We appreciate the thoughtful questions posed by Warkad and associates in regard to our article describing the use of amniotic membrane application and intensive topical corticosteroid application in the setting of acute Stevens-Johnson syndrome and toxic epidermal necrolysis.
The patients included in the study were consecutive. Only patients with acute disease and significant ophthalmic involvement were included in the study. Significant ophthalmic involvement was defined for the purposes of our study as consisting of, at a minimum, conjunctival injection with membrane or pseudomembrane formation.
In the case of Patient 1, the ProKera device (Bio-Tissue Inc., Miami, Florida, USA) was left in place for 8 days. A second ProKera device was then applied and left in place for 3 days. For Patient 2, the ProKera device was left in place for 9 days. However, as we emphasized in the text, the ProKera device covers only the cornea and perilimbal surfaces, thus serving to effect only partial coverage of the ocular surface. Our experience suggests the ProKera device, if used, needs to be combined with application of additional sheets of amniotic membrane such that the ocular surface is covered in its entirety.
We also share the interest in the recent article by Araki and associates describing a beneficial effect of systemic pulse corticosteroid treatment when used in the setting of acute Stevens-Johnson syndrome and toxic epidermal necrolysis. However, the use of systemic corticosteroids, as well as other therapies such as intravenous immunoglobulin, remains controversial. In our series, we did not have the opportunity to meaningfully evaluate the role of systemic steroids in our patients, given that the New York–Presbyterian Hospital is a large regional referral center and patients were transferred to our facility after having received initial systemic treatments with a variety of agents, dosages, and routes of administration.
The profound ocular and systemic involvement in Stevens Johnson syndrome and toxic epidermal necrolysis patients remains a most challenging condition to treat. We hope our experience with prompt and complete coverage of the ocular surface with amniotic membrane combined with intensive topical corticosteroid application will result in this approach taking its place as an element of therapy in the acute stage that can be further examined and refined in additional studies.