Mucous Membrane Grafting For Lid Margin Keratinization in Stevens–Johnson Syndrome: Results

Visual outcome and postoperative complications of cataract surgery in patients with ocular surface disorders

PURPOSE

To determine the visual outcome and postoperative complications of cataract surgery in patients with ocular surface disorders (OSDs).

SETTING

Tertiary eyecare center in North India.

DESIGN

Retrospective observational study.

METHODS

Patients with various OSDs with stabilized ocular surfaces who underwent cataract surgery during this period and had a minimum postoperative follow-up of 6 weeks were included. The primary outcome measures were postoperative corrected distance visual acuity (CDVA) at 6 weeks, best CDVA achieved, and postoperative complications.

RESULTS

The study included 20 men and 24 women. A total of 55 eyes were evaluated: Stevens-Johnson syndrome (SJS) 35 eyes, ocular cicatricial pemphigoid (OCP) 4 eyes, 8 eyes with dry eye disease (DED), 6 eyes with chemical injury and 2 eyes with vernal keratoconjunctivitis (VKC). The mean duration of OSD was 33.9 ± 52.17 months. The median preoperative CDVA was 2.0 (interquartile range [IQR], 1.45 to 2.0). The median CDVA ever achieved was 0.50 (IQR, 0.18 to 1.45) at 2 months and the median CDVA at 6 weeks was 0.6 (IQR, 0.3 to 1.5). Maximum improvement in CDVA was noted in patients with DED and SJS and the least in OCP. Phacoemulsification was performed in 47.27% eyes with intraoperative complications noted in 9% eyes. Postoperative surface complications occurred in 12 (21.82%) eyes. Other postoperative complications occurred in 9 (16%) eyes.

CONCLUSIONS

Cataract surgery outcome can be visually rewarding in patients with OSDs provided ocular surface integrity is adequately maintained preoperatively and postoperatively.

Ocular Manifestations and Outcomes in Children With Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Comparison With Adult Patients

PURPOSE

To compare the clinical features and visual outcomes in children and adults with Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN).

DESIGN

Retrospective comparative case series.

METHODS

This retrospective study included 280 eyes of 140 patients (35 children and 105 adults) with SJS/TEN treated between 2010 and 2020. The primary outcome measures were the final best-corrected visual acuity (BCVA) and severity of dry eye. The secondary outcome measure was the medical and surgical therapies used.

RESULTS

Among 64 eyes of children recruited in the study, acute ocular involvement was found in 58 eyes (90.6%). The chronic score in pediatric patients was significantly higher than that in adult patients (P = .004). The use of antibiotics/nonsteroidal anti-inflammatory drugs (NSAIDs) and Mycoplasma infection were the more common etiologies in children. In all, 75% of eyes in children maintained a visual acuity of 20/40 or better at a mean follow-up time of 4.3 years. The severity of dryness was comparable between the child and adult groups. The proportion of eyes undergoing amniotic membrane and oral mucosa transplantation was significantly higher in children than in adults in the chronic stage, reflecting that children exhibit much more severe complications.

CONCLUSIONS

Although pediatric SJS/TEN patients have more severe ocular complications than adults, most children maintain long-term good vision. Early intervention and aggressive treatment help to preserve vision.

Long-Term Benefits of Tear Exchangeable Limbal-Rigid Contact Lens Wear Therapy in Stevens-Johnson Syndrome Cases

OBJECTIVES

To evaluate the long-term benefits of tear-exchangeable, limbal-rigid contact lens (CL) wear therapy in patients with Stevens-Johnson syndrome (SJS)-associated ocular sequelae.

METHODS

This retrospective study evaluated 50 eyes of 41 SJS patients (15 men and 26 women) who underwent limbal-rigid CL wear therapy for more than 2 years post fitting. Ocular sequelae (i.e., conjunctival hyperemia, corneal neovascularization, and upper tarsus scarring) before fitting and at 3 months, 6 months, 12 months, and annually after initiating CL wear therapy were evaluated and then graded on a severity score (range: 0-3, maximum score: 3). Moreover, visual acuity (VA) at immediately post initiating CL wear therapy was evaluated.

RESULTS

The mean follow-up period was 4.3±1.1 years. Compared with before fitting, the mean conjunctival hyperemia score improved from 1.14 to 0.86 at 3 months of CL wear therapy ( P <0.01) and was maintained thereafter; the mean corneal neovascularization score improved from 2.10 to 1.98 at 3 months of CL wear therapy, with no deterioration of the score observed in all cases at the final follow-up examination, and mean VA (log of minimum angle of resolution) improved from 1.60 to 1.04 at immediately post initiating CL wear therapy ( P <0.01).

CONCLUSIONS

Limbal-rigid CL wear therapy can provide long-term ocular surface stabilization and improved VA in SJS patients.

Single-Staged Surgical Correction of Eyelid Sequelae Along With Lid Margin Mucous Membrane Grafting in Stevens-Johnson Syndrome and Other Cicatricial Ocular Surface Diseases

PURPOSE

The purpose of this study was to study the outcome of single-staged entropion surgery along with lid margin mucous membrane grafting for cicatrizing ocular surface disease.

