Conjunctivochalsis vs. Dry Eye: Do You Know the Difference?

CChal isn't like other surface problems. Here's expert advice on diagnosis and management.

By Steven G. Safran, MD

The first thing that most of us consider when seeing a patient with ocular surface complaints is whether the problem is due to dry eye, blepharitis, allergy or some combination of the above. Dry eye symptoms often develop due to chronic inflammation caused by both blepharitis and allergy, and in chronic situations things can be difficult to sort out without spending a great deal of time on the history and subtle clinical signs. As a result, patients who come in with ocular surface complaints can be among the most labor intensive and time consuming to accurately diagnose and treat effectively.

Because of all the extensive issues in the history regarding medications, systemic disease, triggering factors, the clues in the review of systems and finally the subtleties in the clinical exam that need to be considered to sort out amongst the “big three” ocular surface problems, it is very easy to overlook a fourth problem that is extremely common and may complicate your management of these patients if overlooked. I am referring to the common problem of conjunctivochalasis.

What is Conjunctivochalsis?

Conjunctivochalsis (CChal) is the presence of redundant folds of loose conjunctiva that protrude over the lower eyelid margin and disturb the tear meniscus. Most patients complain of foreign body sensation, tearing, difficulty reading, blurred vision, “red eyes” and general irritation. Thus, on the surface, it sounds like the same kinds of problems that all the other “itchy burny” patients have. How can the clinician differentiate what's causing what?

I think the easiest way to understand conjunctivochalsis, and to explain it to patients, is to think of it in mechanical terms. See Figure 1 for an image from a typical patient.

Figure 1. Garden-variety conjunctivochalsis.

Notice that the tear meniscus is interrupted by the presence of the folds of extra conjunctiva that hang over the lid. This causes the tears to be “shunted” over the edge of the lid laterally, leading to the common complaint of tearing seen with CChal. As one can imagine, the symptoms will be worse in downgaze as the conjunctiva gets “bunched up,” which will lead to increased tearing and foreign-body sensation, particularly when reading.

It should also be clear from Figure 1 why CChal patients would have worsening of their tearing symptoms with punctal occlusion (a bloated tear meniscus gets interrupted by the protruding conjunctiva which shunts over the lateral lid margin rather than allowing it to be distributed effectively over the ocular surface with blinking) and why frequent and vigorous blinking only makes patients feel worse.

I tell patients that blinking with conjunctivalchalsis is like “jogging with loose socks” and they “get it” right away. The more movement there is, the looser the conjunctiva gets and the more rubbing and sliding of tissue occurs. This leads to more irritation and further weakening of the tissue. Another classic CChal sign seen in Figure 1 is the presence of anteroplacement of the mucocutaneous junction, seen clinically as lissamine green staining of the lid margin just under the folds of conjunctiva laterally. This constant contact between lid margin and conjunctiva causes the patients to be aware of a foreign-body sensation. This lid margin irritation may be confused with, or exacerbate, blepharitis.

Distinguishing from ATF

Once you notice the presence of excess conjunctiva disrupting the tear meniscus on slit lamp exam, there are some symptoms and signs that help differentiate the patient's complaints from those caused by aqueous tear deficiency dry eye (ATF). ATF symptoms tend to get worse later in the day and when driving or involved in another activity that involves a reduced blink rate. By contrast, CChal is worse in the morning and exacerbated by frequent blinking. The symptoms of CChal also are exacerbated by looking down, so reading is a particular problem. Tearing, especially when reading, is most common with CChal. Additionally, any patient with recurrent subconjunctival hemorrhage should be evaluated carefully for conjunctivochalasis, as this is an extremely common association.

Whereas ATF patients have surface staining of the exposed areas in the interpalpebral fissure, CChal patients stain in the inferior conjunctival folds and along the lower lid margins. They particularly stain in the contact areas along the lid margin where the mucutaneous junction is anteriorly displaced. ATF patients will have a reduced tear meniscus whereas CChal patients will have a “bloated” tear meniscus that is interrupted by the excess conjunctiva. This is most easily visualized a minute or so after placing lissamine green in the eye. You will also note that CChal patients have delayed clearance of the tear film and tend to have punctal inflammation.

CChal Surgical Considerations

It would seem evident from the above that many of the treatments that are effective for dry eye patients, such as tear supplementation and punctal occlusion, are pretty useless in treating patients when conjunctivochalsis is their primary problem.

The “loose sock” analogy used earlier can help us better understand what needs to be addressed in treating CChal. When your socks start to slide, it usually means that they are too loose, have lost their elasticity and don't adhere to your ankles and this is exactly what is going on with conunctivochalsis. The excess conjunctiva has lost its elasticity, doesn't adhere properly to the underlying globe and then due to constant rubbing and blinking, it gets “stretched” so that the problem becomes worse over time. Often the underlying Tenon's tissue is deficient or virtually absent.

In my practice, symptomatic conjunctivochalsis is primarily a surgical problem. Over the years I have tried a variety of techniques, from office-based primary excision with suture closure, to amniotic membrane grafts with fibrin glue done in the OR, to my current approach of treating patients in the office with radiofrequency surgery as primary therapy with amniotic membrane grafting held in reserve for severe, recalcitrant cases.

Although I did have relatively good success with amniotic membrane grafting, I found the bother of taking patients to the OR, combined with the expense and the occasional occurrence of postoperative fibrosis and chronic injection or scarring of the inferior palpebral conjunctiva as it healed, limited my use of this procedure. Healing with less than acceptable cosmetic results could occur rarely but unpredictably in some patients, and I saw it do just that. I became uncomfortable offering this procedure to patients who did not have severe symptoms because I did not want to take a patient with mild CChal to the OR and have them end up months later with a chronic injection that could be cosmetically unacceptable. For a YouTube video of my technique for amniotic membrane grafting for severe conjunctivalchalsis, go to http://tinyurl.com/cchalvideo to view it.

