Sealing of the Gap between the Conjunctiva and

Tenon Capsule to Improve Symblepharon

Surgery
DANDAN ZHAO, HAN Y. YIN, ANNY CHENG, RENDIAN CHEN, HOSAM SHEHA, AND SCHEFFER C.G. TSENG

PURPOSE:

To report the surgical outcome of sealing

the gap in treating symblepharon caused by various etiologies other than recurrent pterygium.

DESIGN: Retrospective, interventional case series.

METHODS: Sixteen eyes of 14 patients with pathogenic
symblepharon were consecutively operated by conjunctival recession, sealing the gap between recessed conjunctiva and Tenon capsule with a running 9-0 nylon suture,
and covering of the bare sclera with amniotic membrane.
For severe symblepharon where there was conjunctival
shortening, oral mucosa graft was added. Outcome measures include ocular surface inflammation, fornix reformation, and restoration of ocular motility.

RESULTS: The underlying causes of symblepharon
included Stevens-Johnson syndrome (n [ 6), chemical
burn (n [ 5), ocular cicatricial pemphigoid (n [ 1), thermal burn (n [ 1), following excision of conjunctival squamous cell carcinoma (n [ 1), conjunctival scarring
following exposed buckle (n [ 1), and immune dysregulation (n [ 1). Twelve eyes (75%) had an average of 1.6
0.9 previous surgeries. Before surgery, ocular motility restriction was significantly correlated with the severity of
symblepharon. During the follow-up period of 17.1
13.6 months, 13 eyes (81.3%) achieved complete success,
2 eyes (12.5%) achieved partial success, and 1 eye with
immune dysregulation had failure (6.3%). There was no
correlation between the success rate and the severity of
symblepharon. After surgery, the ocular motility and
inflammation were significantly improved. Visual acuity
had improved in 2 of 15 eyes.

CONCLUSIONS: Sealing the gap between the conjunctiva and Tenon capsule is an important step in the surgical
management of pathogenic symblepharon. This method
not only avoids the use of mitomycin C, but also creates
a strong barrier to prevent recurrence, restore ocular
surface integrity, reform a deep fornix, and regain full
ocular motility. (Am J Ophthalmol 2015;160(3):
438446. 2015 by Elsevier Inc. All rights reserved.)
Accepted for publication Jun 9, 2015.
From the Department of Ophthalmology, Yan An Hospital of Kunming
City, Kunming, Yunnan, China (D.Z.); Ocular Surface Center and Ocular
Surface Research & Education Foundation, Miami, Florida (D.Z., H.Y.Y.,
A.C., R.C., H.S., S.C.G.T.); and Department of Ophthalmology,
Shenzhen Childrens Hospital, Shenzhen, Guangzhou, China (R.C.).
Inquiries to Scheffer C.G. Tseng, Ocular Surface Center and Ocular
Surface Research & Education Foundation, 7000 SW 97th Avenue,
Suite 213, Miami, FL 33173; e-mail: stseng@ocularsurface.com

438

2015 BY

YMBLEPHARON 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,1,2 oral mucosa graft,35 or amniotic membrane610
were used for ocular surface reconstruction after
symblepharon lysis. Anchoring sutures were also useful to
secure the released conjunctiva deep into the fornix.10
Various materials have been evaluated to keep the potentially adhesive surfaces apart after surgery and to reduce recurrences such as symblepharon ring,11 silicone sheet
implant,12,13 nylon foilanchored polytetrafluoroetyhlene
(Gore-Tex),14 mitomycin C (MMC),15,16 bevacizumab,17
or postoperative application of b-irradiation.18 Despite all
these efforts, the recurrence rates remained highly variable
from 6.2% to 40%610,16,19,20 (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.21 This technique can be achieved
by anchoring sutures as mentioned above10 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.

ELSEVIER INC. ALL

RIGHTS RESERVED.

