Ocular Manifestations and Outcomes in Children With Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Comparison With Adult Patients.

PURPOSE: To compare the clinical features and visual outcomes in children and adults with Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). DESIGN: Retrospective comparative case series. METHODS: This retrospective study included 280 eyes of 140 patients (35 children and 105 adults) with SJS/TEN treated between 2010 and 2020. The primary outcome measures were the final best-corrected visual acuity (BCVA) and severity of dry eye. The secondary outcome measure was the medical and surgical therapies used. RESULTS: Among 64 eyes of children recruited in the study, acute ocular involvement was found in 58 eyes (90.6%). The chronic score in pediatric patients was significantly higher than that in adult patients (P = .004). The use of antibiotics/nonsteroidal anti-inflammatory drugs (NSAIDs) and Mycoplasma infection were the more common etiologies in children. In all, 75% of eyes in children maintained a visual acuity of 20/40 or better at a mean follow-up time of 4.3 years. The severity of dryness was comparable between the child and adult groups. The proportion of eyes undergoing amniotic membrane and oral mucosa transplantation was significantly higher in children than in adults in the chronic stage, reflecting that children exhibit much more severe complications. CONCLUSIONS: Although pediatric SJS/TEN patients have more severe ocular complications than adults, most children maintain long-term good vision. Early intervention and aggressive treatment help to preserve vision.

Microbial Keratitis in Patients With Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: Experience From a Tertiary Centre in Taiwan.

PURPOSE: The purpose of this study was to analyze the clinical features, causative microorganisms, antibiotic susceptibility, and treatment outcomes in culture-proven microbial keratitis (MK) in patients with Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) and to analyze the potential risk factors. METHODS: We reviewed the medical records of all patients with SJS/TEN who attended our department between 2009 and 2018. Patients with a diagnosis of MK who underwent corneal cultures were enrolled. Demographics; clinical characteristics including ocular findings, treatment, time between onset of SJS/TEN and keratitis; changes in visual acuity; culture results; and antibiotic susceptibility were analyzed. Culture results from prior conjunctival swabs and keratitis were also compared. RESULTS: Sixteen eyes from 12 patients (mean age 40.1 ± 27.7 years) with MK were identified. These patients had the most severe ocular involvement in the acute stage and had more severe ocular complications (SOCs) in the chronic stage compared with patients with SJS/TEN without MK. There were 26 infection episodes during 4.4 ± 6.9 (1.0-25.8) years of follow-up. Oral nonsteroidal anti-inflammatory drugs accounted for half of the causative drugs. Severe dry eye was the most common predisposing factor, followed by topical steroid use, trichiasis, and lid margin keratinization. Staphylococcus was the most common pathogen, and over half of the gram-positive bacteria were resistant to oxacillin/methicillin. Fungal infections (notably Candida ) accounted for nearly one-third of the causative microorganisms. Culture reports from periodic conjunctival swabs were not consistent with those from corneal scrapings. Recurrence of infection was associated with inferior visual outcome. CONCLUSIONS: Patients with SJS/TEN with SOCs are subject to recurrent corneal infections, which are responsible for deterioration of vision. Identifying the risk factors and aggressive treatment as early as possible is pivotal for infection control.

Tear function in patients with diabetes mellitus: A systematic review and meta-analysis.

