Factors Contributing to Long-Term Severe Visual Impairment in Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis

Ocular involvement in Steven-Johnson syndrome/toxic epidermal necrolysis: recent insights into pathophysiology, biomarkers, and therapeutic strategies

PURPOSE OF REVIEW

To review the pathophysiology, recent biomarkers related to the ocular aspects of Steven-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN), and to highlight notable evidence published in recent years.

RECENT FINDINGS

Several studies reveal the relationship between tear cytokines and the pathological components in eyes of SJS/TEN patients. Specific clinical features and associated risk factors in the acute stage have shown significant correlations with chronic ocular sequelae. Recent treatment protocols, including early pulse systemic and topical steroids, as well as tumor necrosis factor-α inhibitors, have demonstrated positive effects on ocular outcomes. In addition to conventional surgical treatment, a new surgical technique, simple oral mucosal epithelial transplantation (SOMET), has been introduced as a simple ocular surface reconstruction for patient with SJS.

SUMMARY

Advancements in knowledge and management strategies have notably enhanced ocular outcomes for SJS/TEN eyes. A deeper understanding of the biomarker changes in these eyes could facilitate the development of future targeted treatment options.

Clinical Characteristics and Treatment of Ophthalmic Sequelae of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis at a Tertiary Eyecare Centre in Hungary

INTRODUCTION

This study analysed the causative factors and clinical characteristics of acute and chronic ocular sequelae of Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) treated at a large third-referral centre in a developed country (Hungary) over a 15-year period.

METHODS

This was a retrospective review of patients with acute and/or chronic SJS/TEN who were managed between 2006 and 2020 at the Department of Ophthalmology of Semmelweis University in Budapest, Hungary. For each subject, clinical data, including patient demographics, clinical history, causative agents of SJS/TEN, and conservative and surgical treatment details, were reviewed.

RESULTS

Ninety-six eyes of 48 patients were included (28 female; 58.3%); the age at disease onset was 32.1 ± 22.4 years. The most common causative factors were medicines (n = 36; 75.0%). Among these drugs, 29.2% were nonsteroidal anti-inflammatory drugs (NSAIDs) (n = 14), 20.8% were antibiotics (n = 10) and 14.6% were antiepileptic drugs (n = 7). In patients with chronic SJS/TEN, the most commonly found ocular sequelae were conjunctival hyperaemia in 45 (56.3%) eyes, symblepharon in 38 (47.5%) eyes, trichiasis/distichiasis in 37 (46.3%) eyes, corneal neovascularization in 31 (38.8%) eyes and corneal scarring in 29 (36.3%) eyes. In patients with chronic SJS/TEN, the most frequently used topical conservative treatment included antibiotics in 53 (66.3%) eyes, preservative-free artificial tears in 50 (62.5%) eyes and topical corticosteroids in 42 (52.5%) eyes of 40 patients. The most frequently performed ocular surgeries for managing chronic ocular sequelae in patients with SJS/TEN were epilation for trichiasis (n = 27; 33.8%), cataract surgery (n = 14; 17.5%), entropion surgery (n = 12; 15.0%), penetrating keratoplasty (PK) (n = 11; 13.8%) and amniotic membrane transplantation (n = 4; 5.0%).

CONCLUSION

Our results suggest that NSAIDs, antibiotics and antiepileptic drugs are the most common causative factors for SJS/TEN in Hungary. Like in other countries, in Hungary, the ocular management of patients with acute and chronic SJS/TEN is heterogeneous, and most cases do not follow modern therapeutic guidelines.

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.

