A symblepharon (plural: symblephara) is an abnormal fibrous adhesion between the palpebral conjunctiva (the conjunctival lining of the inner eyelid surface) and the bulbar conjunctiva (the conjunctival lining covering the white sclera of the eyeball), formed when both surfaces are simultaneously denuded of epithelium by inflammation, trauma, or scarring and the raw wound surfaces fuse together as they heal. The normal conjunctival anatomy provides a smooth, freely mobile interface between eyelid and eyeball — the upper and lower conjunctival fornices (recesses) — that allows full, unrestricted eye movement in all directions. When symblepharon forms, this freely mobile interface is replaced by a tethering band or sheet of fibrous scar tissue that anchors the eyelid to the globe, restricting ocular motility, preventing full lid closure (lagophthalmos), distorting lid position (causing entropion or ectropion), misdirecting lashes toward the cornea (trichiasis), disrupting the tear film, obliterating goblet cells, and in severe cases causing corneal exposure, vascularization, opacification, and permanent visual loss. Symblepharons are classified by location and extent: anterior symblepharon (adhesion in the anterior fornix, less severe); posterior symblepharon (deeper fornix involvement, more visually significant); and total symblepharon (complete obliteration of the fornix — the most devastating form, often requiring complex ocular surface reconstruction with mucous membrane or amniotic membrane grafting). The most clinically significant etiologies are Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) (L51.1/L51.2), ocular cicatricial pemphigoid (OCP) (H10.811-H10.813), chemical burns of the eye (T26.0x-T26.1x), and trachoma (A71.0-A71.9). For AAPC-certified profee coders, the critical coding distinction in symblepharon surgery is which CPT code within the repair of symblepharon family applies: 68340 (division/separation — simplest; with or without conformer); 68330 (conjunctivoplasty without graft — moderate complexity); 68335 (conjunctivoplasty with free graft conjunctiva or buccal mucosa — highest complexity in the traditional family); or an additional unlisted/amniotic membrane code when AMT is performed concurrently — the specific procedure documented in the operative report drives code selection, and no two of these codes may be reported on the same eye at the same session.
Greek σύν (syn) — “together, with, joined”; the variant sym- used before labial consonants (b, p, m); PIE root *sem- — “one, together”
The Greek prefix of union or conjunction; sym- (before b/p/m) and syn- (before other consonants) both mean “together” or “joined with”; appears in [[symbiosis]] (living together), symmetry (measuring together), synthesis (putting together), syndrome (running together), synergy (working together), syndactyly (fused digits); in medical anatomy, sym-/syn- always signals pathological or structural union of structures
Greek βλέφαρον (blepharon) — “eyelid”; possibly from blephein — “to look” or from PIE root for “flap/flicker”
The Greek word for eyelid; the fundamental ophthalmological root for all eyelid conditions; appears in blepharitis (eyelid inflammation), blepharoptosis/ptosis (eyelid drooping), blepharospasm (eyelid spasm), blepharoplasty (eyelid surgery), ankyloblepharon (eyelid fusion — distinct from symblepharon), ablepharia (absence of eyelids); in symblepharon, the -blepharon root refers to the palpebral conjunctiva — the conjunctival lining of the eyelid, not the eyelid itself
The term symblepharon is a pure Greek compound — sym- (together) + blepharon (eyelid) — literally meaning “eyelids joined together” or more precisely in clinical usage, “eyelid [conjunctiva] joined [to the eyeball conjunctiva].” The term entered the English medical lexicon in the early 19th century; one of its earliest documented uses in English ophthalmic literature appears around 1822, as ophthalmology was establishing itself as a specialty following the founding of Moorfields Eye Hospital in London in 1804. The related term ankyloblepharon (from ankylos, “bent/crooked” + blepharon, “eyelid”) describes a distinct but related condition — fusion of the upper to lower eyelid margins themselves (lid-to-lid), rather than lid conjunctiva to eyeball — and the two must not be confused; ankyloblepharon is coded separately as a congenital malformation. The first systematic surgical approach to symblepharon repair was described by Georg Joseph Beer and other early 19th-century German-Viennese ophthalmologists, using mucous membrane grafts from the lip — a technique still used today (CPT 68335, buccal mucous membrane graft) over 200 years later. The introduction of preserved amniotic membrane for ocular surface reconstruction in the 1990s transformed symblepharon management in severe cicatrizing diseases, providing a biological scaffold with anti-inflammatory, anti-fibrotic, and epithelialization-promoting properties that far exceeded the results of conjunctival or mucous membrane grafts alone in conditions like SJS and OCP.
