Symblepharon: Symptoms, Types, Causes and Treatment

Symblepharon is a significant ophthalmic condition characterized by adhesions between the palpebral (eyelid) conjunctiva and the bulbar (eye surface) conjunctiva. This abnormal connection can cause discomfort, visual problems, and disruption of ocular function. Understanding the symptoms, types, causes, and contemporary treatment options for symblepharon is essential for both patients and clinicians. This article provides a comprehensive, evidence-based overview, following the latest research and clinical insights.

Symptoms of Symblepharon

Symblepharon symptoms can range from subtle discomfort to severe functional impairment. Recognizing these signs is crucial for early diagnosis and optimal management. Symptoms often reflect the stage and severity of the adhesion, as well as the underlying cause.

Symptom	Description	Impact	Source(s)
Adhesion	Tissue stuck between eyelid and eye	Limits eye movement	1 3 4
Redness	Conjunctival hyperemia	Ocular discomfort	3
Dryness	Disrupted tear flow	Irritation, dry eye	3
Impaired Vision	Blurred or reduced vision	Affects daily activities	1 3

Table 1: Key Symptoms

Recognizing the Symptoms

The most prominent symptom of symblepharon is the physical adhesion between the eyelid and the globe. This can restrict eye movement, making it difficult to look up, down, or to the sides. Patients often notice:

• Ocular Discomfort: Irritation, a gritty or foreign body sensation, and sometimes pain, particularly when the eye moves or the eyelids blink over the adhesions 1 3.
• Redness and Inflammation: Chronic redness (conjunctival hyperemia) is common, indicating ongoing ocular surface inflammation 3.
• Dryness and Tearing: Adhesions can disrupt the normal flow of tears across the eye, leading to dryness, burning, or excessive tearing as the eye tries to compensate 3.
• Impaired Vision: In severe cases, symblepharon may lead to reduced visual acuity due to corneal involvement, scarring, or abnormal eyelid position 1 3.

Spectrum of Severity

The symptoms of symblepharon exist on a spectrum:

• Mild: Minor adhesions with occasional discomfort.
• Moderate: Noticeable restriction of eye movement and increased redness or dryness.
• Severe: Marked immobility of the eye, severe discomfort, and potential vision loss due to corneal changes 3.

Types of Symblepharon

Symblepharon is not a uniform disease; it varies in its extent, location, and underlying tissue involvement. Understanding these types is vital for tailoring treatment and predicting outcomes.

Type	Definition	Severity/Extent	Source(s)
Anterior	Adhesion at eyelid margin	Less severe, localized	3 4
Posterior	Adhesion extends deep into fornix	More severe, deep-set	3 4
Total	Complete obliteration of fornix	Most severe, pan-adhesive	3
Grading	Classified by length, width, and severity	Guides management	1 3

Table 2: Classification of Symblepharon

Anatomical Classification

• Anterior Symblepharon: Involves only the front (marginal) part of the eyelid conjunctiva. These are usually less severe and may cause minimal symptoms 3 4.
• Posterior Symblepharon: Adhesions extend deeper, involving the fornix (the fold where the eyelid meets the eyeball). This can lead to significant restriction of eyelid or eye movement 3 4.
• Total Symblepharon: The most severe type, where the entire fornix is obliterated by scarring and adhesion, often leading to profound functional impairment 3.

Grading Systems

Severity is often graded based on:

• Length: How far the adhesion extends across the eye surface 1 3.
• Scope/Width: How much of the fornix or conjunctiva is involved 3.
• Associated Ocular Sequelae: Including corneal neovascularization (new blood vessel growth), opacification (clouding), and loss of normal structures like the palisades of Vogt 3.

A commonly used grading system assigns scores based on these features, guiding treatment decisions and prognosis 3.

Clinical Relevance

Understanding the type and grade of symblepharon helps clinicians:

• Predict the likelihood of surgical success.
• Anticipate complications such as recurrence or persistent inflammation 1 3.
• Choose appropriate surgical approaches and post-operative care plans.

Causes of Symblepharon

Symblepharon can result from various insults to the ocular surface, all of which share the common pathway of conjunctival injury followed by aberrant healing and fibrosis.

Cause	Mechanism	Typical Setting	Source(s)
Chemical Burns	Alkali/acid injury to conjunctiva	Workplace accidents	1 3 4 8
Thermal Burns	Heat-induced tissue damage	Industrial/home accidents	1 4
Autoimmune Disorders	Chronic inflammation, scarring	Stevens-Johnson, OCP	2 7
Surgical Trauma	Post-surgical fibrosis	Pterygium, tumor removal	5
Infection/Immune Dysreg.	Chronic conjunctival inflammation	Severe conjunctivitis, TEN	2 7

Table 3: Primary Causes of Symblepharon

Injury-Induced Symblepharon

• Chemical Burns: The most common cause, especially in industrial or agricultural settings. Alkali burns are particularly damaging, leading to rapid tissue destruction and subsequent adhesion formation 1 3 4 8.
• Thermal Burns: Exposure to hot liquids, metals, or flames can denude the conjunctival epithelium, predisposing to symblepharon 1 4.

