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 Table of Contents  
Year : 2022  |  Volume : 2  |  Issue : 1  |  Page : 6-8

Bedside sutureless amniotic membrane transplantation in acute Stevens–Johnson syndrome: Report of two cases

1 Department of Ophthalmology, Advanced Eye Centre, Chandigarh, India
2 Department of Dermatology, Venereology and Leprology, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission25-Jan-2021
Date of Acceptance15-Jun-2021
Date of Web Publication07-Jan-2022

Correspondence Address:
Dr. Jagat Ram
Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_193_21

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Toxic epidermal necrolysis and Stevens–Johnson syndrome (SJS) are part of a spectrum of blistering diseases after hypersensitivity reaction to drugs, with ocular involvement in 69%–84% cases. The role of amniotic membrane transplantation (AMT) has been well established in the patients of SJS in reducing chronic long-term morbidity and sequelae. Herein, we present a report of 2 cases where bedside sutureless AMT was done within the first 5 days of onset. Amniotic membrane was secured in a symblepharon ring made using Ryle's tube. Both the cases had favorable outcomes and show the role of bedside and urgent AMT in these eyes.

Keywords: Amniotic membrane transplantation, AMT in SJS, bedside AMT, Stevens–Johnson syndrome

How to cite this article:
Gupta PC, Khurana S, Vinay K, Kumaran SM, Limbu S, Sharma VK, Ram J. Bedside sutureless amniotic membrane transplantation in acute Stevens–Johnson syndrome: Report of two cases. Indian J Ophthalmol Case Rep 2022;2:6-8

How to cite this URL:
Gupta PC, Khurana S, Vinay K, Kumaran SM, Limbu S, Sharma VK, Ram J. Bedside sutureless amniotic membrane transplantation in acute Stevens–Johnson syndrome: Report of two cases. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Jun 29];2:6-8. Available from: https://www.ijoreports.in/text.asp?2022/2/1/6/334921

Toxic epidermal necrolysis (TEN) and Stevens–Johnson syndrome (SJS) are a spectrum of the disease characterized by acute blisters and eruptions of skin and mucous membranes, after hypersensitivity reaction to drugs. Acute ocular involvement is seen in 69%–84% of cases of SJS/TEN.[1] Multiple case reports have shown the role of cryopreserved amniotic membrane transplantation (AMT) to ocular surface and eyelids in acute disease, limiting the destruction and inflammation.[2] AMT is usually done in the operating room unless the patient is too unstable to transport. Herein, we report the management of two cases of acute SJS with ocular involvement, managed with bedside AMT within the first 5 days of onset of illness.

  Case Reports Top

Case 1

A 28-year-old man was admitted in the dermatology ward with sloughing of skin and mucous membranes involving 20% of the body, after intake of oral paracetamol and aceclofenac for fever. He was diagnosed with SJS-TEN overlap. Bedside ophthalmological evaluation revealed diffuse conjunctival congestion and excoriation of lids OU. Fluorescein staining revealed areas of corneal defects >1 cm OU and conjunctival defect >1 cm OS and >1/3 upper and lower lids OU, hence classified as severe ocular SJS OD [Figure 1]a and extremely severe SJS OS [Figure 1]b.[3] Bilateral bedside AMT was done on the second day, with a prescription of topical antibiotics, steroids, and preservative-free lubricants, with an application of steroid ointment on the lids. Cryopreserved stromal side down AM, wrapped in and around a symblepharon ring made with Ryle's tube number 6, was secured into the upper and lower fornices bilaterally [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d. On day 10, the AM was completely dissolved with no evidence of symblepharon or ocular and/or lid surface defect. Symblepharon ring was removed after 3 weeks. After 9 months, the patient had 20/20 vision OU with clear cornea and no evidence of limbal stem cell deficiency (LSCD) [Figure 1]c and [Figure 1]d. Schirmer's I was 10 mm and 11 mm in the right and left eye, respectively, and tear break-up time (TBUT) 11 s and 12 s. The cornea remained clear, with the absence of LSCD, after 15 months of procedure [Figure 3].
Figure 1: (a) Acute ocular manifestation of the right eye showing corneal and lid defect. (b) Acute ocular manifestation of the left eye showing corneal, conjunctival, and lid defect. (c) Clear cornea with no limbal stem cell deficiency of the left eye at 9-month follow-up. (d) Clear cornea with no limbal stem cell deficiency of the right eye at 9-month follow-up

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Figure 2: (a) Symblepharon ring formed by Ryle's tube. (b) AM secured in the ring. (c) AMT done in the right eye. (d) AMT done in the left eye

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Figure 3: Photograph showing clear cornea in both the eyes 15 months after the procedure

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Case 2

An 8-month-old child was admitted in the pediatric isolation ward with acute sloughing of skin and mucous membranes involving 15% of the body surface area, after taking over the counter anti-histamine cough syrup for upper respiratory tract infection with influenza A (H1N1). Bedside ophthalmological evaluation revealed patches of corneal defect and lower lid ulceration (>1/3) with bulbar conjunctival defect (>1 cm) OS, hence classified as severe ocular involvement OS [Figure 4]a.[3] Right cornea, conjunctiva, and lid margins were uninvolved. Left bedside Ryle's tube assisted AMT was done on the third day, in the same manner as the first case. The patient was started on bilateral topical antibiotic, steroid, and preservative-free lubricant, along with steroid ointment application on the lids. After 3 weeks, the child had no corneal, conjunctival, or lid defect [Figure 4]b. The child followed with us till 2 months.
Figure 4: (a) Corneal and lid defect in the left eye in an 8-month-old child. (b) Postoperative picture showing clear cornea with reduction of photophobia in the child

