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Ceylan A, Mergen B, Aydin FO, Avci E, Yildirim Y. Sutureless Amniotic Membrane Transplantation Using Pediatric Nasogastric Tube for Patients With Acute Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis. Eye Contact Lens 2023; 49:199-203. [PMID: 36943174 DOI: 10.1097/icl.0000000000000986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
PURPOSE Evaluation of the results of sutureless amniotic membrane transplantation (AMT) using a pediatric nasogastric tube (NGT) for patients with acute Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) was aimed. METHODS Twenty-six eyes of 13 patients with SJS/TEN with ocular involvement at a single tertiary care hospital between May 2020 and January 2022 were included in the study. An amniotic membrane was implanted to the ocular surface and conjunctival fornix using a modified symblepharon ring (MR) created by inserting NGT end-to-end. Patients were followed for at least 6 months. The mean duration of the surgery was recorded. The presence of corneal epithelial defect and vascularization, meibomian gland dysfunction (MGD) grade, conjunctival scarring, eyelid margin keratinization, symblepharon, and trichiasis were recorded. RESULTS The mean age of the patients was 38.4±17.6 years. Amniotic membrane transplantation was performed only once for eight patients and twice for five patients. The mean duration of the surgery was 3.2±0.4 min. The modified symblepharon ring was removed 28 days after its application. At the first examination, 20 eyes (76.9%) had a corneal epithelial defect and 6 (23.1%) had early symblepharon. At the postoperative 6 months, although seven eyes (26.9%) had conjunctival scarring and 5 (19.2%) had eyelid margin keratinization, all patients were without any corneal defect, corneal vascularization, or symblepharon. Only 11 eyes (42.3%) showed MGD, and 1 eye (3.8%) showed trichiasis. CONCLUSIONS This study showed that sutureless AMT using pediatric NGT could be a potentially fast and inexpensive treatment option for the treatment of SJS/TEN with ocular involvement at the bedside without the need for general anesthesia.
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Affiliation(s)
- Ali Ceylan
- Department of Ophthalmology, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
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Santamaria JA, Cancio LC, Reed D, Phillips H, Chen S, Carlton DK, Johnson AJ. Complete Fusion of Both Eyelids in Stevens-Johnson Syndrome: Case Report. J Burn Care Res 2021; 42:1023-1025. [PMID: 33528572 DOI: 10.1093/jbcr/irab024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
An 18-year-old woman developed Stevens-Johnson syndrome (SJS) with ocular involvement after taking ibuprofen. She was admitted to another hospital, received saline flushes and bacitracin ophthalmic ointment to the eyes, and became unable to open them. Upon transfer to this burn center 3 weeks after symptom onset, there was complete fusion of both eyelids with no visible cornea or sclera. She underwent bilateral operative scar release. After opening the lids, meticulous debridement of cicatricial membranes and release of symblephara were performed with subsequent placement of amniotic membrane grafts. Her vision slowly improved, though her long-term visual prognosis remains guarded. Early recognition and treatment of SJS or toxic epidermal necrolysis (TEN) with ocular involvement is imperative. Even mild cases may require intensive topical lubrication, steroids, and antibiotics, with early placement of amniotic membrane grafts in severe cases. Prompt intervention and daily evaluation are paramount in preventing lifelong visual disability.
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Affiliation(s)
- Joseph A Santamaria
- Department of Ophthalmology, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
| | - Leopoldo C Cancio
- U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
| | - Donovan Reed
- Department of Ophthalmology, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
| | - Hunter Phillips
- Department of Ophthalmology, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
| | - Sien Chen
- Department of Ophthalmology, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
| | - Darrel K Carlton
- Department of Ophthalmology, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
| | - Anthony J Johnson
- Department of Ophthalmology, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
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Mahmood AH, Alharbi AS, Almanea BA, Alsaati AF. Sutureless Amniotic Membrane (ProKera®) and Intravenous Immunoglobulin in the Management of Ocular Complications of Stevens-Johnson Syndrome-Toxic Epidermal Necrolysis Overlap. Cureus 2021; 13:e16989. [PMID: 34540392 PMCID: PMC8422256 DOI: 10.7759/cureus.16989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2021] [Indexed: 11/05/2022] Open
Abstract
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.