METHODS

Retrospective review of medical records of patients who underwent single-staged surgical correction of cicatricial entropion along with lid margin mucous membrane grafting for lid margin keratinization.

RESULTS

Twenty-six eyes of 19 patients were studied. The mean age of patients was 42.5 years (standard deviation, SD-17.67), of which 7 patients were male and 12 were female. The most common disorder was Stevens-Johnson syndrome (SJS) sequelae (83.33%, n = 20), followed by mucous membrane pemphigoid (n = 4, 16.67%). The most common eyelid changes observed were cicatricial entropion in all 26 eyes (100%, n = 26), followed by trichiasis in 13 eyes (50%, n = 13). Lid margin keratinization was noted in all eyes. Postoperative improvement in corneal surface staining was noted in 70% of the patients (n = 13), no change in 20% of the patients (n = 4), and worsening of corneal surface staining in 10% of the patients (n = 2). Postoperative visual acuity improvement was noted in 50% of the eyes (n = 13), no improvement in 39% of the eyes (n = 10), and vision worsened in 12% of the eyes (n = 3). An entropion recurrence rate of 25% (n = 6) was observed over an average 10-month follow-up, whereas 75% (n = 20) reported no recurrence.

CONCLUSIONS

Single-staged correction of eyelid cicatricial entropion with a lid margin mucous membrane graft (MMG) has promising outcomes in ocular surface diseases. It can decrease the need for multiple surgeries and provide symptomatic relief in patients with chronic cicatricial surface changes.

Perioperative nuances of cataract surgery in ocular surface disorders

Ocular surface disorders (OSDs) constitute a varied spectrum of conditions that could be associated with dryness, compromised limbal status, varying grades of forniceal obliteration, corneal scars, and a possible underlying immune etiology. These associations adversely impact surgical outcomes in the eye. One of the treatable causes of decreased vision in these eyes is cataracts which could be secondary to the disease, its treatment, or age-related. The compromised ocular surface status can interfere with decision-making regarding the technique of cataract surgery, preoperative biometry for intraocular lens (IOL) power calculation, and intraoperative visibility, increasing the possibility of complications and compromising the final visual outcome. The postoperative course can be affected by complications, including melt and infection. Stabilization of the ocular surface by medical or surgical means, and appropriate management of underlying immune etiology, if any, helps improve and maintain a healthy ocular surface, optimizing cataract outcomes. With the help of pre, intra, and postoperative tools and means, such as punctal occlusion, ocular surface reconstruction, systemic immunosuppression, illuminators, capsule staining dyes, optical iridectomy, prosthetic replacement of the ocular surface ecosystem (PROSE) lenses, and others, the visual outcome post-cataract surgery in these eyes can be maximized. This article highlights the nuances of performing cataract surgery in various OSDs and the need to have a comprehensive stepwise approach is emphasized.

Clinical Aspects of Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis With Severe Ocular Complications in India

Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a spectrum of rare, severe immunological blistering skin reactions which are triggered by medication intake or infections. The acute phase is characterized by necrolysis of the skin and desquamation of mucosa, primarily oral and ocular, with significant mortality rates. The chronic phase is characterized by multi-organ sequelae with increased rates of morbidity and reduced quality of life for patients who have survived the acute phase. Since the primary goal in the acute phase is saving the life of the patient, ocular involvement is often missed and a significant proportion of patients present to an ophthalmologist with the chronic ocular sequelae. In India, chronic ocular sequelae and low vision are observed in two-thirds of patients who present in the chronic phase of SJS/TEN. In the chronic phase of ocular involvement, there are definite windows of opportunity which if targeted with specific interventions such as scleral lenses and mucous membrane grafts can help reduce the incidence of corneal blindness and improve the quality of life for patients with SJS/TEN. Over the last decade, several studies from India have advanced the understanding of the natural course of ocular involvement in SJS/TEN and the outcomes of timely interventions in the chronic phase of the disease. We present an overview of the epidemiology of ocular complications of SJS/TEN in India, the specific challenges faced in the management of ocular complications in the acute stage and recent advances in management of the chronic ocular complications of the disease.

Acute and Chronic Management of Ocular Disease in Stevens Johnson Syndrome/Toxic Epidermal Necrolysis in the USA

Stevens Johnson syndrome and toxic epidermal necrolysis are on a spectrum of a severe, immune-mediated, mucocutaneous disease. Ocular involvement occurs in the vast majority of cases and severe involvement can lead to corneal blindness. Treatment in the acute phase is imperative in mitigating the severity of chronic disease. Advances in acute treatment such as amniotic membrane transplantation have shown to significantly reduce the severity of chronic disease. However, AMT is not a panacea and severe chronic ocular disease can and does still occur even with aggressive acute treatment. Management of chronic disease is equally critical as timely intervention can prevent worsening of disease and preserve vision. This mini-review describes the acute and chronic findings in SJS/TEN and discusses medical and surgical management strategies.

Mucous membrane grafting (fibrin glue vs. suture) for lid margin pathologies in Stevens-Johnson syndrome: randomized comparative study

OBJECTIVE

To compare fibrin glue (with three cardinal sutures) (FG) and polygalactin suture (PS) for mucous membrane grafting (MMG) in terms of graft apposition and recurrence of lid margin keratinization (LMK) and metaplastic lashes (ML) in patients with Stevens-Johnson syndrome (SJS).

