Amniotic membrane therapy in the acute phase of toxic epidermal necrolysis

Gary N. Foulks, MD, FACS

oxic epidermal necrolysis (TEN) is an uncommon but devastating immune reaction with bullous inammation 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 inammatory 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.1,2 The adverse consequences of the disease are especially problematic to the pediatric patient.3 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 from TEN.4 Therapy for the acute inammatory phase of TEN, however, has only recently considered the use of AMT.5,6 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 inammation, prevent conjunctival adhesions, and protect the corneal surface is nding greater acceptance as indicated in the article by Tandon et al7 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 memAuthor afliations: University of Louisville School of Medicine, Louisville, Kentucky Submitted October 1, 2007. Revision accepted October 3, 2007. Reprint requests: Gary N. Foulks, MD, FACS, Arthur and Virginia Keeney Professor of Ophthalmology, University of Louisville School of Medicine, 301 East Muhammad Ali Boulevard, Louisville, KY 40202 (email: gnfoul01@gwise.louisville.edu) J AAPOS 2004;11:531. Copyright 2004 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/2004/$35.00 0 doi:10.1016/j.jaapos.2007.10.001

branes can be done in the burn unit after appropriate preparation with topical dilute betadine solution. Adequate sedation is particularly important for the pediatric patient, although postoperative discomfort is usually less than the discomfort of the active inammation of TEN. The AMT eliminates the need for daily lysis of incipient symblepharon; this is particularly advantageous in children. The details of application of the AMT have varied depending upon the surgeon and the degree of involvement of the ocular surface. When there is loss of corneal epithelium, application of the AMT across the entire anterior ocular surface with reection into the conjunctival fornix has been used. When the corneal epithelium is intact, smaller size amniotic membrane segments have been placed over the involved conjunctival surfaces and over the lid margin, much as described by Tandon et al.7 Most often the AMT is secured with sutures to the eyelid and ocular surface, but the membrane can be held in place with brin glue (Tisseel; Baxter International Inc., Baxter.com). When faced with the severe inammatory reaction that has damaged the eyelid margin, tarsal and bulbar conjunctiva, and especially the cornea, practitioners are well advised to consider the option of amniotic membrane transplantation in the acute phase of the illness to prevent symblepharon and the long-term ocular complications of TEN. Given the tendency of children to develop more severe inammation and greater scarring, the use of AMT to reduce inammation and limit the degree of scarring can be advantageous in both the acute and the chronic stages of the disease.
References
1. Haber J, Hopman W, Gomez M, Cartotto R. Late outcomes in adult survivors of toxic epidermal necrolysis after treatment in a burn center. J Burn Care Rehabil 2005;26:33-41. 2. Oplatek A, Brown K, Sen S, Halerz M, Supple K, Gamelli RL. Long term follow up of patients treated for toxic epidermal necrolysis. J Burn Care Res 2006;27:26-33. 3. Sheridan RL, Schulz JT, Ryan CM, Schnitzer JJ, Lawlor D, Driscoll DN, et al. Long term consequences of toxic epidermal necrolysis in children. Pediatrics 2002;109:74-8. 4. Solomon A, Espana EM, Tseng SC. Amniotic membrane transplantation for reconstruction of the conjunctival fornices. Ophthalmology 2003;110:93-100. 5. John T, Foulks GN, John ME, Cheng K, Hu D. Amniotic membrane in the surgical management of acute toxic epidermal necrolysis. Ophthalmology 2002;109:351-60. 6. Kobayashi A, Yoshita T, Sugiyama K, Miyashita K, Niida Y, Koizumi S, et al. Amniotic membrane transplantation in acute phase of toxic epidermal necrolysis with severe corneal involvement. Ophthalmology 2006;113:126-32. 7. Tandon A, Cackett P, Mulvihill A, Fleck B. Amniotic membrane grafting for conjunctival and lid surface disease in the acute phase of toxic epidermal necrolysis. J AAPOS 2007;11:612-13.

Journal of AAPOS

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