10-Year Retrospective Review Of Ocular Involvement In Toxic Epidermal Necrolysis At Chelsea And Westminster Hospital

Toxic Epidermal Necrolysis (TEN)  is a rare, life-threatening immune reaction involving the skin and mucosal surfaces. Over half of patients exhibit ocular symptoms, leading to severe cicatrising consequences and visual impairment. Epithelial defects at the lid margin, conjunctiva and cornea are used to grade ocular involvement in TEN into mild, moderate or severe in order to guide treatment. Mild-moderate symptoms can be managed with immunomodulating drops, preservative-free tear drops and antibiotic drops. Amniotic membrane transplantation (AMT) is recommended for severe disease. We assessed the incidence, severity and management of ocular symptoms in patients with TEN over a decade at Chelsea and Westminster Hospital.

This is a retrospective case series of all patients treated for TEN at a tertiary burns unit in Chelsea and Westminster Hospital, London, between 2013 and 2023. We present our multidisciplinary experience of this rare illness.

The records of 24 patients treated for TEN between 2013-2023 at Chelsea and Westminster Hospital were analysed. Data was collected on the presence and severity of ocular involvement and its correlation to dermatological status. Additionally, we evaluated the medical and surgical management of ocular involvement in patients with TEN as well as their long-term visual outcomes.

Of 24 patients, 16 had ocular involvement and 3 did not; data was unavailable for 5.  Mild to moderate ocular disease occurred in 7 patients while severe disease developed in 9. Severe ocular disease correlated with higher total body surface area (TBSA) involvement but not with Severity-of-Illness Score for Toxic Epidermal Necrolysis (SCORTEN). All patients received intensive eye drops and systemic immunosuppression. The severe disease group underwent cryopreserved AMT (except 1 who refused treatment); 2 patients responded well with resolution of inflammation and minimal ocular sequalae, 5 developed sight-threatening complications and 1 died. Ocular sequelae included visual impairment and chronic dry eye, seen in 5 patients respectively.

Nearly two-thirds of TEN patients had ocular involvement in our study, with two-thirds developing long-term consequences. Severe ocular disease correlated with higher TBSA involvement but not with SCORTEN. Early and regular ophthalmic input is necessary to individualise ophthalmic treatment for TEN. Evidence for systemic immunosuppression in the acute phase is lacking. Ongoing education and multidisciplinary care are important for improving outcomes in this rare disease.