Clinical Characteristics of Patients With Chronic Stevens-Johnson Syndrome Treated at a Major Tertiary Eye Hospital Within the United Kingdom

The purpose of this study is to provide a comprehensive review of the clinical characteristics in chronic Stevens-Johnson syndrome (SJS) patients within the United Kingdom population, their causative factors, treatment profile and prognosis. This retrospective series included 91 patients with chronic SJS treated at Moorfields Eye Hospital (London, United Kingdom). A chart review included visual acuity and presence of clinical findings (including lid abnormalities and ocular surface findings). All medical and surgical treatments were also recorded. Approximately a half of patients were White British but there were significant numbers of patients from other ethnic groups, South Asian and Black in particular. Oral antibiotics were the causative agent in almost a half of the patients with SJS, systemic infections in 14%, non-steroidal anti-inflammatory drugs in 8% and anticonvulsants in 7%. The age of onset was varied but a significant proportion of patients developed acute SJS in childhood. There was a significant correlation between visual acuity at initial referral to final recorded vision. Vision was found to continue to significantly deteriorate over time despite therapeutic interventions. Our regression model shows that ~62% of the variance in final vision can be explained by the initial vision and duration disease. The majority of our patients were on advanced ocular surface treatments including serum drops, topical ciclosporin and retinoic acid drops. Of particular significance, approximately a third of our patient cohort was also on systemic immune suppression. In conclusion, chronic SJS within the UK population under tertiary care remains an area of unmet clinical need. Current medical and surgical modalities prevent worsening of vision in severe ocular disease from SJS.

Case Report: Wound Closure Acceleration in a Patient With Toxic Epidermal Necrolysis Using a Lyophilised Amniotic Membrane

Background: Toxic epidermal necrolysis (TEN) is a rare life-threatening disease that mainly affects the skin and mucous membranes, resulting from a toxic delayed-type hypersensitivity (DTH) reaction (type IV reaction) to the presence of foreign antigens such as drugs. The clinical symptoms are caused by pathophysiological processes leading to massive apoptosis of keratinocytes in the dermo-epidermal junction. This results in the formation of a bulla and subsequent separation of the entire epidermis with the exposure of the dermis. The current approach in the local therapy of TEN prefers the use of biological dressings, which helps provide several critical requirements for defect healing; in particular, it helps in the acceleration of the spontaneous wound closure (re-epithelialization) of the skin defect and the reduction of the risk of development of various complications and infections, such as the risk of pathological scar maturation. This paper is a case report of the use of a lyophilized amniotic membrane (AM) for accelerating wound healing in a patient with TEN. Case Presentation: We report a case of an 8-year-old girl transferred to our center with a histologically confirmed diagnosis of TEN. Despite the application of immunosuppressive therapy consisting of corticosteroids and intravenous immunoglobulins, we have observed disease progression and exfoliation of up to 60% of the total body surface area (TBSA). In the facial area, which is cosmetically privileged, we decided to use the lyophilized amniotic membrane (Amnioderm®) to cover up approximately 2% of the TBSA. Within 2 days after the application, we observed accelerated reepithelialisation, with rapid wound closure. We have not observed any side effects nor infections during the subsequent phases of wound healing. Skin defects in non-facial areas of the body were treated with synthetic dressings. When compared to the areas covered with the lyophilized AM, the healing process was prolonged. Conclusions: To our knowledge, this is the first case study using a lyophilized amniotic membrane in the treatment of a patient with TEN. The AM application in the cosmetically-privileged area (face), proved to be very efficient in the treatment of TEN patients. The use of this allogeneic material demonstrated excellent biocompatibility and caused a unique acceleration of epithelialization and wound healing, yielding also excellent long-term results. The current study opens broad possibilities for clinical application of the used material, the improvement of current therapy of patients with TEN and better outcomes and recovery of patients.

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.