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Affiliation(s)
- Abdulhameed H Mahmood
- Ophthalmology, Salmaniya Medical Complex, Manama, BHR
- Ophthalmology, Anterior Segment Division, Prince Sultan Military Medical City, Riyadh, SAU
| | | | | | - Anoud F Alsaati
- Ophthalmology, Anterior Segment Division, Prince Sultan Military Medical City, Riyadh, SAU
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Chronic Ocular Sequelae and Subsequent Surgical Interventions in Stevens-Johnson Syndrome After Amniotic Membrane Transplantation. Cornea 2021; 41:632-634. [PMID: 34294633 DOI: 10.1097/ico.0000000000002816] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/26/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of this study was to describe the chronic ocular sequelae and subsequent surgical interventions after amniotic membrane transplantation (AMT) in a patient with Stevens-Johnson syndrome (SJS). METHODS A 30-year-old woman was diagnosed with SJS after taking phenytoin prescribed for generalized tonic-clonic seizures. Bedside AMT covering the eyelid margins, the conjunctiva, and the cornea was performed in both eyes during the acute phase during hospitalization. A repeat AMT was necessary after 5 days. After AMT, she was prescribed topical steroids, antibiotics, and artificial tears. She was asked to follow up every 2 weeks in the first 3 months after AMT. RESULTS Eyelid-related complications such as trichiasis, distichiasis, eyelid margin keratinization (LMK), and cicatricial entropion developed during the follow-up period within the first year after AMT. Eyelid margin mucous membrane graft (MMG) of all eyelids was performed at the earliest clinical sign of lid-related keratopathy due to LMK. The right eye developed upper eyelid and lower eyelid cicatricial entropion, for which anterior lamellar repositioning with eyelid margin MMG was performed. Electroepilation of the trichiatic eyelashes in all 4 eyelids was performed more than once to maintain a healthy ocular surface. CONCLUSIONS Successful AMT was performed twice within the first week of ocular involvement in the acute phase of SJS. Chronic ocular sequelae affecting the eyelid margin were identified during the chronic phase and were successfully treated with eyelid margin MMG. Necessity for the close follow-up and the need for subsequent interventions to maintain visual acuity should be explained to patients after acute SJS with ocular involvement.
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Amniotic Membrane-Covered Conformer and Fibrin Glue for Toxic Epidermal Necrolysis. Cornea 2021; 40:525-528. [PMID: 33881813 DOI: 10.1097/ico.0000000000002591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Stevens-Johnson syndrome and its more severe form, toxic epidermal necrolysis, are immunologic disorders that cause widespread blistering of the skin and mucous membranes. Its incidence is higher in children and can lead to long-term disabling ocular surface complications that can be averted with amniotic membrane transplantation early in the disease. To introduce an amniotic membrane treatment technique that is time efficient and minimally invasive but still allows for extensive coverage of the ocular mucosal surfaces to prevent and lessen the severity of the complications from ocular surface sequelae. METHODS The procedure was undertaken in the operating room under general anesthesia. Symblephara were divided before an amniotic membrane-covered conformer was placed into the fornices. Fibrin glue was used to secure the conformer and to keep the palpebral aperture closed. Topical chloramphenicol 0.5% and prednisolone 0.5% were prescribed 4 times a day. RESULTS After 7 days, the conformers were removed and new amniotic membrane-covered conformers were reapplied in both eyes for a further week. After the second round of treatment, the conformers were left out for 3 days. Inferior symblephara reformed in the left lower fornix, and therefore, a third round of treatment was undertaken in the left eye only, which was then removed after 7 days. A follow-up at 8 weeks revealed 20/20 vision with minimal symblephara in either eye. CONCLUSIONS This novel technique, using an amniotic membrane-covered conformer in combination with fibrin glue, allows for the coverage of the entire ocular surface and protection of the lid margins while requiring minimal preparation and surgical time. This technique could also be used in patients with other cicatrizing ocular surface conditions, such as chemical or thermal injuries or postreconstructive surgery of the fornices.
