PREVENTION AND TREATMENT O F SYMBLEPHARON H E R B E R T E. K A U F M A N , M.D.,
AND E D G A R L. T H O M A S ,
New Orleans,
The problem of prevention and treat ment of symblepharon is fairly common in the patient population seen at the Loui siana State University Eye Center. We have developed a relatively simple meth od of managing this problem, including techniques that apparently have not been observed before. Symblepharon are easier to prevent than to treat. Conjunctival damage can be caused by chemical burns, drug reactions, Stevens-Johnson syndrome, and other problems. Previously, attempts have been made to separate the symblepharon with glass rods and other implements as they begin to form when raw surfaces touch each other. In our experience this has not been satisfactory. Observation of the donor bed of con junctival flaps provided a clue to the management of these problems. If even relatively large conjunctival flaps were done (such as Gundersen flaps, which leave the whole superior bulbar area void of conjunctiva), no symblepharon formed unless the flap had extended up into the upper fornix and two raw surfaces in the fornix touched one another. That is, con junctiva can be removed from one sur face, either bulbar or palpebral, without formation of symblepharon if the other conjunctival surface is intact. Further, reepithelialization occurs spontaneously in a surface denuded of conjunctiva. Heal ing is completed rapidly even without artificial covering by mucous membrane
From the Louisiana State University Eye Center, Louisiana State University Medical Center School of Medicine, New Orleans, Louisiana. Reprint requests to Herbert E. Kaufman, M.D., LSU Eye Center, 136 S. Roman St., New Orleans, LA 70112.
M.D.
Louisiana
or conjunctiva from elsewhere, and the surface appears normal within a few days. In cases of acute conjunctival damage, symblepharon can be prevented if the raw surfaces are separated until re-epithelialization occurs. Similarly, symble pharon can be repaired without mu cous membrane grafts if only one raw surface is present, or if the two raw sur faces can be separated until epithelial healing occurs. Thus the treatment of symblepharon can be simplified, and mu cous membrane grafts eliminated in most cases. SUBJECTS AND METHODS
More than 100 patients with symbleph aron have been seen here and at the University of Florida teaching hospital. Acute conjunctival damage can occur from chemical burns, either acid or alka line, and from acute drug reactions and the Stevens-Johnson syndrome. In many cases the conjunctival epithelium has suf fered extensive damage, and the raw sur faces of conjunctiva adhere to one anoth er. We found that the repeated division of symblepharon with glass rods and other implements was unsatisfactory, and that separating the raw surfaces until epitheli al healing took place was essential. Two techniques have been used. The simplest method is to insert into the for nix a large doughnut-shaped methylmethacrylate conformer, normally measuring approximately 20 to 26 mm outside diam eter and 14 to 22 mm inside diameter. The hole in the center permits the appliance to be tolerated and minimizes the tendency to damage the cornea. In severe chemical burns and drug re actions, symblepharon have formed cen tral to the conformer, the eyelid adhering
AMERICAN JOURNAL O F OPHTHALMOLOGY 88:419-423, 1979
419
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AMERICAN JOURNAL OF OPHTHALMOLOGY
Fig. 1 (Kaufman and Thomas). The eye of a young engineer who had been burned with ammonia which circulated in a solar heater. Symblepharon were prevented by the insertion of a soft contact lens and doughnut-shaped conformer.
either to the bulbar surface or to the cornea itself, which tends to fix the con former in the fornix. To prevent this prob lem, we first insert a therapeutic soft contact lens and then place the conformer into the fornix (Figs. 1 and 2). The pupil is dilated and other treatment is given as necessary, but this procedure has been well tolerated in adults. The conformer can be removed within two weeks, and usually symblepharon formation is com pletely prevented. This technique does not prevent acute conjunctival hyperemia
Fig. 2 (Kaufman and Thomas). Symblepharon tending to form after a sulphuric acid burn. The use of the conformer and soft contact lens permitted healing in two weeks. After the appliances were removed no tendency to further adhesion formation was observed.
