Effect of Postoperative Subconjunctival Corticosteroid Injections in a Multimodal Approach for the Treatment of Severe Symblepharon

Introduction

Symblepharon is a challenging ocular surface condition involving the bulbar and palpebral conjunctiva, which occurs due to partial or complete adhesions between these structures [1]. This condition may arise from external factors such as chemical or thermal burns or endogenous factors like Stevens-Johnson syndrome (SJS), ocular cicatricial pemphigoid (OCP), and severe dry eye disease. The entire ocular surface can be affected, leading to various complications, including restricted ocular motility, lagophthalmos, entropion, ptosis, and secondary detrimental effects on the cornea, which may impair vision [2].

Symblepharon is difficult to treat due to its high recurrence rate. Patients with advanced clinical stages of the disease often experience a high rate of therapeutic failure [3]. However, in cases caused by systemic diseases, systemic immunosuppressants can effectively control the condition [4]. Conversely, traumatic causes of symblepharon often require surgical intervention. Over time, the surgical approach has evolved from initial symblepharon lysis to defect covering with various techniques and additional measures. To address the defect, tissues such as the amniotic membrane, oral and nasal mucosa, conjunctival grafts, and split-thickness skin graft have been used [5]. In addition to surgery, non-surgical treatments like mitomycin C (MMC), artificial tears, and symblepharon rings are available. Despite the numerous surgical approaches, there is no consensus on the most effective method for achieving the best long-term results.

The development of new therapeutic approaches requires a better understanding of the molecular mechanisms behind the symblepharon formation. Although the exact pathophysiology remains unclear, several stages in its development have been identified, including conjunctival inflammation, tissue remodeling, and fibrosis. New treatment methods take these various stages into consideration and are currently being developed. These strategies include anti-adhesion therapies or treatments based on animal models to prevent or resolve symblepharon during these phases. Each stage involves distinct cellular and biological processes, which are essential to tailor effective therapeutic interventions [11].

Publikationsverlauf

Eingereicht: 21. Oktober 2024

Angenommen: 17. Dezember 2024

Artikel online veröffentlicht:
07. Februar 2025

• References

• 1 Li T, Shao Y, Lin Q. et al. Reversed skin graft combining with lip mucosa transplantation in treating recurrent severe symblepharon: A case report. Medicine (Baltimore) 2018; 97: e12168
• 2 Kaufman HE, Thomas EL. Prevention and treatment of symblepharon. Am J Ophthalmol 1979; 88: 419-423
• 3 Cheng J, Zhai H, Wang J. et al. Long-term outcome of allogeneic cultivated limbal epithelial transplantation for symblepharon caused by severe ocular burns. BMC Ophthalmol 2017; 17: 8
• 4 Branisteanu DC, Stoleriu G, Branisteanu DE. et al. Ocular cicatricial pemphigoid (Review). Exp Ther Med 2020; 20: 3379-3382
• 5 Kheirkhah A, Ghaffari R, Kaghazkanani R. et al. A combined approach of amniotic membrane and oral mucosa transplantation for fornix reconstruction in severe symblepharon. Cornea 2013; 32: 155-160
• 6 Ballen PH. Mucous membrane grafts in chemical (lye) burns. Am J Ophthalmol 1963; 55: 302-312
• 7 Solomon A, Espana EM, Tseng SC. Amniotic membrane transplantation for reconstruction of the conjunctival fornices. Ophthalmology 2003; 110: 93-100
• 8 Patel BC, Sapp NA, Collin R. Standardized range of conformers and symblepharon rings. Ophthalmic Plast Reconstr Surg 1998; 14: 144-145
• 9 Ralph RA. Reconstruction of conjunctival fornices using silicone rubber sheets. Ophthalmic Surg 1975; 6: 55-57
• 10 Tseng SC, Di Pascuale MA, Liu DT. et al. Intraoperative mitomycin C and amniotic membrane transplantation for fornix reconstruction in severe cicatricial ocular surface diseases. Ophthalmology 2005; 112: 896-903
• 11 Swarup A, Ta CN, Wu AY. Molecular mechanisms and treatments for ocular symblephara. Surv Ophthalmol 2022; 67: 19-30
• 12 Schrader S, Notara M, Beaconsfield M. et al. Tissue engineering for conjunctival reconstruction: established methods and future outlooks. Curr Eye Res 2009; 34: 913-924
• 13 Koizumi N, Inatomi T, Suzuki T. et al. Cultivated corneal epithelial stem cell transplantation in ocular surface disorders. Ophthalmology 2001; 108: 1569-1574
• 14 Schonberg S, Stokkermans TJ. Ocular Pemphigoid. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023
• 15 Saw VP, Schmidt E, Offiah I. et al. Profibrotic phenotype of conjunctival fibroblasts from mucous membrane pemphigoid. Am J Pathol 2011; 178: 187-197
• 16 Gaballa SA, Kompella UB, Elgarhy O. et al. Corticosteroids in ophthalmology: drug delivery innovations, pharmacology, clinical applications, and future perspectives. Drug Deliv Transl Res 2021; 11: 866-893