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Shanbhag SS, Hall L, Chodosh J, Saeed HN. Long-term outcomes of amniotic membrane treatment in acute Stevens-Johnson syndrome/toxic epidermal necrolysis. Ocul Surf 2020; 18:517-522. [PMID: 32200005 DOI: 10.1016/j.jtos.2020.03.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 01/21/2020] [Accepted: 03/11/2020] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Swapna S Shanbhag
- Department of Ophthalmology, Massachusetts Eye & Ear, Boston, MA, USA; The Cornea Institute, L.V. Prasad Eye Institute, Hyderabad, India
| | - Leangelo Hall
- Department of Ophthalmology, Massachusetts Eye & Ear, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - James Chodosh
- Department of Ophthalmology, Massachusetts Eye & Ear, Boston, MA, USA
| | - Hajirah N Saeed
- Department of Ophthalmology, Massachusetts Eye & Ear, Boston, MA, USA.
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Shanbhag SS, Chodosh J, Saeed HN. Sutureless amniotic membrane transplantation with cyanoacrylate glue for acute Stevens-Johnson syndrome/toxic epidermal necrolysis. Ocul Surf 2019; 17:560-564. [PMID: 30872140 DOI: 10.1016/j.jtos.2019.03.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 03/05/2019] [Accepted: 03/05/2019] [Indexed: 12/01/2022]
Abstract
Amniotic membrane (AM) transplantation, when performed in the acute phase in Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) for patients with ocular complications, is known to reduce the morbidity of ocular complications in the chronic phase. In conditions such as SJS/TEN, AM needs to be secured to the ocular surface as well as the eyelids. Previously, techniques of securing a large sheet of AM with fibrin glue to the ocular surface and with sutures and bolsters to the eyelids have been described in the acute phase of SJS/TEN. These techniques often necessitate the use of an operating room in acutely ill patients. We describe a bedside technique that uses cyanoacrylate glue to secure the AM to the eyelids, as well as long-term outcomes in 4 patients with acute SJS/TEN. The combination of a custom symblepharon ring to secure AM over the entire ocular surface and cyanoacrylate glue to secure AM to the eyelid margins is quick, painless, does not require local or general anesthesia, and might prove useful in other conditions previously shown to benefit from AMT, such as ocular chemical injuries.
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Affiliation(s)
- Swapna S Shanbhag
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - James Chodosh
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - Hajirah N Saeed
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA.
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White KD, Abe R, Ardern-Jones M, Beachkofsky T, Bouchard C, Carleton B, Chodosh J, Cibotti R, Davis R, Denny JC, Dodiuk-Gad RP, Ergen EN, Goldman JL, Holmes JH, Hung SI, Lacouture ME, Lehloenya RJ, Mallal S, Manolio TA, Micheletti RG, Mitchell CM, Mockenhaupt M, Ostrov DA, Pavlos R, Pirmohamed M, Pope E, Redwood A, Rosenbach M, Rosenblum MD, Roujeau JC, Saavedra AP, Saeed HN, Struewing JP, Sueki H, Sukasem C, Sung C, Trubiano JA, Weintraub J, Wheatley LM, Williams KB, Worley B, Chung WH, Shear NH, Phillips EJ. SJS/TEN 2017: Building Multidisciplinary Networks to Drive Science and Translation. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2018; 6:38-69. [PMID: 29310768 PMCID: PMC5857362 DOI: 10.1016/j.jaip.2017.11.023] [Citation(s) in RCA: 124] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 11/20/2017] [Accepted: 11/21/2017] [Indexed: 12/17/2022]
Abstract
Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a life-threatening, immunologically mediated, and usually drug-induced disease with a high burden to individuals, their families, and society with an annual incidence of 1 to 5 per 1,000,000. To effect significant reduction in short- and long-term morbidity and mortality, and advance clinical care and research, coordination of multiple medical, surgical, behavioral, and basic scientific disciplines is required. On March 2, 2017, an investigator-driven meeting was held immediately before the American Academy of Dermatology Annual meeting for the central purpose of assembling, for the first time in the United States, clinicians and scientists from multiple disciplines involved in SJS/TEN clinical care and basic science research. As a product of this meeting, this article summarizes the current state of knowledge and expert opinion related to SJS/TEN covering a broad spectrum of topics including epidemiology and pharmacogenomic networks; clinical management and complications; special populations such as pediatrics, the elderly, and pregnant women; regulatory issues and the electronic health record; new agents that cause SJS/TEN; pharmacogenomics and immunopathogenesis; and the patient perspective. Goals include the maintenance of a durable and productive multidisciplinary network that will significantly further scientific progress and translation into prevention, early diagnosis, and management of SJS/TEN.
