Lichen planus (LP) is a chronic inflammatory disorder that typically affects the skin and mucous membranes, characterized by an abnormal immune response where T-cells mistakenly attack the body’s own epithelial cells. When this condition involves the eye, it is termed Ocular Lichen Planus (OLP), a rare but potentially serious complication. OLP is a type of cicatrizing conjunctivitis, meaning it causes scarring, and it requires specialized medical attention to prevent permanent damage to the ocular surface.
How Lichen Planus Affects the Eye
Ocular Lichen Planus develops when the body’s immune system targets the basal layer of the conjunctival epithelium, the clear membrane covering the white part of the eye and the inner surface of the eyelids. This T-cell mediated autoimmune inflammation leads to a chronic, progressive process of damage and subsequent scarring. The disease is classified as a cicatrizing conjunctivitis, causing fibrosis beneath the outer layer of the conjunctiva.
This subepithelial fibrosis causes the tissue to shrink and pull on surrounding structures, which is the mechanism behind the physical changes observed in the eye. The inflammation can also affect tear-producing goblet cells and the lacrimal drainage system, leading to severe dysfunction of the ocular surface. While OLP is often seen in conjunction with lichen planus elsewhere in the body, such as the mouth or skin, it can rarely occur in isolation, making diagnosis more challenging.
The Distinct Physical Appearance of OLP
The physical appearance of OLP is marked by signs of chronic inflammation and progressive scarring, primarily affecting the conjunctiva. In early stages, the inflammation may cause conjunctival hyperemia, which is a generalized redness on the white of the eye and inner eyelid. A specific sign is the appearance of white, streaky, or lacy patches on the tarsal conjunctiva, often described as reticular striae.
As the disease progresses, the most damaging physical changes occur due to the underlying fibrosis and shrinkage of tissue. The conjunctival fornices—the deep folds where the eyelid meets the eyeball—begin to shorten and flatten, a condition known as fornix shortening. This loss of depth restricts eye movement and impairs the eye’s ability to hold a sufficient tear film.
The most severe scarring manifestation is the formation of symblepharon, which are adhesions that form between the inner surface of the eyelid and the eyeball itself. These bands of tissue tether the eyelid and restrict the movement of the eye and eyelid, resulting in a distorted ocular surface. The chronic irritation and dryness can also lead to secondary changes on the cornea, such as irregular surface epithelium and subepithelial haze, which can impair vision.
Common Associated Symptoms
Patients with OLP often experience significant discomfort due to the chronic inflammation and surface damage. A persistent sensation of a foreign body or grittiness is common, alongside chronic irritation and a burning feeling. These symptoms reflect the ongoing inflammatory process and the resulting severe dry eye.
Severe dryness is a hallmark symptom, resulting from damage to the tear-producing structures and the destruction of goblet cells within the conjunctiva. Patients may also develop photophobia, which is an uncomfortable sensitivity to light, linked to the inflammation and damage to the corneal surface. These symptoms tend to worsen over time without treatment, leading to a significant impact on daily life and visual function.
Managing OLP and Preventing Vision Loss
The primary goal of managing OLP is to suppress the underlying autoimmune inflammation, thereby halting the progression of scarring and preventing irreversible vision loss. Early diagnosis, often requiring a biopsy to distinguish it from other cicatrizing conditions, is paramount for a better outcome. Treatment is typically a long-term commitment and requires close collaboration between an ophthalmologist and a dermatologist.
Initial management often involves topical therapies, such as high-dose corticosteroid eye drops or topical immunosuppressive agents like cyclosporine, to control acute flare-ups and reduce surface inflammation. When the disease is more aggressive or fails to respond to localized treatments, systemic immunosuppressive medications are introduced. These systemic agents may include drugs like Dapsone or Methotrexate, which work to reduce the overactive immune response throughout the body.
Lubricating eye drops and artificial tears are used continuously to manage the severe dry eye component and protect the ocular surface from friction damage. For advanced cases where severe scarring has already caused symblepharon or significant fornix shortening, surgical interventions may be considered. These procedures, which can include lysis (cutting) of symblepharon or stem cell transplants for severe corneal damage, are generally reserved as a last resort and are aimed at restoring the structural integrity of the eye.