A 28-year-old woman presents to the eye clinic 6 weeks after a chemical splash injury to her right eye from an industrial cleaning solution (ammonia-based). She had received immediate irrigation and topical treatment. Now she complains of progressive redness, foreign body sensation, and recurrent episodes of eye discharge. On slit-lamp examination, the cornea shows central scarring with neovascularization, and the conjunctiva demonstrates symblepharon formation with loss of conjunctival fornices. What is the most appropriate next step in management?

Explanation

## Late-Stage Alkali Burn Management: Surgical Intervention **Key Point:** Symblepharon formation in the chronic phase of alkali injury requires surgical intervention to prevent further complications and restore conjunctival surface area. ### Phases of Chemical Burn Management ```mermaid flowchart TD A[Chemical Burn Injury]:::outcome --> B{Acute Phase<br/>0-7 days}:::decision B -->|Immediate| C[Copious irrigation<br/>Topical antibiotics<br/>Cycloplegics]:::action C --> D[Systemic vitamin C<br/>Acetazolamide<br/>Lubricants]:::action A --> E{Intermediate Phase<br/>1-4 weeks}:::decision E -->|Manage inflammation| F[Topical steroids<br/>Lubricants<br/>Prevent adhesions]:::action A --> G{Chronic Phase<br/>4+ weeks}:::decision G -->|Symblepharon present| H[Surgical lysis +<br/>Conjunctival autograft +<br/>Amniotic membrane]:::action H --> I[Restore fornices<br/>Prevent recurrence]:::outcome ``` **High-Yield:** The **chronic phase (>4 weeks)** is characterized by fibrosis and symblepharon formation. Medical management alone is insufficient; surgical intervention is required. ### Symblepharon: Definition and Pathophysiology **Symblepharon** = adhesion between the tarsal and bulbar conjunctiva, resulting from loss of conjunctival surface and subsequent fibrosis. **Mechanism in alkali burns:** 1. Destruction of conjunctival epithelium and Goblet cells 2. Loss of conjunctival fornices 3. Fibroblast proliferation and collagen deposition 4. Formation of adhesions between raw surfaces 5. Progressive loss of ocular surface area ### Management Strategy by Phase | Phase | Timeline | Clinical Features | Management | |-------|----------|-------------------|-------------| | **Acute** | 0–7 days | Pain, corneal haze, conjunctival blanching | Irrigation, antibiotics, cycloplegics, vitamin C | | **Intermediate** | 1–4 weeks | Inflammation, epithelialization begins | Topical steroids, lubricants, prevent adhesions (glass rod, bandage) | | **Chronic** | >4 weeks | Symblepharon, neovascularization, scarring | **Surgical lysis + conjunctival autograft + amniotic membrane** | **Clinical Pearl:** In this patient, 6 weeks have passed. The presence of symblepharon, corneal scarring, and neovascularization indicates the chronic fibrotic phase. Medical management alone will not reverse the structural damage. ### Surgical Management of Symblepharon **Indications for surgery:** - Symblepharon involving >25% of fornix - Progressive loss of conjunctival surface - Recurrent epithelial defects - Functional impairment (restricted ocular motility, discomfort) **Surgical technique:** 1. **Lysis of adhesions** — careful separation of tarsal and bulbar conjunctiva 2. **Conjunctival autograft** — harvest from contralateral eye or oral mucosa to restore surface area 3. **Amniotic membrane transplantation** — reduces inflammation, promotes epithelialization, prevents recurrence 4. **Placement of spacer** (silicone sheet or bandage contact lens) to prevent re-adhesion during healing **Mnemonic: CAA = Conjunctival Autograft + Amniotic membrane = Cure for Adhesions** ### Why Other Options Fail - **Topical therapy alone:** Cannot reverse established fibrosis or restore lost conjunctival surface. The structural damage is irreversible without surgery. - **Corneal transplantation:** Premature; the ocular surface (conjunctiva, tear film) must be optimized first. A graft will fail in a hostile environment. - **Systemic corticosteroids indefinitely:** Prolonged systemic steroids carry significant risks (infection, metabolic complications) and do not address the mechanical problem of symblepharon. **Warning:** Delaying surgical intervention allows progressive fibrosis and further loss of conjunctival surface, worsening long-term prognosis. [cite:Khurana AK Comprehensive Ophthalmology 7e Ch 3; Parson's Diseases of the Eye 22e Ch 8]