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Affiliation(s)
- Katie D White
- Vanderbilt University Medical Center, Nashville, Tenn
| | - Riichiro Abe
- Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | | | - Thomas Beachkofsky
- Wilford Hall Ambulatory Surgical Center, Lackland Air Force Base, San Antonio, Texas
| | | | - Bruce Carleton
- University of British Columbia, Vancouver, British Columbia, Canada; B.C. Children's Hospital, British Columbia, Vancouver, British Columbia, Canada
| | - James Chodosh
- Massachusetts Eye and Ear, Harvard Medical School, Boston, Mass
| | - Ricardo Cibotti
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Md
| | - Robert Davis
- University of Tennessee Health Sciences, Memphis, Tenn
| | | | - Roni P Dodiuk-Gad
- Emek Medical Center, Technion-Institute of Technology, Afula, Israel; Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | | | | | - James H Holmes
- Wake Forest Baptist Medical Center, Winston-Salem, NC; Wake Forest University School of Medicine, Winston-Salem, NC
| | | | | | | | - Simon Mallal
- Vanderbilt University Medical Center, Nashville, Tenn; Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia
| | - Teri A Manolio
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Md; F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Md
| | | | | | - Maja Mockenhaupt
- Medical Center and Medical Faculty-University of Freiburg, Freiburg, Germany
| | | | - Rebecca Pavlos
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia
| | | | - Elena Pope
- University of Toronto, Toronto, Ontario, Canada; Hospital for Sick Children, Toronto, Ontario, Canada
| | - Alec Redwood
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia
| | | | | | | | | | - Hajirah N Saeed
- Massachusetts Eye and Ear, Harvard Medical School, Boston, Mass
| | - Jeffery P Struewing
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Md
| | | | | | - Cynthia Sung
- Duke-NUS Medical School, Singapore, Singapore; Health Sciences Authority, Singapore, Singapore
| | - Jason A Trubiano
- Austin Health, Heidelberg, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia
| | | | - Lisa M Wheatley
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | | | | | | | - Neil H Shear
- Vanderbilt University Medical Center, Nashville, Tenn
| | - Elizabeth J Phillips
- Vanderbilt University Medical Center, Nashville, Tenn; Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia.
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Creamer D, Walsh SA, Dziewulski P, Exton LS, Lee HY, Dart JKG, Setterfield J, Bunker CB, Ardern-Jones MR, Watson KMT, Wong GAE, Philippidou M, Vercueil A, Martin RV, Williams G, Shah M, Brown D, Williams P, Mohd Mustapa MF, Smith CH. U.K. guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in adults 2016. Br J Dermatol 2017; 174:1194-227. [PMID: 27317286 DOI: 10.1111/bjd.14530] [Citation(s) in RCA: 155] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2016] [Indexed: 12/11/2022]
Affiliation(s)
- D Creamer
- Department of Dermatology, King's College Hospital NHS Foundation Trust, London, SE5 9RS, U.K
| | - S A Walsh
- Department of Dermatology, King's College Hospital NHS Foundation Trust, London, SE5 9RS, U.K
| | - P Dziewulski
- St Andrews Centre for Plastic Surgery and Burns, Mid Essex Hospital Services NHS Trust, Chelmsford, CM1 7ET, U.K
| | - L S Exton
- British Association of Dermatologists, Willan House, 4 Fitzroy Square, London, W1T 5HQ, U.K
| | - H Y Lee
- Dermatology Unit, Singapore General Hospital, Singapore