DESIGN

Prospective randomized comparative interventional study.

METHODS

Twenty patients diagnosed with SJS and lid margin abnormalities including LMK with or without ML were randomized to undergo either fibrin glue (FG)-assisted MMG (n = 10) or continuous 8-0 polygalactin suture (PS)-assisted MMG (n = 10). They were evaluated preoperatively and during follow-up at 1 week and 1, 2, 3, and 6 months. The parameters assessed were best-corrected visual acuity (BCVA), tear break-up time (TBUT), Schirmer-1 test, corneal and conjunctival complications, graft apposition and width (GW), LMK, ML, impression cytology, and operative time. The primary outcome measures are incidence of graft displacement and recurrence of LMK and ML.

RESULTS

None of the eyelids in FG group (0/40) and 1 eyelid in PS group (1/40) had graft displacement. Recurrence of LMK occurred in 7.5% of eyelids (3/40) in both the study groups. Recurrence of ML occurred in 2.5% (1/40) in FG group and 5% (2/40) in PS group. The mean operative time for MMG in FG group was 39.5 ± 2.40 min and in PS group was 56 ± 1.63 min (p = 0.001).

CONCLUSIONS

As graft apposition with suture involves significantly longer intraoperative time, if cost is not a limiting factor then fibrin glue is a viable option for the MMG for lid margin pathologies.

Clinical Aspects of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis With Severe Ocular Complications in Brazil

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are acute and potentially fatal inflammatory vesiculobullous reactions that affect the skin and mucous membranes, and which are most often triggered by particular medications and infections. In Brazil, the drugs most frequently associated with TEN and SJS include cold medicine such as dipyrone and NSAIDs, followed by carbamazepine, phenobarbital, penicillin, and allopurinol. Genetic variations have been found to increase the risk of SJS/TEN in response to triggering factors such as medications. The most closely associated genes found in Brazilian cold-medicine-related SJS/TEN patients with severe ocular complications are HLA-A^*66:01 in those of mixed African and European ancestry and HLA-B^*44:03 and HLA-C^*12:03 in those of solely European ancestry. Our classification system for grading ocular surface complication severity in SJS/TEN patients revealed the most severe complications to be limbal stem cell deficiency and dry eye. Changes to the conjunctival flora have also been observed in SJS/TEN patients. Our group identified bacterial colonization in 95% of the eyes (55.5% of which were gram-positive cocci, 25.5% of which were gram-negative bacilli, and 19% of which were gram-positive bacilli). Several new treatment options in the acute and chronic ocular management of the SJS/TEN patients have been described. This article highlights some Brazilian institutions' contributions to ocular surface care in both the acute phase (including the use of amniotic membrane transplantation) and the chronic phase (such as eyelid margin and fornix reconstruction, minor salivary gland transplantation, amniotic membrane and limbal transplantation, scleral contact lenses, anti-angiogenic eyedrops for corneal neovascularization, ex-vivo cultivated limbal epithelium transplantation, conjunctival-limbal autografting, oral mucosa transplantation, and keratoprosthesis).

Lid margin keratinization in Stevens-Johnson syndrome: Review of pathophysiology and histopathology

Lid margin keratinization (LMK) is a chronic ocular sequela of Stevens-Johnson syndrome (SJS), which causes lid wiper epitheliopathy and progressive ocular surface damage. The exact etiopathogenesis of LMK, however, remains elusive. This review summarizes the potential pathophysiological mechanisms of LMK and describes its histopathological features. A literature search of articles discussing the pathophysiology of LMK in SJS was performed. The possible pathophysiologic mechanisms contributing to LMK, as identified on the literature review, included loss of the muco-cutaneous junction barrier leading to epidermalization, dyskeratosis involving the meibomian gland orifices, altered lid margin microbiome, and de novo squamous metaplasia of the marginal conjunctival epithelium. Based on these mechanisms, the possible sources of keratinized epithelium at the posterior lid margin in SJS could be the adjacent anterior eyelid skin, hyperkeratinized epithelium from the meibomian gland ductal orifices, or the inflamed marginal conjunctiva. The epithelial, sub-epithelial, and stromal changes seen in keratinized posterior lid margins in SJS patients undergoing mucous membrane grafting were also investigated. The findings revealed keratinizing squamous metaplasia of the posterior lid margin accompanied by subepithelial infiltration of helper T cells predominantly on the conjunctival side. The visible meibomian gland orifices had ductal hyperkeratinization and plugging. These findings support a role for inflammation in the pathogenesis of LMK in SJS. Future research can be directed at delineating the pathways that lead to LMK by studying the changes in the lid margin microbiome, and the molecular mechanisms regulating keratinization in the conjunctiva and the meibomian gland orifices in eyes affected by SJS.

