Case Study

A 45-year-old woman presented with restricted eye movements, redness, and discomfort in her right eye following a severe episode of Stevens–Johnson syndrome (SJS) six months earlier.

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Symblepharon Formation

On examination, the lower conjunctival fornix was obliterated, and fibrous adhesions were seen between the bulbar and palpebral conjunctiva.

The patient had reduced tear meniscus height, mild corneal vascularization, and limitation of ocular motility.

Based on these findings, a diagnosis of symblepharon formation secondary to Stevens–Johnson syndrome was made.

Disease Entity

Symblepharon formation refers to the adhesion or scarring between the palpebral (eyelid) and bulbar (eyeball) conjunctiva.

This fibrotic connection restricts ocular motility, causes chronic irritation, and may distort the fornices or eyelid position.

The condition often develops after severe ocular surface inflammation, chemical burns, autoimmune disorders, or trauma.

The extent of adhesion may vary from small localized bands to complete obliteration of the conjunctival fornices, significantly affecting visual function, ocular comfort, and cosmesis.

Pathophysiology

The formation of symblepharon is the result of conjunctival epithelial loss followed by fibroblastic proliferation and scarring.

When the normal conjunctival epithelium is destroyed, the underlying subepithelial tissue becomes exposed and inflamed.

During healing, the raw bulbar and palpebral surfaces adhere to each other, leading to the formation of fibrous bands.


Chronic inflammation, persistent epithelial defects, and repeated trauma perpetuate fibrosis. In severe cases, complete fornix obliteration and ankyloblepharon (fusion of eyelids) can occur.

Causes

Symblepharon may result from various inflammatory, traumatic, or iatrogenic causes, including:

  • Chemical or thermal burns – particularly alkali burns

  • Stevens–Johnson syndrome / Toxic epidermal necrolysis

  • Ocular cicatricial pemphigoid (OCP)

  • Severe conjunctivitis (e.g., membranous or pseudomembranous)

  • Post-surgical scarring (after pterygium or strabismus surgery)

  • Mechanical trauma or radiation injury

  • Infectious causes – such as trachoma

  • Chronic use of topical medications leads to toxic conjunctivitis

Clinical Features

Patients with symblepharon often present with:

  • Restricted ocular motility due to conjunctival adhesions

  • Foreign body sensation, dryness, and redness

  • Decreased fornix depth causing difficulty in eye movement or prosthesis fitting (in anophthalmic patients)

  • Cosmetic deformity or eyelid malposition

  • Corneal complications, such as exposure keratopathy or secondary vascularization

Examination Findings (Summarized):

  • Visible fibrous adhesion between the bulbar and palpebral conjunctiva

  • Fornix shortening or obliteration

  • Limitations of extraocular movements

  • Tear film instability and keratinization ofthe  ocular surface

  • Secondary dry eye signs on Schirmer’s test

  • Fluorescein staining showing epithelial irregularity

Classification

Symblepharon can be classified according to extent or severity:

  1. Localized – Small adhesion involving a limited conjunctival area.

  2. Partial – Involvement of one fornix but sparing ocular motility.

  3. Total – Complete fornix obliteration and severe motility restriction.

  4. Recurrent – After failed surgical correction due to ongoing inflammation.

Differential Diagnosis

  • Conjunctival inclusion cysts

  • Pterygium recurrence

  • Conjunctival fibrosis secondary to trauma or infection

  • Ocular surface squamous neoplasia (OSSN)

These conditions may mimic adhesions but differ in etiology and treatment approach.

Symblepharon Formation

Diagnostic Approach

Diagnosis of symblepharon is largely clinical, based on slit-lamp examination and assessment of ocular motility.
However, ancillary tests are important for evaluating underlying causes and surgical planning:

  • Ocular surface staining with fluorescein or lissamine green to assess epithelial defects.

  • Schirmer’s test and tear breakup time (TBUT) for dry eye evaluation.

  • Conjunctival biopsy for immunofluorescence in suspected OCP.

  • Anterior segment OCT to assess conjunctival architecture and adhesion depth.

Management

Treatment of symblepharon depends on severity, underlying cause, and degree of functional impairment.

The goals are to restore ocular surface integrity, preserve motility, and prevent recurrence.

1. Medical Management

  • Treat the underlying cause (e.g., control inflammation in OCP or SJS).

  • Lubricating drops and ointments to reduce friction.

  • Topical corticosteroids or cyclosporine for inflammatory control.

  • Bandage contact lenses to protect the cornea and minimize adhesion formation.

2. Surgical Management

Surgery is indicated in moderate to severe cases or when vision and motility are affected.

Surgical Techniques Include:

  • Symblepharon lysis: Careful dissection and separation of adhesions.

  • Amniotic membrane transplantation (AMT): Used to reconstruct the conjunctival surface and reduce fibrosis.

  • Conjunctival or mucous membrane grafting: Buccal mucosa or nasal mucosa used to replace lost tissue.

  • Fornix reconstruction: Maintains fornix depth using conformers, symblepharon rings, or scleral shells.

  • Use of antimetabolites (mitomycin C): Prevents recurrence in selected cases.

  • Sutureless techniques with fibrin glue to minimize postoperative scarring.

3. Postoperative Care

  • Regular lubrication and anti-inflammatory drops.

  • Maintenance of ocular surface moisture using punctal plugs or moisture chambers.

  • Frequent follow-up to monitor for recurrence or infection.

Prognosis

The prognosis depends on the cause, extent of fibrosis, and success of surgical reconstruction. Early recognition and intervention yield better outcomes.

Symblepharon Formation

Chronic cicatrizing diseases such as OCP or SJS have higher recurrence rates and require lifelong monitoring.


Functional recovery of ocular motility and cosmetic improvement can be achieved in most cases with appropriate surgical planning and postoperative care.

Prevention

Preventing symblepharon formation involves early management of ocular burns, infections, and autoimmune disorders.

  • Immediate irrigation and surface protection after chemical injuries.

  • Use of amniotic membrane grafts in acute ocular burns or SJS to prevent adhesion formation.

  • Early control of inflammation in OCP with systemic immunosuppressive therapy.

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References

  1. Foster CS, et al. Symblepharon Formation: Pathophysiology and Management Strategies. Ophthalmology.

  2. Sharma N, et al. Surgical Management of Symblepharon: Techniques and Outcomes. Cornea.

  3. Kheirkhah A, et al. Amniotic Membrane Transplantation in Ocular Surface Reconstruction. Br J Ophthalmol.

  4. Holland EJ, et al. Ocular Surface Complications of Stevens–Johnson Syndrome. Ophthalmology.

  5. Tauber J, et al. Ocular Cicatricial Pemphigoid: Clinical Features and Management. Surv Ophthalmol.

  6. Tseng SCG. Role of Amniotic Membrane in Preventing Symblepharon Formation. Cornea.

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