Symblepharon

(This is the adhesion between the conjunctival surfaces or between the conjunctival surface and the cornea. This sign may be easily missed if the lids especially the lower lids are not everted, there may be associated shortening of the fornix. In clinical examination, the most common cases are ocular cicatricial pemphigoid (usually bilateral) or chemical injury (usually unilateral))

Congenital
(may be isolated or associated with systemic condition such as Goldenharg's syndrome)

Acquired
 

• traumatic including chemical injury

• post-surgical (Commonly seen with pterygium operation. The condition can also occur following conjunctival incision for retinal detachment or squint surgery)

• inflammatory conditions (this include ocular cicatricial pemphigoid and Steven-Johnson's syndrome)

 
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Pigmented lesion of the conjunctiva
(This is rarely the only physical sign in the examination except perhaps adrenochrome. This is because the adrenochrome is found mainly in the fornix and tarsal conjunctiva and unless you perform a methodical examination by everting the lids during slit-lamp examination the sign is easily missed. Pigmented lesions are best classified into melanocytic and non-melanocytic lesions)

Melanocytic lesions
 

• congenital pigmentation

 
benign epithelial melanosis (flat and brownish pigmentation around the limbus, often found in coloured race)

melanosis oculi (unilateral episcleral pigmentation with associated increased pigmentation of the uvea tract, common in coloured race. Naevus of Ota is melanosis oculi with associated skin pigmentation)

• acquired melanosis

primary acquired malenosis

secondary pigmentation (may result from hormonal problem as in Addison's disease, radiation or chronic conjunctival irritation)
 

• pigmented naevi

(seen mainly in the bulbar conjunctiva with cystic appearance)
 
• malignant melanoma

• primary arising from the naevi, primary acquired melanosis and rarely congenital melanosis
• secondary which can either be an extension from the uveal tumour or metastasis from the skin

Non-melanocytic lesions
 

• pigment deposits (such as adrenochrome, argyrosis)
• foreign body (such as iron)
• staphyloma (due to thinned sclera )
• alkaptouria (pigmentation is usually at the insertion of the horizontal recti)
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