A beginner's guide to mucous membrane grafting for lid margin keratinization: Review of indications, surgical technique and clinical outcomes

The posterior lid margin, where the mucocutaneous junction (MCJ) between the eyelid skin and tarsal conjunctiva is located, plays a critical role in maintaining the homeostasis of the ocular surface. Posterior migration of the MCJ leads to lid-margin keratinization (LMK), which has a domino effect on the delicate balance of the ocular surface microenvironment. This occurs most commonly following Stevens-Johnson syndrome/toxic epidermal necrolysis and is not known to regress spontaneously or with medical therapy. Over time, LMK causes blink-related chronic inflammatory damage to the corneal surface which may have blinding consequences. Lid-margin mucous membrane grafting (MMG) is the only definitive therapy for LMK. Timely MMG can significantly alter the natural course of the disease and not only preserve but even improve vision in affected eyes. Literature searches were conducted on PubMed, using the keywords "mucous membrane grafts," "lid margin keratinization," "Stevens-Johnson syndrome," "toxic epidermal necrolysis," "lid related keratopathy," and "lid wiper epitheliopathy". This review, which is a blend of evidence and experience, attempts to describe the indications, timing, surgical technique, postoperative regimen, and clinical outcomes of MMG for LMK. The review also covers the possible complications and pearls on how they can be effectively managed, including how suboptimal cosmetic outcomes can be avoided. The authors hope that this review will aid ophthalmologists, including cornea and oculoplasty specialists, to learn and perform this vision-saving surgery better, with the aim of helping their patients with chronic ocular surface disorders, relieving their suffering, and improving their quality of life.

Surgical Management of Limbal Stem Cell Deficiency

Treatment of limbal stem cell deficiency is challenging. Multiple options can be adopted according to the underlying cause and the patient and physician preferences. Stem cell transplant is a common treatment modality and several techniques have been described with outcomes varying by the laterality of the condition. Keratoprosthesis is a preferred option for bilateral conditions. Indications for type 1 and type 2 keratoprosthesis differ and the past 2 decades have seen a revolution in the field of keratoprosthesis with encouraging and improved outcomes. Management also includes preventive measures and measures to optimize/stabilize the ocular surface that would go a long way in reducing the deterioration of the ocular surface. The aim of this review is to provide an overview of the currently available techniques and to present a comprehensive algorithm to assist in decision making for unilateral and bilateral limbal stem cell deficiency.

Lid-Related Keratopathy in Stevens-Johnson Syndrome: Natural Course and Impact of Therapeutic Interventions in Children and Adults

PURPOSE

To compare the long-term visual outcomes of different management strategies in children and adults with Stevens-Johnson Syndrome (SJS)-induced chronic lid-related keratopathy.

DESIGN

Retrospective comparative case series.

METHODS

This study included 705 eyes of 401 patients (81 children and 320 adults) with SJS who presented with chronic lid-related keratopathy between 1990 and 2015. Affected eyes received either conservative therapy [topical medications (n = 363)] or definitive management (n = 342) that included mucous membrane grafting (MMG), prosthetic replacement of the ocular surface ecosystem (PROSE) contact lenses, or both. The primary outcome measure was change in best corrected visual acuity (BCVA) over time. The secondary outcome measure was the odds of developing corneal ulceration or perforation in the first year.

RESULTS

The treatment subgroups were comparable at baseline in terms of BCVA and previous management (P > .10). Over 10 years, children and adults who received conservative therapy lost at least 5 lines of median BCVA and carried a 3 times higher risk of developing corneal ulceration in the first year. Conversely, definitive therapy provided significant benefit by improving median BCVA (P < .0001). In children, MMG was more effective than PROSE (P = .009), whereas PROSE was more effective than MMG in adults (P = .028). However, the combination of MMG followed by PROSE provided the best results in both children and adults (P < .036).

CONCLUSIONS

Both MMG and PROSE changed the natural course and helped in preserving and improving vision in eyes with SJS-induced lid-related keratopathy. Regardless of age, those who received both MMG and PROSE had the best long-term visual outcomes.

Ocular Sequelae of Stevens-Johnson Syndrome: A Comprehensive Approach

The chronic sequelae of Stevens-Johnson syndrome cause severe ocular morbidity. Among the various manifestations, including dry eye, cicatrization causing forniceal shortening, adnexal disorders, lid margin keratinization, and limbal stem cell deficiency, keratinization of the lid margin leads to progressive ocular surface damage through constant blink-induced microtrauma. This damage induces corneal punctate keratopathy and neovascularization and can produce epithelial defects leading to corneal infection or perforation. Management strategies for chronic ocular sequelae are broadly categorized into ocular surface stabilization procedures, tectonic procedures, and visual rehabilitation procedures. Interventions in the acute stage of the disease include amniotic membrane grafting. Timely intervention helps to prevent deterioration of the ocular surface in these eyes.

Long-term outcomes of amniotic membrane treatment in acute Stevens-Johnson syndrome/toxic epidermal necrolysis

PURPOSE

To report the long-term outcomes of amniotic membrane (AM) use in the form of transplantation (AMT) and self-retained amniotic membrane (ProKera® device, PD) in acute Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN).

METHODS

Electronic records of all patients with a diagnosis of SJS/TEN at Massachusetts Eye and Ear between January 2008 and January 2018 were reviewed. Patients who received AM in acute SJS/TEN were selected. Only patients with follow-up ≥ 3 months after discharge were included.