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http://dx.doi.org/10.1016/j.ajo.2015.06.003

TABLE 1. Literature Summary of Symblepharon Surgery Techniques Studies

Source

Technique

Eyes
(N)

Tseng 19978

AMT

Patel 20127
Katircioglu 20039

AMT
AMT AS

10
6

Solomon 200310

AMT AS

17

Jain 20046

AMT AS

20

Tseng 200516

MMC AMT AS

18

Kheirkhah 200819 MMC CAU/OMG

AMT AS

61

Kheirkhah 201320 MMC OMG

AMT AS

32

Underlying Cause

Symblepharon Severity

OCP (n 2), TB (n 1), RP

(n 1), TEN (n 1)
Severe (n 3), moderate
(n 2), mild (n 1)
Autoimmune disorders
One location (n 11), 2
(n 9), after ocular surgery
locations (n 5), 3
(n 4), after ocular trauma
locations (n 1)
(n 4)
RP (n 5), acid burns (n 1), Stage II or III
alkali burns (n 5), SJS
(n 4), TB (n 3), and
congenital symblepharon
(n 2)
CB/TB (n 7), RP (n 5),
One location (n 6), 2
SJS (4 eyes), OCP (n 2)
locations (n 12)
SJS (n 26), CB (n 19),
Grade I (n 17), grade II
chronic cicatricial
(n 26), grade III (n 9),
conjunctivitis of unknown
grade IV (n 9)
cause (n 9), RP (n 3),
MMP (n 2),
pseudopemphigoid
(n 1), lid sebaceous
carcinoma (n 1)
CB (n 16), TB (n 7), SJS Grade III (n 19), grade IV
(n 5), OCP (n 2),
(n 13)
xeroderma pigmentosum
(n 1), graft-vs-host
disease (n 1)
Alkali burn

Mean (SD)
Follow-up
(mo)

Minimal
Follow-up
(mo)

Recurrence
Rate

14.54

5.5

6
10

20%
16.67%

37

17.65%

12

12

40%

18.75%

12

14.8%

6.2%

14.16
25

16.4

40%

AMT amniotic membrane transplant; AS anchoring suture; CAU conjunctival autograft; CB chemical burn; MMC mitomycin;
MMP mucous membrane pemphigoid; OCP ocular cicatricial pemphigoid; OMG oral mocusa graft; RP recurrent pterygium;
SJS Stevens-Johnson syndrome; TB thermal burn; TEN toxic epidermal necrolysis.

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.
The severity of symblepharon was graded according to its
length, width, and inflammation, as previously reported.19
The length of the symblepharon was defined as the distance
VOL. 160, NO. 3

between the lid margin and the limbus. It was graded as I if it

was equal to or greater than the length of the palpebral conjunctiva (Figure 2, Top left), II if it was shorter than the
length of the palpebral conjunctiva but equal to or greater
than that of the tarsus (Figure 2, Top middle), III if it was
shorter than the tarsus (Figure 2, Top right), or IV if it was
close to zero; ankyloblepharon was added to this category
as well (Figure 2, Bottom left). The width of symblepharon
was defined as the horizontal width in relation to the width
of the eyelid. It was graded as a if the width was one-third
or less of the eyelid width (Figure 2, Top left), b if it was
more than one-third but equal to or less than two-thirds of
the eyelid width (Figure 2, Top middle), or c if it was more
than two-thirds of the eyelid width (Figure 2, Top right).
Inflammation was judged by conjunctival hyperemia and
graded as 0 if absent (Figure 2, Top left), 1 if mild
(Figure 2, Top right), 2 if moderate (Figure 2, Bottom middle), or 3 if severe (Figure 2, Bottom right).

SEALING THE GAP IN SYMBLEPHARON SURGERY

439

FIGURE 1. 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).

