Management of Ocular Conditions in the Burn Unit: Thermal and Chemical Burns and Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis

Abstract

Patients in burn intensive care units suffer from potentially life-threatening conditions including thermal or chemical burns and Stevens-Johnson syndrome/toxic epidermal necrolysis. There is often involvement of the ocular surface or adnexal structures which may be present at the time of hospital admission or may develop later in the hospital course. This article will describe the types of ocular burns, the mechanisms and manifestations of Stevens-Johnson syndrome/toxic epidermal necrolysis, the circumstances that may influence outcome, and acute and long-term treatment strategies, including new and evolving options.

The Ocular Surface Chemical Burns

“…Long-term rises of intraocular pressure can occur from fibrotic damage to the trabecular meshwork as well as the inflammatory debris trapping within the meshwork [1–3]. Conjunctival inflammation and loss of goblet cells can leave the ocular surface prone to dryness, scarring, and contracture of the fornices [2, 3, 6, 7]. …”

“…The initial examination (after thorough irrigation as described below) includes a complete eye examination [1, 2, 7]. It is essential to make sure that no foreign bodies are embedded in any part of the ocular structures.…”

“…Acute periocular signs of injury include periorbital edema and erythema, deepithelialized skin, and loss of eyelashes and eyebrows. Early signs include corneal and conjunctival epithelial defects, chemosis, conjunctival inflammation, limbal ischemia (Figure 1), corneal cloudiness, sterile ulceration, edema, and occasionally perforation [1, 7]. High intraocular pressure may result from damage and/or inflammation of the trabecular meshwork.…”

Immunologic Mediators in Stevens–Johnson Syndrome and Toxic Epidermal Necrolysis

“…SJS/TEN is characterized by diffuse epidermal necrosis and can lead to extensive corneal damage and loss of vision. [2][3][4] SJS/TEN is thought to be a cytotoxic T lymphocyte (CTL) immune-mediated disorder. Recurrent cases of SJS/TEN usually begin within 48 hours of rechallenge, suggesting an immunological memory.…”

Complications of Stevens–Johnson syndrome beyond the eye and skin

“…Ocular and cutaneous sequelae are the two most common and have been well described in the literature. The diffuse epithelial necrosis in SJS and TEN can lead to severe chronic conjunctivitis, pseudomembrane formation, trichiasis, and extensive corneal damage leading to blindness [3,13,14]. Long-term cutaneous sequelae include nail deformities, pigmentation abnormalities, and dermatitides [15].…”