an 18-year - old female patient presented with inability to open both eyes for 6 weeks .
she had a history of fever from malaria 2 months back for which she was treated with oral chloroquin phosphate 500 mg .
she developed erythematous papular eruptions on the trunk , mouth , and limbs along with pain , redness , and watering from both eyes 5 days after taking the medication followed by gross diminution of vision and inability to open her eyes .
the erythematous lesions resolved completely at 4 weeks with medications , but she was unable to open her eyes and she was referred to us for further evaluation and management . at the time of presentation ,
her visual acuity was positive perception of light in both eyes , with both the upper lids adhered to almost the whole of the cornea , and part of the lower bulbar conjunctiva with the lower lid [ fig . 1 ] .
b - scan ultrasonography ( usg ) revealed acoustically clear vitreous , normal chorioretinal thickness , and normal optic nerve head with an attached retina .
close - up view shows the cornea and upper tarsal conjunctiva being totally adhered in both eyes ( b ) routine blood examination , blood glucose , and serum urea and creatinine levels were within normal limits .
physician evaluation was done by meticulous history taking , clinical examinations , and key laboratory examinations to exclude other blistering skin diseases such as pemphigus vulgaris , bullous pemphigoid , mucocutaneous diseases like behet 's syndrome and reiter 's syndrome , and vasculitis like systemic lupus erythematosus .
the patient was taken up for surgery and superficial lamellar dissection of the cornea was done to separate the conjunctivocorneal adhesion , followed by release of symblepharon between palpebral and bulbar conjunctiva .
the inspection of the limbus revealed areas of scattered peripheral corneal neovascularization affecting less than 3 clock hours in both eyes , which implied the areas of limbal stem cell deficiency ( lscd ) of the corresponding areas .
the buccal mucous membrane was harvested after injecting 2% xylocaine with adrenaline ( 1 in 200,000 ) into the proposed site and the graft was removed from below moving upward .
after harvesting , the extra fat was removed from the graft . a mucous membrane graft ( mmg ) of size 27  8 mm ( right eye ) and 26  8 mm ( left eye ) was placed over the raw area of superior bulbar conjunctiva and secured with interrupted stitches using 8 - 0 vicryl .
the lower bulbar conjunctiva was covered by a mmg of size 15  7 mm ( right eye ) and 14  7 mm ( left eye ) and sutured in a similar fashion .
this was followed by the placement of a symblepharon ring to prevent the recurrence of symblepharon and a temporary tarsorrhaphy was placed in both eyes to achieve some pressure effect on the mmg by the symblepharon ring [ fig . 2 ] .
the patient was given a systemic antibiotic ( cephalexin 500 mg three times a day for 5 days ) and a nonsteroidal anti - inflammatory ( ibugesic 100 mg , paracetamol 500 mg , combination twice daily after meal for 4 days ) along with a topical antibiotic steroid ( gatiflxaciin with dexamethasone , one drop six times a day for 1 month ) combination , and a tear substitute ( carboymethylcellulose ) was prescribed for six times a day for 6 months . early post - operative view ( seventh day ) :  gross appearance ( a ) .
close - up view of both eyes with the bandage contact lens and symblepharon ring seen in situ ( b ) the re - epithelialization of the corneal epithelium was completed by in 10 days .
temporary tarsorrhaphy was removed after 2 weeks and both the bcl and the symblepharon ring was removed at 4 weeks . except few sectors of peripheral corneal vascularization , no other sequelae were observed postoperatively .
best corrected visual acuity of 20/120 in both sides after 1 month and 20/80 after 3 months [ fig .
3 ] was achieved and maintained till the 2.5-year follow - up without any other sequelae .
close - up view showing well reconstruction in the inferior fornix in both eyes ( b )
the exact etiology of sjs is not known and the understanding of the etiopathogenesis and management protocol of ocular adnexal complication of sjs has been limited so far . often , patients of sjs are treated by a physician or dermatologist in early phases and later referred to an eye care center .
patients often consult an ophthalmologist with severe ocular sequelae only after the resolution of skin lesions , as in our case .
the acute stage of the sjs is characaterized by bilateral catarrhal and membranous conjunctivitis . during the chronic stage of the disease , most patients have various alterations of the ocular surface , such as symblepaharon , entropion , trichiasis , dry eye , limbal cell deficiency , conjunctival inflammation and corneal neovascularization .
the major aim of treatment in late phases of sjs is ocular surface reconstruction to correct cicatricial sequalae and chronic inflammation .
management option in late cases is a challenge and is often frustrating , because of the combination of various alterations in surface milieu causing severe dryness and surface inflammation leading to treatment failure .
several surgical approaches for the reconstruction of the ocular surface in cicatricial disorders with or without significant lscd have been tried with encouraging results . to reconstruct and maintain the ocular surface ,
a full - thickness oral mmg is the simplest graft to use if a conjunctiva is not available .
it is preferred over split - thickness mucosal grafts as it contracts less in comparison , though a split - thickness graft is more preferable from the cosmesis point of view because of its lesser bulk and pinky appearance however , amniotic membrane transplantation ( amt ) is an accepted approach to the surgical management of chronic symblephera because of the unique properties of the membrane , especially in cases with significant lscd .
it can be combined with limbal transplantation and with an adjunctive antimetabolite . however , in cases with an adequate reserve of limbal stem cells , mucosal tissue transplantation achieves equally good results as seen in our case .
mucosal tissue transplantation can be considered in situations where cost and inadequate infrastructure are concerned .
our case had a partial lscd which was scattered and amounting to 34 clock hours in each eye .
as such the corneal re - epitheliazation was satisfactory after the procedure . in cases of severe bilateral lscd , an additional procedure of stem cell harvesting and ex vivo culture would have been required .
the ultimate aim of treatment of the chronic phase of ocular surface disorders like sjs is restoration of the anatomical structures and physiologic properties of the ocular surface .
 an 18-year - old woman was referred with late sequelae of chloroquine - induced steven  johnson syndrome . at the time of presentation , the symblepharon was involving the upper lids to almost the whole of the cornea , and part of the lower bulbar conjunctiva with the lower lid bilaterally . 
 other ocular examinations were not possible due to the symblepharon . 
 b - scan ultrasonography revealed acoustically clear vitreous , normal chorioretinal thickness , and normal optic nerve head , with an attached retina . 
 conjunctivo - corneal adhesion released by superficial lamellar dissection of the cornea . 
 ocular surface reconstruction was carried out with a buccal mucous membrane . 
 a bandage contact lens was placed over the cornea followed by the symblepharon ring to prevent further adhesion . 
 the mucosal graft was well taken up along with corneal re - epithelization . 
 best corrected visual acuity of 20/120 in both sides after 1 month and 20/80 after 3 months was achieved and maintained till the 2.5-year follow - up . 
Case Report
Discussion