TABLE 2. Clinical Characteristics, Surgical Procedures, and Outcomes in Eyes With Various Grades of Symblepharon

Visual Acuity
Eye

Postoperative

Age

No. Sex

(y)

3
4

F
F

57 Chronic
cicatricial
conjunctivitis
41 Conjunctival
scar
21 SJS
44 SJS

5
6
7
8
9
10

F
M
M
F
F
F

23
75
72
15
23
2

11
12
13
14

F
M
M
F

83
55
55
74

15 M
16 F

Ocular Motility
Restriction

Underlying Cause

SJS
CB
CB
CB
SJS
TB

OCP
SJS
SJS
Conjunctival
tumor
49 CB
51 CB

Prior Surgery, No.

Grading OMGa Outcome

Inflammation

Follow-up
Pre

Post

Pre

Post

(mo)

SL MMC AS, 1

Ia1

CS

20/20

20/20

AMT, 3

Ia2

CS

20/25

20/25

19

LR, 1
AMT,1 AMT OMG,
1 LR, 1
AMT, 1
KLAL,1
CAU AMT, 1
LR, 1
AMT, 1
AMT, 1 SL
AMT AS,1
LR, 1

IIa1
IIa1




CS
CS

1
0

CF
HM

CF
HM

0
0

0
0

8
33

IIc0
IIc0
IIIa0
IIIa3
IIIc1
IIIc0







CS
CS
CS
CS
F
CS

1
0
0
0
1
0

0
0
0
0
0
0

45
7
7
9
45
18






CS
CS
PS
CS

0
0
0
1

HM
HM
CF
20/400
20/30
Not
checked
HM
HM
HM
20/30

0
0
0
0
0
2

IIIc1
IIIc1
IIIc1
Excision of tumor SL, IIIc1
2 CAU AMT, 1
IVb0
IVc2

HM
HM
CF
CF
20/30
Not
checked
HM
HM
HM
20/30

2
1
2
2

0
0
0
0

4
11
9
6

CS
PS

0
1

20/30
CF

20/20
CF

3
3

0
0

24
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.

The surgery was carried out by a single surgeon

(S.C.G.T.) under general anesthesia or topical anesthesia
with 2% lidocaine gel, depending on the severity of symblepharon. Epinephrine (1:1000) drops were instilled for hemostasis in all patients. The eyelids were separated using
440

a speculum or 4-0 silk sutures (Ethicon Inc, Somerville,

New Jersey, USA), then a 7-0 traction suture (Vicryl;
Ethicon Inc) was placed at limbal episclera to achieve
adequate exposure. All eyes received symblepharon lysis,
which involved circumlunar incision of the conjunctiva

AMERICAN JOURNAL OF OPHTHALMOLOGY

SEPTEMBER 2015

FIGURE 2. Photographs demonstrating symblepharon grading. According to the length, symblepharon was graded as I if it was equal
to or greater than the length of palpebral conjunctiva (Top left), II if it was shorter than the length of the palpebral conjunctiva but
equal to or more than that of the tarsus (Top middle), III if it was shorter than the tarsus (Top right), or IV if it was close to zero;
ankyloblepharon was added to this category as well (Bottom left). According to the width, symblepharon was graded as a if the width
was one-third or less of the eyelid width (Top left), b if it was more than one-third but equal to or less than two-thirds of the eyelid
width (Top middle), or c if it was more than two-thirds of the eyelid width (Top right). Inflammation was also graded as 0 if absent
(Top left), 1D if mild (Top right), 2D if moderate (Bottom middle), or 3D if severe (Bottom right).