RESULTS

Data of 55 eyes of 29 patients were analyzed. All 55 eyes received the first AM at a median interval of 5 days (inter-quartile range (IQR): 3-7 days) after onset of skin rash. Fifty-six percent of eyes (31/55) received AMT while 44% (24/55) received PD. Forty percent of eyes (22/55) required a repeat AMT or PD. Median follow-up after initial AM was 2.5 years (IQR: 1.2-3.6 years). At last follow-up, the best-corrected visual acuity was ≥20/40 in 87% of eyes (48/55). The most common complications in the chronic phase were meibomian gland disease and dry eye, seen in 78% of eyes (43/55) and 58% of eyes (32/55) respectively.

CONCLUSIONS

Long-term results show that early use of AM in the acute phase of SJS/TEN may be effective in mitigating severe vision loss after SJS/TEN. However, eyelid-related complications and dry eye remain a common problem even with the use of AM.

Stevens-Johnson syndrome/toxic epidermal necrolysis with severe ocular complications

Introduction: Stevens-Johnson syndrome (SJS) and its severe phenotype, toxic epidermal necrolysis (TEN), are acute inflammatory vesiculobullous reactions of the skin and mucosa. Approximately 50% of SJS/TEN patients diagnosed by dermatologists and in burn units suffer from severe ocular complications (SOC) in the acute stage.Areas covered: Earlier studies on patients with SJS/TEN with SOC identified cold medicines including multi-ingredient cold medications and non-steroidal anti-inflammatory drugs as the main eliciting drugs. HLA analyzes showed that genetic predisposition might play a role in the response to these drugs. Our analysis of the association between HLA genotypes and cold medicine-related SJS/TEN (CM-SJS/TEN) with SOC revealed that certain HLA genotypes play a role in the development of SJS/TEN with SOC. Genetic predisposition and other factors contributing to the elicitation of CM-SJS/TEN with SOC and the management of patients in the acute and chronic stage of the disease are discussed.Expert opinion: The main sequelae of SJS/TEN are ocular sequelae with visual disturbance. SJS/TEN with SOC needs ophthalmic treatment in addition to systemic treatment from the onset time to reduce the ophthalmic sequelae. In addition, HLA examination and public awareness of SJS/TEN with SOC due to cold medicine use might contribute to preventing visual disturbance due to SJS/TEN.Abbreviations: SJS: Stevens-Johnson syndrome; TEN: toxic epidermal necrolysis; SOC: severe ocular complications.

Ocular Surface Reconstruction Using Circumferentially-trephined Autologous Oral Mucosal Graft Transplantation in Limbal Stem Cell Deficiency

PURPOSE

To investigate the effects of transplantation of a circumferentially-trephined autologous oral mucosal graft using a vacuum trephine on ocular surface reconstruction in patients with limbal stem cell deficiency.

METHODS

Patients with a limbal stem cell deficiency who underwent transplantation of autologous oral mucosal graft performed by a particular surgeon in Seoul National University Hospital were included. The medical records of these five patients were retrospectively reviewed. The lower labial mucosal graft inside the inferior lip was trephined to a depth of 250 μm using a donor vacuum trephine with a 9-mm diameter. Outside markings were made using a 14-mm intraoperative keratometer. The oral mucosal graft was dissected under a microscope using a Beaver mini-blade as either a ring or a crescent-shaped strip with a 5-mm width. The mucosal graft was transplanted onto the limbus in the limbal-deficient eye. Best-corrected visual acuity and corneal status were measured during the follow-up period.

RESULTS

Four patients were diagnosed with Stevens-Johnson syndrome and one was diagnosed with atopy-associated immune keratitis. The mean follow-up period was 10.4 ± 2.9 months. After 4 months, visual acuity improved in all patients, and the mean improvement in logarithm of the minimum angle of resolution visual acuity was 0.526 ± 0.470 (range, 0.15 to 1.10). Corneal surface erosion and neovascularization decreased in four patients, and stromal opacity decreased in two patients. The engraftments maintained ocular surface stabilization in four of the five patients at the last follow-up.

CONCLUSIONS

Transplantation of circumferential autologous oral mucosal grafts may be effective for the treatment of limbal stem cell deficiency.

Oral mucosa grafting in periorbital reconstruction

To provide an extensive literature review on the clinical indications of oral mucosa grafts (OMG) and minor salivary gland grafts (MSGG) in periorbital reconstruction together with safe practice graft harvesting techniques to minimize donor-site morbidity. A literature review was performed by searching the databases of PUBMED, EMBASE, and COCHRANE library using the keywords: minor salivary glands; oral mucosal graft; orbit; and eye. The bibliographies of the pertinent articles were examined for additional papers. Indications for OMG include treatment of recurrent pterygia; socket contracture in anophthalmic patients; repair of eyelid deformities; ocular surface and fornix reconstruction following tumour resection, cicatricial ocular surface disorders, or chemical burns. More novel uses include repair of glaucoma aqueous drainage device erosions or leaking trabeculectomy blebs; scleral buckle exposure; and keratoprosthesis-related corneal melts as well as lining the dacryocystorhinostomy tract to prevent closure. Simultaneous MSGG transplantation may be used in the treatment of severe dry eyes or dry anophthalmic cavities. Harvesting from the inner cheek is preferred to lower lip as it causes less post-operative discomfort and neurosensory deficits. Suturing is recommended for smaller ovoid grafts as it allows less painful closure without tension, while larger rectangular defects are best left to heal by secondary intention. OMG and MSGG transplantation is a viable alternative to replace conjunctiva and restore the ocular surface. The donor site is readily accessible and widely available in most patients, grafting is fast and cheap, and the same site may undergo repeated harvesting with few donor site complications.

