Sarcoid-induced symblepharon.

Dear Editor,

Sarcoidosis can have many clinical manifestations. The lungs are most frequently affected, but ocular involvement occurs in about 25-50% of histologically proven cases of sarcoidosis.1 Uveitis is the most common manifestation of intraocular sarcoidosis, although any part of the globe or ocular adnexa may be involved.2 Cicatrizing conjunctivitis caused by sarcoidosis is well documented, and granulomatous inflammation of the conjunctiva is the second most common ophthalmic finding in sarcoidosis.3 However, sarcoid-related symblepharon is a rarely reported complication of sarcoidosis.1,4,5 We report a case of histopathologically proven symblepharon caused by sarcoidosis.

A 31-year-old African American male was referred to the oculoplastic and orbital surgery clinic for evaluation of right lower eyelid symblepharon. The patient had complaints of irritation of the right eye caused by inturned lashes, as well as tearing of both eyes. His past medical history was significant for a diagnosis of sarcoidosis made three and a half years earlier based on histopathological specimens from excised nasal polyps and skin lesions on the anterior neck. He had not received any treatment for the disease at the time of presentation to the eye clinic. The patient′s chest radiograph demonstrated hilar lymphadenopathy, indicating mild lung involvement. He had no other history of eye surgery or other eye problems. Aside from a diagnosis of schizoaffective disorder and mild mental retardation, the patient was otherwise healthy.

Ocular examination revealed a best corrected visual acuity of 20/30 in each eye, with mild restriction in both abduction and adduction in the right eye. His intraocular pressures were 10 and 8 mmHg in the right and left eye, respectively by applanation tonometry. External and slit-lamp exams showed symblepharon of the right lower lid involving the lateral canthal angle with associated conjunctival granulomas [Fig. 1]. The anterior and posterior segments were normal.

Figure 1

31-year-old with biopsy-proven sarcoid-induced symblepharon

The patient underwent lysis and excision of the right lower lid symblepharon with extensive conjunctivoplasty and placement of a mucous membrane graft from the lower lip. A right symblepharon ring as well as a right temporary suture tarsorrhaphy were subsequently placed.

The excised tissue was submitted for histopathological analysis. The biopsy revealed nodular granulomas with adjacent chronic inflammatory cells. The granulomas were made up of histiocytes with an occasional Langerhans giant cell, consistent with sarcoidosis [Fig. ].

Figure 2

Histological specimen from excised symblepharon demonstrating sarcoidosis. A. Granuloma; B. Langerhans giant cell; C. Conjunctival epithelium

There was mild recurrence of the symblepharon at the one month postoperative follow-up examination, and the patient elected not to have further surgery.

The patient in this report did not have any evidence of other ocular manifestations commonly caused by sarcoidosis, such as uveitis, glaucoma, vitritis, periphlebitis, or retinal changes; his only manifestation of sarcoidosis was symblepharon and associated conjunctival granulomas. The pathological hallmark of sarcoidosis is the noncaseating epithelioid granuloma, which was consistent with the granulomatous inflammation described in the lesions of this patient. Disease occurs when granulomata affect the involved tissue as space-occupying lesions which damage and deform the normal structure and can cause inflammation, as in this rare case leading to symblepharon.