Fornix Reconstruction And Simple Limbal Epithelial Transplantation After Thermal Burn Injury: A 6-Year Follow-Up

Thermal and chemical ocular burns are one of the most common ocular injuries. They can lead to symblepharon formation, fornix shortening, and stem cell insufficiency. Treatment usually involves symblepharon removal and reconstruction of the conjunctiva using oral or nasal mucosa, amniotic membrane transplantation (AMT), or a conjunctival graft with or without stem cell transplantation. At present, there is no consensus about the optimal surgical treatment for severe ocular surface damage after ocular burns.

We aim to present a clinical case of a male developing limbal stem cell deficiency (LSCD), and  symblepharon after suffering a thermal burn injury to his right eye (RE).

A 55-year-old Caucasian male was presented to our clinic after a fireworks injury to his RE. He had a history of peripheral artery disease but no history of eye diseases or eye operations.

Examination revealed a burn of the upper eyelid, a conjunctival chemosis and a total corneal epithelial defect. Visual acuity was counting fingers. His left eye (LE) was intact.

The corneal epithelial defect on the RE was treated with topical therapy, bandage contact lens (BCL), and AMT three times. Three months later, the corneal defect was healed.

One year after the injury, a pannus covered the cornea up to the visual axis. Between the upper eyelid, bulbar conjunctiva, and corneal pannus, a pronounced symblepharon developed. A reconstruction of the upper fornix with symblepharon separation and pannus dissection was performed. Oral mucosal epithelial transplantation (OMT) was sutured on the tarsal conjunctiva. AMT was secured with fibrin glue to the bulbar conjunctiva and over the cornea. The BCL was inserted, and temporal tarsorrhaphy was performed. Four months later, a combined operation for optimization of the inverted eyelid position with lid split procedure and autologous conjunctival transplantation, as well as simple limbal epithelial transplantation (SLET) using autologous limbal stem cells from the LE were performed.

Ten months later, the cornea remained clear with mild peripheral neovascularisation over four clock hours and a smaller symblepharon. A cataract surgery with a one-piece intraocular lens placed in the posterior capsular sac was performed. Postoperatively, a scleral lens was fitted. Due to excess mucus formation, prolonged use was not comfortable, the patient preferred BCL for ocular discomfort.

Up until now, the symblepharon and peripheral corneal vascularization on the RE have remained stable with a visual acuity of 0.1.

A broad spectrum of consequences of an ocular thermal burn and its complex treatment are presented.

There is no consensus regarding the optimal treatment of such pathologies. After stabilization of the ocular surface, we performed a fornix reconstruction using OMT and AMT, followed by a lid split, conjunctival autograft and SLET. The eye remained stable also after cataract surgery.

In such complex cases, it is important to consider all aspects of the pathology and address them with deliberate planning of various surgical procedures. Our case using a combined approach presents a good outcome with a satisfied patient six years after the injury.