🔀 ALIASES / ALTERNATE TERMS
Term
Relationship
Symblephara
Correct Greek-derived plural of symblepharon (analogous to phenomena/phenomenon); symblepharons also acceptable in clinical English
Conjunctival adhesion
Descriptive clinical synonym; used in clinical notes when formal term not employed; same ICD-10 code family H11.23x
Palpebral-bulbar adhesion
Anatomically descriptive synonym; specifies the two surfaces joined (palpebral = eyelid; bulbar = eyeball); used in ophthalmology operative reports
Anterior symblepharon
Adhesion in the anterior conjunctival fornix; less severe; does not restrict posterior gaze; commonly from chemical burns or post-surgical scarring
Posterior symblepharon
Adhesion in the posterior fornix (deeper, closer to equator of globe); more visually significant; restricts eye movement; associated with OCP and SJS
Total symblepharon
Complete obliteration of the conjunctival fornix by adhesion; most severe; requires extensive reconstruction with mucous membrane or amniotic membrane grafting; can cause functional blindness
⚠️ DISTINCT from symblepharon — ankyloblepharon is upper-to-lower eyelid margin fusion (lid to lid), not lid conjunctiva to bulbar conjunctiva; congenital or acquired; coded separately; do NOT use H11.23x for ankyloblepharon
Cicatricial conjunctivitis
The inflammatory process causing symblepharon formation; scarring (cicatricial) inflammation of the conjunctiva from autoimmune, infectious, or chemical causes; coded by etiology (OCP, SJS, trachoma, chemical burn) rather than as symblepharon until adhesion has formed
Fornix obliteration
Severe symblepharon where the conjunctival recess (fornix) is completely eliminated; descriptive term in operative reports indicating total symblepharon requiring complex reconstruction
⚠️ NOT symblepharon — pterygium is a fibrovascular growth of conjunctiva onto the cornea, NOT an adhesion between palpebral and bulbar conjunctiva; different ICD-10 code H11.001-H11.059 and different CPT codes (65420/65426 excision); do NOT confuse
🔗 RELATED TERMS
Conjunctiva — the transparent mucous membrane lining the inner eyelid (palpebral conjunctiva) and covering the anterior sclera (bulbar conjunctiva); the two surfaces of the conjunctiva that adhere together to form symblepharon; the fornix is the redundant fold/recess where palpebral and bulbar conjunctiva meet; its integrity is essential for tear film distribution, ocular motility, and corneal protection
Stevens-Johnson syndrome (SJS)/Toxic epidermal necrolysis (TEN) — the most common cause of severe bilateral symblepharon in the Western world; drug-induced severe mucocutaneous reaction causing full-thickness epithelial necrosis of skin and mucous membranes including conjunctiva; acute-phase ocular management includes amniotic membrane transplant to prevent symblepharon formation; SJS coded L51.1; TEN coded L51.2; SJS/TEN overlap L51.3
Ocular cicatricial pemphigoid (OCP) / Mucous membrane pemphigoid (MMP) — autoimmune IgG/IgA subepithelial blistering disease causing progressive cicatrizing (scarring) conjunctivitis and symblepharon formation over years; the leading cause of progressive bilateral symblepharon in older adults; staged by Foster classification; coded H10.811-H10.813 (other chronic allergic conjunctivitis); systemic immunosuppression required to halt progression
Trachoma — Chlamydia trachomatis infection; leading infectious cause of preventable blindness worldwide; chronic conjunctival infection causes progressive tarsal conjunctival scarring, trichiasis, and eventually corneal opacification; symblepharon is a late-stage complication (trachomatous scarring = stage TS); coded A71.0 (initial stage) / A71.1 (active stage) / A71.9 (unspecified); sequelae B94.0