SEPTEMBER, 1979
or pain from ciliary body necrosis and corneal damage, but it does prevent the formation of symblepharon with no ap parent deleterious effect on the eye itself. Not all burns form symblepharon, and the insertion of a conformer into every burn is unnecessary. In doubtful cases, the patient is hospitalized or closely ob served. If there is any tendency to sym blepharon formation, the symblepharon can usually be divided with a blunt in strument during the first 12 to 24 hours. At this point, rather than redividing on a daily basis (which is often impossible to do satisfactorily), we insert the conformer and the soft contact lens. In children and in patients whose coop eration is less certain, the same result can be obtained by lining the eyelid with a soft clear plastic (Fig. 3). We performed the first operations of this kind more than ten years ago. Because the initial material used was gas-sterilized Saran Wrap, the operation was locally nicknamed a saranoplasty. Other soft clear plastic drapes such as those used for surgical drapes in the operating room can also be used. A piece of plastic is cut long enough to extend from canthus to canthus and from
Fig. 3 (Kaufman and Thomas). A soft clear plastic lines the undersurface of the eyelid. Three doublearmed sutures are placed near one end of the plastic and positioned equidistantly through the upper for nix of the eyelid. As the sutures are tightened, they pull the lining material into place, and then anchor the plastic as it folds up over the lashes and the front of the eyelid. A soft contact lens has not been necessary with this procedure.
VOL. 88, NO. 3, PART I
SYMBLEPHARON
421
the upper part of the outer eyelid, around the margin and up into the fornix, turning down somewhat onto the bulbar surface but not covering it entirely. Three mat tress sutures are placed approximately equidistant through the plastic before it is inserted into the fornix. The sutures are passed through the fornix and appear on the front of the eyelid where they pene trate the plastic on the front side of the eyelid. This simplifies inserting the plas tic into the fornix and holds it in place. The final tucking of the plastic into the fornix can be done with a blunt scalpel handle or other instrument. Bolsters and other implements to prevent tearing are unnecessary if 4-0 chromic catgut suture is used through the fornix, but sutures of other materials can be used, and bolsters of cotton, catheters, or other substances employed if the surgeon is concerned about eyelid damage. This saranoplasty is done on either the upper or lower eyelid or both. The cornea has not been damaged in any of our patients, nor has it been necessary to use a soft contact lens to protect the cornea. The protective material can be removed in about two weeks. Preformed adhesions can also be divid ed and will not reform if the surfaces are separated until epithelialization takes place. Minimal adhesions can be divided and separated for at most two weeks without reformation. Even patients with relatively extensive symblepharon formation with out subconjunctival fibrosis and those with large-scale symblepharon (which in some centers would certainly be treated with a mucous membrane graft) can also be treated so simply. In most cases sepa rating the raw surfaces prevents reforma tion of the symblepharon, and moderately extensive adhesions can be treated with either of the techniques previously de scribed. Only the most extensive conjunctival symblepharon or completely fore 1
shortened fornices require mucous mem brane grafts. Much of the shortening in the cases of foreshortened fornices in some of the advanced chemical burns is caused by subconjunctival fibrosis and scarring. In our experience, attempting to stretch the scar has been ineffective as long as the fibrosis remains; an extensive dissection and removal of all subconjunctival fibro sis and scarring is necessary. This scar ring may extend to the orbital rim and even back into the prbit above and below. If all scarring is "not removed, and a fornix is fashioned with a mucous membrane graft, the cicatrix simply contracts again and the fornix is obliterated once more. In those patients with extensive subconjunc tival fibrosis, mucous membrane grafts are often necessary in conjunction with the removal of the scar tissue. We use full-thickness buccal mucous membrane when these extensive dissections are re quired because this tissue tends to con tract less than partial-thickness mucous membrane. We fix the mucous membrane to the fornix by sutures identical fo the sutures used with the plastic lining, and we often keep the mucosal surfaces, which might adhere, separate from each other with a conformer and soft contact lens as previously described. DISCUSSION