| | - J K G Dart
- Moorfields Eye Hospital, 162 City Road, London, EC1V 2PD, U.K
| | - J Setterfield
- Mucosa and Salivary Biology, Dental Institute, King's College London, Guy's Campus, Great Maze Pond, London, SE1 9RT, U.K
| | - C B Bunker
- University College Hospital, London, NW1 2BU, U.K
| | - M R Ardern-Jones
- Clinical Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton General Hospital, Southampton, SO16 6YD, U.K
| | - K M T Watson
- Department of Dermatology, Orpington Hospital, Orpington, Kent, BR6 9JU, U.K
| | - G A E Wong
- Department of Dermatology, University Hospital of South Manchester NHS Foundation Trust, Manchester, M23 9LT, U.K
| | - M Philippidou
- Department of Histopathology, King's College Hospital NHS Foundation Trust, London, SE5 9RS, U.K
| | - A Vercueil
- Intensive Care Medicine, King's College Hospital NHS Foundation Trust, London, SE5 9RS, U.K
| | - R V Martin
- St Andrews Centre for Plastic Surgery and Burns, Mid Essex Hospital Services NHS Trust, Chelmsford, CM1 7ET, U.K
| | - G Williams
- Late of the Burns Centre, Chelsea and Westminster NHS Foundation Trust, London, SW10 9NH, U.K
| | - M Shah
- Department of Burns and Plastic Surgery, University Hospitals of South Manchester, Southmoor Road, Wythenshawe, Manchester, M23 9LT, U.K
| | - D Brown
- St John's Institute of Dermatology, Guy's and St Thomas NHS Foundation Trust, London, SE1 9RT, U.K
| | - P Williams
- Department of Dermatology, King's College Hospital NHS Foundation Trust, London, SE5 9RS, U.K
| | - M F Mohd Mustapa
- British Association of Dermatologists, Willan House, 4 Fitzroy Square, London, W1T 5HQ, U.K
| | - C H Smith
- St John's Institute of Dermatology, Guy's and St Thomas NHS Foundation Trust, London, SE1 9RT, U.K
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Successful Treatment of Acute Ocular-Involving Toxic Epidermal Necrolysis Using Amniotic Membrane Suture Fixated to Custom Designed Symblepharon Rings. Cornea 2016; 35:578-81. [PMID: 26863497 DOI: 10.1097/ico.0000000000000770] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of this study is to describe a novel technique using amniotic membrane suture-fixated onto custom-designed symblepharon rings in a patient with acute toxic epidermal necrolysis (TEN). METHODS A 61-year-old man developed bilateral symblephara and severe ocular surface inflammation from Stevens-Johnson syndrome/TEN secondary to allopurinol. Eight days after admission, he was treated with placement of custom-designed symblepharon rings, designed by one of the authors (A.A.), covered with amniotic membrane. This method was used to allow for efficient placement of the membrane and to minimize operative time and perioperative risks due to his worsening systemic condition. RESULTS On postoperative day 49, his visual acuity was 20/20 in the right eye and 20/25 in the left eye. Both eyes were quiet with only small symblephara noted temporally. CONCLUSIONS The use of amniotic membrane suture-fixated to custom-designed symblepharon rings provides sufficient coverage of the ocular surface, leading to excellent visual and clinical outcomes by reducing inflammation and protecting the ocular surface from the cicatrizing sequelae associated with ocular-involving TEN. This novel technique is less invasive, more time efficient, and likely safe for even the most critically ill patients with significant risk for mortality, thus allowing any treating ophthalmologist to comfortably perform this important sight-saving procedure.