Chemical burn of the eye — alkali burns (lye, ammonia, cement) far more destructive than acid burns due to liquefactive necrosis penetrating deep into ocular tissues; emergency irrigation + amniotic membrane transplantation in severe grades (Roper-Hall III-IV; Dua V-VI) to prevent symblepharon; acute burn coded T26.00XA-T26.12XA (right/left eye, thermal/chemical, initial encounter)
Lagophthalmos — inability to fully close the eyelid; a direct complication of symblepharon tethering the eyelid open; causes exposure keratopathy and corneal ulceration; coded H02.201-H02.213 (unspecified/right/left lagophthalmos); may coexist with or be caused by symblepharon
Entropion — inward turning of the eyelid margin caused by cicatricial conjunctival shortening in symblepharon; causes trichiasis; coded H02.011-H02.059 (right/left upper/lower lid); cicatricial entropion from symblepharon requires separate surgical correction (CPT 67921/67923) in addition to symblepharon repair
trichiasis — misdirected eyelashes abrading the cornea; caused by cicatricial distortion of the lid margin in symblepharon; coded H02.051-H02.059 (right/left upper/lower); may require epilation (CPT 67820), electrolysis (CPT 67825), or lid surgery to correct
Dry eye syndrome / Keratoconjunctivitis sicca — goblet cell destruction from conjunctival scarring in symblepharon causes severe mucin-deficient dry eye; coded H04.121-H04.123 (dry eye syndrome right/left/bilateral); often concurrent with and worsened by symblepharon; may require punctal occlusion (CPT 68761), lubricants, or cyclosporine
Amniotic membrane transplantation (AMT) — placement of preserved or fresh human amniotic membrane (cryopreserved or PROSE) over the ocular surface to promote healing, suppress inflammation, and prevent symblepharon formation acutely or to reconstruct the conjunctival surface in established symblepharon; CPT 65778 (placement on ocular surface) or 65779 (placement on corneal surface); a critical tool in acute SJS and chemical burn management
Conformer — a clear plastic or silicone prosthetic device placed in the conjunctival fornix after symblepharon division (CPT 68340) to maintain fornix depth and prevent re-adhesion while the conjunctival surface re-epithelializes; the conformer is included in the CPT 68340 descriptor (“with or without insertion of conformer or contact lens”) — not separately billable
Graft-versus-host disease (GVHD) — ocular — allogeneic stem cell transplant complication causing cicatrizing conjunctivitis and symblepharon; similar in clinical appearance to OCP; management includes topical immunosuppression and PROSE scleral lens; coded T86.09 (complication of bone marrow transplant) with ocular manifestation coded additionally
Corneal pannus / vascularization — fibrovascular ingrowth from the limbus onto the corneal surface in severe symblepharon with limbal stem cell deficiency; coded H16.401-H16.403 (corneal neovascularization); a sign of advanced ocular surface disease requiring limbal stem cell transplantation in addition to symblepharon repair
⚠️ H11.23 (symblepharon) is the parent category — it is NOT billable. Laterality is required: H11.231 = right, H11.232 = left, H11.233 = bilateral, H11.239 = unspecified. H11.239 (unspecified) should be avoided — query laterality from clinical documentation. Symblepharon is an Excludes1 note excludes keratoconjunctivitis (H16.2-) from the H11 section — do NOT code H11.23x and H16.2- together. Always code the UNDERLYING ETIOLOGY (SJS, OCP, chemical burn, trachoma) in addition to H11.23x when known — the etiology code is essential for medical necessity on claims for surgical repair.