With simple techniques, symblepharon can often be prevented, and even moder ately extensive symblepharon without subconjunctival fibrosis can be treated. Mucous membrane grafts can usually be avoided. All of this presupposes, however, that the basic disease is nonprogressive. In the case of progressive conjunctival cicatri zation, such as in patients with ocular pemphigoid or benign mucous membrane pemphigus, we agree with the wide spread clinical impression that conjunc tival surgery is often accompanied by an
422
AMERICAN JOURNAL OF OPHTHALMOLOGY
exacerbation of the inflammatory process and a renewed tendency to adhesion formation, even if relatively large doses of corticosteroids are used orally for some time after the surgery. When vision is threatened by symblepharon, which cause exposure, or when the cornea is being progressively damaged by trichiasis, risky reconstructive surgery may be the only choice. The surgeon must recog nize the risk and differentiate among the prognoses of various syndromes so he can judge the wisdom of intervention more accurately. In addition to severing obvious cicatrices when extensive trichiasis occurs in these cases, our most satis factory solution has been a tarsal-fracture procedure which permits the lashes to be turned away from the globe and allows the tarsus to heal pointing out away from the eye. Symblepharon that are extensive enough to restrict the motion of the globe (especially if they form above) may pre sent a real hazard in other types of ocular surgery, such as cataract extraction. The force of the repetitive pull of the sym blepharon can tear out even the best su tures and open the incision. We have seen several patients in whom this happened. The surgeons often blamed the wound problem on deficient healing caused by the underlying disease, rather than on symblepharon pull. Intraocular surgery need not be avoided in patients with conjunctival cicatrization; however, the adhesion must be eliminated as part of the surgical procedure. We divide any significant symblepha ron before the intraocular incision is made. This may increase intraoperative bleeding, but, with time, seepage usually stops, and a wait of five or ten minutes generally results in a satisfactory field. The operation is then continued normal ly, and at the finish, a soft lens and doughnut-shaped conformer are placed so that the acute postoperative period is
SEPTEMBER, 1979
not complicated by repeated symblepha ron formation. Symblepharon between the eyelid and the bulbar conjunctiva can sometimes be treated without conformers or separators if only one raw surface is present. For example, if an adhesion between the eye lid and globe can be divided near the corneoscleral limbus and the conjunctiva swung down to the fornix so that the eyelid remains completely lined, even though the globe is now bare, the surface will re-epithelialize with minimal ten dency to repeated symblepharon forma tion (Fig. 4). If there is any question, a separator can be used between eyelid and globe as described previously, but the principle of trying to keep one surface completely lined seems valid. The idea of putting material into the eye to line the conjunctival surface until re-epithelialization takes place is not new. The conformer we use (the Walker ring) has been available for some time, flushfitting scleral lenses have been tried, and substances such as silicone sheeting have been used to cover the eyelid and palpebral conjunctiva. 1 - 4 However, to our knowledge, it has not been appreciated how extensively this simple technique
Fig. 4 (Kaufman and Thomas). If the symblepha ron (s) is removed, leaving one raw surface (r) and one epithelial surface (ep), the tendency to sym blepharon formation is inhibited and a device to separate the eyelid from the globe may not be necessary or may be needed for only a short time.
VOL. 88, NO. 3, PART I
SYMBLEPHARON
can be used, how much difficulty can be avoided by its use in preventing adhe sions, and how many relatively large ad hesions can be treated with these simple methods.
mucous membrane grafts. Symblepharon can interfere with intraocular surgery and disrupt cataract incisions unless they are divided and separated at the time of sur gery.
SUMMARY
REFERENCES
Symblepharon after acute conjunctival injury can be prevented by separating the raw surfaces for one to two weeks, until re-epithelialization takes place. We have used a soft contact lens and a conjunctival ring without a corneal center, or lined the eyelid and palpebral conjunctiva with plastic. This often eliminates the need for
1. Guibor, P., and Smith, B.: Symblepharon shield. Trans. Am. Acad. Ophthalmol. Otolaryngol. 77:484, 1973. 2. Zagora, E.: Eye Injuries. Springfield, Charles C. Thomas, 1970, pp. 409-412. 3. Choy, A. E., Asbell, R. L., and Taterka, H. B.: Symblepharon repair using a silicone sheet implant. Ann. Ophthalmol. 9:197, 1977. 4. Stallard, H. B.: Eye Surgery, 5th ed. Baltimore, Williams and Wilkins, 1973, pp. 245-249; 779-782.