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UK guidelines for the management of Stevens–Johnson syndrome/toxic epidermal necrolysis in adults 2016. J Plast Reconstr Aesthet Surg 2016; 69:e119-e153. [DOI: 10.1016/j.bjps.2016.01.034] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 01/14/2016] [Indexed: 12/13/2022]
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Kohanim S, Palioura S, Saeed HN, Akpek EK, Amescua G, Basu S, Blomquist PH, Bouchard CS, Dart JK, Gai X, Gomes JAP, Gregory DG, Iyer G, Jacobs DS, Johnson AJ, Kinoshita S, Mantagos IS, Mehta JS, Perez VL, Pflugfelder SC, Sangwan VS, Sippel KC, Sotozono C, Srinivasan B, Tan DTH, Tandon R, Tseng SCG, Ueta M, Chodosh J. Acute and Chronic Ophthalmic Involvement in Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis - A Comprehensive Review and Guide to Therapy. II. Ophthalmic Disease. Ocul Surf 2016; 14:168-88. [PMID: 26882981 DOI: 10.1016/j.jtos.2016.02.001] [Citation(s) in RCA: 138] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Revised: 02/03/2016] [Accepted: 02/03/2016] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Sahar Kohanim
- Vanderbilt Eye Institute, Vanderbilt University School of Medicine, USA
| | - Sotiria Palioura
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, USA
| | - Hajirah N Saeed
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, USA
| | - Esen K Akpek
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, USA
| | - Guillermo Amescua
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, USA
| | | | | | | | - John K Dart
- Moorfields Eye Hospital, NHS Foundation Trust, UK
| | - Xiaowu Gai
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, USA
| | | | - Darren G Gregory
- Rocky Mountain Lions Eye Institute, University of Colorado School of Medicine, USA
| | - Geetha Iyer
- Dr G Sitalakshmi Memorial Clinic for Ocular Surface Disorders, Sankara Nethralaya, India
| | - Deborah S Jacobs
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, USA; Boston Foundation for Sight, USA
| | | | | | | | - Jodhbir S Mehta
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore
| | - Victor L Perez
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, USA
| | | | | | | | | | - Bhaskar Srinivasan
- Dr G Sitalakshmi Memorial Clinic for Ocular Surface Disorders, Sankara Nethralaya, India
| | - Donald T H Tan
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore
| | - Radhika Tandon
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, India
| | - Scheffer C G Tseng
- Ocular Surface Center, Ocular Surface Research & Education Foundation, USA
| | - Mayumi Ueta
- Kyoto Prefectural University of Medicine, Japan
| | - James Chodosh
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, USA.
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Gervasio KA, Wu AY. Diagnostic Delay and Amniotic Membrane Transplantation in a Child With Atypical Stevens-Johnson Syndrome. J Pediatr Ophthalmol Strabismus 2015; 52 Online:e41-4. [PMID: 26301401 PMCID: PMC7584684 DOI: 10.3928/01913913-20150811-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Accepted: 05/08/2015] [Indexed: 11/20/2022]
Abstract
A 4-year-old boy presented with a 6-day history of severe non-limbic-sparing conjunctivitis. Atypical Stevens-Johnson syndrome with a possible cause of Mycoplasma pneumoniae was suspected as the precipitant of the clinical symptoms. The patient recovered with amniotic membrane transplantation and intravenous immunoglobulin therapy despite an initial delay in diagnosis.
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14
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Amnion doughnut: a novel method for sutureless fixation of amniotic membrane to the bulbar and palpebral conjunctiva in acute ocular-involving Stevens-Johnson syndrome. Cornea 2015; 33:1240-4. [PMID: 25222004 DOI: 10.1097/ico.0000000000000254] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE The aim of this study was to describe a novel surgical method for the sutureless placement of amniotic membrane on the bulbar and palpebral conjunctiva in the setting of ocular-involving acute Stevens-Johnson syndrome. METHODS Within 6 days of an acute Stevens-Johnson episode, a 27-year-old male developed early symblepharon, despite aggressive lubrication and topical steroid therapy. He underwent symblepharon lysis and placement of an amniotic membrane wrapped around a symblepharon ring. RESULTS The patient maintained 20/20 vision in each eye with no recurrent symblepharon formation except for the temporal canthus (which was not covered with amniotic membrane). CONCLUSIONS Symblepharon rings covered in amniotic membrane provide a sutureless way to fixate amniotic membrane to the bulbar and palpebral conjunctiva. This gave very good anatomic and functional outcomes in a patient with acute Stevens-Johnson syndrome. Future research could be directed toward the development of a symblepharon ring that will be able to better protect the far temporal conjunctiva.
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