Ocular Damage and SJS/TEN
by, Scheffer C. G. Tseng, M.D. PHD 		Close Window

Thank you to Dr. Tseng for taking time out of his busy schedule to provide the following article


SJS, especially when associated with TENS, is a horrible disease affecting the eye. As the medical director of Ocular Surface Center in Miami, Florida, I have a precious opportunity of seeing and taking care of quite a few patients in the last three years after I left the Bascom Palmer Eye Institute, University of Miami. The following are our progresses made and I would like to share them with you:

  1. We have retrospectively reviewed clinical data from 38 patients with SJS, of which 27 with additional TENS. Our results showed that acute stage of SJS/TENS was characterized by tarsal conjunctival ulceration, an as-yet-poorly recognized finding. Keratinization of eyelid margin with variable degrees of meibomian gland dysfunction was observed in all cases. Floppy eyelid, trichiasis, partially or totally opened lacrimal punctum, symblepharon and aqueous tear deficiency were not significantly correlate with corneal complication. In contrast, there was a strong correlation between the severity of eyelid margin and tarsal pathology and the extent of corneal complications (Spearman r: 0.54, P= 0.0005). A multivariable regression analysis also showed that the extent of eyelid and tarsal pathology had a significant effect on corneal complications (Coefficient: 0.84, P=0.006). We thus conclude that Acute SJS/TENS patients are characterized by severe inflammation and ulceration of the tarsal conjunctiva and lid margins. If left unattended, lid margin keratinization and tarsal scar together with lipid tear deficiency contribute to corneal complications because of blink-related microtrauma. Attempts to suppress inflammation and scarring by amniotic membrane transplantation at the acute stage (preferably within the first week) and to prevent microtrauma at the chronic stage are vital to avoid sight-threatening complications. This paper is now accepted for publication in Ophthalmology in 2005. Please also visit my website www.ocularsurface.com for more information.
  2. As a consultant for Bio-Tissue, Inc., a company that has manufactured and distribute cryopreserved amniotic membrane in the past, I have helped to popularize this new surgical procedure in the last 10 years. Amniotic membrane transplantation has been approved by Medicare in January 2004. In the past two years, I have also helped Bio-Tissue to manufacture a "sutureless" amniotic membrane, called "Prokera", which has been approved by FDA as a medical device so that amniotic membrane can be applied to the patient's eye without the use of sutures. By doing so, this may facilitate the clinical use of amniotic membrane especially during the acute phase of SJS/TENS when there is a difficulty of bringing the patient to the operating room. Bio-Tissue will formally lauch this product in March 2005.
  3. When SJS reaches a chronic phase, surgical reconstruction of scar-induced complication becomes necessary. One major hurdle is the severe adhesion between the lid and the globe, called symblepharon or obliteration of the fornix. We have developed a new surgical procedure to release such adhesion and to prevent its recurrence after surgery. This new surgical procedure is based on the use of amniotic membrane as a graft in conjunction with the intraoperative application of mitomycin C. The paper describing this procedure has been accepted for publication in Ophthalmology, 2005, and the video has been awarded as "the best show" in the last annual meeting of American Academy of Ophthalmology in New Orleans.
  4. When SJS affects the cornea leading to the total loss of limbal stem cells in a state termed "limbal stem cell deficiency", restoration of vision relies on transplantation of limbal epithelial stem cells. One new approach is to transplant these cells expanded in culture on a piece of amniotic membrane from the limbal tissue obtained by a small biopsy. In USA, our center and TissueTech, Inc. are the first that receive FDA's approval to conduct a clinical trial to transplant such culture-expanded cells together with amniotic membrane for patients suffering from total limbal stem cell deficiency caused by a number of diseases including SJS. We have also received a grant support from National Institute of Health, National Eye Institute to help the manufacturing of such a tissue-engineered product to our patients (for more information, please visit website www.biotissue.com).