Exfoliation syndrome

The angle of the eye is examined by gonioscopy, which requires the use of special lenses. Gonioscopy is performed to rule out angle-closure or secondary causes of lOP elevation, such as angle recession, pigmentary glaucoma, and exfoliation syndrome. The peripheral contour of the iris is examined for plateau iris, and the trabecular meshwork for peripheral anterior synechiae, as well as for neovascular or inflammatory membranes. 

The hyaluronan in the component of pseudoexfoliation material from human donor eyes has been analyzed histochemically. Hyaluronan was found to coat the fibrillar exfoliation material on the lens, zonules, iris epithelium, and ciliary body (85). The major component of the pseudoexfoliation material on the posterior surface of the iris was histochemically verified as chondroitin sulfate, while the minor component was hyaluronan (86). A polarization microscopic analysis demonstrated the presence of more sulfated glycosaminoglycans in exfoliation syndrome than in control subjects. 

Although patients with pseudoexfoliation syndrome generally showed higher blood-aqueous barrier permeability than the control subjects, the patients implanted with heparin surface-modified intraocular lenses showed decreased permeability compared with the control subjects after surgery (95). Correspondingly, eyes with exfoliation syndrome exhibited a reduced incidence of posterior capsule opacification after implantation of heparin surface-modified intraocular lenses (96). 

Gartaganis SP, Georgakopoulos CD, Exarchou AM, Mela EK, Lamari F, Karamanos NK. Increased aqueous humor basic fibroblast growth factor and hyaluronan levels in relation to the exfoliation syndrome and exfoliative glaucoma. Acta Ophthalmol Scand 2001 79 572-575. 

Fitzsimmons TD, Fagerholm P, Wallin O. Hyaluronan in the exfoliation syndrome. Acta Ophthalmol Scand 1997 75 257-260. 

Baba H. Histochemical and polarization optical investigation for glycosaminoglycans in exfoliation syndrome. Graefes Arch CUn Exp Ophthalmol 1983 221 106-109. 

Zetterstrom C. Incidence of posterior capsule opacification in eyes with exfoliation syndrome and heparin-surface-modified intraocular lenses. J Cataract Refract Surg 1993 19 344-347. 

Skin—rash, erythema, irritation, skin eruptions, exfoliative dermatitis, Stevens-Jbhnson syndrome, ecchymosis, and purpura... 

Rash, exfoliative dermatitis, Sevens-Johnson syndrome, nausea, vomiting, diarrhea, abdominal pain, hematologic changes... 

Pemphigus, bullous dermatitis herpetiformis, severe erythema multiforme (Stevens-Johnson syndrome), exfoliative dermatitis, mycosis fungoides, severe psoriasis, severe seborrheic dermatitis, angioedema, urticaria, various skin disorders, such as lichen planus or keloids... 

Stevens-Johnson syndrome, a severe erythema, was seen in five people occupationally exposed to trichloroethylene for 2-5 weeks at levels ranging from 19 to 164 ppm (Phoon et al. 1984). The study authors suggested that the erythema was caused by a hypersensitivity reaction to trichloroethylene. An exfoliative dermatitis (Goh and Ng 1988) and scleroderma (Czirjak et al. 1993), also thought to have an immune component, have been reported in persons occupationally exposed to trichloroethylene. 

Tretinoin -naturally occurring retinoid -retinoic acid syndrome -fever -chest pain -hypoxia -pulmonary infiltrates -pleural/pericardial effusions -nausea and vomiting -mucocutaneous effects -arthralgias -headaches -increased triglycerides -xerostomia, exfoliation, chelitis... 

A concern with the administration of lamotrigine is that it has the potential to induce the Stevens-Johnson syndrome (exfoliative dermatitis). The incidence of a serious rash in clinical trials appears to be about 0.08% with monotherapy and 0.13% with combination therapy. The rash usually resolves when lamotrigine is stopped, but all patients starting lamotrigine should be cautioned to be vigilant for the development of a rash, especially during the first 6 months of treatment. 