Purpose: To examine tear function in patients with diabetes mellitus (DM). Design: Systematic review and meta-analysis. Method: We searched Embase and PubMed from database inception to March 16, 2022. We included observational studies that compared tear function between patients with and without DM. Tear function was measured using invasive tear breakup time (ITBUT) and Schirmer's 1 test. Pooled results are presented as standard mean difference (SMD) with 95% confidence interval (CI) based on random-effects models. Results: We included 59 studies (7,234 eyes) comparing the tear function between patients with and without DM. This meta-analysis indicated that patients with DM had worse tear function than those without DM (ITBUT: SMD: -0.98, 95% CI: -1.27 to -0.69; Schirmer's 1 test: SMD: -0.45, 95% CI: -0.64 to -0.26), and the results remained consistent in patients with different types of DM (e.g., type 1 DM and type 2 DM) and from different ethnic backgrounds (e.g., Asian vs. non-Asian). Patients with DM under poor glycemic control had worse tear function than those of the non-DM group (ITBUT: SMD: -1.26, 95% CI: -1.86 to -0.66; Schirmer's 1 test: SMD: -0.25, 95% CI: -0.48 to -0.02), whereas there were no significant differences in tear function between patients with DM under optimal glycemic control and non-DM groups. Conclusions: We found that patients with type 1 or type 2 DM had significantly reduced tear function. The level of tear function could be determined by glycemic control, and therefore, our findings suggest that glycemic control in patients with DM is critical for maintaining tear function. Systematic Review Registration: https://www.crd.york.ac.uk/prospero, identifier CRD42021250498.

Dry eye disease in patients with type II diabetes mellitus: A retrospective, population-based cohort study in Taiwan.

Purpose: To investigate the risk and protective factors of dry eye disease (DED) in patients with type II diabetes mellitus (DM). Design: A retrospective cohort study using Chang- Gung research database collecting data from 2005 to 2020. Methods: Patients with type II DM were included, and those with previous ocular diseases were excluded. Ten thousand twenty nine developed DED (DED group), and 142,491 didn't (non-DED group). The possible risk and protective factors were compared and analyzed using the logistic regression model. Results: A majority of the DED group were female with significantly higher initial and average glycated hemoglobin levels, and higher incidence of diabetic neuropathy and retinopathy. In conditional logistic regression model, advanced age was a risk factor. After adjusting for sex, age, and DM duration; average glycated hemoglobin level, diabetic neuropathy, retinopathy, and nephropathy with eGFR 30 ~ 59 and intravitreal injection, vitrectomy, pan-retinal photocoagulation, and cataract surgery were contributing factors of DED. Considering antihyperglycemic agents, DPP4 inhibitor, SGLT2 inhibitor, GLP-1 agonist, and insulin monotherapy and dual medications combining any two of the aforementioned agents were protective factors against DED compared with metformin alone. In the monotherapy group, SLGT2 inhibitor had the lowest odds ratio, followed by GLP1 agonist, DPP4 inhibitor, and insulin. Conclusions: DED in patients with DM is associated with female sex, advanced age, poor diabetic control, microvascular complications and receiving ocular procedures. GLP-1 agonist, SGLT-2 inhibitor, DPP4 inhibitor, and insulin are superior to metformin alone in preventing DM-related DED. A prospective randomized control trial is warranted to clarify our results.

Clinical Aspects of Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis With Severe Ocular Complications in Taiwan.

Purpose: Over the last decade, there has been tremendous progress in the treatment of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). To understand whether this has resulted in better ophthalmic outcomes, we aimed to study the incidence of severe ocular complications (SOCs) in the acute and chronic stage among SJS/TEN patients, major causative medications, and therapeutic effect of medical and surgical treatment. Methods: Using electronic medical records review of patients of Chang Gung Memorial Hospital Linkou Branch from 2010 to 2020, 119 patients (236 eyes) received ophthalmic consultation during the acute stage and were retrospectively studied. Sotozono's grading score systems for acute and chronic SJS/TEN were employed for accessing correlation between acute and chronic presentations, the therapeutic effect of systemic etanercept treatment, and outcome of early amniotic membrane transplantation (AMT) performed in patients with severe acute SOCs. Results: There were 46 male and 73 female patients with a mean age of 45.6 ± 22.7 years old (2-90 years), and follow-up time of 408.3 ± 351.0 (116-1,336) days. The numbers of patients with SJS, overlap syndrome, and TEN were 87, 9, and 23, respectively. In total, 109 eyes (55 patients) had acute SOCs, which comprised 46.2% of patients who underwent ophthalmic examination. Antiepileptics were the most common category of culprit drugs causing SOCs in the acute stage. At the end of follow-up, there were 14 eyes (9 patients) with chronic SOCs (5.9%), and non-steroidal anti-inflammatory drugs and cold medicine were the most common causative medications that were associated with severe chronic sequela. The correlation between Sotozono's acute and chronic grading score showed a positive relationship [Spearman's rank correlation coefficient (r) = 0.52, p < 0.001]. The average chronic grading scores in patients receiving systemic corticosteroid combined with etanercept treatment were significantly lower than those receiving corticosteroid only, Finally, the average chronic grading scores in patients receiving AMT <7 days after onset were significantly lower than those performed beyond 7 days. Conclusion: Our study implies that acute manifestation can be an indicator for chronic sequelae. Additional early etanercept treatment and early AMT showed beneficial effect in reducing chronic ocular sequela.