Stevens-Johnson syndrome (SJS — drug-induced mucocutaneous reaction; severe bilateral symblepharon; acute phase: AMT critical to prevent adhesion; code SJS as principal/first-listed, H11.23x as manifestation)
Active stage of trachoma (Chlamydia trachomatis — active infection causing conjunctival scarring; late symblepharon from trachomatous scarring; code A71.x for active infection)
Sequelae of trachoma (late-stage trachoma complications: symblepharon, trichiasis, corneal opacity — code when trachoma is the historic cause but active infection resolved)
Chemical / Thermal Burn — Initial Encounter (Acute Symblepharon Prevention)
Burn of cornea and conjunctival sac, right eye, initial encounter (alkali/acid chemical burn of conjunctiva — highest symblepharon risk; Roper-Hall III-IV; initial encounter)
Burn of cornea and conjunctival sac, right eye, sequela (post-chemical burn symblepharon — when the acute burn has resolved and symblepharon is the residual sequela; use -S 7th character; sequence H11.231 first, T26.11XS as cause)
Trichiasis without entropion, right upper eyelid (misdirected lashes from cicatricial lid distortion in symblepharon; code separately when documented — distinct from H11.23x)
Cicatricial entropion of right upper eyelid (inward lid-turning from cicatricial conjunctival scarring; code additionally when entropion documented with symblepharon)
⚠️ The symblepharon repair CPT family (68330-68340) is organized by COMPLEXITY of repair: 68340 = simplest (division only, conformer/contact lens); 68330 = moderate (conjunctivoplasty without graft); 68335 = complex (conjunctivoplasty WITH free graft — conjunctiva or buccal mucosa). Do NOT report more than one of these three codes on the same eye at the same session — they are not add-on codes and billing multiple repair codes for a single eye is a NCCI bundle violation. When amniotic membrane transplantation (CPT 65778/65779) is performed at the same session as symblepharon repair, both codes may be reported WITH modifier -59 on the AMT code to break the bundle — confirm NCCI edits with each payer. Laterality modifiers (-RT/-LT/-E1-E4 eyelid modifiers) are required on all unilateral procedures.
Repair of symblepharon; division of symblepharon, with or without insertion of conformer or contact lens (simplest symblepharon repair — lysis/division of the adhesive bands with scissors or blunt dissection; conformer or contact lens inserted to maintain fornix; no conjunctival grafting; used for anterior/limited symblepharon; conformer is INCLUDED in this CPT descriptor — do NOT bill conformer separately)
Repair of symblepharon; conjunctivoplasty, without graft (intermediate complexity — adhesion divided AND conjunctival surface rearranged/reconstructed without a free graft; local tissue advancement flap; used for moderate symblepharon where local tissue is sufficient; amniotic membrane is sometimes placed in lieu of a graft — when performed WITHOUT a separately obtained free graft, 68330 applies)
Repair of symblepharon; with free graft conjunctiva or buccal mucous membrane (includes obtaining graft) (highest complexity in the standard repair family — conjunctivoplasty WITH a free graft of autologous conjunctiva from the fellow eye or buccal mucous membrane from the inner cheek; includes harvesting the graft at the same session; used for posterior/total symblepharon and severe cicatrizing disease; graft harvest is INCLUDED in the CPT — do NOT separately bill the harvesting procedure)
Amniotic Membrane Transplantation — For Ocular Surface Reconstruction
Placement of amniotic membrane on the ocular surface; without sutures (sutureless AMT — PROKERA biologic corneal bandage or cryopreserved AM applied to ocular surface without suturing; acute SJS, chemical burn — preventive AMT to prevent symblepharon formation; may be billed WITH 68340 or 68330 with modifier -59 on 65778)
Placement of amniotic membrane on the ocular surface; multiple layers sutured (sutured multilayer AMT — complex reconstruction; used for established symblepharon with limbal stem cell deficiency; reports separately with modifier -59 when concurrent with 68330/68335)
Concurrent Lid/Lash Procedures — When Symblepharon Causes Secondary Lid Disease
Correction of trichiasis; epilation, by forceps only (eyelash removal by forceps — for mild trichiasis from symblepharon-related lid distortion; typically performed in-office)
