Severe corneal burn due to the accidental application of salicylic acid packed in a plastic dropper bottle / Quemadura corneal grave debida a la aplicación accidental de ácido salicílico envasado en un frasco gotero plástico

Eye burns due to the accidental application of pharmacological or nonpharmacological substances packaged in plastic dropper bottles have been described for more than three decades and continue to occur. These burns can cause potentially serious corneal injuries. We report the case of a patient who mistakenly applied salicylic acid to the right eye after confusing it with an eye lubricant, which caused him a severe corneal burn. Fortunately, after aggressive medical and surgical management (including oxygen therapy and amniotic membrane grafting), the visual results were good. We suggest conducting educational campaigns and taking legislative measures in our country to avoid packaging corrosive substances in this type of dropper bottle to reduce the risk of accidental burns.

Las quemaduras oculares por aplicación accidental de sustancias farmacológicas o no farmacológicas envasadas en frascos goteros plásticos, se han descrito desde hace más de tres décadas y siguen ocurriendo. Estas quemaduras pueden causar lesiones potencialmente graves de la córnea. Se presenta el caso de un paciente que se aplicó ácido salicílico en el ojo derecho al confundir el envase con el de un lubricante ocular, lo que le causó una grave quemadura corneal. Afortunadamente, tras un manejo médico y quirúrgico agresivo (incluida oxigenoterapia e injerto de membrana amniótica) los resultados visuales fueron buenos. Se sugiere hacer campañas educativas y adoptar normas en el país para evitar el envase de sustancias corrosivas en este tipo de frascos goteros, con el fin de disminuir el riesgo de quemaduras accidentales.

Secuelas oftalmológicas secundarias a Síndrome de Stevens - Johnson / Ophthalmic sequelae due to Stevens - Johnson syndrome / Sequelas oftalmológicas secundárias à Síndrome de Stevens - Johnson

Figura A. Simblefaron, es decir adherencia de los bordes de los dos párpados (flecha blanca) y queratinización del limbo esclero-corneal (flecha amarilla) en el ojo derecho. Figura B. Ojo derecho: irregularidad del borde del párpado inferior con obstrucción completa y queratinización de los puntos de drenaje de las Glándulas de Meibomio, como consecuencia de la inflamación crónica secundaria al Síndrome de Stevens - Johnson. Figura C. Ojo derecho: conjuntivalización completa por falla del limbo y pérdida del epitelio corneal en el ojo derecho de la paciente, llevando a una córnea totalmente opaca como secuela del ojo seco severo crónico secundario al síndrome de Stevens - Johnson. Figura D. Ojo izquierdo: queratoprótesis de Boston Tipo I in situ. Se aprecia el cilindro central que permite el paso de la luz al interior del ojo. Los agujeros que translucen a través del tejido se encuentran en la placa de titanio que sostiene fijo el cilindro óptico al tejido corneal de un donante, que se suturó a la córnea periférica de la paciente. Ese tejido corneal donante se encuentra completamente conjuntivalizado y opaco, pero el extremo del cilindro óptico, al ser de material sintético, mantiene la transparencia. Se evidencia queratinización de la superficie con acúmulo de queratina en la interfase entre el material sintético del cilindro y el tejido corneal.

Figure A. Symblepharon, i.e., adhesion from the edges of the two eyelids (white arrow) and keratinization of the sclerocorneal limbus (yellow arrow) in the right eye. Figure B. Right eye: irregularity from the edge of the lower eyelid with complete obstruction and keratinization of the excretory ducts of the Meibomian glands, due to chronicity of the inflammation in consequence to Stevens - Johnson syndrome. Figure C. Right eye: showing complete conjunctivalization due to limbus failure and loss of the corneal epithelium in the patient's right eye, leading to corneal haze as a sequel to chronic severe dry eye secondary to Stevens - Johnson syndrome. Figure D. Left eye: Boston type I keratoprosthesis in situ. As showed, the central cylinder allows light to enter through the eye. The holes seen through the tissue are on the titanium plate that holds the optical cylinder in place on the corneal tissue of a donor, sutured to the patient's peripheral cornea. This donor corneal tissue is completely conjunctivalized and hazy, but since the end of the optical cylinder is made of synthetic material, it remains transparent. Keratinization of the surface is evident, with an accumulation of keratin in the interface between the synthetic material of the cylinder and the corneal tissue.

Figura A. Simbléfaro, ou seja, aderência das bordas das pálpebras (seta branca) e queratinização do limbo esclerocorneano (seta amarela) no olho direito. Figura B. Olho direito: irregularidade da borda da pálpebra inferior com obstrução completa e queratinização dos pontos de drenagem das glândulas meibomianas, como consequência da inflamação crônica secundária à síndrome de Stevens - Johnson. Figura C. Olho direito: conjuntivalização completa devido a falha do limbo e perda do epitélio corneano no olho direto da paciente, ocasionando uma córnea completamente opaca como sequela do olho seco crônico grave secundário à síndrome de Stevens-Johnson. Figura D. Olho esquerdo: ceratoprótese de Boston Tipo I in situ. O cilindro central que permite a passagem da luz para o olho é apreciado. Os orifícios translúcidos através do tecido estão na placa de titânio que segura o cilindro óptico ao tecido corneano de um doador, o qual foi suturado à córnea periférica da paciente. Esse tecido corneano doado está completamente conjuntivalizado e opaco, mas o extremo do cilindro óptico, por ser feito de material sintético, mantém a transparência. É evidente a queratinização da superfície com acúmulo de queratina na interface entre o material sintético do cilindro e o tecido corneano.

Uso de inmunoglobulina humana endovenosa en pacientes con necrolisis epidérmica tóxica y síndrome de sobreposición Stevens Johnson necrolisis tóxica epidérmica / Use of intravenous immunoglobulin for the treatment of toxic epidermal necrolysis and Stevens-Johnson/toxic epidermal necrolysis overlap syndrome. Review of 15 cases

Background: Toxic epidemial necrolysis (TEN) is an acute adverse drug reaction, that has an unpredictable progression and a 30 percent mortality. The incidence of TEN in the general population is approximately 0.4 to 1.2 cases/million/year. It is characterized pathologically by keratinocyte apoptosis which leads to epidemial detachment. Keratinocyte apoptosis is triggered by activation of the Fas-FasL, pathway and could be prevented by the use of intravenous immunoglobulin (IVIG). Aim: To report the experience with the use of IVIG in TEN. Material and methods: Retrospective study of 15 patients with a diagnosis of Stevens-Johnson/TEN overlap (SJS/TEN) or TEN, that received a total dose of 23 ± 0.6 mg/kg of IVIG over aperiod of 3 to 4 days. The infusion was initiated during the first 24 hours after diagnosis and was associated with standard care for burn victims. Steroids were avoided if the patient was not in chronic steroidal therapy. Results: All patients responded to IVIG in a lapse of 46.4 ± 14.2 hours from the beginning of infusion. Eighty percent of patients survived, but one developed acute renal failure due to IVIG, and another became blind due to corneal opacities, a complication of TEN. Those who survived were discharged after a lapse of 19-8 ± 6.6 days from the beginning of the disease. Conclusions: Despite the lack of blind, multicentric and randomized trials, we agree with some international studies that IVIG is beneficial as a treatment for SSJ/NET and TEN.