Dermatologic diseases Pemphigus bullous dermatitis herpetiformis severe erythema multiforme (Stevens-Johnson syndrome) mycosis fungoides severe psoriasis angioedema or urticaria exfoliative, severe seborrheic, contact, or atopic dermatitis. 

Other-Fever, flushing hyperglycemia inappropriate antidiuretic hormone syndrome rash alopecia. Ethylenediamine in aminophylline can cause sensitivity reactions, including exfoliative dermatitis and urticaria. Cardiovascular Palpitations tachycardia extrasystoles hypotension circulatory failure life-threatening ventricular arrhythmias. 

Hypersensitivity reactions Discontinue at first appearance of skin rash or other signs of allergic reactions. In some instances, rash may be followed by more severe hypersensitivity reactions such as exfoliative, urticarial or purpuric lesions, or Stevens-Johnson syndrome, generalized vasculitis, irreversible hepatotoxicity and rarely, death. 

Adverse reactions may include drowsiness ataxia dizziness slurred speech headache vertigo weakness impairment of visual accommodation euphoria overstimulation paradoxical excitement nausea vomiting diarrhea palpitations tachycardia various arrhythmias syncope hypotensive crises allergic/idiosyncratic reactions leukopenia acute nonthrombocytopenic purpura petechiae ecchymoses eosinophilia peripheral edema fever hyperpyrexia chills angioneurotic edema bronchospasm oliguria anuria anaphylaxis erythema multiforme exfoliative dermatitis stomatitis proctitis Stevens-Johnson syndrome bullous dermatitis paresthesias agranulocytosis aplastic anemia thrombocytopenic purpura. 

CNS - Asthenia, confusion, depression, dizziness, drowsiness, headache, nystagmus, peripheral neuropathy (see Warnings), psychotic reactions, vertigo. Dermatologic Erythema multiforme (including Stevens-Johnson syndrome), exfoliative dermatitis (rare) transient alopecia. 

Hypersensitivity Fever, skin eruptions of various types, including exfoliative dermatitis, infectious mononucleosis-like, or lymphoma-like syndrome, leukopenia, agranulocytosis, thrombocytopenia, Coombs positive hemolytic anemia, jaundice, hepatitis, pericarditis, hypoglycemia, optic neuritis, encephalopathy, Leoffler s syndrome, vasculitis, and a reduction in prothrombin. 

Skin - Severe, occasionally fatal dermatologic reactions, including toxic epidermal necrolysis, Stevens-Johnson syndrome, exfoliative dermatitis, skin necrosis, and erythema multiforme, have been reported within days of methotrexate administration. 

A variety of idiosyncratic reactions may be seen shortly after therapy has begun. Skin rashes, usually morbilliform in character, are most common. Exfoliative dermatitis or toxic epidermal necrolysis (Lyellis syndrome) has been observed but is infrequent. Other rashes occasionally have been reported, as have a variety of blood dyscrasias and hepatic necrosis. 

Stevens-Johnson syndrome, erythema multiforme, exfoliative dermatitis, and anaphylaxis occur rarely. 

An exanthematous rash is one of the more common side effects of carbamazepine, occurring in 3%-17% of patients. This reaction typically begins within 2-20 weeks after the start of treatment. Car-bamazepine is generally discontinued if a rash develops because of the risk of progression to an exfoliative dermatitis or Stevens-Johnson syndrome, a severe bullous form of erythema multiforme. 

The common side effects are nausea and vomiting. The others are allergic symptoms including drug fever, skin rash, urticaria, eosinophilia, photosensitization reactions, serum sickness like syndrome. Stevens-Johnson syndrome and exfoliative dermatitis are also common with longer acting agents. 

