Post-acute phase and sequelae management of epidermal necrolysis: an international, multidisciplinary DELPHI-based consensus

BACKGROUND

Long-term sequelae are frequent and often disabling after epidermal necrolysis (Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN)). However, consensus on the modalities of management of these sequelae is lacking.

OBJECTIVES

We conducted an international multicentric DELPHI exercise to establish a multidisciplinary expert consensus to standardize recommendations regarding management of SJS/TEN sequelae.

METHODS

Participants were sent a survey via the online tool "Survey Monkey" consisting of 54 statements organized into 8 topics: general recommendations, professionals involved, skin, oral mucosa and teeth, eyes, genital area, mental health, and allergy workup. Participants evaluated the level of appropriateness of each statement on a scale of 1 (extremely inappropriate) to 9 (extremely appropriate). Results were analyzed according to the RAND/UCLA Appropriateness Method.

RESULTS

Fifty-two healthcare professionals participated. After the first round, a consensus was obtained for 100% of 54 initially proposed statements (disagreement index < 1). Among them, 50 statements were agreed upon as 'appropriate'; four statements were considered 'uncertain', and ultimately finally discarded.

CONCLUSIONS

Our DELPHI-based expert consensus should help guide physicians in conducting a prolonged multidisciplinary follow-up of sequelae in SJS-TEN.

Going paperless: improved cataract surgery outcome data quality in a new fully electronic unit

OBJECTIVES

To report outcome data on the first 5000 consecutive cataract cases at a new paperless eye unit and benchmark against the Royal College of Ophthalmologists' National Ophthalmology Database (RCOphth NOD).

METHODS

Using the in-built audit tool of the electronic medical records system, data from all cataract operations performed between 1 April 2014 and 13 January 2017 were compiled.

RESULTS

Five thousand and eight cases were recorded of which the overall intra-operative complication rate was 2.4%, the most common being posterior capsular rupture-1.14%. Follow-up data on post-operative complications were recorded in 98.6% of cases. Pre- and post-operative visual acuities was measured in 98.0% of cases. In all, 40.8% of eyes achieved a visual acuity of 6/6 or better and 90.7% achieved 6/12 or better.

CONCLUSIONS

A data set of >5000 consecutive cataract operations was obtained in this eye department. The recording of pre- and post-operative visual acuity in 98% of cases compare very favourably to the RCOphth NOD Audit Report 2017 where pre- and post-operative visual acuities were recorded in only 57.1% of operations. Despite this difference, the outcome measures from this unit and RCOphth NOD were very similar, validating the results of the RCOphth NOD audit reports. Significantly, when applying the RCOphth NOD audit criteria for measuring post-operative visual acuity, approximately 15% of cases were excluded from the data set, reducing the completeness of the data set. Paperless ophthalmology units are feasible in today's NHS and can produce near complete cataract data sets; this can ultimately lead to more comprehensive and reliable aggregate cataract outcome data.

The effect of perioperative allergic conjunctivitis on corneal lymphangiogenesis after corneal transplantation

INTRODUCTION

Perioperative allergic conjunctivitis accelerates the speed of corneal allograft rejection. This study examines the effect of allergic conjunctivitis, with and without dexamethasone treatment, on the early inflammatory response and lymphangiogenesis in the host cornea following corneal transplantation.

METHODS

Allogeneic fully MHC-mismatched C57Bl/6 strain donor corneas were transplanted into naive A/J mice and into A/J mice with active allergic conjunctivitis. Further groups of allograft recipients with allergic conjunctivitis were treated post-operatively with twice daily topical dexamethasone 0.1% or phosphate-buffered saline. Mice were killed on days 2 and 6 and corneas were examined by (i) fluorescent immunohistochemistry of frozen sections using anti-CD11b, anti-F4/80 and anti-Gr-1 antibodies, or (ii) whole-mount staining with anti-LYVE-1 antibody. Lymphatic ingrowth and numbers of cells infiltrating the host cornea were compared between groups.

RESULTS

There were significantly higher numbers of CD11b(+) cells and LYVE-1(+) vessels in the host cornea at day 2 in allergic compared with naive recipients, but no differences between naive and allergic recipients at day 6. In allergic eyes, dexamethasone treatment significantly inhibited LYVE-1 expression at days 2 and 6, and significantly improved allograft survival in recipients with allergic conjunctivitis if maintained for a week.

CONCLUSIONS

The innate immune response to allogeneic corneal tissue is more vigorous in the presence of allergic conjunctivitis than in naive eyes and is associated with accelerated lymphatic ingrowth to host cornea. Topical dexamethasone inhibits lymphatic ingrowth and this may be one mechanism by which topical steroid enhances graft survival.

Use of ultrasonic pachymetry for measurement of changes in corneal thickness in mouse corneal transplant rejection

BACKGROUND/AIMS

Diagnosis of rejection in the mouse model of corneal transplantation is based on subjective judgement of loss of graft transparency. The aims of this study were to (1) evaluate a pachymetry technique to measure changes in mouse corneal thickness and (2) correlate increases in transplant thickness with clinical and histological features of rejection.

