Case 1

A 28-year-old male was admitted to our hospital 2 h after having splashed molten silver metal into his right eye. On initial examination, visual acuity was limited to light perception. Anterior segment examination revealed burns of the upper and lower eyelids and eyelashes, a completely opaque cornea, 360° limbal ischemia, and severe burns in the bulbar conjunctiva. The fundus could not be visualized. Intraocular pressure (IOP) was 20 mmHg as measured by Icare Pro Tonometer (Helsinki, Finland). The ocular surface was rinsed thoroughly with 1 L of Ringer's lactate solution over 20 min (Figure 1 A), during which a hardened silver metal, approximately 1 cm diameter, that was buried into the upper fornix was noticed and removed. B-scan ocular ultrasonography was also performed, which did not reveal any other intraocular damage. Medical treatment at this stage consisted of topical 10% acetylcysteine, 10% vitamin C, moxifloxacin, 1% cyclopentolate, preservative-free artificial tears, 1% prednisolone, and oral vitamin C 1.5 g/day. Eight hours after the injury, amniotic membrane transplantation (AMT) was performed, and a polymethylmethacrylate symblepharon ring (conformer, 24 mm in diameter, with a 10-mm-diameter hole in the middle) was placed in the right eye.

Figure 1 A) Biomicroscopic examination showed burns of the upper and lower eyelids and eyelashes, total corneal loss of transperancy, 360° limbal ischemia, and diffuse burns in the bulbar conjunctiva approximately two and a half hours following an incidence of molten silver metal burn in the right eye. B) Central corneal melting, stromal infiltration, circumferential conjunctival hyperemia, chemosis, mucopurulent discharge, eyelid edema and eyelid hyperemia in the second month. C) Following removal of the conformer, severe symblepharon developed, resulting in total loss of the upper and lower fornices. Total corneal conjunctivalization was seen 5 months following the incidence. 

Visual acuity on the 20^th day after the burn was still limited to light perception. Slit-lamp examination revealed an opaque cornea, chemosis, swollen eyelids, and profound mucopurulent secretion. Samples were taken for microbiological examination (swap specimens of the bulbar conjunctiva were obtained for microbiologic analysis. Sabouraud dextrose agar was used for fungal cultures, and liquid thioglycolate medium was used for aerobic and anaerobic bacterial cultures. Gram staining for bacteria and Giemsa staining for fungi was performed for light microscopic examination). Gram-positive diplococci were observed by Gram staining as were many yeast cells by Giemsa staining. Topical moxifloxacin was discontinued. Topical vancomycin (50 mg/mL), amphotericin B (1.5 mg/ml), 5% natamycin, and oral itraconazole (200 mg/day) were initiated. Methicillin-resistant Staphylococcus aureus (MRSA) andCandida sp. were detected by culture. One month following AMT, the residues of the amniotic membrane were removed under aseptic conditions. The conformer was removed, cleaned, and replaced. One and a half months after the ocular burn, the patient reported right ocular pain. B-scan ultrasonography was performed; however, examination of the vitreous and retina was unremarkable.

In the second month, visual acuity was light perception, and anterior segment examination revealed corneal edema, central melting, stromal infiltration, conjunctival hyperemia, chemosis, mucopurulent secretion, and eyelid edema (Figure 1 B). Despite the medical therapy, the clinical manifestations worsened; this was ascribed to increased adhesion of microorganisms and hypoxic environment due to the presence of the conformer, which was therefore removed. Repeat samples were obtained for cultures and microscopy. No bacteria were seen on Gram stain, but yeast cells were detected by Giemsa staining. The vancomycin dosage was reduced. Cultures were negative for bacteria positive for Candida sp. In the fifth month following the incident, the ocular surface infection had completely resolved. The removal of the conformer led to the inevitable consequences of severe symblepharon formation and secondary severe ocular surface damage (Figure 1 C).

Case 2

A 57-year-old man had molten bronze splashed into his right eye, and was referred to our clinic 1 day after the first evaluation. On examination, visual acuity was finger counting at 1 m. Slit-lamp examination showed that the upper and lower eyelids, along with the eyelashes, were almost completely burned. The corneal epithelium was absent, and anterior segment details could not be visualized. Limbal ischemia was noted in the inferior half, and the bulbar conjunctiva was burned. Symblepharon formation was present in the inferior fornix. IOP was 19 mmHg as measured by the iCare Pro Tonometer (Figure 2 A). The ocular surface was rinsed with 1 L of Ringer's lactate solution for 15 min with an eyelid speculum inserted. The same day, the patient was transferred to the operating room. Adhesions in the lower fornix were removed, AMT was performed, and a conformer was inserted. Medical treatment consisted of topical 10% acetylcysteine, 10% vitamin C, moxifloxacin, 1% cyclopentolate, preservative-free artificial tears, 1% prednisolone, and oral vitamin C 1.5 g/day.

Figure 2 A) External photograph 1 day after an incidence of a molten bronze metal burn in the right eye, showing burns of the upper and lower eyelids and all eyelashes. Entire corneal epithelium was damaged. Iris and lens details were hazy. 180° of the inferior limbus was ischemic and bulbar conjunctiva was burned. B) Mucopurulent secretions, membranes, crusts on the upper and lower eyelids and palpebral conjunctiva, and amniotic membrane residues on the cornea in the first month following the incidence. C) Severe hypertrophic and hyperemic conjunctiva migrated onto the opaque cornea. Symblepharon formation caused total adhesion of the superior and inferior fornix in the third month following the incidence. 

At the two-weeks follow-up visit, oral acetazolamide 250 mg tablets were added due to IOP elevation to 28 mmHg. After one month, mucopurulent secretions, membranes on the upper and lower eyelids and palpebral conjunctiva, crusts, and amniotic membrane residues were removed under aseptic conditions after sampling for microbiological examination (Figure 2 B). The conformer was removed, cleaned, and replaced. Microscopy revealed gram-positive diplococci and yeast cells. Topical moxifloxacin was discontinued, and topical cefazolin (50 mg/mL), amphotericin B (1.5 mg/mL), 5% natamycin, and oral itraconazole (200 mg/day) were initiated. β-hemolytic streptococci and Candida spp. were isolated by culture.

One and half months later, despite the polymethylmethacrylate symblepharon ring (22 mm diameter, with a 10-mm-diameter hole in the middle), we found adhesions between the inferior palpebral conjunctiva and inferior corneal quadrant and intense granulation tissue in the conjunctiva; therefore, adhesions were released and granulation tissue was excised. The 22-mm diameter symblepharon ring with five 2-mm-diameter holes was re-inserted. Oral non-steroidal anti-inflammatory drug was prescribed. Despite medical therapy, infiltrates developed in the superior nasal cornea. Mucopurulent secretion developed into purulent secretion, prompting a repeat of microbiologic analyses. Bacteria were not observed on Gram stain; however, yeast cells were observed in the Giemsa staining. Cefazolin dosage was reduced from the two-hourly regimen to four times a day. Topical (10 mg/mL) and oral (400 mg) voriconazole were added, whereas topical Natamycin 5% and oral topical itraconazole were stopped. While cultures were negative for bacteria, Candida spp. were isolated. Due to lack of clinical improvement, the symblepharon ring was removed. The infection improved clinically over the next month, but symblepharon formation was seen in the superior and inferior fornix. Migration of hypertrophic and hyperemic conjunctiva onto the opaque cornea was observed (Figure 2 C).