All sulfonamides, including antimicrobial sulfas, diuretics, diazoxide, and the sulfonylurea hypoglycemic agents, have been considered to be partially cross-allergenic. Flowever, evidence for this is not extensive. The most common adverse effects are fever, skin rashes, exfoliative dermatitis, photosensitivity, urticaria, nausea, vomiting, diarrhea, and difficulties referable to the urinary tract (see below). Stevens-Johnson syndrome, although relatively uncommon (ie, < 1% of treatment courses), is a particularly serious and potentially fatal type of skin and mucous membrane eruption associated with sulfonamide use. Other unwanted effects include stomatitis, conjunctivitis, arthritis, hematopoietic disturbances (see below), hepatitis, and, rarely, polyarteritis nodosa and psychosis. 

The serious adverse effects associated with bevacizumab include GI perforation, hemorrhage, hypertension, complications in wound healing, nephritic syndrome, congestive heart failure and arterial thromboembolic events. Patients receiving bevacizumab commonly experience pain, asthenia, headache, abdominal pain, nausea, vomiting, anorexia, upper respiratory infection and exfoliative dermatitis. 

More serious types of skin reactions are rare, but angioedema, non-thrombocytopenic purpura, exfoliative dermatitis, and Stevens-Johnson syndrome have been reported. 

The most freqnently reported reactions to topically applied snlfonamides are local irritation, stinging, and binning. Contact dermatitis is common with topical application of these dmgs, and they can cause more serious dermatologic problems such as erythema nodosum, erythema multiforme (Stevens-Johnson syndrome), and exfoliative dermatitis. In addition to hypersensitivity reactions, topical administration of snlfonamides can lead to local photosensitization, which can result in sunburn on the Ud margins or skin of the face. 

A dose-escalation study in 35 patients with psoriasis confirmed that constitutional symptoms in response to denileukin diftitox were dose-related and less frequent at lower doses (below 5 micrograms/kg/day) (17). There was only one case of mild vascular leak syndrome. Skin reactions compatible with delayed hypersensitivity reactions were noted in three patients, including one case of exfoliative dermatitis. 

Dangerous reactions such as exfoliative dermatitis and Lyell s syndrome rarely develop (SEDA-5, 108). 

Nifedipine, verapamil, and diltiazem have aU been implicated as possible causes of erythema multiforme and its variants, Stevens-Johnson syndrome and toxic epidermal necrolysis, and/or exfoliative dermatitis from FDA data (112). 

A skin rash occurs in 5-20% of patients started on carbamazepine, and is a common cause of early drug withdrawal. The rash is usually erythematous or maculopapular and may accompany systemic manifestations of hypersensitivity. Exfoliative dermatitis, Stevens-Johnson syndrome, and toxic epidermal necrolysis are relatively rare (SED-13, 148) (55,56). 

Oono T, Kanzaki H, Yoshioka T, Arata J. Staphylococcal scalded skin syndrome in an adult. Identification of exfoliative toxin A and B genes by polymerase chain reaction. Dermatology 1997 195(3) 268-70. 

A 40-year-old Afro-American woman developed an exfoliative rash and blistering and swelling of the tongue (12). A diagnosis of Stevens-Johnson syndrome was made. She had not taken any medications other than two doses of a formulation that contained G. biloba. Her condition responded to treatment with prednisolone, clotrimazole, and famotidine. G. biloba was withdrawn and no further events occurred. However, 5 months later she still had tenderness in the soles of the feet, peeling of the nails, and discoloration of the skin. 

The types of skin adverse effect also vary with different compounds. The most serious life-threatening reactions, such as erythema multiforme and its variants (Stevens-Johnson syndrome, toxic epidermal necrolysis, exfoliative erythroderma) are uncommon and occur mainly with the butazone derivatives and to a lesser extent with piroxicam, sulindac, and possibly fenbufen. In large series reported in France, Germany, and the USA, NSAIDs are most often implicated 12 (44%) of the most commonly implicated 29 drugs (168). 

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