423
AND E D G A R L. T H O M A S ,
New Orleans,
The problem of prevention and treat ment of symblepharon is fairly common in the patient population seen at the Loui siana State University Eye Center. We have developed a relatively simple meth od of managing this problem, including techniques that apparently have not been observed before. Symblepharon are easier to prevent than to treat. Conjunctival damage can be caused by chemical burns, drug reactions, Stevens-Johnson syndrome, and other problems. Previously, attempts have been made to separate the symblepharon with glass rods and other implements as they begin to form when raw surfaces touch each other. In our experience this has not been satisfactory. Observation of the donor bed of con junctival flaps provided a clue to the management of these problems. If even relatively large conjunctival flaps were done (such as Gundersen flaps, which leave the whole superior bulbar area void of conjunctiva), no symblepharon formed unless the flap had extended up into the upper fornix and two raw surfaces in the fornix touched one another. That is, con junctiva can be removed from one sur face, either bulbar or palpebral, without formation of symblepharon if the other conjunctival surface is intact. Further, reepithelialization occurs spontaneously in a surface denuded of conjunctiva. Heal ing is completed rapidly even without artificial covering by mucous membrane
From the Louisiana State University Eye Center, Louisiana State University Medical Center School of Medicine, New Orleans, Louisiana. Reprint requests to Herbert E. Kaufman, M.D., LSU Eye Center, 136 S. Roman St., New Orleans, LA 70112.
M.D.
Louisiana
or conjunctiva from elsewhere, and the surface appears normal within a few days. In cases of acute conjunctival damage, symblepharon can be prevented if the raw surfaces are separated until re-epithelialization occurs. Similarly, symble pharon can be repaired without mu cous membrane grafts if only one raw surface is present, or if the two raw sur faces can be separated until epithelial healing occurs. Thus the treatment of symblepharon can be simplified, and mu cous membrane grafts eliminated in most cases. SUBJECTS AND METHODS
More than 100 patients with symbleph aron have been seen here and at the University of Florida teaching hospital. Acute conjunctival damage can occur from chemical burns, either acid or alka line, and from acute drug reactions and the Stevens-Johnson syndrome. In many cases the conjunctival epithelium has suf fered extensive damage, and the raw sur faces of conjunctiva adhere to one anoth er. We found that the repeated division of symblepharon with glass rods and other implements was unsatisfactory, and that separating the raw surfaces until epitheli al healing took place was essential. Two techniques have been used. The simplest method is to insert into the for nix a large doughnut-shaped methylmethacrylate conformer, normally measuring approximately 20 to 26 mm outside diam eter and 14 to 22 mm inside diameter. The hole in the center permits the appliance to be tolerated and minimizes the tendency to damage the cornea. In severe chemical burns and drug re actions, symblepharon have formed cen tral to the conformer, the eyelid adhering
AMERICAN JOURNAL O F OPHTHALMOLOGY 88:419-423, 1979
419
420
AMERICAN JOURNAL OF OPHTHALMOLOGY
Fig. 1 (Kaufman and Thomas). The eye of a young engineer who had been burned with ammonia which circulated in a solar heater. Symblepharon were prevented by the insertion of a soft contact lens and doughnut-shaped conformer.
either to the bulbar surface or to the cornea itself, which tends to fix the con former in the fornix. To prevent this prob lem, we first insert a therapeutic soft contact lens and then place the conformer into the fornix (Figs. 1 and 2). The pupil is dilated and other treatment is given as necessary, but this procedure has been well tolerated in adults. The conformer can be removed within two weeks, and usually symblepharon formation is com pletely prevented. This technique does not prevent acute conjunctival hyperemia
Fig. 2 (Kaufman and Thomas). Symblepharon tending to form after a sulphuric acid burn. The use of the conformer and soft contact lens permitted healing in two weeks. After the appliances were removed no tendency to further adhesion formation was observed.
