Severe eye complications from Stevens-Johnson syndrome in a human immunodeficiency virus-infected patient in Malawi

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.

[Factors associated with the severity of acute ocular involvement in Stevens-Johnson syndrome and toxic epidermal necrolysis in sub-Saharan Africa]

AIM

The purpose of this study was to identify risk factors associated with the severity of acute ocular involvement in Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) in sub-Saharan Africa.

PATIENTS AND METHOD

A retrospective study was carried out at the dermatology department in collaboration with the ophthalmology department for SJS/TEN patients between January 2000 and December 2016 in Lomé (Togo). The severity of acute ocular involvement was evaluated using the Power classification, and the drug eruption score was assessed using de Bastuji-Garin classification.

RESULTS

A total of 107 cases of SJS/TEN (84 cases of SJS, 20 cases of TEN and 3 cases of overlap syndrome) were analyzed. There were 71 women and 36 men, with an average age of 32.3±12.5 years (range: 5 to 75 years). Sulfonamides (37.4%) were the most commonly used drugs followed by nevirapine (22.4%). HIV serology was positive in 46 (58.2%) of the 79 patients tested. A total of 54 (50.5%) patients had acute ocular involvement, which was mild in 29.9% of patients, moderate in 13.1% and severe in 7.5%. In multivariate analysis, exposure to sulfadoxine was the sole factor associated with moderate or severe acute ocular involvement in SJS/TEN (adjusted odds ratio=3.3; 95% CI=[1.1; 10.2]).

CONCLUSION

Exposure to sulfadoxine was identified in our study as a risk factor associated with the severity of acute ocular involvement in SJS/TEN. Multicenter studies should be conducted in sub-Saharan Africa to confirm this associated risk factor.

TFOS DEWS II pathophysiology report

The TFOS DEWS II Pathophysiology Subcommittee reviewed the mechanisms involved in the initiation and perpetuation of dry eye disease. Its central mechanism is evaporative water loss leading to hyperosmolar tissue damage. Research in human disease and in animal models has shown that this, either directly or by inducing inflammation, causes a loss of both epithelial and goblet cells. The consequent decrease in surface wettability leads to early tear film breakup and amplifies hyperosmolarity via a Vicious Circle. Pain in dry eye is caused by tear hyperosmolarity, loss of lubrication, inflammatory mediators and neurosensory factors, while visual symptoms arise from tear and ocular surface irregularity. Increased friction targets damage to the lids and ocular surface, resulting in characteristic punctate epithelial keratitis, superior limbic keratoconjunctivitis, filamentary keratitis, lid parallel conjunctival folds, and lid wiper epitheliopathy. Hybrid dry eye disease, with features of both aqueous deficiency and increased evaporation, is common and efforts should be made to determine the relative contribution of each form to the total picture. To this end, practical methods are needed to measure tear evaporation in the clinic, and similarly, methods are needed to measure osmolarity at the tissue level across the ocular surface, to better determine the severity of dry eye. Areas for future research include the role of genetic mechanisms in non-Sjögren syndrome dry eye, the targeting of the terminal duct in meibomian gland disease and the influence of gaze dynamics and the closed eye state on tear stability and ocular surface inflammation.

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

Purpose. To study the correlation between demographics and clinical variables and long-term severe visual impairment in patients with Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN). Methods. A retrospective chart review of SJS/TEN patients between 2004 and 2014 was conducted. Demographics, causative agents, ocular manifestations, and visual outcomes were collected. The data were analyzed using a multivariate logistic regression model. Results. Of the 89 patients including SJS (65, 73.03%), TEN (15, 16.85%), and SJS-TEN overlap (9, 10.11%), 55 were female. The mean age was 41.58 ± 19.17 years. The most common identified agents were medications. Among these groups, antibiotics were the most prevalent (47.19%). Three patients (3.7%) had unknown etiology. Antibiotics and nonpharmaceutical triggers were significantly associated with long-term severe visual impairment (odds ratio 4.32; P = 0.015 and 7.20; P = 0.037, resp.). There was a significant negative relationship between HIV infection and long-term severe visual impairment (P = 0.021). Among all chronic ocular complications, only corneal neovascularization significantly correlated with severe visual impairment (P = 0.001). Conclusions. SJS/TEN patients caused by nonpharmaceutical triggers or antibiotics have an increased risk of developing long-term severe visual impairment from corneal neovascularization. HIV infection might be a protective factor against long-term poor visual outcomes.