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Jacob S Heng, Nabeel Malik, Naresh Joshi, Michelle Hayes, Marcela Vizcaychipi; Management of ocular complications in patients with toxic epidermal necrolysis on the intensive care unit. Invest. Ophthalmol. Vis. Sci. 2014;55(13):1470.
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Toxic epidermal necrolysis (TEN) is a severe, life-threatening de-epithelializing skin condition that frequently involves the ocular surface. This study aims to investigate the ocular complications and their management in TEN patients admitted to the intensive care unit (ICU).
Case notes of patients admitted to ICU with TEN at a tertiary referral center between 2005 and 2013 were retrospectively reviewed. Ocular complications were graded as mild, moderate and severe. Patient’s characteristics, SCORTEN severity score for TEN, duration of mechanical ventilation, and treatment were correlated with resolution of ocular complications and time to resolution.
There were 9 females and 1 male with a median age of 41 years, median percentage of body surface area affected of 85%, and median SCORTEN score of 2. 8 patients were mechanically ventilated with a median duration of 26 days. 1 patient died on ICU. 9 out of 10 (90%) patients had ocular complications with 4 being graded as mild, 2 as moderate and 3 as severe. All had bilateral ocular disease. Conjunctival injection was present in 9 patients, corneal epitheliopathy in 4, symblepharon formation in 4, ankyloblepharon formation in 3 and lagophthalmos in 2. Topical therapy included topical lubricants in 9 patients, topical antibiotics in 8, topical steroids in 8 and topical immunosuppressants in 3. Therapeutic contact lenses were used in 2 patients and amniotic membranes in 1. Systemic therapy included IVIG in 9 patients, corticosteroids in 4 and immunosuppressants in 5. Median time to resolution of ocular complications was 27 days. 4 out of 9 (44%) patients still had active ocular disease at the time of discharge. Only milder severity of ocular involvement at presentation, but not mode of topical or systemic therapy, was associated with resolution of ocular complications (p=0.046), and a trend towards shorter time to resolution of ocular complications (p=0.057). All patients were seen by an ophthalmologist prior to transfer or within 48 hours of admission.
The high rate of ocular complications in TEN patients admitted to ICU highlights the need for early assessment and treatment by an ophthalmologist. The significant proportion of patients still experiencing ocular disease at the time of discharge emphasizes the need for long-term follow-up as these patients are also expected to experience long-term sequelae.
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