SEPTEMBER, 1979
or pain from ciliary body necrosis and corneal damage, but it does prevent the formation of symblepharon with no ap parent deleterious effect on the eye itself. Not all burns form symblepharon, and the insertion of a conformer into every burn is unnecessary. In doubtful cases, the patient is hospitalized or closely ob served. If there is any tendency to sym blepharon formation, the symblepharon can usually be divided with a blunt in strument during the first 12 to 24 hours. At this point, rather than redividing on a daily basis (which is often impossible to do satisfactorily), we insert the conformer and the soft contact lens. In children and in patients whose coop eration is less certain, the same result can be obtained by lining the eyelid with a soft clear plastic (Fig. 3). We performed the first operations of this kind more than ten years ago. Because the initial material used was gas-sterilized Saran Wrap, the operation was locally nicknamed a saranoplasty. Other soft clear plastic drapes such as those used for surgical drapes in the operating room can also be used. A piece of plastic is cut long enough to extend from canthus to canthus and from
Fig. 3 (Kaufman and Thomas). A soft clear plastic lines the undersurface of the eyelid. Three doublearmed sutures are placed near one end of the plastic and positioned equidistantly through the upper for nix of the eyelid. As the sutures are tightened, they pull the lining material into place, and then anchor the plastic as it folds up over the lashes and the front of the eyelid. A soft contact lens has not been necessary with this procedure.
VOL. 88, NO. 3, PART I
SYMBLEPHARON
421
the upper part of the outer eyelid, around the margin and up into the fornix, turning down somewhat onto the bulbar surface but not covering it entirely. Three mat tress sutures are placed approximately equidistant through the plastic before it is inserted into the fornix. The sutures are passed through the fornix and appear on the front of the eyelid where they pene trate the plastic on the front side of the eyelid. This simplifies inserting the plas tic into the fornix and holds it in place. The final tucking of the plastic into the fornix can be done with a blunt scalpel handle or other instrument. Bolsters and other implements to prevent tearing are unnecessary if 4-0 chromic catgut suture is used through the fornix, but sutures of other materials can be used, and bolsters of cotton, catheters, or other substances employed if the surgeon is concerned about eyelid damage. This saranoplasty is done on either the upper or lower eyelid or both. The cornea has not been damaged in any of our patients, nor has it been necessary to use a soft contact lens to protect the cornea. The protective material can be removed in about two weeks. Preformed adhesions can also be divid ed and will not reform if the surfaces are separated until epithelialization takes place. Minimal adhesions can be divided and separated for at most two weeks without reformation. Even patients with relatively extensive symblepharon formation with out subconjunctival fibrosis and those with large-scale symblepharon (which in some centers would certainly be treated with a mucous membrane graft) can also be treated so simply. In most cases sepa rating the raw surfaces prevents reforma tion of the symblepharon, and moderately extensive adhesions can be treated with either of the techniques previously de scribed. Only the most extensive conjunctival symblepharon or completely fore 1
shortened fornices require mucous mem brane grafts. Much of the shortening in the cases of foreshortened fornices in some of the advanced chemical burns is caused by subconjunctival fibrosis and scarring. In our experience, attempting to stretch the scar has been ineffective as long as the fibrosis remains; an extensive dissection and removal of all subconjunctival fibro sis and scarring is necessary. This scar ring may extend to the orbital rim and even back into the prbit above and below. If all scarring is "not removed, and a fornix is fashioned with a mucous membrane graft, the cicatrix simply contracts again and the fornix is obliterated once more. In those patients with extensive subconjunc tival fibrosis, mucous membrane grafts are often necessary in conjunction with the removal of the scar tissue. We use full-thickness buccal mucous membrane when these extensive dissections are re quired because this tissue tends to con tract less than partial-thickness mucous membrane. We fix the mucous membrane to the fornix by sutures identical fo the sutures used with the plastic lining, and we often keep the mucosal surfaces, which might adhere, separate from each other with a conformer and soft contact lens as previously described. DISCUSSION
