Aetiology

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:

• trauma
  • surgery
  • thermal, radiation, mechanical, chemical
  • trichiasis
  • entropion (see Clinical Management Guideline)
• exposure
  • ectropion (see Clinical Management Guideline)
  • lagophthalmos and other distrubance of lid function
• autoimmune
  • ocular cicatricial pemphigoid (OCP)
  • Stevens-Johnson syndrome (erythema multiforme major)
  • graft versus host disease
• infection (N.B. very few forms of infective conjunctivitis cause scarring)
  • trachoma (recurrent infection by Chlamydia trachomatis [serotypes A-C])
• allergy
  • vernal keratoconjunctivitis (see Clinical Management Guideline)
  • atopic keratoconjunctivitis (see Clinical Management Guideline)
• ligneous conjunctivitis
  • rare form of chronic conjunctivitis characterised by pseudomembranous lesions of ‘woody’ consistency
• drug-induced 
  • preservatives in topical anti-glaucoma medications are most frequently implicated; topical antivirals, vasoconstrictors and some systemic drugs have also been associated with drug-induced cicatricial conjunctivitis

Predisposing factors

OCP is primarily a disease of the elderly
Stevens-Johnson syndrome usually occurs in previously healthy young adults

• hypersensitivity reaction precipitated by many different antigens including
  • bacteria, viruses, fungi, drugs

Trachoma: a disease of under-privilege and compromised hygiene

           -     globally, the leading infectious cause of blindness

Atopic keratoconjunctivitis typically affects young atopic adults

Symptoms of conjunctival scarring

Symptoms depend on severity and type of scarring
Reduced tear components and compromised lid function both lead to dry eye

• grittiness, burning, foreign body sensation
• blurred vision in severe cases

Signs of conjunctival scarring

Depends on aetiology
Surgical and traumatic scarring

• focal, linear or diffuse scarring according to cause

OCP produces sequence of conjunctival changes

• bilateral (often asymmetrical)
• diffuse hyperaemia, papillae
• bullae leading to ulceration and pseudomembrane formation
• subepithelial fibrosis, shortening of the fornices and sometimes symblepharon
• secondary corneal changes

Stevens-Johnson syndrome produces sequence of conjunctival changes

• acute bilateral mucopurulent conjunctivitis
• fibrosis and keratinisation follow acute phase
• secondary corneal changes due to tear deficiency, exposure, keratinisation of the tarsal conjunctiva

Vernal keratoconjunctivitis

• tarsal sub-conjunctival fibrosis
• pannus (especially at upper limbus)

Atopic keratoconjunctivitis

• tarsal sub-conjunctival fibrosis
• conjunctival shrinkage
• forniceal shortening

Trachoma

• follicles (upper tarsus)
• pannus (especially at upper limbus)
• conjunctival inflammation leading to scarring and trichiasis
  • Von Arlt’s line (horizontal line of scarring parallel to lid margin)
• Herbert’s pits (depressions at the upper limbus representing resolved limbal follicles)
• secondary corneal changes

Differential diagnosis

A comprehensive ophthalmic and medical history should reveal the cause
If no apparent cause, rule out early stages of OCP

Management by optometrist

Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere

Check for signs of dry eye

• reduced tear meniscus
• low tear break up time
• fluorescein (drops or diagnostic strips) for staining of ocular surface – typically inferior third of cornea and interpalpebral conjunctiva

Check for signs of mechanical trauma to cornea due to:

• trichiasis, keratinised tarsal conjunctiva

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:

• to prevent desiccation by maintaining a fluid layer beneath the lens
• to prevent trauma from keratinised conjunctiva
• to promote healing of epithelial defects

(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) 
 

Management category

Mild scarring resulting from minor trauma or surgery:

• B2: alleviation / palliation: normally no referral

Moderate to severe scarring:

• B1: initial management (including drugs) followed by routine referral. Any conjunctival scarring of unknown aetiology should be referred
• A3: urgent referral (within one week) if ocular autoimmune disease is suspected 

Possible management by ophthalmologist

• Topical and/or systemic immunosuppression if autoimmune aetiology
• Conjunctival or buccal mucus membrane grafts, stem cell transplantation, amniotic membrane transplantation, lid surgery (but surgery in OCP can stimulate inflammation and produce further scarring)

Evidence base

*GRADE: Grading of Recommendations Assessment, Development and Evaluation (www.gradingworkinggroup.org)
 

Sources of evidence

Branisteanu DC, Stoleriu G, Branisteanu DE, Boda D, Branisteanu CI, Maranduca MA, Moraru A, Stanca HT, Zemba M, Balta F. Ocular cicatricial pemphigoid (Review). Exp Ther Med. 2020;20(4):3379-3382

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

Singh S, Donthineni PR, Shanbhag SS, Senthil S, Ong HS, Dart JK, Basu S. Drug induced cicatrizing conjunctivitis: A case series with review of etiopathogenesis, diagnosis and management. Ocul Surf. 2022;24:83-92.

Conjunctival scarring
Version 9
Date of search 14.07.23
Date of revision 18.07.23
Date of publication 17.10.23
Date for review 13.07.25
© College of Optometrists