Clinical and pathogenic aspects of the severe cutaneous adverse reaction epidermal necrolysis (EN)

The severe cutaneous adverse reaction epidermal necrolysis (EN) which includes toxic epidermal necrolysis and the milder Stevens-Johnson syndrome is characterized by epidermal loss due to massive keratinocyte apoptosis and/or necroptosis. EN is often caused by a drug mediating a specific TCR-HLA interaction via the (pro)hapten, pharmacological interaction or altered peptide loading mechanism involving a self-peptide presented by keratinocytes. (Memory) CD8 + T cells are activated and exhibit cytotoxicity against keratinocytes via the perforin/granzyme B and granulysin pathway and Fas/FasL interaction. Alternatively drug-induced annexin release by CD14 + monocytes can induce formyl peptide receptor 1 death of keratinocytes by necroptosis. Subsequent keratinocyte death stimulates local inflammation, activating other immune cells producing pro-inflammatory molecules and downregulating regulatory T cells. Widespread epidermal necrolysis and inflammation can induce life-threatening systemic effects, leading to high mortality rates. Research into genetic susceptibility aims to identify risk factors for eventual prevention of EN. Specific HLA class I alleles show the strongest association with EN, but risk variants have also been identified in genes involved in drug metabolism, cellular drug uptake, peptide presentation and function of CD8 + T cells and other immune cells involved in cytotoxic responses. After the acute phase of EN, long-term symptoms can remain or arise mainly affecting the skin and eyes. Mucosal sequelae are characterized by occlusions and strictures due to adherence of denuded surfaces and fibrosis following mucosal inflammation. In addition, systemic pathology can cause acute and chronic hepatic and renal symptoms. EN has a large psychological impact and strongly affects health-related quality of life among EN survivors.

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.

Clinical clues predictive of Stevens-Johnson syndrome as the cause of chronic cicatrising conjunctivitis

Purpose

This study aimed to identify the clinical clues in patients with chronic cicatrising conjunctivitis (CCC), that were suggestive of Stevens-Johnson syndrome (SJS) as the aetiology.

Methods

This was a cross-sectional observational study of 75 patients presenting with CCC from 2016 to 2018. Those with a documented diagnosis of SJS (n=43) were included as cases; while those with a positive serology or tissue biopsy for a non-SJS condition were included as controls (n=32). The features in the medical history and clinical examination that were positively and negatively associated with SJS were scored +1 and −1, respectively. A receiver operating characteristic (ROC) curve analysis was performed to detect the threshold score for optimal sensitivity and specificity of the scoring system.

Results

No single feature had absolute sensitivity and specify for SJS. The 10 positive features suggestive of SJS (p<0.0001) included (1) history of: acute conjunctivitis, fever or drug intake preceding conjunctivitis, peeling of skin on pressure, loss of nails and severe morbidity with hospital admission; and (2) clinical features of: skin discoloration, nail disfigurement, lip-margin dermalisation, lid-margin keratinisation and distichiasis. The two negative criteria were history of mucosal ulcers without skin involvement and recurrent mucosal ulceration. On ROC analysis, a score of >5 showed a sensitivity of 90.7% and specificity of 93.8% for the diagnosis of SJS.

Conclusions

The combination of clinical clues identified in this study can help clinicians confirm SJS as the aetiology of conjunctival cicatrisation, especially when reliable documentation of the acute episode is not available.

Ocular manifestations in patients with Stevens-Johnson syndrome in Malawi-review of the literature illustrated by clinical cases

PURPOSE

In Sub-Saharan Africa, manifestations of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are commonly seen in human immunodeficiency virus-infected patients receiving nevirapine-based antiretroviral therapy and/or cotrimoxazole. These patients often face severe ocular complications that lead to moderate to severe visual impairment or blindness.

METHODS

Review of the current literature, illustrated by retrospective hospital-based case series: Eight patients at Lions Sight First Eye Hospital, Blantyre, Malawi with severe ocular complications like severe cicatrizing conjunctivitis with symblephara, corneal punctate erosions, corneal vascularization, and corneal ulceration are illustrated after the diagnosis of SJS/TEN.

RESULTS

Light perception was reported in six (12 eyes) of them; two patients (4 eyes) had moderate visual impairment (6/36 and 6/18). In one patient, eye problems started after therapy with cotrimoxazole; in seven after therapy, with antiretroviral therapy.