Reversed skin graft combining with lip mucosa transplantation in treating recurrent severe symblepharon: A case report

RATIONALE

Recurrent symblepharon is very difficult to cure. Techniques applied in symblepharon with no recurrence or low recurrent rate is rare and vital.

PATIENTS CONCERNS

A 12-year-old boy with severe symblepharon caused by firework underwent 2 surgeries for treating severe symblepharon. But both surgeries were failed and symblepharon recurred.

DIAGNOSIS

He was diagnosed with conjunctival sac defect and recurrent symblepharon.

INTERVENTION

The patient received reconstruction with mucosal grafts and a reversed split-thickness skin graft, and suture upper and lower eyelids for 10 days.

OUTCOME

Recurrent symblepharon was cured and the conjunctival sac was reconstructed.

LESSONS

Reversed split-thickness skin graft is much less soft compared to other materials to treat symblepharon and can be used to reconstruct conjunctival sac with no or little recurrence.

Chronic Ocular Sequelae of Stevens-Johnson Syndrome in Children: Long-term Impact of Appropriate Therapy on Natural History of Disease

PURPOSE

To describe the long-term ocular and visual morbidity in children with chronic sequelae of Stevens-Johnson syndrome (SJS) and visual outcomes of various management strategies.

DESIGN

Retrospective comparative case series.

METHODS

This study included 568 eyes of 284 children with SJS who presented between 1990 and 2015. Affected eyes received either conservative therapy (n = 440) or definitive management (n = 128), including lid margin mucous membrane grafting (MMG), prosthetic replacement of the ocular surface ecosystem (PROSE) contact lenses, allogeneic limbal transplantation, or keratoprosthesis using an algorithmic approach based on the severity of dryness and cause and extent of corneal damage. The primary outcome measure was best-corrected visual acuity (BCVA).

RESULTS

Two thirds of patients presented more than a year after acute SJS, 99% without prior amniotic membrane grafting, with low vision or blindness in 60% of eyes. Children 8 years or younger in age had significantly worse ocular and visual morbidity (P ≤ .037). At 5 years of follow-up, definitive therapy significantly altered the natural history of the disease by improving BCVA and preventing the development or progression of keratopathy, as compared to conservative therapy (P ≤ .002). In eyes with lid-related keratopathy, MMG was significantly more effective than PROSE, although both were significantly better than conservative therapy and the combination of MMG followed by PROSE provided the best results (P < .0001).

CONCLUSION

Children receiving suboptimal care during acute SJS presented later with severe ocular and visual morbidity. Timely therapy, particularly with PROSE and MMG in eyes with lid-related keratopathy, changed the natural course and helped in preserving and improving vision.

Oral mucosal grafting combined with tenonplasty for ocular surface and lid margin reconstruction in an atypical sectorial chemical burn

A 46-year-old woman presented with chemical injury in both eyes after the instillation of undefined eye-drops prescribed by quack. She had an atypical presentation in the form of bilateral severe necrosis of both lids and whole palpebral conjunctiva. Extensive debridement with conjunctival epitheliectomy, tenonplasty and amniotic membrane transplantation (AMT) was performed. Characteristic differences from typical chemical injuries were a sectorial involvement of ocular surface and keratinisation over distorted lid margins. Lid margin needed replacement by labial mucous membrane for the restoration of ocular surface. Ocular surface reconstruction with AMT in acute phase and mucous membrane grafting for involved lid margins in late phase achieves vision salvage and avoids late complications in drug-induced chemical injury.

Ocular surface cytokine profile in chronic Stevens-Johnson syndrome and its response to mucous membrane grafting for lid margin keratinisation

BACKGROUND

To study the tear cytokine and the conjunctival and oral mucosal marker profile in chronic ocular Stevens-Johnson syndrome (SJS) and their alteration following mucous membrane grafting (MMG) for lid margin keratinisation (LMK).

