What is Symblepharon
A symblepharon is a fibrous tract that connects bulbar conjunctiva to conjunctiva on the eyelid.
Symblepharon, Normal Fornix
Symblepharon, Upper Fornix
When do Symblepharons occur?
Cicatricial pemphigoid; auto-immune disease which affects mucus membranes such as the mouth and oral pharynx, conjunctiva, nares and genitalia
Atopic keratoconjunctivitis: This is a hypersensitivity to environmental allergies including asthma, rhinitis, dermatitis and eczema.
Toxic epidermal necrosis (TEN): A potentially life-threatening disorder which is commonly drug-induced.
Stevens Johnson Syndrome
Trauma
Burns
Benign mucous membrane pemphigoid disease
Erythema multiforme: This is an acute multi-cutaneous hypersensitivity reaction
Charateristics of steven johnson syndrom
Equal age and sex distribution
disease associated with a 5-15% mortality rate
Ocular involvement in 50%
Associated with various infections and medications most notably sulfa
Ocular involvement in 50%
Pathogenesis of steven johnshon syndrom
Angiitis-->Erythematous lesion-->Bullae-->Rupture-->Scar
Prodrome:
Fever, chills, and headache
7 days later bullous mucosal lesions develop
Sequealae
Problems are related to the destruction of Goblet cells and a lack of conjunctival mucus which leads to keratinization and scarring.
Lid scarring with symblepharon
Corneal scarring
Keratitis sicc
"Well, the last time I had a picture taken I could hardly see my eyes because of the weight of heavy eyelid. Then I paid attention to how I was actually using my eyes and I really noticed when I was looking at anything especially the computer I was straining my forehead to see better. Since I have had it done I no longer have to lift the forehead and tilt my head to see. It is amazing! I love..." D. Rock 63 Yrs Old with Fat Droopy Eyes - Salt Lake City, UT
What are the treatment options?
Careful removal of the symblepharon and either adjacent tissue rearrangement, conjunctival graft or use of an amniotic membrane graft may be performed. The amniotic membrane has some advantages when
autogenous conjunctiva is not available:
It facilitates epithelialization
It maintains normal epithelial phenotype (with goblet cells when performed on conjunctiva ),
It reduce inflammation, vascularization and scarring.
The use of human amniotic membrane for the surgical treatment of an ocular surface disorder was initially reported by de Rotth in 1940. During the 1990s, the role of amniotic membrane transplantation in treating a variety of ocular surface defects and abnormalities has been revived.
Symblepharon- treating diseases of the ocular surface
The goal of ocular surface reconstruction is to reconstruct a functional ocular surface. Conjunctival grafts, buccal mucosa or preserved amniotic membrane can be employed.
Mucous membrane grafting has rarely been used as a treatment for unilateral chemical injury and is used in desperate cases of bilateral injury where advancement of Tenon's capsule is not possible and allograft limbal tissue is not available.
Amniotic membrane transplantation provides a favorable extracellular matrix substrate for epithelial migration and adhesion. This procedure is not effective in replacing the normal stem cells. An amniotic membrane transplant is often one step in a sequence of procedures.
Steps in the surgical technique include
Remove scar tissue of the ocular surface
Perform superficial keratectomy
Recess the residual conjunctival free border toward the fornix
Drape the amniotic membrane over the denuded ocular surface
Suture graft to the free conjunctival tissues
Perform partial tarsorrhaphy to prevent graft movement
Use a conformer to prevent the adhesion of mucosal membranes
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