at the perilimbal region of the symblepharon, followed by

relaxing incisions toward the fornix along the borders of
symblepharon. Healthy Tenon capsule was distinguished
from the subconjunctival abnormal fibrovascular tissue
(Figure 3, Top left) by its appearance and by using dry
Weck-cel (Beaver-Visitec International, Inc, Waltham,
Massachusetts, USA), which tended to catch the abnormal
tissue (Figure 3, Top middle). The healthy Tenon was identified as nonsticky, relatively nonstretchable, dense, white,
and fascia-like tissue (Figure 3, Top right), while the
abnormal fibrovascular tissue was sticky, slimy, stretchable,
and vascular. The fibrovascular tissue was then carefully
dissected off without excising the overlying conjunctiva
or the underlying healthy Tenon.
Removal of the abnormal fibrovascular tissue invariably
resulted in further recession of the incised conjunctiva into
the fornix. The gap created between the recessed conjunctiva
and the cut edge of the Tenon capsule was identified and sealed
using a 9-O nylon running suture (Ethicon Inc) along the
entire fornix (Figure 3, Middle left and Center). In eyes with
severe symblepharon or ankyloblepharon where there was a
shortage of the remaining conjunctival tissue, oral mucosa graft
was attached to the lid margin with a running 8-O Vicryl suture
(Ethicon Inc) before being used to seal the gap, as mentioned
above (Figure 3, Middle right and Bottom left). One layer of
amniotic membrane (AmnioGraft; Bio-Tissue, Miami, Florida, USA) was then used to cover the exposed extraocular musVOL. 160, NO. 3

cle (Figure 3, Bottom middle) and the second layer to cover the
entire bare sclera (Figure 3, Bottom right), both by fibrin glue
(Tisseel; Baxter Inc, Westlake Village, California, USA).
Postoperatively, topical 0.3% ofloxacin drops (Ocuflox;
Allergan Inc, Irvine, California, USA) were applied 3
times per day together with 1% prednisolone acetate
(Pred Forte; Allergan Inc) 4 times per day. The former
was discontinued when epithelialization was complete,
while the latter was tapered off according to the extent of
conjunctival inflammation. Subconjunctival injection of
Kenalog (Bristol-Myers Squibb Company, Princeton,
New Jersey, USA) was given in selective cases.
The surgical outcome was determined based on reviewing documented photographs by a masked reader (A.C).
Complete success was defined as restoration of a smooth
ocular surface without scarring, reformation of a deep
fornix, and regaining of full ocular motility. Partial success
was defined as focal scarring, incomplete formation of the
fornix, or residual ocular motility restriction. Failure was
defined as recurrence of the symblepharon.
All data were reported as mean 6 standard deviation and
were analyzed using SPSS statistical software, version 19.0
(SPSS Inc, Chicago, Illinois, USA). The correlation in
different grades of symblepharon with motility restriction and
inflammation was analyzed by Fisher x2 analysis. Correlation
among the variable preoperative factors and complete success
was analyzed by multivariate regression analysis. Differences

SEALING THE GAP IN SYMBLEPHARON SURGERY

441

FIGURE 3. Photographs showing the key surgical steps in symblepharon surgery. After symblepharon lysis, healthy Tenon capsule
was distinguished from the subconjunctival fibrovascular tissue by its appearance (Top left; the border is marked by arrows) and by
contacting with a dry Weck-cel to catch the abnormal tissue (Top middle, marked by arrows). After excision of abnormal fibrovascular tissue, the healthy Tenon was identified (Top right) and sealed with the recessed conjunctiva by a 9-O nylon running suture
along the entire fornix (Middle left and Center). In eyes with severe symblepharon, oral mucosa graft is attached to the lid margin
by a running 8-O Vicryl suture to one edge while the other is used for the sealing of the gap (Middle right and Bottom left). Amniotic
membrane then was used to cover the exposed muscle (Bottom middle) and the entire bare sclera (Bottom right) by fibrin glue.

between preoperative and postoperative factors were analyzed

by paired t test. P < .05 was considered statistically significant.