With simple techniques, symblepharon can often be prevented, and even moder ately extensive symblepharon without subconjunctival fibrosis can be treated. Mucous membrane grafts can usually be avoided. All of this presupposes, however, that the basic disease is nonprogressive. In the case of progressive conjunctival cicatri zation, such as in patients with ocular pemphigoid or benign mucous membrane pemphigus, we agree with the wide spread clinical impression that conjunc tival surgery is often accompanied by an
422
AMERICAN JOURNAL OF OPHTHALMOLOGY
exacerbation of the inflammatory process and a renewed tendency to adhesion formation, even if relatively large doses of corticosteroids are used orally for some time after the surgery. When vision is threatened by symblepharon, which cause exposure, or when the cornea is being progressively damaged by trichiasis, risky reconstructive surgery may be the only choice. The surgeon must recog nize the risk and differentiate among the prognoses of various syndromes so he can judge the wisdom of intervention more accurately. In addition to severing obvious cicatrices when extensive trichiasis occurs in these cases, our most satis factory solution has been a tarsal-fracture procedure which permits the lashes to be turned away from the globe and allows the tarsus to heal pointing out away from the eye. Symblepharon that are extensive enough to restrict the motion of the globe (especially if they form above) may pre sent a real hazard in other types of ocular surgery, such as cataract extraction. The force of the repetitive pull of the sym blepharon can tear out even the best su tures and open the incision. We have seen several patients in whom this happened. The surgeons often blamed the wound problem on deficient healing caused by the underlying disease, rather than on symblepharon pull. Intraocular surgery need not be avoided in patients with conjunctival cicatrization; however, the adhesion must be eliminated as part of the surgical procedure. We divide any significant symblepha ron before the intraocular incision is made. This may increase intraoperative bleeding, but, with time, seepage usually stops, and a wait of five or ten minutes generally results in a satisfactory field. The operation is then continued normal ly, and at the finish, a soft lens and doughnut-shaped conformer are placed so that the acute postoperative period is
SEPTEMBER, 1979
not complicated by repeated symblepha ron formation. Symblepharon between the eyelid and the bulbar conjunctiva can sometimes be treated without conformers or separators if only one raw surface is present. For example, if an adhesion between the eye lid and globe can be divided near the corneoscleral limbus and the conjunctiva swung down to the fornix so that the eyelid remains completely lined, even though the globe is now bare, the surface will re-epithelialize with minimal ten dency to repeated symblepharon forma tion (Fig. 4). If there is any question, a separator can be used between eyelid and globe as described previously, but the principle of trying to keep one surface completely lined seems valid. The idea of putting material into the eye to line the conjunctival surface until re-epithelialization takes place is not new. The conformer we use (the Walker ring) has been available for some time, flushfitting scleral lenses have been tried, and substances such as silicone sheeting have been used to cover the eyelid and palpebral conjunctiva. 1 - 4 However, to our knowledge, it has not been appreciated how extensively this simple technique
Fig. 4 (Kaufman and Thomas). If the symblepha ron (s) is removed, leaving one raw surface (r) and one epithelial surface (ep), the tendency to sym blepharon formation is inhibited and a device to separate the eyelid from the globe may not be necessary or may be needed for only a short time.
VOL. 88, NO. 3, PART I
SYMBLEPHARON
can be used, how much difficulty can be avoided by its use in preventing adhe sions, and how many relatively large ad hesions can be treated with these simple methods.
mucous membrane grafts. Symblepharon can interfere with intraocular surgery and disrupt cataract incisions unless they are divided and separated at the time of sur gery.
SUMMARY
REFERENCES
Symblepharon after acute conjunctival injury can be prevented by separating the raw surfaces for one to two weeks, until re-epithelialization takes place. We have used a soft contact lens and a conjunctival ring without a corneal center, or lined the eyelid and palpebral conjunctiva with plastic. This often eliminates the need for
1. Guibor, P., and Smith, B.: Symblepharon shield. Trans. Am. Acad. Ophthalmol. Otolaryngol. 77:484, 1973. 2. Zagora, E.: Eye Injuries. Springfield, Charles C. Thomas, 1970, pp. 409-412. 3. Choy, A. E., Asbell, R. L., and Taterka, H. B.: Symblepharon repair using a silicone sheet implant. Ann. Ophthalmol. 9:197, 1977. 4. Stallard, H. B.: Eye Surgery, 5th ed. Baltimore, Williams and Wilkins, 1973, pp. 245-249; 779-782.
423
