inflammation, large conjunctival defects, pseudomembrane formation, and total corneal epithelial defects.

RESULTS

At 9-month follow-up, insertion of ProKera resulted in complete reepithelialization, clear corneas, and vision of 20/20 in both eyes. However, because ProKera only covered the cornea and perilimbal conjunctiva, these 2 eyes still showed some conjunctival inflammation several months after discharge from the hospital. Eventually, 1 eye showed mild lid margin keratinization and cicatricial entropion, and both eyes showed trichiasis.

CONCLUSIONS

These data suggest that ProKera, when inserted during the acute stage of TEN, may be effective in healing corneal epithelial defects and preventing corneal sequelae. Because of the limited area covered, ProKera may not prevent cicatricial complications in the fornix, tarsus, and eyelid margin as effectively as sutured amniotic membrane transplantation.

New insights in toxic epidermal necrolysis (Lyell's syndrome): clinical considerations, pathobiology and targeted treatments revisited

Drug-induced toxic epidermal necrolysis (TEN), also known as Lyell's syndrome, is a life-threatening drug reaction characterized by extensive destruction of the epidermis and mucosal epithelia. The eyes are typically involved in TEN. At present, the disease has a high mortality rate. Conceptually, TEN and the Stevens-Johnson syndrome are closely related, although their severity and outcome are different. Distinguishing TEN from severe forms of erythema multiforme relies on consideration of aetiological, clinical and histological characteristics. The current understanding of the pathomechanism of TEN suggests that keratinocytes are key initiator cells. It is probable that the combined deleterious effects on keratinocytes of both the cytokine tumour necrosis factor (TNF)-alpha and oxidative stress induce a combination of apoptotic and necrotic events. As yet, there is no evidence indicating the superiority of monotherapy with corticosteroids, ciclosporin (cyclosporine) or intravenous immunoglobulins over supportive care only for patients with TEN. However, the current theory of TEN pathogenesis supports the administration of a combination of antiapoptotic/antinecrotic drugs (e.g. anti-TNF-alpha antibodies plus N-acetylcysteine) targeting different levels of the keratinocyte failure machinery.

Management of acute Stevens-Johnson syndrome and toxic epidermal necrolysis utilizing amniotic membrane and topical corticosteroids

PURPOSE

To describe the results of a novel treatment approach to the acute ophthalmic management of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN).

DESIGN

Retrospective interventional case series.

METHODS

setting: Institutional. study population: Sixteen eyes of 8 patients with acute, biopsy-proven SJS or TEN and significant ophthalmic involvement. interventional procedure(s): Application of amniotic membrane to the ocular surface, either in the operating room or at the bedside, and short-term use of intensive topical corticosteroid medication. main outcome measures: Visual acuity, slit-lamp appearance of the ocular surface, and patients' subjective impression of ocular comfort.

RESULTS

Two patients expired during the hospitalization. Mean follow-up time for the surviving patients was 7.7 months. Four surviving patients in whom the entire ocular surface (ie, the cornea, bulbar and palpebral conjunctiva, and eyelid margins) was treated with amniotic membrane retained visual acuities of 20/40 or better and an intact ocular surface. In contrast, the initial 2 patients in the study who were treated with only a Prokera device or unsutured amniotic membrane sheets, leaving the palpebral conjunctiva and eyelid margins uncovered, developed more significant ocular surface abnormalities, and 1 developed a corneal perforation.

CONCLUSIONS

Amniotic membrane coverage of the ocular surface in its entirety coupled with the use of intensive short-term topical corticosteroids during the acute phase of SJS and TEN is associated with the preservation of good visual acuity and an intact ocular surface. Partial amniotic membrane coverage of the ocular surface may not serve to minimize the cicatrizing ocular sequelae of SJS and TEN as effectively as complete coverage.

Amniotic membrane transplantation as a new therapy for the acute ocular manifestations of Stevens-Johnson syndrome and toxic epidermal necrolysis

Stevens-Johnson syndrome and its more severe variant, toxic epidermal necrolysis, have relatively low overall incidence; however, this disease presents with high morbidity and mortality. The majority of patients develop ocular inflammation and ulceration at the acute stage. Due to the hidden nature of these ocular lesions and the concentration of effort toward life-threatening issues, current acute management has not devised a strategy to preclude blinding cicatricial complications. This review summarizes recent literature data, showing how sight-threatening corneal complications can progressively develop from cicatricial pathologies of lid margin, tarsus, and fornix at the chronic stage. It illustrates how such pathologies can be prevented with the early intervention of cryopreserved amniotic membrane transplantation to suppress inflammation and promote epithelial healing at the acute stage. Significant dry eye problems and photophobia can also be avoided with this intervention. This new therapeutic strategy can avert the catastrophic ophthalmic sequelae of this rare but devastating disease.

Limbal stem cell transplantation: new progresses and challenges

Patients with limbal stem cell deficiency (LSCD) suffer from photophobia and a severe loss of vision uncorrectable by conventional PKP. This literature review shows that new strategies can be formulated for treating LSCD. Early cryopreserved amniotic membrane transplantation (AMT) as a temporary biological bandage with sutures or with sutureless ProKera in the acute stage of chemical burn and Stevens-Johnson syndrome prevents the occurrence of LSCD by preserving and expanding the remaining limbal epithelial stem cells. Similarly, remaining limbal stem cells can also be expanded in corneal surfaces with partial or nearly total LSCD if corneal pannus is removed and AMT is performed as a graft with or without sutures by the use of fibrin glue. Moreover, AMT as a temporary bandage and a graft using fibrin glue can also facilitate corneal surface reconstruction by reducing the size of a conjunctival limbal autograft (CLAU) to one 60 degrees graft for unilateral total LSCD as well as promote the success of a keratolimbal allograft (KLAL) for bilateral total LSCD. The latter success is further dictated by effective systemic immunosuppression and by measures to restore the ocular surface defenses, suppress conjunctival inflammation, and correct cicatricial complications so that a stable tear film can be maintained before surgery. This review also summarizes recent findings and outlines future challenges that we need to overcome in squamous metaplasia, that is, another major type of ocular surface failure.