RESULTS
THIS STUDY INCLUDED 16 EYES OF 14 PATIENTS (5 MALE AND 9

female) with a mean age of 47.3 6 24.7 years (range, 283

years). The underlying cause of symblepharon included
Stevens-Johnson syndrome (SJS) (n 6), chemical burn
(n 5), ocular cicatricial pemphigoid (OCP) (n 1), thermal burn (n 1), following excision of conjunctival squamous cell carcinoma (n 1), conjunctival scarring
following exposed buckle (n 1), and immune dysregulation
(n 1). Twelve eyes (75%) had an average of 1.6 6 0.9 previous surgeries (range, 13). Topical or systemic steroids and
442

immune modulation were used to control preoperative ocular

inflammation in 5 of 6 SJS eyes (83.3%), 1 of 1 OCP eye
(100%), 1 of 5 chemical burn eyes (20%), and 1 of 1 conjunctival scarring eye following exposed buckle (100%). More
specifically, in the 7 cases of OCP and SJS, oral steroids
and immune modulation were used in 3 eyes and topical steroid eye drops were used in the other 3 eyes.
Before surgery, the severity of symblepharon based on
the length was I in 2 eyes (12.5%), II in 4 eyes (25%), III
in 8 eyes (50%), and IV in 2 eyes (12.5%). The grading
of the symblepharon width was a in 6 eyes (37.5%), b in
1 eye (6.3%) and c in 9 eyes (56.3%). Inflammation was
found in 2 of 2 grade I eyes, 2 of 4 grade II eyes, 6 of 8 grade
III eyes, and 1 of 2 grade IV eyes (Table 2). Ocular motility
restriction was significantly correlated with the severity of
symblepharon (P .02 for both length and width). There
was no ocular motility restriction in grade I and II, mild

AMERICAN JOURNAL OF OPHTHALMOLOGY

SEPTEMBER 2015

(1) in 1 of 8 grade III eyes, moderate (2) in 3 of 8 grade

III eyes, and severe (3) in 2 of 2 grade IV eyes.
Surgery was uneventfully performed in all cases, with sealing the gap by 9-0 nylon running sutures in all cases. Amniotic membrane was used to cover the bare sclera in all eyes
and to cover the muscle in 11 eyes with or without motility
restriction. Four eyes with severe symblepharon had extreme
conjunctival shortage and required oral mucosa graft to allow
adequate sealing of the gap. Amniotic membrane and oral
mucosa graft were completely secured on the eye surface after
surgery with either suture or fibrin glue.
After surgery, the mean follow-up time was 17.1 6
13.6 months. Thirteen eyes (81.3%) achieved complete
success, 2 eyes (12.5%) achieved partial success, and 1
eye with immune dysregulation (6.3%) had failure
(Figure 4). There was no correlation between the success
rate and the severity of symblepharon (P .57 and P
.37 for length and width, respectively). Based on the
symblepharon length, complete success was achieved in
all grade I and II eyes, 75% of grade III eyes, and 50% of
grade IV eyes. Based on the symblepharon width, complete
success was noted in all grade a and b eyes and 66.7% of
grade c eyes. Cases with partial success or failure developed
scarring or recurrence within 4 months after surgery. Multivariate regression analysis showed that the total success
(Complete success Partial success) had no significant
correlation with age (P .29), underlying cause of symblepharon (P .24), preoperative ocular motility restriction
(P .09), or preoperative inflammation (P .29).
Besides the anatomic success in eliminating symblepharon
and regaining a deeper fornix, conjunctival inflammation
was markedly reduced in 8 of 11 eyes with preoperative
inflammation (72.7%) (P .02). However, all partial success
and failure eyes showed a mild inflammatory activity (1)
that persisted through follow-up after surgery. The average
length of time for topical steroid eye drops in 12 eyes was
6.0 6 1.9 weeks. For the 4 remaining eyes (2 with SJS, 1
with OCP, 1 with chemical burn), topical steroid drops
were continued during the entire follow-up period. Subconjunctival injection of Kenalog was given 2 months after surgery in 1 eye with SJS but the eye failed to improve. Both oral
steroids and systemic medications were used in 1 patient with
SJS and 1 patient with OCP before and after surgery.
Other additional benefits of the surgery included significantly improved ocular motility in all 7 eyes with prior
ocular motility restriction (P .006) and improved visual
acuity in 2 eyes (13.3%); conditions in the other 13 eyes
(86.7%) remained unchanged without any additional surgery to restore the vision.