In this video you will see how loose the conjunctiva is, with almost total absence of underlying Tenon's tissue. Although the majority of these cases heal beautifully, some do get fibrovascular scarring that is noticeable and problematic.

In-office radiofrequency surgery has given me an approach that I am very comfortable offering to patients with very mild to very severe CChal. It has the advantage of being done in the office, under topical anesthesia. Further, I've not seen any side effects or cosmetic problems, although in some cases a second treatment is required.

I initially started doing this procedure using a very fine 0.004 mm electrode. After topical application of Tetravisc, I would lay the patient back with a speculum and, with the aid of an office microscope, I'd use a forceps to hold the excess conjunctiva and pass the tip of the electrode into the conjunctiva and “shrink” it. However, this took many applications and occasionally caused subconjunctival bleeding. It also became clear to me that one could inadvertently perforate the globe accidentally if not careful.

I then modified my approach to my current technique: laying the patient back after administering topical anesthesia, having the patient look up slightly and then gathering up all the excess conjunctiva with an angled Macpherson forceps in one hand while the other hand uses a bullnose tip electrode (Ellman TF1B) to “paint” the excess conjunctiva above the clamp of the forceps and shrink it until the tissue no longer contracts. I move along the inferior cul de sac treating laterally, centrally and nasally. Usually I do one or two “gathering and painting” maneuvers in each section until there is no excess conjunctiva.

This treatment accomplishes the removal of excess tissue and triggers a healing process that promotes better adhesion of the new conjunctiva to the globe. While there is some postoperative inflammation, usually this resolves completely in less than one month; I only use mild postoperative steroids, as I don't want to completely suppress this.

In Figure 2, you will see a postoperative picture of the same patient two weeks after treatment. He now has a continuous tear film and his symptoms are much improved.

Figure 2. Two weeks after in-office radiofrequency surgery with my modified technique.

See Figure 3 for another “before” picture of a patient who was status post premium IOL surgery with a complaint of “difficult reading”. The problem was not related to her implant, but rather her ocular surface. Although her conjunctivochalasis is fairly mild, her symptoms were not.

Figure 3. Before radiofrequency treatment.

Figure 4 shows the same patient after radiofrequency treatment.

Figure 4. After radiofrequency treatment.

Figure 5 shows another patient who had chronic irritation and inflammation associated with her conjunctivolchalasis that resolved almost completely with treatment.

Figure 5. Conjunctivalchalsis caused this patient chronic irritation and inflammation.

In the post-treatment picture (Figure 6), you can see the reduction of inflammation and the downward angling of the conjunctival blood vessels toward the inferior cul de sac caused by the treatment.

Figure 6. Radiofrequency surgery reduced the inflammation and angled the conjunctival blood vessels downward.

As with any surgery it is best not to operate on a “hot eye.” I like to quiet things down a bit if there is a great deal of inflammation by treating whatever other ocular surface issues the patients has (blepharitis, dry eye, allergy) prior to performing any ocular surface surgery, including treatment for conjunctivochalasis.

Bear These in Mind

It is important to remember that conjunctivochalsis may be present in up to 88% of autoimmune thyroid disease patients.¹ If other signs or symptoms of thyroid disease are present, you should consider this diagnosis. Also note that conjunctivochalsis may be mimicked by fluid tracking from a glaucoma filtering procedure; it is best not to treat these patients as routine conjunctivochalsis (see Figure 7).

Figure 7. Pseudoconjunctivochalasis due to exuberant filtering from a well-functioning trabeculectomy seven years postop.

Also note that chronic severe conjunctivochalsis can cause the upregulation of inflammatory mediators such as cytokines, elevated tear interleukin levels,² and increased HLA-DR expression on conjunctival epithelial cells.³ Thus chronic conjunctivochalsis is not simply a mechanical problem, but may lead to increased inflammation that can exacerbate or complicate dry eye, blepharitis, allergy or any combination of the above.

The potentiating effect CChal has on patients with inflammatory ocular surface issues is not a one-way street, either; chronic inflammation from allergy can lead to conjunctival edema and chemosis that can contribute to the development of CChal. Dry eye and blepharitis can increase the frictional component of the lid acting on the conjunctiva and increase inflammation, which will hasten the onset and worsen the severity of CChal as well.

Over time, as ocular surface disease becomes more chronic, the inflammation from all these components tends to blend together. This makes the individual contributing factors more difficult to isolate and separate. Being able to recognize and treat the mechanical contribution to the problem caused by conjunctivochalasis helps to “drain the swamp” of confounding issues. It is rewarding to the patient and gratifying to the clinician. OM

References

1. de Almeida SF, de Sousa LB, Vieira LA, Chiamollera MI, Barros Jde N. Cliniccytologic study of conjunctivochalasis and its relation to thyroid autoimmune diseases: prospective cohort study. Cornea. 2006 Aug;25(7):789-793.
2. Erdogan-Poyraz C, Mocan MC, Bozkurt B, Gariboglu S, Irkec M, Orhan M. Elevated tear interleukin-6 and interleukin-8 levels in patients with conjunctivochalasis. Cornea. 2009 Feb;28(2):189-193.
3. Mrugacz M, Zywalewska N. HLA-DR antigen expression on conjunctival epithelial cells in patients with dry eye. Klin Oczna. 2005;107(4-6):278-279.

Steven G. Safran, MD, is in private practice in Lawrenceville, NJ. He is often referred difficult cataract cases that are complicated by retinal and other issues. He can be reached via e-mail at safran12@comcast.net.