Limbal stem cell transplantation: new progresses and challenges

Patients with limbal stem cell deficiency (LSCD) suffer from photophobia and a severe loss of vision uncorrectable by conventional PKP. This literature review shows that new strategies can be formulated for treating LSCD. Early cryopreserved amniotic membrane transplantation (AMT) as a temporary biological bandage with sutures or with sutureless ProKera in the acute stage of chemical burn and Stevens-Johnson syndrome prevents the occurrence of LSCD by preserving and expanding the remaining limbal epithelial stem cells. Similarly, remaining limbal stem cells can also be expanded in corneal surfaces with partial or nearly total LSCD if corneal pannus is removed and AMT is performed as a graft with or without sutures by the use of fibrin glue. Moreover, AMT as a temporary bandage and a graft using fibrin glue can also facilitate corneal surface reconstruction by reducing the size of a conjunctival limbal autograft (CLAU) to one 60 degrees graft for unilateral total LSCD as well as promote the success of a keratolimbal allograft (KLAL) for bilateral total LSCD. The latter success is further dictated by effective systemic immunosuppression and by measures to restore the ocular surface defenses, suppress conjunctival inflammation, and correct cicatricial complications so that a stable tear film can be maintained before surgery. This review also summarizes recent findings and outlines future challenges that we need to overcome in squamous metaplasia, that is, another major type of ocular surface failure.

Temporary sutureless amniotic membrane patch for acute alkaline burns

OBJECTIVE

To evaluate the clinical outcome of a new sutureless approach for a temporary amniotic membrane patch (ProKera; Bio-Tissue, Inc, Miami, Florida) in eyes with acute burns.

METHODS

Retrospective review of 5 eyes of 5 patients with grades I to III acute alkaline burns, receiving ProKera insertion within 8 days of injury.

RESULTS

These eyes had either total (2 cases) or extensive (60%-75%, 3 cases) corneal epithelial defects with limbal (120 degrees -360 degrees ) and conjunctival (30%-60%) epithelial defects. ProKera was inserted within a mean (SD) of 3.7 (3.1) days after burn and repeated 1 to 3 times for 3 cases. Conjunctival defects reepithelialized in 8.2 (5) days (range, 5-17 days), while limbal and corneal defects healed in 13.6 (8.3) days (range, 5-25 days). The latter was completed with circumferential closure of limbal defects followed by centripetal healing of corneal defects. In 3 eyes, early peripheral corneal neovascularization was followed by marked regression on completion of healing. During 16.8 (10.8) months of follow-up, all eyes retained a stable surface with improved corneal clarity, and without limbal deficiency or symblepharon.

CONCLUSION

This sutureless application of an amniotic membrane patch allows for early delivery of its biologic actions, which may help preserve remaining limbal stem cells for rapid expansion and prevent late cicatricial complications in eyes with mild and moderate acute alkaline burns.

Minimal conjunctival limbal autograft for total limbal stem cell deficiency

PURPOSE

To report the results of one 60 degrees conjunctival limbal autograft (CLAU) combined with amniotic membrane (AM) transplantation for an eye with total limbal stem cell deficiency (LSCD).

METHODS

One eye of a patient with chronic total LSCD and symblepharon caused by chemical burn was subjected to symblepharon lysis, removal of pannus from corneal surface, AM transplantation to cover the conjunctival and corneal surfaces as a permanent graft, one 60 degrees CLAU to the superior limbal area, and insertion of ProKera as a temporary AM patch to cover the CLAU.

RESULTS

After surgery, corneal epithelialization over the AM was evident adjacent to the CLAU on day 6, progressed to pass the horizontal midline by day 11, and was completed by day 18. During a follow-up of 1 year, the corneal surface remained stable and smooth, and the stroma considerably regained clarity with regression of midstromal vascularization. The best-corrected visual acuity improved from 20/400 to 20/50. The conjunctival inflammation completely resolved, and the fornices were deep.

CONCLUSIONS

One 60 degrees CLAU combined with AM transplantation as both a permanent graft and a temporary patch can restore the entire corneal surface in an eye with total LSCD caused by chemical burn.

The ophthalmologic management of acute Stevens-Johnson syndrome

Stevens-Johnson syndrome (SJS) and its more severe variant, toxic epidermal necrolysis (TEN), cause significant ocular surface damage. The majority of affected patients develop conjunctival inflammation during the acute phase of the disease. If intense, this inflammation yields permanent destruction of the normal mucosal tissue of the ocular surface and eyelids. Loss of the normal glandular structures leads to severe dry eye problems and vision loss. Medical treatments do little to arrest these problems, and repairing the damage after the acute phase is difficult, if not impossible. Recently, the application of cryopreserved amniotic membrane to the ocular surface during the acute phase of the disease has shown great promise in limiting the destructive inflammation and its long-term sequelae. A rationale for this treatment and a detailed description of the application procedure are provided, along with practical guidelines for the managing surgeon.