DISCUSSION
THE SURGICAL GOALS OF TREATING SYMBLEPHARON ARE

to remove the cicatrix; restore ocular surface integrity;

VOL. 160, NO. 3

reconstruct the fornix; improve the ocular motility, if

restricted; and prevent recurrence. A variety of surgical approaches have been attempted to achieve these goals, with
variable results610,16,19,20 (Table 1). Previously we have reported a high success rate of 85.2% by selectively deploying
cicatrix lysis, amniotic membrane transplantation, intraoperative MMC, oral mucosa graft, conjunctival autograft,
and anchoring sutures.19 We have also reported a significant improvement in the surgical outcome of symblepharon following multiple pterygium surgeries by sealing
the gap, which was created between the excised edges of
the conjunctiva and the Tenon capsule following bare
sclera excision of the pterygium.21 Specifically, in that
study, we used 3 different methods of sealing the gap (ie,
anchoring sutures, fibrin glue, and a running suture).
Because we have reported that the ensuing fibrinolysis of
fibrin glue did not keep the gap sealed as long as 9-0 nylon
did to withstand emanation of fibrovascular tissue in treating multi-recurrent pterygium,21 we chose the latter in this
study to seal the gap. Herein, we deployed the surgical technique of sealing the gap by a continuous 9-O nylon running
suture in treating pathogenic symblepharon induced by
causes other than recurrent pterygium. Our results showed
that this surgical technique not only creates a strong barrier
to prevent recurrences, but also helps restore ocular surface
integrity, reform a deep fornix, and regain full ocular
motility.
The surgical technique of sealing the gap can further
improve the surgical outcome by addressing the following
2 major features that might have been overlooked in the
symblepharon surgery. Firstly, it is important to recognize
that the residual abnormal fibrovascular tissue, if not thoroughly removed, might impede the surgical outcome.6
Previously, this abnormality has been addressed by the
use of MMC.15,16 However, we noted that intraoperative
thorough and meticulous removal of subconjunctival
fibrovascular tissue without removing the upper
conjunctival epithelium or the remaining healthy Tenon
capsule was important. The way of distinguishing
abnormal fibrovascular tissue and the healthy Tenon
capsule is by paying attention to the color, texture,
stretchability/stickiness, and vascularity, of which the
stretchability/stickiness can be further distinguished with
the help of a Weck-cel (Figure 3, Top middle and Top
right). In brief, upon contact, abnormal fibrovascular tissue
tended to adhere to Weck-cel and was stretchable and
vascular. Secondly, after thorough and meticulous
removal of the subconjunctival fibrovascular tissue, the
gap (space) is created between the recessed conjunctiva
and the underlying healthy Tenon capsule. If this gap
was not sealed with a running 9-O nylon suture, it can
slowly invite recurrences. Because sealing the gap is sufficient in achieving satisfactory outcome, we recommend
abandoning the use of MMC in symblepharon repair.
Future studies are needed to determine if the above measures are sufficient to mitigate the use of MMC. Taking

SEALING THE GAP IN SYMBLEPHARON SURGERY

443

FIGURE 4. Representative surgical outcome in eyes with various grades of symblepharon. Preoperative (Left column) and postoperative photographs (Right column) of Case 2 with Grade Ia2D symblepharon (Top row, left and right), Case 6 with grade IIc0
symblepharon (Second row, left and right), Case 11 with grade IIIc1D symblepharon (Third row, left and right), and Case 15
with grade IVb0 symblepharon (Bottom row, left and right).