Laser Acupuncture Improves Tear Film Stability in Patients with Dry Eye Disease: A Two-Center Randomized-Controlled Trial.

Objectives: To investigate the efficacy of laser acupuncture (LA) therapy in patients with dry eye disease (DED). Design: A two-center randomized controlled trial. Settings/Location: The Department of Ophthalmology, Chinese Medicine at the Kaohsiung Chang Gung Memorial Hospital, and the Sunming Eye Clinic in South Taiwan. Subjects: Fifty-nine participants ages 20 to 65 years were enrolled and randomly assigned to the experimental group (LA plus conventional treatment) or the sham control group (LA without laser output plus conventional treatment). Interventions: Subjects underwent LA treatment three times a week for 12 weeks. The subjects in the experimental group sequentially received 0.375 J of energy at each of the following acupoints: BL2, TE23, ST2, LI4, ST36, and GB37. Subjects in the control group received a sham LA treatment, without any laser output. Outcome Measures: The primary outcome measure was ocular surface disease index (OSDI). The secondary outcome measures included tear film breakup time (TFBUT), Schirmer-I test finding, and visual analog scale (VAS) score. Results: At 4 and 12 weeks after the first visit, the experimental group showed significant improvement of dry eye symptoms as measured by OSDI, TFBUT, Shirmer-I test, and VAS. Compared with the control group, the OSDI (7.23, p = 0.001) and TFBUT (-1.78, p = 0.001) significantly improved in the experimental group at 12 weeks of treatment. Conclusions: LA improved the symptoms and tear stability related to DED in conjunction with conventional treatment. The authors suggest that LA be considered a complementary therapy for DED when conventional treatment does not provide satisfactory effects. Trial Registration: ClinicalTrials.gov Identifier NCT03204903.

Effect of laser acupuncture on dry eye: A study protocol for a 2-center randomized controlled trial.

BACKGROUND: Dry eye is a common ophthalmologic disorder that causes ocular discomfort and has become a worldwide health concern. Patients with dry eye often turn to complementary and alternative medicine (CAM) because of unsatisfactory conventional treatments. Acupuncture is one of the most popular interventions of CAM used, and laser acupuncture (LA) is a noninvasive technique. METHODS: This protocol is a 2-center randomized controlled trial investigating the effect of laser acupuncture on dry eye. Two hundred participants aged 20 to 65 years will be randomly assigned to the experimental group (LA plus conventional treatment) or the sham control group (LA without laser output plus conventional treatment) at 2 clinical research centers in South Taiwan. The subjects will undergo LA treatment thrice a week for 12 weeks. The subjects in the experimental group will sequentially receive 0.375 J of energy at each of the following acupoints: BL2, TE23, ST2, LI4, ST36, and GB37. The subjects in the control group will also receive a sham LA treatment, without any laser output. Outcome assessments will include evaluation of the ocular surface disease index (OSDI), tear film break-up time (TFBUT), Schirmer-I test finding, and the visual analog scale (VAS) score at 4 and 12 weeks before treatment. The OSDI, TFBUT, Schirmer-I test result, and VAS score of the participants will be analyzed and compared between the experimental and control groups using the paired t test and one-way analysis of variance. OBJECTIVES: The aim of this protocol is to investigate the efficacy of LA therapy in patients with dry eye. TRIAL REGISTRATION: ClinicalTrials.gov NCT03204903.