Conjunctival scarring
The CMGs are guidelines on the diagnosis and management of a range of common and rare, but important, eye conditions that present with varying frequency in primary and first contact care.
The CMGs are guidelines on the diagnosis and management of a range of common and rare, but important, eye conditions that present with varying frequency in primary and first contact care.
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All conjunctival scarring is, by definition, ‘cicatricial’; but the term ‘cicatrising conjunctivitis’ is generally reserved for scarring in which there is significant tissue shrinkage, usually with distortion of the fornices and/or the lids
Many conditions can cause conjunctival scarring
Can be focal, multifocal or diffuse
Severity ranges from trivial to sight threatening
Many potential causes:
OCP is primarily a disease of the elderly
Stevens-Johnson syndrome usually occurs in previously healthy young adults
Atopic keratoconjunctivitis typically affects young atopic adults
Symptoms depend on severity and type of scarring
Reduced tear components and compromised lid function both lead to dry eye
Depends on aetiology
Surgical and traumatic scarring
OCP produces sequence of conjunctival changes
Stevens-Johnson syndrome produces sequence of conjunctival changes
Vernal keratoconjunctivitis
Atopic keratoconjunctivitis
Trachoma
A comprehensive ophthalmic and medical history should reveal the cause
If no apparent cause, rule out early stages of OCP
Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere
GRADE* Level of evidence and strength of recommendation always relates to the statement(s) immediately above
Check for signs of dry eye
Check for signs of mechanical trauma to cornea due to:
Taping to reduce entropion (temporary measure)
Taping lids together at night in lagophthalmos
(GRADE*: Level of evidence=low, Strength of recommendation=strong)
Therapeutic contact lens. All types of lens have been used. When the eye is relatively dry the first choice may be a scleral lens:
(GRADE*: Level of evidence=low, Strength of recommendation=weak)
Ocular lubricants for tear deficiency/instability related symptoms (drops for use during the day, unmedicated ointment for use at bedtime)
NB Patients on long-term medication may develop sensitivity reactions which may be to active ingredients or to preservative systems (see Clinical Management Guideline on Conjunctivitis Medicamentosa). They should be switched to unpreserved preparations
(GRADE*: Level of evidence=low, Strength of recommendation=strong)
Mild scarring resulting from minor trauma or surgery:
Moderate to severe scarring:
*GRADE: Grading of Recommendations Assessment, Development and Evaluation (www.gradingworkinggroup.org)
Sources of evidence
Ciralsky JB, Sippel KC, Gregory DG. Current ophthalmologic treatment strategies for acute and chronic Stevens-Johnson syndrome and toxic epidermal necrolysis. Curr Opin Ophthalmol. 2013;24(4):321-8
Radford CF, Rauz S, Williams GP, Saw VP, Dart JK. Incidence, presenting features, and diagnosis of cicatrising conjunctivitis in the United Kingdom. Eye (Lond). 2012;26(9):1199-208
Rajak SN, Makalo P, Sillah A, Holland MJ, Mabey DC, Bailey RL, Burton MJ. Trichiasis surgery in The Gambia: a 4-year prospective study. Invest Ophthalmol Vis Sci. 2010;51(10):4996-5001
Saw VP, Minassian D, Dart JK, Ramsay A, Henderson H, Poniatowski S, Warwick RM, Cabral S. Amniotic membrane transplantation for ocular disease: a review of the first 233 cases from the UK user group. Br J Ophthalmol 2004;91:1042-7
Sharma N, Thenarasun SA, Kaur M, Pushker N, Khanna N, Agarwal T, Vajpayee RB. Adjuvant Role of Amniotic Membrane Transplantation in Acute Ocular Stevens-Johnson Syndrome: A Randomized Control Trial. Ophthalmology. 2016;123(3):484-91
Many conditions can cause the conjunctiva, the thin transparent membrane covering the white of the eye and the underside of the eyelids, to become scarred. These include injury, infection, allergy and autoimmune diseases, in which the body’s immune system attacks its own cells or tissues. On a global scale, a major cause of conjunctival scarring and blindness is an infectious disease called trachoma, which is not common in the UK but affects many millions of people in North Africa and South Asia.
Scarring damages the conjunctiva and makes it less able to retain tears and protective mucus. Patients may have symptoms of dry eye, with grittiness, burning and, in severe cases, blurred vision. They may be helped by artificial tear drops, eyelid surgery and transplantation of amniotic membrane (innermost layer of the placenta) on to the eye surface.
Corneal scarring
Version 6
Date of search 24.04.17
Date of revision 25.05.17
Date of publication 05.12.17
Date for review 23.04.19
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