Ocular features and histopathologic changes during follow-up of toxic epidermal necrolysis

Abstract

Objective: To evaluate ocular surface histopathologic changes and ocular sequelae in the follow-up of patients with toxic epidermal necrolysis (TEN).

Design: Prospective, consecutive, comparative, interventional case series.

Participants: Eleven patients (22 eyes) with TEN that developed after drug treatment and 33 normal subjects as the control group.

Methods: Toxic epidermal necrolysis diagnosis was based on data obtained from medical records. Only patients with ocular involvement in the acute stage were included. Patients and controls underwent a complete ophthalmic assessment, including tear film evaluation and corneal and conjunctival impression cytology. These were performed at the beginning of the study (∼1 month after TEN) and 6 and 12 months later. Tear film production and stability were evaluated by break-up time, Schirmer's test with anesthesia, rose bengal, and fluorescein staining pattern. Conjunctival retraction was determined by studying the vanishing point in eye abduction of the lacunar folds.

Main outcome measures: Break-up time, Schirmer's test, fluorescein and rose bengal stain, corneal and conjunctival epithelial squamous metaplasia, conjunctival retraction, and ocular sequelae.

Results: Mild or moderate ocular involvement was present in 73% of patients in the acute stage. Ocular involvement was not related to TEN severity, area of skin involvement, or drug etiology. One-year follow-up, ocular manifestations, slit-lamp findings, and epithelial cell squamous metaplasia were related to ocular involvement severity in the acute phase. We found pathologic conjunctival retraction in 86.4% of patients. Decreased levels of break-up time and Schirmer's test were found in patients with TEN. Conjunctival cytology showed a marked decrease in goblet cell density. No patients died, and there were no recurrences of TEN during the study.

Conclusions: Ocular involvement in the acute stage was not related to TEN severity or etiology. Ocular sequelae were related to ocular involvement severity in the acute phase. Early ophthalmic assessment and frequent follow-up are helpful because ocular involvement represents the first long-term complication in patients with TEN. Impression cytology and measurement of conjunctival retraction can be useful tools in the assessment of dynamic ocular changes in patients with TEN.