Cicatrizing conjunctivitis is a group of inflammatory eye disorders that lead to progressive and permanent scarring of the conjunctiva, the clear membrane covering the white part of the eye and inner eyelids. Unlike common forms of “pink eye,” which are temporary and resolve without lasting effects, this condition is a chronic process. If not properly managed, persistent inflammation and subsequent scarring can cause significant damage to the ocular surface, leading to severe discomfort and vision loss.
Underlying Causes of Cicatricial Scarring
Cicatricial scarring on the conjunctiva stems from various conditions that provoke chronic inflammation. A primary category involves autoimmune diseases, where the body’s defense system incorrectly targets conjunctival tissue. Ocular Cicatricial Pemphigoid (OCP) is a primary autoimmune cause, characterized by autoantibodies attacking proteins in the conjunctiva’s basement membrane. This attack initiates a cascade of inflammation that results in fibrosis.
Severe, acute reactions can also precipitate this scarring process. Conditions like Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are systemic disorders, often triggered by medications, that cause widespread damage to mucous membranes, including the conjunctiva. The intense initial injury is followed by a disorganized healing response that leads to significant scar formation. These conditions are a medical emergency, with ocular scarring being a long-term complication.
Chronic infections are another source of cicatrizing conjunctivitis. Trachoma, caused by repeated infections with the bacterium Chlamydia trachomatis, is a well-known example. The recurrent inflammatory cycles lead to scarring of the inner eyelid and lasting damage. Other causes include physical or chemical trauma, such as severe acid or alkali burns, and less frequently, chronic allergic eye diseases or long-term use of certain topical eye medications.
Signs and Disease Progression
The initial presentation of cicatrizing conjunctivitis is often subtle and may be mistaken for more common eye conditions. Patients report persistent symptoms such as redness, a burning sensation, irritation, and excessive tearing. These symptoms are generally unresponsive to standard treatments for dry eye or common conjunctivitis, which can be a clue to the underlying process.
An ophthalmologist’s examination may reveal early evidence of fibrosis, such as fine white lines beneath the conjunctival surface. Over time, more significant changes occur, including forniceal foreshortening, which is a shrinkage of the pocket-like space between the eyelid and the eyeball. This reduction in space can limit eye movement and impair the eye’s ability to retain a healthy tear film.
As the scarring worsens, adhesions may form, tethering the eyelid to the eyeball in a condition known as symblepharon, which can restrict eye movement. Another complication is trichiasis, where the eyelashes turn inward and rub against the cornea, causing constant irritation and potential abrasion. This cascade of structural changes disrupts the ocular surface, leading to chronic dry eye, corneal damage, and in advanced cases, irreversible vision loss.
The Diagnostic Process
The diagnostic process begins with a detailed clinical examination of the eye. Using a slit lamp, a specialized microscope, the doctor looks for characteristic signs of scarring like subepithelial fibrosis, forniceal foreshortening, or a symblepharon. Early, subtle signs like fibrosis around the caruncle (the small, pink bump in the inner corner of the eye) may also be noted.
When an autoimmune cause like Ocular Cicatricial Pemphigoid is suspected, a conjunctival biopsy is the primary diagnostic test. This procedure involves taking a small sample of tissue from the conjunctiva, from an area showing inflammation. The tissue sample is then analyzed using direct immunofluorescence to detect specific antibodies bound to the basement membrane, which confirms an autoimmune attack is occurring.
To support the diagnosis, physicians may order blood tests to screen for circulating antibodies or inflammatory markers associated with systemic autoimmune diseases. This helps determine if the eye condition is an isolated issue or part of a broader disorder. A review of the patient’s medical history, including long-term use of topical eye drops, is also important, as some medications can induce a similar scarring process.
Treatment and Management Strategies
The primary goal for autoimmune-related cases is to suppress the immune system to halt inflammation and prevent further scarring. Systemic immunosuppression is the main approach, and treatment is typically long-term. It may start with oral corticosteroids to quickly reduce inflammation, followed by steroid-sparing agents like methotrexate or mycophenolate for sustained control. In resistant cases, biologic agents such as rituximab may be used to target specific components of the immune system.
Alongside systemic therapy, topical treatments are used to manage symptoms and protect the ocular surface. Aggressive lubrication with preservative-free artificial tears, gels, and ointments is important to combat the severe dry eye from conjunctival scarring. In some instances, topical anti-inflammatory medications like corticosteroid or cyclosporine drops may be used cautiously for localized relief, though their long-term use is carefully monitored.
Surgical intervention is reserved for managing the complications of scarring and is only performed once the underlying inflammation is controlled. Procedures may be necessary to correct trichiasis, where eyelashes are redirected away from the cornea. Scar tissue adhesions (symblepharon) can be surgically released to improve eye movement and eyelid function. In cases of significant surface damage, reconstruction using mucous membrane or amniotic membrane grafts can help restore a more stable conjunctival surface.