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A 26-year-old man with ocular complications after adverse reaction to phenytoin
Digital Journal of Ophthalmology 2016
Volume 22, Number 4
October 4, 2016
DOI: 10.5693/djo.03.2015.05.002
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Ritesh Gupta, MD | Faculty of Medicine, University of Toronto, Toronto, Canada
Vasudha Gupta, MD, FRCSC | Department of Ophthalmology, McMaster University, Hamilton, Ontario, Canada
Yasser Khan, MD, FRCSC | Faculty of Medicine, University of Toronto, Toronto, Canada Department of Ophthalmology, McMaster University, Hamilton, Ontario, Canada
Diagnosis and Discussion
TEN is usually triggered by immunological reaction, with incidence rate of 0.4-1.2 cases per million persons and mortality rates in the range of 25%-35%.(4,5) It is most commonly caused by drugs taken for the first time (usually anticonvulsants and antibiotics).(2) It was suspected in this patient, because symptoms occurred after recent change to one of the well-recognized causative agents (phenytoin) in the absence of an infection or history of specific medical conditions to support an alternative etiology.

Incidence of ocular involvement during the acute phase is between 50% and 88%(4,6) and chronic complications have been noted in up to 35% of survivors.(2) An inflammatory reaction involving the ocular surface destroys goblet cells and results in decreased secretion of mucin, which impairs tear distribution and stability. Frank scarring of the bulbar and forniceal conjunctivae can lead to symblepharon or ankyloblepharon, which cause inadequate blinking/closure and affect ocular motility. Loss of the normal glandular structures of the ocular surface and eyelids leads to severe dry eye problems and vision loss.(2)

The optimal acute ocular therapeutic regimen for TEN remains a topic for continued debate. Various interventions have been proposed, including intravenous methylprednisolone, topical steroids, and immunomodulator as well as a “Triple TEN” acute ocular management protocol, which comprises administration of triamcinolone into each of the fornices, insertion of a scleral shell spacer, and placement of amniotic membrane tissue over the corneal and limbal regions.(7)