The conjunctiva lining the inner surface of the lid and covering the white of the eye normally forms a free fold between lid and globe. This fold, the fornix, is what allows the eye to move freely in every direction and the lid to glide over the surface. Symblepharon is the adhesion of those two surfaces to each other, partly or completely obliterating the fornix.
The adhesion forms when two raw surfaces heal against one another. That is why the most important feature of symblepharon is that it is preventable: keeping the two surfaces apart during the early phase of an injury avoids a picture that would otherwise need surgery.
Immediately after an injury, the aim is to stop two raw surfaces from touching. This means placing an amniotic membrane on the ocular surface, fitting a conformer or ring in the fornices, and dividing early adhesions at regular intervals. Anti-inflammatory treatment and intensive lubrication are inseparable parts of this phase. Measures taken early often remove the need for major reconstruction later.
In established symblepharon the operation has two stages. First the adhesion is carefully divided, scar tissue is cleared and the depth of the fornix is re-created. The decisive stage, though, is the second: covering the bare area that is exposed. If it is left uncovered the adhesion returns quickly. The options are:
At the end of surgery a conformer, silicone ring or temporary sutures keep the fornix open, which is the most effective way of preventing new adhesions. Any lid margin deformity or lash misdirection is corrected in the same session.
Symblepharon is never managed in isolation. Severe dryness is handled with intensive lubrication, punctal plugs and, where needed, serum drops prepared from the patient's own blood. If limbal stem cell deficiency has developed, the ocular surface is restored on that front first. In autoimmune cases, surgery performed before the disease is suppressed systemically can inflame the tissue and make matters worse, so timing is agreed with the other specialties involved.
Redness, swelling and stinging are expected in the first week after surgery. If a conformer or ring has been fitted, the doctor decides when it comes out; removing it early lets the adhesion return. The graft settles over two to four weeks, and the surface and eye movements become comfortable over two to three months. Lubricating treatment continues throughout.
Recurrence of the adhesion is the main problem, particularly on an autoimmune background and with extensive defects, which is why follow-up in the first year is frequent. Other possibilities are incomplete graft take, residual lid malposition needing correction, and persistent dryness.
If you notice the eye catching on movement, double vision, a lid that will not close fully, lashes rubbing the eye or redness that does not settle, I would advise an assessment. After a chemical injury, a severe infection or eye surgery, catching this picture early keeps the treatment far simpler. Related conditions are collected under ocular surface diseases.
Ayşe Dolar Bilge MD, FEBOphth.
Ophthalmologist, Oculoplastic Surgery
As an Ophthalmologist, Dr. Ayşe Dolar Bilge, I provide diagnosis and treatment services with my experienced team.
Symblepharon is an adhesion between the inner surface of the eyelid and the surface of the eye. It develops when two raw surfaces heal against each other. It is most often seen after chemical and thermal burns, trauma involving the ocular surface, severe membranous infections, and autoimmune conditions such as ocular pemphigoid and Stevens-Johnson syndrome.
An established adhesion does not open by itself; scar tissue contracts over time and tightens the picture further. In the very early phase after an injury, however, measures taken while the adhesion is still forming can prevent it altogether. That is why regular review in the first weeks after a severe surface injury matters so much.
The operation has two stages. The adhesion is first divided carefully, scar tissue is cleared and the depth of the fornix is re-created. The bare area that is exposed is then covered with suitable tissue: a conjunctival autograft in limited cases, or amniotic membrane or an oral mucous membrane graft for broader areas. A conformer or silicone ring is placed at the end to keep the fornix open.
Recurrence is the main challenge in this surgery, and two things decide the risk: whether the bare area was covered with suitable tissue, and whether the underlying disease is controlled. In autoimmune cases such as ocular pemphigoid, surgery performed before the disease is suppressed systemically may well recur. Wearing the conformer that keeps the fornix open for as long as the surgeon advises also lowers the risk.
The key is keeping the two raw surfaces from touching in the early phase. Placing an amniotic membrane on the ocular surface, fitting a conformer or ring in the fornices, dividing early adhesions at regular intervals and maintaining anti-inflammatory treatment all serve that purpose. With these measures in place, the need for major reconstruction later usually disappears.
When the adhesion stays limited to the white of the eye, vision is usually preserved. It is affected if the adhesion advances onto the cornea, if the surface dries and breaks down because the lid cannot close fully, or if inturned lashes rub the cornea. Restricted eye movement can also cause double vision in advanced cases.
Redness, swelling and stinging are expected in the first week. The graft settles over two to four weeks, and the surface and eye movements become comfortable over two to three months. If a conformer or ring was fitted, the surgeon decides when it is removed, since taking it out early can allow the adhesion to return. Lubricating treatment continues throughout this period.
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