Amniotic Membrane With Living Related Corneal Limbal/Conjunctival Allograft for Ocular Surface Reconstruction in Stevens-Johnson Syndrome

Abstract

Objective: To report the use of preserved amniotic membrane and living related corneal limbal/conjunctival transplantation in total limbal stem cell and conjunctival deficiency secondary to severe Stevens-Johnson syndrome.Design: Prospective, noncomparative, interventional case series.Patients and Methods: Ten eyes of 10 patients with total limbal stem cell and conjunctival deficiency secondary to Stevens-Johnson syndrome underwent excision of cicatricial tissue followed by amniotic membrane and living related corneal limbal/conjunctival transplantation. Main Outcome Measures:Reconstruction of corneal epithelium (clear appearance without epithelial defect, normal fluorescein permeability, and the absence of conjunctiva-derived goblet cells on impression cyto-logic testing), decrease in corneal vascularization, and improvement in visual acuity.Results: During a mean follow-up of 16.7 months, satisfactory ocular surface reconstruction was obtained in 2 eyes (20%), with reduced inflammation and vascularization and a mean epithelialization time of 3 weeks. Surgical failure was observed in 4 cases (40%) and complications (infection) in 4 cases (40%). Visual acuity improved in 4 eyes (40%), remained stable in 5 eyes (50%), and decreased in 1 eye (10%).Conclusions: Amniotic membrane and living related corneal limbal/conjunctival transplantation were successful in 20% of severe cases of total limbal stem cell and conjunctival deficiency secondary to Stevens-Johnson syndrome. A high proportion of postoperative complications, in particular, infection, seemed to jeopardize a favorable outcome.

Modified tectonic keratoplasty with minimal corneal graft for corneal perforation in severe Stevens - Johnson syndrome: a case series study

“…Also, because the amniotic membrane cannot control corneal melting effectively in dry eyes [18], it does not seem to work well in patients with SJS [6,10], which was further confirmed in 6 patients in this study. Conjunctival flaps could be used for small eccentric corneal perforations [1], but could not seal large corneal perforations associated with corneal melting because the leap would continue under the flap [19,20].…”

Modified tectonic keratoplasty with minimal corneal graft for corneal perforation in severe Stevens - Johnson syndrome: a case series study

“…Also, because the amniotic membrane cannot control corneal melting effectively in dry eyes [18], it does not seem to work well in patients with SJS [6,10], which was further confirmed in 6 patients in this study. Conjunctival flaps could be used for small eccentric corneal perforations [1], but could not seal large corneal perforations associated with corneal melting because the leap would continue under the flap [19,20].…”

Stevens–Johnson Syndrome and Toxic Epidermal Necrolysis: A Systematic Review of Ophthalmic Management and Treatment

“…A total of 5409 unique studies were captured in our search, with 301 moving to full-text review; 5108 studies were excluded at the title and abstract stage because they did not focus on ophthalmic SJS/TEN or lacked measurable ocular outcomes. In total, 194 studies were included in the review ( Figure 1 ) [ 7 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 …”

Contemporary limbal stem cell transplantation – a review

“…Criteria for success are related to health of the ocular surface and relief from symptoms if any, on one hand and improvement of vision on the other. Despite the patient and surgeon commitment that is required, the procedures are worth pursuing where indicated as several studies have reported both short‐term 49–53 and long‐term 48,54–58 success. Often the actual improvement in visual acuity achieved is modest but it does make a significant difference to the patient's quality of life as we have recently ascertained by application of the NEI VQF 25, with some additional questions, to patients with limbal transplants 59 In general, the best results are obtained with auto grafts, next best with living related grafts and are modest with CD grafts, with most of these failing in 5 years 58 .…”

Modified tectonic keratoplasty with minimal corneal graft for corneal perforation in severe Stevens - Johnson syndrome: a case series study

“…Also, because the amniotic membrane cannot control corneal melting effectively in dry eyes [18], it does not seem to work well in patients with SJS [6,10], which was further confirmed in 6 patients in this study. Conjunctival flaps could be used for small eccentric corneal perforations [1], but could not seal large corneal perforations associated with corneal melting because the leap would continue under the flap [19,20].…”

Stevens–Johnson Syndrome and Toxic Epidermal Necrolysis: A Systematic Review of Ophthalmic Management and Treatment

“…A total of 5409 unique studies were captured in our search, with 301 moving to full-text review; 5108 studies were excluded at the title and abstract stage because they did not focus on ophthalmic SJS/TEN or lacked measurable ocular outcomes. In total, 194 studies were included in the review ( Figure 1 ) [ 7 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 …”

Contemporary limbal stem cell transplantation – a review

“…Criteria for success are related to health of the ocular surface and relief from symptoms if any, on one hand and improvement of vision on the other. Despite the patient and surgeon commitment that is required, the procedures are worth pursuing where indicated as several studies have reported both short‐term 49–53 and long‐term 48,54–58 success. Often the actual improvement in visual acuity achieved is modest but it does make a significant difference to the patient's quality of life as we have recently ascertained by application of the NEI VQF 25, with some additional questions, to patients with limbal transplants 59 In general, the best results are obtained with auto grafts, next best with living related grafts and are modest with CD grafts, with most of these failing in 5 years 58 .…”

Modified tectonic keratoplasty with minimal corneal graft for corneal perforation in severe Stevens - Johnson syndrome: a case series study

“…Also, because the amniotic membrane cannot control corneal melting effectively in dry eyes [18], it does not seem to work well in patients with SJS [6,10], which was further confirmed in 6 patients in this study. Conjunctival flaps could be used for small eccentric corneal perforations [1], but could not seal large corneal perforations associated with corneal melting because the leap would continue under the flap [19,20].…”

Stevens–Johnson Syndrome and Toxic Epidermal Necrolysis: A Systematic Review of Ophthalmic Management and Treatment

“…A total of 5409 unique studies were captured in our search, with 301 moving to full-text review; 5108 studies were excluded at the title and abstract stage because they did not focus on ophthalmic SJS/TEN or lacked measurable ocular outcomes. In total, 194 studies were included in the review ( Figure 1 ) [ 7 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 …”

Contemporary limbal stem cell transplantation – a review

“…Criteria for success are related to health of the ocular surface and relief from symptoms if any, on one hand and improvement of vision on the other. Despite the patient and surgeon commitment that is required, the procedures are worth pursuing where indicated as several studies have reported both short‐term 49–53 and long‐term 48,54–58 success. Often the actual improvement in visual acuity achieved is modest but it does make a significant difference to the patient's quality of life as we have recently ascertained by application of the NEI VQF 25, with some additional questions, to patients with limbal transplants 59 In general, the best results are obtained with auto grafts, next best with living related grafts and are modest with CD grafts, with most of these failing in 5 years 58 .…”