CONCLUSION

SJS/TEN in Sub Saharan Africa correlates significantly with moderate visual impairment up to blindness. Early recognition of eye complications and involvement of ophthalmologists in the acute stage, early treatment with local steroids, and close monitoring for up to 6 months after the acute phase are crucial. Severe ocular complications seem to be more severe in dark skin phototype.

Ocular and Mucocutaneous Sequelae among Survivors of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis in Togo

Aim

The aim of this study was to assess ocular and mucocutaneous sequelae among SJS/TEN survivors and identify risk factors of ocular sequelae.

Patients and Method

Late complications among SJS/TEN survivors were assessed using 2 methods: a retrospective assessment of medical records only or a retrospective assessment of medical records and physical examination of survivors who were contacted by phone.

Results

Between January 1995 and December 2017, 177 cases of SJS/TEN (138 cases of SJS, 29 cases of TEN, and 10 cases SJS/TEN overlap) were admitted into two university hospitals of Lomé (Togo). There were 113 women and 64 men, with an average age of 31.7±13.0 years (range: 5 to 80 years). The most used drugs were antibacterial sulfonamides (35.6%) and nevirapine (24.3%). HIV serology was positive in 68 (59.1%) of the 115 patients tested. Sixty-four (52,5%) of the 122 patients, who had been examined by an ophthalmologist during the acute stage, had acute ocular involvement, which was mild in 27.9% of patients, moderate in 13.1%, and severe in 11.5%. We recorded 17 deaths (i.e., three cases of SJS, 12 of TEN, and two of SJS/TEN overlap), including 11 cases of HIV infected patients. Of the 160 SJS/TEN survivors, only 71 patients were assessed 6 months after hospital discharge. Among them, forty-three (60.6%) patients had sequelae. Concerning mucocutaneous sequelae, the main lesions were diffuse dyschromic macules (38.0% of patients) and ocular sequelae were dominated by decreased visual acuity (14.1% of patients). In multivariate analysis, exposure to sulfadoxine (odds adjusted ratio = 5.95; 95%CI= [1.36-31.35]) and moderate (adjusted odds ratio = 5.85; 95%CI = [1.23-31.81]) or severe (adjusted odds ratio = 48.30; 95%CI = [6.25-1063.66]) ocular involvement at acute stage were associated with ocular sequelae.

Conclusion

Ocular and mucocutaneous sequelae are common in SJS/TEN survivors. Exposure to sulfadoxine and severity of acute ocular involvement are risk factors of ocular sequelae.

Effectiveness of photodynamic therapy with verteporfin combined with intrastromal bevacizumab for corneal neovascularization in Stevens-Johnson syndrome

PURPOSE

To investigate the effectiveness of combined photodynamic therapy with verteporfin and intrastromal injection of bevacizumab for the treatment of corneal neovascularization in patients with Stevens-Johnson syndrome (SJS).

METHODS

Eight eyes of eight patients with SJS having corneal neovascularization who were refractory to 1% prednisolone instillation received photodynamic therapy with verteporfin (6 mg/m²) combined with intrastromal bevacizumab injection (2.5 mg/0.1 mL). Best-corrected visual acuity and intraocular pressure were assessed, and slit-lamp biomicroscopic examination was performed before treatment and at 1 week and every month. A chronic ocular manifestation score was assigned based on the involvement area or the severity before treatment. The cumulative length of corneal blood vessels and area of corneal neovascularization were measured by anterior segment photographs before and after treatment.

RESULTS

At 3 and 6 months after treatment, all eyes showed regression of corneal neovascularization. Complete regression was achieved in five eyes (62.5%) and partial regression in three eyes (37.5%). Among five patients who were followed up for more than 1 year, two eyes maintained complete regression and one eye maintained partial regression at 1 year. However, two eyes with severe chronic ocular manifestation showed revascularization.

CONCLUSIONS

Combined photodynamic therapy with intrastromal bevacizumab injection can effectively inhibit corneal neovascularization in patients with SJS. However, patients with severe chronic ocular manifestation may exhibit revascularization.