A symblepharon is a fibrous adhesion of the palpebral conjunctiva and the bulbar conjunctiva of the eye. It is most commonly caused by a response to inflammation, as a result of inherited or systemic disease, or trauma.
The symptoms of symblepharon are dependent on the degree of the fibrous adhesions . The adhesions that are located between the palpebral conjunctiva and the bulbar conjunctiva may occur only in the anterior region (anterior symblepharon), in the fornix (posterior symblepharon), or comprise the whole eyelid (total symblepharon). Patients may complain of mucous build up around the corners of the eye, eye redness, frequent tearing, feeling of 'dry eye' that is attributed to an inability to close the eyelid, restriction of ocular motility, reduced visual acuity, and/or involvement of the cornea. Additionally, diplopia (which occurs secondary to restricted ocular motility), entropion (eyelid inverted or folded inward), inability to fully close the eyelids (lagophthalmos), and altered cosmetic appearance may also be present .
Entire Body System
Surgical therapy Congenital ankyloblepharon The surgical management of congenital ankyloblepharon depends on the type and extent of the lid margins adhesions. [eyewiki.aao.org]
Lacrimal Gland Enlargement
This patient had keratoconjunctivitis sicca, lacrimal gland enlargement, and cicatrization of the conjunctiva with symblepharon. Biopsies of the lacrimal gland, conjunctiva, skin, nasal polyps, and epididymis all showed sarcoidosis. [ncbi.nlm.nih.gov]
Workup consists of a review of medical history, assessment of current medications, and an ocular examination . Laboratory tests may be performed when they are clinically indicated or to rule out a disease that is associated with symblepharon . Symblepharon is a physical finding that can be a result of one of many etiologies. Therefore, the patient's medical history should include questions that evaluate presence of conditions commonly associated with symblepharon like ocular cicatricial pemphigoid, history of trauma, ocular chemical exposure, or conjunctival burns, recent ocular surgeries, pseudopemphigoid conditions, Stevens-Johnson syndrome, sarcoidosis, atopic keratoconjunctivitis, porphyria cutanea tarda, epidemic keratoconjunctivitis, squamous papilloma of the conjunctiva, ocular rosacea, and xeroderma pigmentosum     .
The ocular examination should consist of the following:
- Assessment of extraocular movements (EOMS): EOMS will show restricted ocular movements.
- An external and slit-lamp examination: This is done by everting the eyelids and inspecting the palpebral conjunctiva for any scarring or symblepharon during an upward gaze.
- A visual acuity test: In most patients with symblepharon, their visual acuity is usually normal, nearly normal, or unaffected by the condition itself.
- Intraocular pressures (IOP): IOP should also be evaluated to rule out other conditions.
Depending on the clinical findings, laboratory tests to rule out associated systemic diseases may be performed. These include complete blood count (CBC), erythrocyte sedimentation rate (ESR), antinuclear antibody (ANA) levels, rheumatoid factor (RF), rapid plasma reagin (RPR), and uric acid level. Patients who are suspected of having dry eye syndrome should be tested for fodrin (a cytoskeletal protein), muscarinic M3 receptor, and sjögren syndrome (SS) specific antibodies (anti-RO [SS-A] and anti-LA [SS-B]) to confirm the diagnosis. Patients who have signs and symptoms of Stevens-Johnson syndrome will have increased levels of tumor necrosis factor (TNF)–alpha by the local tissue dendrocytes and T-cell proliferation  . The following antibodies can be tested to rule out cicatricial pemphigoid: bullous pemphigoid antigen 1 and 2 (BPAG, BPAG2), type VII collagen, laminin 5, laminin 6, and b4 integrin subunit .
- Holsclaw DS. Ocular cicatricial pemphigoid. Int Ophthalmol Clin. 1998;38:89-106.
- Romanes GJ. Treatment of established symblepharon with split skin homograft. Brit J Opthal. 1953; 37: 236-41.
- Gruchalla RS. 10. Drug allergy. J Allergy Clin Immunol. 2003 Feb. 111(2 Suppl):S548-59.
- King MJ. Ocular lesions in Boeck′s sarcoid. Trans Am Ophthalmol Soc. 1939;37:422–58.
- Moin M, Kersten RC, Bernardini F, Kulwin D. Destructive eyelid lesions in sarcoidosis. Ophthal Plast Reconstr Surg. 2001;17:123–5.
- Flach A. Symblepharon in sarcoidosis. Am J Ophthalmol. 1978;85:210–4.
- Assier-Bonnet H, Aractingi S, Cadranel J, Wechsler J, Mayaud C, Saiag P. Stevens-Johnson syndrome induced by cyclophosphamide: report of two cases. Br J Dermatol. 1996; 135:864-6.
- Vajpayee RB, Shekhar H, Sharma N, Jhanji V.Demographic and clinical profile of ocular chemical injuries in the pediatric age group. Ophthalmology. 2014;121:377-80
- Ondas O, Keles S. Central corneal thickness in patients with atopic keratoconjunctivitis. Med Sci Monit. 2014 Sep 21;20:1687-90.
- De Rojas MV, Dart JK, Saw VP. The natural history of Stevens Johnson syndrome: patterns of chronic ocular disease and the role of systemic immunosuppressive therapy. Br J Ophthalmol. 2007;91:1048-53.
- Morel E, Escamochero S, Cabañas R, Díaz R, Fiandor A, Bellón T. CD94/NKG2C is a killer effector molecule in patients with Stevens-Johnson syndrome and toxic epidermal necrolysis. J Allergy Clin Immunol. 2010;125:703-10.
- Inachi S, Mizutani H, Shimizu M. Epidermal apoptotic cell death in erythema multiforme and Stevens-Johnson syndrome. Contribution of perforin-positive cell infiltration. Arch Dermatol. 1997;133:845-9.