METHODS

In a 1-year prospective study, SJS cases (n=25) and age-matched/sex-matched healthy controls (n=25) were recruited. Tear specimen (Schirmer's strip), conjunctival and oral mucosal imprints were collected from controls and SJS cases pre-MMG and post-MMG (at first follow-up, n=17). Tear cytokines were profiled using 27-bioplex array. Transforming growth factor-beta (TGF-β)-mediated extracellular matrix changes in conjunctival and oral mucosal cells were analysed by gene expression studies. 30 RESULTS: Tear cytokine profiling of chronic SJS cases at pre-MMG stage revealed significant upregulation of cytokines granulocyte-macrophage colony-stimulating factor (GM-CSF), interleukin (IL)-8, IL-1β, monocyte chemoattractant protein-1, IL-15, IL-2, IL-17A and basic fibroblast growth factor (bFGF) with downregulation of IP-10 (interferon gamma-induced protein 10), tumour necrosis factor-α, interferon-γ, IL-10, vascular endothelial growth factor, regulated upon activation normal T-cell expressed and secreted (RANTES), IL-7, IL-12p70 and IL-13, with maximal increase in GM-CSF and maximal downregulation of IP-10, respectively. Of these, IL-2, IL-15, bFGF and IL-17A showed significant correlation with disease severity, pre-MMG. Conjunctival cells pre-MMG showed increase in TGF-β1, TGF-βRII, connective tissue growth factor and collagen-III gene expression by 10, 67, 173 and 184 folds, respectively, which dropped to 1.3, 11, 13.5 and 19 folds correspondingly, post-MMG. However, their expressions in oral mucosa were negligible.

CONCLUSION

A proinflammatory, profibrotic, antiapoptotic ocular surface milieu characterises chronic ocular SJS. IP-10, an antifibrotic cytokine was noted to be maximally downregulated, unlike in other forms of chronic dry eye disease. The alterations in the ocular surface are seen to reverse largely with MMG for LMK.

Treatment Modalities and Clinical Outcomes in Ocular Sequelae of Stevens-Johnson Syndrome Over 25 Years--A Paradigm Shift

PURPOSE

To highlight and compare the outcomes of management for the ocular sequelae of Stevens-Johnson syndrome (SJS) over 25 years in a tertiary eye care institute.

METHODS

A retrospective chart review of 798 eyes of 399 patients with SJS evaluated between January 1990 and December 2004 (group I) and of 847 eyes of 517 patients between January 2005 and December 2014 (group II) was done. The primary and secondary outcome measures were a change in the best-corrected visual acuity (BCVA) and an improvement in the symptoms and the ocular surface status, respectively. The groups were subdivided into procedures for ocular surface stabilization (A) and visual rehabilitation (B) and those managed conservatively (C).

RESULTS

In the subgroup A of group II, an improvement/stabilization of BCVA after punctal cautery (231 eyes), mucous membrane grafting for lid margin keratinization (393 eyes), and fornix reconstruction (28 eyes) was noted in 93.6% of eyes. In subgroup B, all 10 eyes that underwent limbal allograft in group I failed when compared with an improvement of BCVA to better than 20/200 in 65.5% of the 61 eyes that underwent keratoprostheses. It was noted that the limbal status worsened in 66.9% of eyes treated conservatively in group I.

CONCLUSIONS

Stabilization procedures show a beneficial role while conservative management can lead to deterioration in chronic ocular sequelae of SJS. Keratoprosthesis, specifically the modified osteo-odonto-keratoprosthesis, forms the mainstay for visual rehabilitation in the end-stage disease. This study highlights the improved outcomes with a paradigm shift in the management modalities.

Acute and Chronic Ophthalmic Involvement in Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis - A Comprehensive Review and Guide to Therapy. II. Ophthalmic Disease

Our purpose is to comprehensively review the state of the art with regard to Stevens- Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), with particular attention to improving the management of associated ocular surface complications. SJS and TEN are two ends of a spectrum of immune-mediated disease, characterized in the acute phase by a febrile illness followed by skin and mucous membrane necrosis and detachment. Part I of this review focused on the systemic aspects of SJS/TEN and was published in the January 2016 issue of this journal. The purpose of Part II is to summarize the ocular manifestations and their management through all phases of SJS/TEN, from acute to chronic. We hope this effort will assist ophthalmologists in their management of SJS/TEN, so that patients with this complex and debilitating disease receive the best possible care and experience the most optimal outcomes in their vision and quality of life.

Stevens-Johnson syndrome: The role of an ophthalmologist

Stevens-Johnson syndrome (SJS) is an acute blistering disease of the skin and mucous membranes. Acute SJS leads to the acute inflammation of the ocular surface and chronic conjunctivitis. If not properly treated, it causes chronic cicatricial conjunctivitis and cicatricial lid margin abnormalities. Persistent inflammation and ulceration of the ocular surface with cicatricial complications of the lids leads to chronic ocular sequelae, ocular surface damage, and corneal scarring. The destruction of the glands that secrete the tear film leads to a severe form of dry eye that makes the management of chronic SJS difficult. The option that is routinely used for corneal visual rehabilitation, keratoplasty, is best avoided in such cases. We describe the management strategies that are most effective during the acute and chronic stages of SJS. Although treatments for acute SJS involve immunosuppressive and immunomodulatory therapies, amniotic membrane transplantation is also useful. The options for visual rehabilitation in patients with chronic SJS are undergoing radical change. We describe the existing literature regarding the management of SJS and highlight recent advances in the management of this disorder.

