Treatment Modalities and Clinical Outcomes in Ocular Sequelae of Stevens-Johnson Syndrome Over 25 Years--A Paradigm Shift.

PURPOSE: To highlight and compare the outcomes of management for the ocular sequelae of Stevens-Johnson syndrome (SJS) over 25 years in a tertiary eye care institute. METHODS: A retrospective chart review of 798 eyes of 399 patients with SJS evaluated between January 1990 and December 2004 (group I) and of 847 eyes of 517 patients between January 2005 and December 2014 (group II) was done. The primary and secondary outcome measures were a change in the best-corrected visual acuity (BCVA) and an improvement in the symptoms and the ocular surface status, respectively. The groups were subdivided into procedures for ocular surface stabilization (A) and visual rehabilitation (B) and those managed conservatively (C). RESULTS: In the subgroup A of group II, an improvement/stabilization of BCVA after punctal cautery (231 eyes), mucous membrane grafting for lid margin keratinization (393 eyes), and fornix reconstruction (28 eyes) was noted in 93.6% of eyes. In subgroup B, all 10 eyes that underwent limbal allograft in group I failed when compared with an improvement of BCVA to better than 20/200 in 65.5% of the 61 eyes that underwent keratoprostheses. It was noted that the limbal status worsened in 66.9% of eyes treated conservatively in group I. CONCLUSIONS: Stabilization procedures show a beneficial role while conservative management can lead to deterioration in chronic ocular sequelae of SJS. Keratoprosthesis, specifically the modified osteo-odonto-keratoprosthesis, forms the mainstay for visual rehabilitation in the end-stage disease. This study highlights the improved outcomes with a paradigm shift in the management modalities.

Modified osteo-odonto keratoprosthesis--the Indian experience--results of the first 50 cases.

PURPOSE: To study the results of the modified osteo-odonto keratoprosthesis (MOOKP) surgery in bilateral end-stage ocular surface disorders. METHODS: The MOOKP surgery is performed as a routine in 3 stages. Stage 1A involves removal of the iris and anterior vitrectomy with a corneal transplant if indicated. Stage 1B + 1C usually performed simultaneously involves harvesting the buccal mucosa and transplanting it onto the ocular surface along with fashioning of the osteo-odonto alveolar lamina. Stage 2 involves transplanting the osteo-odonto alveolar lamina to the eye 3 months later. RESULTS: The MOOKP surgery was completed in 50 eyes of 47 patients with a mean follow-up of 15.38 months (range: 1-54 months). Anatomic success was achieved in 96% of the eyes. Functional success of visual acuity > or = 20/60 was noted in 66% of eyes. Complications included oroantral fistula (6%), trophic mucosal alterations (8%), lamina exposure (central 6% and peripheral 8%), mucous membrane overgrowth (2%), hypotony (2%), expulsion of optic cylinder (4%), endophthalmitis (2%), glaucoma (20%), sterile vitritis (6%), and retinal detachment (2%). CONCLUSIONS: MOOKP is the keratoprosthesis of choice in bilateral end-stage ocular surface disorders in the Indian subcontinent. Complications do occur and have to be recognized and treated early.

Mucous membrane grafting for lid margin keratinization in Stevens­Johnson syndrome: results.

PURPOSE: To study the efficacy of mucous membrane grafting asa surgical technique to address lid margin keratinization, an important cause for chronic blink-related microtrauma in Stevens­Johnson syndrome (SJS). METHODS: The keratinized strip of conjunctiva along the lid margin was excised and replaced by lip mucous membrane using fibrin glue in 54 eyes of 31 patients with lid margin keratinization after SJS. This was a retrospective case series carried out between April 2005 and November 2006. RESULTS: In 50 of 54 eyes (92.6%), there was improvement or stabilization in patient comfort, conjunctival hyperemia, ocular surface staining characteristics, and best-corrected visual acuity over a mean follow-up period of 6 months. CONCLUSIONS: The authors describe the method of mucous membrane grafting for addressing lid margin keratinization, one of the important causes for persistent inflammation in SJS. This procedure not only improves patient comfort and visual acuity by reducing surface inflammation but also possibly prevents further deterioration of ocular surface in SJS.

Vitreoretinal surgery in eyes with Pintucci biointegrable keratoprosthesis.

PURPOSE: The purpose of this study was to describe the challenges in preoperative evaluation, complexity of surgical maneuvers, and intricacies of postoperative management in eyes with Pintucci biointegrable keratoprosthesis requiring vitreoretinal intervention. Ocular surface disorders like Stevens-Johnson syndrome, chemical burns, and ocular cicatrical pemphigoid render the eye inamenable to penetrating keratoplasty. Hence, permanent keratoprosthesis is used for visual rehabilitation in such eyes. Management of vitreoretinal complications in such eyes is a challenging situation because of the difficult approach, limited visibility and maneuverability, and meticulous postoperative care. METHODS: Five patients (mean age: 18 years) with Pintucci biointegrable keratoprosthesis who underwent surgical intervention for vitreoretinal disorders between 2003 and 2008 were evaluated. All patients underwent pars plana vitrectomy with adjunct procedures and intraocular tamponade. RESULTS: Retinal reattachment was achieved in all cases. Mean best corrected visual acuity improved from 20/10,000 to 20/1,200. Mean duration of follow-up was 108 days. CONCLUSION: Vitreoretinal surgery in eyes with Pintucci biointegrable keratoprosthesis is a highly challenging situation that requires intricate planning and an integrated approach. However, it can result in good anatomical and functional outcomes.