Autoimmune and Inflammatory Disorders

• Stevens-Johnson Syndrome (SJS) / Toxic Epidermal Necrolysis (TEN): These severe, systemic disorders can cause widespread mucosal damage, including the conjunctiva, leading to symblepharon 2 7.
• Ocular Cicatricial Pemphigoid (OCP): A chronic autoimmune disease resulting in relentless conjunctival inflammation and scarring 2.

Surgical and Iatrogenic Causes

• Post-Surgical Scarring: Procedures such as multiple pterygium excisions or tumor removals can inadvertently damage conjunctival tissue, triggering fibrosis and adhesion 5.

Other Contributing Factors

• Chronic Conjunctivitis: Severe, untreated infections can result in persistent inflammation and scarring.
• Immune Dysregulation: Disorders that disrupt normal healing can precipitate abnormal adhesions, even in the absence of overt trauma 2.

The Pathophysiological Sequence

Regardless of the initial cause, symblepharon forms when two opposing, raw surfaces in the fornix are left in contact during healing. Without intervention to separate and protect these surfaces, fibrous tissue bridges form, leading to permanent adhesions 4 6.

Treatment of Symblepharon

Treating symblepharon is multifaceted and depends on the severity, chronicity, and underlying etiology. Approaches range from prevention and early intervention to advanced surgical reconstruction.

Treatment	Approach/Method	Outcome/Goal	Source(s)
Prevention	Separation, rings, soft lenses	Prevent adhesion	6 7
Amniotic Membrane	Grafting, covering raw surfaces	Promote healing, reduce scarring	2 5 7
Limbal Stem Cell Tx	CLET, limbal autograft	Restore ocular surface	1 5
Mucosal Grafting	Oral mucosa for severe cases	Deep fornix reformation	2
Novel Materials	Gore-Tex, synthetic barriers	Prevent recurrence	8

Table 4: Treatment Strategies

Prevention and Early Intervention

• Separation Techniques: In the acute phase of conjunctival injury, preventing the eyelid and globe surfaces from sticking together is paramount. Devices such as soft contact lenses, symblepharon rings, and plastic sheets are used to maintain separation until healing occurs 6 7.

• Amniotic Membrane Transplantation: Covering the injured surface with amniotic membrane has been shown to reduce inflammation, promote epithelialization, and prevent fibrosis. This can be accomplished using suture-fixated amniotic membranes on custom-designed rings, especially in critically ill patients 7.

Surgical Reconstruction

When established symblepharon interferes with function or vision, surgery is required:

• Symblepharon Lysis: Cutting the adhesions to free the eyelid from the globe. This is often the first step but must be followed by strategies to prevent re-adhesion 2 8.
• Amniotic Membrane and Limbal Autografting: After symblepharon lysis, the bare sclera can be covered with an amniotic membrane and/or limbal stem cell tissue to reconstruct the ocular surface and suppress fibrosis 1 2 5.
• Oral Mucosal Grafts: In severe cases with significant conjunctival loss, grafting oral mucosa can help reform a deep fornix and prevent recurrence 2.

Advanced and Novel Techniques

• Gore-Tex Barriers: Newer approaches include the use of synthetic materials like Gore-Tex, which act as physical barriers to prevent the reformation of adhesions after surgical lysis. These have shown promising results in preventing recurrence, especially after chemical injuries 8.

• Cultivated Limbal Epithelial Transplantation (CLET): Allogeneic (donor-derived) limbal stem cells are cultivated and transplanted to restore ocular surface integrity. CLET is particularly effective in less severe cases and when inflammation is well-controlled 1.

Factors Influencing Treatment Success

• Severity and Grading: Mild and moderate cases have significantly higher surgical success rates than severe or total symblepharon 1 3 8.
• Inflammation Control: Preoperative and postoperative control of inflammation is critical; high inflammatory activity correlates with poorer outcomes and higher recurrence 1 2.
• Eyelid Abnormalities: Issues such as entropion (inward turning of the eyelid) or trichiasis (misdirected eyelashes) must be addressed to prevent recurrence 1.

Postoperative Management

• Close Monitoring: Regular follow-up is required to detect early signs of recurrence or complications.
• Adjunctive Therapies: Topical anti-inflammatories, lubricants, and sometimes immunosuppressive agents may be used to support healing and prevent new adhesions.

Conclusion

Symblepharon is a complex disorder with significant implications for ocular health, comfort, and vision. Timely recognition, accurate classification, and individualized treatment are crucial for optimal outcomes. Current advances in surgical techniques and barrier materials offer hope for improved management and reduced recurrence.

Key Takeaways:

• Symblepharon manifests as adhesions between the eyelid and eyeball, leading to discomfort, reduced eye movement, and sometimes vision loss.
• Types are classified by anatomical location (anterior, posterior, total) and severity grading, which guides treatment.
• Main causes include chemical and thermal burns, autoimmune diseases like Stevens-Johnson syndrome and OCP, and surgical trauma.
• Early prevention focuses on separating healing surfaces; established cases require surgical lysis, amniotic membrane grafts, limbal stem cell therapy, and sometimes synthetic barriers or oral mucosal grafts.
• Treatment success hinges on early intervention, control of inflammation, and addressing contributing eyelid abnormalities.

By understanding the full scope of symblepharon, both patients and healthcare providers can work towards preserving ocular function and quality of life.