444

AMERICAN JOURNAL OF OPHTHALMOLOGY

SEPTEMBER 2015

advantage of the natural tendency of the Tenon capsule to

retract posteriorly, the described technique of sealing the
gap appeared to be as effective as the anchoring sutures
in restoring a deep fornix. Consequently, it also eliminates
the postoperative need for the patient to come back for the
removal of anchoring sutures.
In this study, the recurrence rate of symblepharon was
6.3%, which was comparable to 3.1% when similar sealing
the gap was used for treating recurrent pterygium,21 but
overall less than 14.8% in our previous report, where sealing the gap was not performed19 (Table 1). Complete success was also noted to increase from 63.9% to 81.3%
compared with our previous study. Our results were similar
to Kheirkhahs combined approach of MMC oral mucosa
graft amniotic membrane transplantation anchoring
suture for fornix reconstruction in severe symblepharon,
which also achieved a low recurrence rate of 6.2%20
(Table 1). However, we did not use an anchoring suture
or MMC and should also help avoid its potential serious
toxic effects of MMC such as scleral necrosis.22,23, Owing
to the limited number of cases in this study, the severity
of the symbleparon did not influence the outcome.
Controlling inflammation both preoperatively and postoperatively has substantial impact on the outcome of the
surgery. In our study, topical steroids were used to control
preoperative ocular inflammation in 5 of 6 SJS eyes, 1 of
1 OCP eye, 1 of 5 chemical burn eyes, and 1 of 1 conjunctival scarring eye following exposed buckle, while oral steroids or immune modulation were used in 3 eyes with SJS/
OCP. All eyes underwent operation with stabilized preop-

erative inflammation. Postoperative inflammation control

was used in patients with SJS and OCP. As in other
studies,24,25 the time period with oral or topical antiinflammatory medication was extended appropriately to
control postoperative inflammation. In our study, 5 of 7
eyes with SJS/OCP continued the use of topical and/or systemic steroids during the follow-up period. Subconjunctival injection of Kenalog was used 2 months after the
surgery in 1 eye with SJS but the eye failed to improve.
The 2 cases with partial success had suffered from severe
symblepharon due to either chemical burn or SJS, in which
postoperative inflammation continued. The failed case had
immune dysregulation, which persisted after surgery, leading to the recurrence.26 Therefore further studies are necessary to improve the management of preoperative and
postoperative inflammation in patients with autoimmune
disease.
In summary, our findings highlight the importance of
the fibrovascular tissue emanating from the fornix in
contributing to symblepharon growth and demonstrate
the effectiveness of sealing the gap in combating symblepharon recurrences. We believed that sealing of the gap
between the conjunctiva and Tenon capsule is an effective surgical technique to create a strong barrier for
preventing recurrence, reconstructing a deep fornix,
improving visual acuity, regaining full ocular motility,
and reducing conjunctival inflammation in symblepharon. We speculate that failure in sealing such a gap
explains the highly variable recurrence rates by different
surgical approaches.

ALL AUTHORS HAVE COMPLETED AND SUBMITTED THE ICMJE FORM FOR DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST
and none were reported. Financial Disclosures: Scheffer C.G. Tseng has obtained a patent for the method of preparation and clinical uses of amniotic
membrane and has licensed the rights to TissueTech, Inc, which procures and processes, and to Bio-Tissue, Inc, which is a subsidiary of TissueTech,
Inc, to distribute cryopreserved amniotic membrane for clinical and research uses. Funding/Support: This study was supported in part by an unrestricted
grant from Ocular Surface Research Education Foundation, Miami, Florida. All authors attest that they meet the current ICMJE requirements to qualify as
authors.

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Biosketch
Dandan Zhao, MD, is an attending Ophthalmologist working at YanAn Hospital of Kunming City, Kunming, Yunnan,
China. She received her master degree from Sichuan University and majored in Ophthalmology. Dr. Zhao received a
government founded training program where she completed a fellowship at Ocular Surface Research & Education
Foundation, Miami, FL, in March 2015. Her primary research interests include ocular surface disease and clinical use of
amniotic membrane.

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