Symblepharon refers to any adhesion between the palpebral and bulbar conjunctiva that develops following diverse etiologies such as trauma, chemical injuries, infections, and immune dysregulation. The pathogenic effects of symblepharon depend on its location and severity. In general, mild symblepharon located near the lacrimal gland orifices may cause blockage and lead to dry eye, while that located at the inferior fornix may obliterate the tear reservoir and interfere with effective replenishment of tears in the meniscus and the ocular surface. In severe cases, symblepharon may cause inadequate blinking, lagophthalmos, and ocular motility restriction.

No treatment is necessary if symblepharon does not carry the aforementioned pathogenic elements. However, patients with pathogenic symblepharon, as defined above, should be treated to avoid sight-threatening corneal complications as a result of cumulative insults and chronic inflammation. A variety of surgical approaches have been reported for the treatment of symblepharon. Tissue substitutes such as conjunctiva, oral mucosa graft, or amniotic membrane were used for ocular surface reconstruction after symblepharon lysis. Anchoring sutures were also useful to secure the released conjunctiva deep into the fornix. Various materials have been evaluated to keep the potentially adhesive surfaces apart after surgery and to reduce recurrences such as symblepharon ring, silicone sheet implant, nylon foil–anchored polytetrafluoroetyhlene (Gore-Tex), mitomycin C (MMC), bevacizumab, or postoperative application of β-irradiation. Despite all these efforts, the recurrence rates remained highly variable from 6.2% to 40% ( Table 1 ).

For managing symblepharon caused by multi-recurrent pterygia, we have recently reported a significant improvement of the surgical outcome in restoring caruncle morphology and full ocular motility by adding an extra step termed “sealing the gap,” with or without conjunctival autograft or oral mucosa graft, which is added for eyes with a severe shortage of remaining conjunctival tissue, measured from the tip of the symblepharon to the remaining caruncle. This technique can be achieved by anchoring sutures as mentioned above or by a running 9-O nylon suture. Herein, we reported our clinical experience in adding this extra step, “sealing the gap,” using such a running suture ( Figure 1 ) to manage symblepharon caused by various etiologies other than recurrent pterygia.

Schematic illustration showing the surgical procedure of sealing the gap in symblepharon surgery. After symblepharon lysis and removal of subconjunctival fibrovascular tissue (Left, pink), the healthy Tenon (Middle, yellow) was identified and an anatomic gap was created between the excised conjunctiva (Middle, red) and the Tenon capsule (Middle, green). The gap was sealed by running sutures and then a deep fornix was reconstructed by pulling the Tenon capsule when it naturally retracts posteriorly (Right, arrow).

Methods

This retrospective interventional case series study was approved by the Institutional Review Board of Baptist Hospital of Miami/South Miami Hospital Inc, Miami, Florida. A total of 16 eyes of 14 patients who underwent surgical correction of symblepharon with the technique of “sealing the gap” from July 19th, 2010 through February 27th, 2015 were included in this study. Before surgery, possible advantages and disadvantages of the procedures were explained fully to the patients and their written informed consents were obtained. The advantages and disadvantages of the off-label use of fibrin glue in ophthalmology were also discussed. Demographic information, clinical presentation, prior surgeries, and outcomes are summarized in Table 2 .

Table 2

Clinical Characteristics, Surgical Procedures, and Outcomes in Eyes With Various Grades of Symblepharon

Eye No.	Sex	Age (y)	Underlying Cause	Prior Surgery, No.	Grading	OMG a	Outcome	Postoperative Inflammation	Visual Acuity		Ocular Motility Restriction		Follow-up (mo)
									Pre	Post	Pre	Post
1	F	57	Chronic cicatricial conjunctivitis	SL + MMC + AS, 1	I a 1+	−	CS	0	20/20	20/20	0	0	6
2	M	41	Conjunctival scar	AMT, 3	I a 2+	−	CS	0	20/25	20/25	0	0	19
3	F	21	SJS	LR, 1	II a 1+	−	CS	1+	CF	CF	0	0	8
4	F	44	SJS	AMT,1 AMT + OMG, 1 LR, 1	II a 1+	−	CS	0	HM	HM	0	0	33
5	F	23	SJS	AMT, 1	II c 0	−	CS	1+	HM	HM	0	0	45
6	M	75	CB	KLAL,1	II c 0	−	CS	0	HM	HM	0	0	7
7	M	72	CB	CAU + AMT, 1	III a 0	+	CS	0	CF	CF	0	0	7
8	F	15	CB	LR, 1	III a 3+	−	CS	0	CF	20/400	0	0	9
9	F	23	SJS	AMT, 1	III c 1+	−	F	1+	20/30	20/30	0	0	45
10	F	2	TB	AMT, 1 SL + AMT + AS,1	III c 0	+	CS	0	Not checked	Not checked	2−	0	18
11	F	83	OCP	LR, 1	III c 1+	−	CS	0	HM	HM	2−	0	4
12	M	55	SJS		III c 1+	−	CS	0	HM	HM	1−	0	11
13	M	55	SJS		III c 1+	−	PS	0	HM	HM	2−	0	9
14	F	74	Conjunctival tumor	Excision of tumor + SL, 2 CAU + AMT, 1	III c 1+	−	CS	1+	20/30	20/30	2−	0	6
15	M	49	CB		IV b 0	+	CS	0	20/30	20/20	3−	0	24
16	F	51	CB		IV c 2+	+	PS	1+	CF	CF	3−	0	22

 

AMT = amniotic membrane transplant; AS = anchoring suture; CAU = conjunctival autograft; CB = chemical burn; CF = count fingers; CS = complete success; F = failure; HM = hand motion; KLAL = keratolimbal allograft; LR = lid reconstruction; MMC = mitomycin C; OCP = ocular cicatricial pemphigoid; OMG = oral mocusa graft; PS = partial success; SJS = Stevens-Johnson syndrome; SL = symblepharon lysis; TB = thermal burn.

a +, yes; −, no.

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