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  Discussion Top

SJS can occur due to adverse hypersensitivity reaction to multiple drugs and can result in multiple mucosal eruptions which can be potentially fatal. The common drugs causing SJS-TEN are antibiotics (mostly sulfonamides), anticonvulsants (phenobarbital, phenytoin), and non-steroidal anti-inflammatory drugs (oxicam derivatives).[4],[5]

SJS patients are prone to chronic sequelae of the disease like cicatrizing conjunctivitis with symblepharon, severe dry eyes, eyelid margin keratinization, LSCD, with dry eye as a significant contributor. AMT in the acute phase helps to maintain tear secretion. In addition, keratinization of the lid margin and tarsal conjunctival scarring can cause blink-related microtrauma and hence corneal complications; this can be prevented by AMT as the AM forms a protective barrier by covering the ocular surface. AM has anti-inflammatory properties, which helps in the healing of the ocular surface. In addition, AM may act as a scaffold for epithelial stem cells, preventing LSCD.[6],[7] In patients with corneal and conjunctival defect, ProKera can be used, but in the presence of lid involvement, along with corneal or conjunctival involvement, AMT of the ocular surface, including the lid margins, should be done.[8]

The role of an early amniotic membrane has been advocated, with the window of opportunity till 5–10 days.[3] Increased risk of dry eye, tarsal scarring, and decreased vision has been seen in eyes receiving AMT after 6 days. A contralateral eye study[9] and a randomized controlled trial[10] reported better visual outcomes, TBUT, and Schirmer's test in the eye with AMT than without AMT. We were able to achieve favorable outcomes in both our patients by early AMT.

A multidisciplinary approach is must for these patients and it is extremely important that the physician realizes the importance of ophthalmic examination and the role of early AMT in these patients. Bedside evaluation with fluorescein staining is extremely important, along with sweeping of fornices for symblepharon lysis till AMT is done. SJS patients are mostly too unstable to transport to the operating room in the acute phase, so bedside AMT helps. This technique takes 15–20 min only and can be done under the local anesthesia bedside. This technique does not require sutures on the conjunctiva or cornea, as the symblepharon ring helps to secure the amniotic membrane to the conjunctiva. Though the application of AM on eyelids has been advocated in the literature,[8] we could not cover the lid due to limited availability.

  Conclusion Top

AMT should be done as soon as possible in SJS-TEN patients with moderate-to-severe ocular surface inflammation, in corneal, conjunctival, or lid defects, and can be done bedside using this technique.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Yip LW, Thong BY, Lim J, Tan AW, Wong HB, Handa S, et al. Ocular manifestations and complications of Stevens-Johnson syndrome and toxic epidermal necrolysis: An Asian series. Allergy 2007;62:527-31.  Back to cited text no. 1
Tseng SC, Espana EM, Kawakita T, Di Pascuale MA, Li W, He H, et al. How does amniotic membrane work? Ocul Surf 2004;2:177-87.  Back to cited text no. 2
Gregory DG. New grading system and treatment guidelines for the acute ocular manifestations of Stevens-Johnson syndrome. Ophthalmology 2016;123:1653-8.  Back to cited text no. 3
Roujeau JC. The spectrum of Stevens-Johnson syndrome and toxic epidermal necrolysis: A clinical classification. J Invest Dermatol 1994;102:28S-30S.  Back to cited text no. 4
Sotozono C, Ueta M, Nakatani E, Kitami A, Watanabe H, Sueki H, et al. Japanese Research Committee on Severe Cutaneous Adverse Reaction. Predictive factors associated with acute ocular involvement in Stevens-Johnson syndrome and toxic epidermal necrolysis. Am J Ophthalmol 2015;160:228-237.e2.  Back to cited text no. 5
Chang Y-S, Huang F-C, Tseng S-H, Hsu C-K, Ho C-L, Sheu H-M. Erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis: Acute ocular manifestations, causes, and management. Cornea 2007;26:123-9.  Back to cited text no. 6
Di Pascuale MA, Espana EM, Liu DT-S, Kawakita T, Li W, Gao YY, et al. Correlation of corneal complications with eyelid cicatricial pathologies in patients with Stevens-Johnson syndrome and toxic epidermal necrolysis syndrome. Ophthalmology 2005;112:904-12.  Back to cited text no. 7
Saeed HN, Chodosh J. Ocular manifestations of Stevens-Johnson syndrome and their management. Curr Opin Ophthalmol 2016;27:522-9.  Back to cited text no. 8
Ciralsky JB, Sippel KC. Prompt versus delayed amniotic membrane application in a patient with acute Stevens-Johnson syndrome. Clin Ophthalmol 2013;7:1031-4.  Back to cited text no. 9
Sharma N, Thenarasun SA, Kaur M, Pushker N, Khanna N, Agarwal T, et al. Adjuvant role of amniotic membrane transplantation in acute ocular Stevens-Johnson syndrome: A randomized control trial. Ophthalmology 2016;123:484-91.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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