Amniotic membrane therapy in the acute phase of toxic epidermal necrolysis

Abstract

Toxic epidermal necrolysis (TEN) is an uncommon but devastating immune reaction with bullous inflammation of the skin and mucous membranes. It often occurs as a reaction to medication but can occur in association with systemic infections as well. Fatal outcomes have been the rule in the past, with mortality as high as 70% to 90% of cases. TEN is the extreme end of a spectrum that includes erythema multiforme and Stevens-Johnson syndrome. Ocular inflammatory involvement is frequent in the acute phase and results in chronic scarring and vascularization of the ocular surface as well as dry eye disease. Survival rates are improving to the range of 70% with new approaches to therapy, particularly with rapid transfer of the patient to and management in specialized burn treatment units, where newer therapies of immunomodulation and plasmapheresis can be employed along with aggressive prophylaxis of secondary bacterial infection and sepsis. With improved survival, however, has come a greater prevalence of ocular surface problems that decrease quality of life with frequent photophobia (54%) and dry eye (31%) as well as symblepharon and corneal vascularization. The adverse consequences of the disease are especially problematic to the pediatric patient. Management of the chronic sequelae of TEN has been attempted with buccal mucosal grafting with some success, but more recently the use of amniotic membrane transplantation (AMT) has been advocated for surgical repair of the ocular surface damage resulting fromTEN. Therapy for the acute inflammatory phase of TEN, however, has only recently considered the use of AMT. Previously, the management of the acute ocular involvement of TEN included application of topical steroids, frequent lysis of adhesions between the tarsal and bulbar conjunctiva, and occasionally the use of bandage soft contact lenses. The use of AMT to suppress inflammation, prevent conjunctival adhesions, and protect the corneal surface is finding greater acceptance as indicated in the article by Tandon et al in this issue of the Journal of AAPOS. Candidates for AMT are typically on ventilator support and are heavily sedated so that application of the amniotic mem-