METHODS

Orthotopic corneal allografts (C57BL/6 strain donor) and syngeneic grafts were performed in A/J mice. Graft transparency was graded and corneal thickness measured by pachymetry on alternate days. Transverse sections of donor cornea excised from eyes representative of clinical opacity grades 1-4 were prepared, photographed, graft section thickness measured and stromal graft-infiltrating cells counted. Intraobserver and interobserver variations in pachymetry were statistically tested.

RESULTS

Graft thickness, as measured by pachymetry, increased with each clinical opacity grade. Thickness for opacity grades 0, 1 and 2 was less than 300 microm in all recipients. Graft thickness for grades 3 and 4 was greater than 300 microm in all cases. For measurements up to 400 mum, there was a good correlation between thickness as measured by in vivo pachymetry and in histopathological sections. The mean interobserver bias was -11.35 microm, while the mean intraobserver bias was +3.96 microm. Stromal cellularity increased with increasing corneal thickness up to approximately 300 microm.

CONCLUSION

In vivo graft pachymetry provides a new and reliable way to objectively diagnose rejection in the mouse model of corneal transplantation.

Aqueous humor alloreactive cell phenotypes, cytokines and chemokines in corneal allograft rejection

As biopsies are not taken at the time of human corneal allograft rejection, most information on the early cellular changes in rejection is from animal models. We examined the phenotype of alloreactive cells present in the human anterior chamber during corneal graft rejection by flow cytometry and quantified aqueous humor levels of cytokines and chemokines using cytometric bead array. Aqueous and peripheral blood samples were taken from patients with graft endothelial rejection (n = 11) and from control patients undergoing cataract surgery (n = 8). CD45(+)CD4(+), CD45(+)CD8(+) and CD45(+)CD14(+) cells were found in aqueous during rejection; no CD45(+) cells were seen in control samples. Higher proportions of CD45(+) cells found in aqueous during rejection were CD14(+), denoting monocyte/macrophage lineage, than were CD4(+) or CD8(+). Large elevations were seen in aqueous levels of IL-6, MCP-1 and IP-10 during rejection compared with controls; smaller but still statistically significant increases were seen in MIP-1alpha and eotaxin. The role of CD14(+) cells in allorejection is unclear as is the potential of these chemokines and their receptors as therapeutic targets. Aqueous humor samples offer a unique opportunity to analyze components of the allogeneic response in direct contact with donor tissue but without artifacts inherent in examination of tissue.

Dural AVM supplied by the ophthalmic artery

Dural arteriovenous malformations in the anterior cranial fossa are rare and are especially prone to haemorrhage. These lesions are usually treated by surgical excision. We report the embolization of an anterior cranial fossa DAVM using an endovascular approach via the ophthalmic artery.

Ocular injury in hurling

OBJECTIVES

To describe the clinical characteristics of ocular injuries sustained in hurling in the south of Ireland and to investigate reasons for non-use of protective headgear and eye wear.

METHODS

Retrospective review of the case notes of 310 patients who attended Cork University Hospital or Waterford Regional Hospital between 1 January 1994 and 31 December 2002 with ocular injuries sustained during a hurling match. A confidential questionnaire on reasons for non-use of protective headgear and eye wear was completed by 130 players.

RESULTS

Hurling related eye injuries occurred most commonly in young men. Fifty two patients (17%) required hospital admission, with hyphaema accounting for 71% of admissions. Ten injuries required intraocular surgical

INTERVENTION

retinal detachment repair (5); macular hole surgery (1); repair of partial thickness corneal laceration (1); repair of globe perforation (1); enucleation (1); trabeculectomy for post-traumatic glaucoma (1). Fourteen eyes (4.5%) had a final best corrected visual acuity (BCVA) of <6/12 and six (2%) had BCVA <3/60. In the survey, 63 players (48.5%) reported wearing no protective facemask while playing hurling. Impairment of vision was the most common reason cited for non-use.

CONCLUSIONS

Hurling related injury is a significant, and preventable, cause of ocular morbidity in young men in Ireland. The routine use of appropriate protective headgear and faceguards would result in a dramatic reduction in the incidence and severity of these injuries, and should be mandatory.

Supported employment as an intervention package: a preliminary analysis of functional variables

In this two-experiment investigation, the long-term (at least 6 months) employment of 51 moderately mentally retarded clients who were placed into 64 supported employment positions was first evaluated relative to 10 training and posttraining components that comprised a supported employment training package. In Experiment 1, chi-square analyses were used to identify three components that differentiated successful (employed for at least 6 months) from unsuccessful clients. In Experiment 2, 4 successful clients were further evaluated in a nonconcurrent multiple baseline design to determine whether the three variables identified during the group analysis (client advocate, collateral behavior, and follow-up plan) were included in the training packages. These results are discussed in terms of the need to establish better the functional variables of supported employment training programs.