Corneal transplantation and glaucoma

Glaucoma is the leading cause of irreversible vision loss post-keratoplasty and an important cause of graft failure. With newer techniques, such as lamellar, endothelial, and laser-assisted keratoplasty as well as keratoprosthesis gaining popularity, clinicians will need to consider the incidence, risks, evaluation, and management of glaucoma for each type of keratoplasty when determining which type of transplant may be most appropriate. A comprehensive literature search of glaucoma in the setting of corneal transplantation was performed and serves as the basis for this review. Preexisting glaucoma and aphakia are notable risk factors. Patients that are candidates for deep anterior lamellar keratoplasty may benefit from reduced rates of post-keratoplasty glaucoma. Although glaucoma also complicates eyes with Descemet stripping endothelial keratoplasty, the severity is less and the intraocular pressure is more easily controlled when compared to penetrating keratoplasty. Endothelial keratoplasty creates unique perioperative issues mostly related to management of anterior chamber air bubbles.

Oral mucosal grafts: old technique in new light

PURPOSE

To present an update on indications and efficacy of oral mucosal grafts in the clinical management of ocular surface diseases focusing on the new developments of the last 5 years.

METHODS

Pubmed research on the databases of the years 2007 up to 2012 for the key words mucous membrane graft and eye, fornix reconstruction, eyelid reconstruction, and conjunctival replacement.

RESULTS

Well-documented clinical indications for oral mucosal grafting to the ocular surface include correction of restricted socket syndrome, ocular adnexal reconstruction after tumor resection, cicatricial ocular surface diseases and therapy-refractory pterygia. New indications are conjunctival insufficiency after filtrating glaucoma surgery and the combination of mucosa and amniotic membrane grafting for fornix reconstruction. Moreover, different strategies for ex vivo mucous epithelial cell expansion are under discussion.

CONCLUSIONS

Oral mucosal grafting is a viable option for the replacement of the conjunctiva. Advantages include easily accessibility of grafts in sufficient size even for repeated procedures and a high stability of the grafts. On the other hand, nasal mucosal grafts are superior for some indications due to the lack of goblet cells in the oral mucosa.

Outcome of Boston Keratoprosthesis in a Developing Country-Importance of Patient Selection, Education, and Perioperative Care: The Indian Experience

PURPOSE

We aim to analyze the results of Boston type 1 keratoprosthesis from the Indian subcontinent, with particular emphasis on patient education and perioperative care.

DESIGN

Retrospective interventional case series.

METHODS

This was a retrospective study of patients operated on for Boston type 1 keratoprosthesis between January 2008 and April 2011.

RESULTS

Of 20 patients who underwent surgery, the indications included silicone oil-induced keratopathy (8 eyes; 40%), chemical injury (7 eyes; 35%), repeated graft failures (3 eyes, 15%), and 2 pediatric eyes (10%)-1 sclerocornea and 1 congenital anterior staphyloma. The mean follow-up was 21.8 months ranging from 6 to 45 months. Best corrected postoperative visual acuity was noted to be greater than 20/200 in 16 (80%) of 20 eyes. Anatomic integrity was maintained in 18 eyes (90%). Repeated corneal melt necessitated removal of the prosthesis with corneal transplant in 2 eyes. There was no infection or endophthalmitis in any of the 20 eyes.

CONCLUSIONS

The good anatomic and functional results, with no postoperative infection in our experience with Boston keratoprosthesis over a 3-year period, are encouraging. Strict inclusion criteria and ensuring good patient compliance are important factors in determining good results with a low risk of infection in a tropical developing country.

Oral mucosal graft to correct lid margin pathologic features in cicatricial ocular surface diseases

PURPOSE

To evaluate the efficacy of oral mucosal graft to correct not only lid margin keratinization and trichiasis or distichiasis, but also incomplete closure in severe cicatricial ocular surface diseases.

DESIGN

Retrospective, noncomparative, interventional case series.

METHODS

Twenty-two eyes (39 eyelids) of 19 patients received an oral mucosal graft during lid margin reconstruction from September 2007 through February 2010. Relief of symptoms, conjunctival inflammation, corneal epithelial abnormalities, and visual acuity were compared before and after surgeries as outcome measures.

RESULTS

Among 22 eyes, 10 eyes (45.5%) had lid margin keratinization, trichiasis or distichiasis, or both, resulting in blink-related microtrauma. The oral mucosal graft resulted in successful correction in 6 eyes; in the remaining eyes, trichiasis in 3 eyes and distichiasis in 1 eye were away from the corneal surface. Incomplete closure present in 12 (54.5%) eyes was completely corrected in 9 eyes and was much improved in the remaining 3 eyes. During a mean follow-up of 16.2 months, reports of foreign body sensation, photophobia, pain, burning, tearing, and discharge were relieved significantly in 17 (77.3%) of 22 eyes. The visual acuity was improved in 13 eyes (59.1%) and was maintained in 8 eyes. Conjunctival inflammation was reduced markedly in 19 eyes (86.4%). Corneal epithelial defect and superficial punctate keratopathy were healed rapidly or improved in 14 eyes, and regression of superficial vascularization was noted in 1 eye.

CONCLUSIONS

Oral mucosal graft can reduce not only blink-related microtrauma caused by lid margin keratinization and trichiasis or distichiasis, but also exposure caused by cicatricially induced incomplete closure, thus preventing further deterioration of the ocular surface.