Correction of trichiasis; epilation by other than forceps (e.g., by electrosurgery, cryotherapy, laser surgery) (more permanent lash ablation — electrolysis, cryotherapy, or laser; for recurrent trichiasis from cicatricial lid disease)
Repair of entropion; suture (suture repair of cicatricial entropion concurrent with or following symblepharon repair — bill separately with -59 if distinct procedure on same eye same session; verify NCCI)
Closure of the lacrimal punctum; by plug, each (punctal plug insertion for dry eye concurrent with symblepharon — bill per punctum; may be performed at same session as symblepharon repair; verify NCCI; use -RT/-LT)
Closure of the lacrimal punctum; by thermocauterization, ligation, or laser surgery (permanent punctal occlusion for severe mucin-deficient dry eye in cicatrizing disease)
Bilateral — bilateral simultaneous symblepharon repair (e.g., bilateral SJS or chemical burn); report the CPT once with -50; verify payer policy — some payers require separate -RT/-LT lines instead
Upper left eyelid (eyelid-specific modifier when repair involves the upper palpebral conjunctiva specifically; used when eyelid involvement is specifically documented)
Distinct procedural service — required when CPT 65778 or 65779 (amniotic membrane) is billed alongside 68330, 68335, or 68340 at the same session on the same eye; establishes AMT as a distinct procedure from the symblepharon repair itself; without -59 the AMT code will bundle into the repair code per NCCI
Increased procedural complexity — total symblepharon in severe SJS/OCP requiring extensive fornix reconstruction beyond the typical procedure description; prior failed repair with dense re-adhesion; bilateral simultaneous reconstruction in a single-session complex case; requires special report
Multiple procedures — secondary procedures at same session; e.g., symblepharon repair (68335) and concurrent trichiasis correction (67825) or entropion repair (67921) — append -51 to the lower-RVU secondary procedure
Unplanned return to OR within global period — recurrent symblepharon with re-adhesion requiring re-division (68340) within the 90-day global period of the original repair (68335 or 68330)
Staged procedure — planned second-stage symblepharon repair or lid reconstruction within 90-day global period; e.g., initial AMT + 68340 (stage 1) followed by planned 68335 with buccal graft (stage 2) in the same operative cycle
⚠️ Coding Notes & Payer Guidance
68340 vs. 68330 vs. 68335 — one per eye per session, no stacking: The three repair codes form a hierarchy of complexity for symblepharon repair — 68340 (division only), 68330 (conjunctivoplasty without graft), 68335 (conjunctivoplasty with free graft). These are NOT add-on codes and are NOT separately reportable on the same eye at the same session. The operative report must document which procedure was performed; the code is then selected based on the most complex component performed. If a surgeon divides the symblepharon (68340 level) AND performs conjunctivoplasty without graft (68330 level) in the same eye, only 68330 is billed. If conjunctivoplasty with a free graft (68335) is performed, only 68335 is billed — it incorporates all simpler components by definition.
AMT (65778/65779) + symblepharon repair — the -59 modifier question: CPT 65778 and 65779 (amniotic membrane placement) will NCCI-bundle with the conjunctivoplasty codes (68330/68335) when billed on the same eye same date without a modifier. Per AAPC ophthalmology coding guidance, modifier -59 (or -XS on Medicare) should be appended to the AMT code to establish it as a distinct service — the AMT addresses the corneal/limbal surface while the symblepharon repair addresses the conjunctival fornix adhesion. Document both procedures clearly with separate descriptions in the operative report, including the separate anatomical sites (forniceal conjunctiva vs. corneal/limbal surface) that each addressed.
SJS/TEN and chemical burn — etiology coding is medical necessity: When billing symblepharon repair for a patient with SJS, OCP, or chemical burn, the etiology code (L51.1, L51.2, H10.81X, T26.1XXS) must be present on the claim alongside H11.231/H11.232/H11.233. Medicare and most commercial payers’ LCDs for ocular surface procedures require a documented clinical condition explaining why surgical intervention is medically necessary beyond cosmetic benefit. Omitting the etiology code leaves the symblepharon code (H11.23x) without the clinical context that establishes severity and necessity, increasing denial risk.
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