Predictors of Vision Loss and Surgical Intervention in Stevens-Johnson Syndrome: A Multicenter Nationwide Cohort Study.

Abstract

To identify presenting manifestations and clinical predictors of surgical intervention and progressive vision loss in chronic Stevens-Johnson syndrome (SJS). Retrospective, multicenter clinical cohort study. Multicenter analysis of medical records from tertiary referral centers. Machine-learning-based random forest models, followed by multivariate logistic regression, were used to identify predictors of surgery and visual loss. A total of 228 eyes from 115 patients were analyzed. The median delay to presentation at specialized centers was 1 year. Findings at presentation included superficial punctate keratitis (83.3%), conjunctival hyperemia (71.9%), limbal stem cell deficiency (LSCD, 59.2%), symblepharon (54.3%), corneal neovascularization (48.2%), trichiasis (47.3%), and lid margin keratinization (LMK, 42.5%). During follow-up, 53.5% of eyes underwent surgery, most commonly mucous membrane grafting (21.4%). LMK (aOR: 11.5, 95% CI: 3.56-36.92) and conjunctivalization (aOR: 2.8, 95% CI: 1.33-5.75) were predictors of the need for surgery. Longer follow-up duration (aOR: 1.4, 95% CI: 1.00-1.89), use of systemic immunomodulatory therapy (IMT, aOR: 1.5, 95% CI: 1.08-2.17), and associated agents antibiotics (aOR: 3.9, 95% CI: 1.60-9.5) and NSAIDs (aOR: 4.8, 95% CI: 1.58-14.77) were predictors of vision loss. Chronic SJS often presents with advanced disease, frequent need for surgery, and progressive vision loss. Chronicity of disease and antibiotic or NSAID exposure predicted visual deterioration, while LMK and conjunctivalization predicted the need for surgery. Delayed referral and limited use of acute-phase therapies may contribute to poor outcomes, emphasizing the need for national guidelines for early referral, standardized care, and coordinated strategies to prevent avoidable vision loss.