Corneal Clarity

Is conjunctivochalasis on your dry eye radar?

How to diagnose and treat a disease often confused with dry eye.

By Thomas John, MD

Thomas John, MD, a world leader in lamellar corneal surgery, is a clinical associate professor at Loyola University at Chicago, and in private practice in Oak Brook, Tinley Park and Oak Lawn, Ill. His e-mail is tjcornea@gmail.com.

Conjunctivochalasis refers to conjunctival laxity that leads to excess or redundant bulbar conjunctival folds that billow or pile up over the eyelid margin or cover the lower eyelid punctum, or both. Although W.L. Hughes initially coined the term conjunctivochalasis in 1942,¹ the detection of non-edematous, loose conjunctiva dates back to the Viennese ophthalmologist Anton Elschnig in 1908.² Scottish ophthalmologist Sir William Steward Duke-Elder referred to it as “conjunctival hyperplasia.” Here, I review how to manage and treat this condition.

Why you need to know

Conjunctivochalasis can be a major player of ocular surface disease and it often involves both eyes. However, even though it is a relatively common condition, it often eludes the radar screen of the examining physician, and the patient remains symptomatic. Additionally, it may be mistaken for or coexist with dry eyes. In the latter case, symptoms may overlap from both the ocular surface conditions, so the proper diagnosis is important to determine the appropriate treatment.

Garden-variety conjunctivochalasis.

In an epidemiologic study of 1,416 patients, conjunctivochalasis was diagnosed in 98.5% of patients age 60 and older.³ In another study, Fourier-domain OCT confirmed increased incidence of conjunctivochalasis in the older age group.⁴ We should add conjunctivochalasis to the growing list of age-related diseases; it often demands more focus in its early diagnosis.

Etiology and risk factors

We do not yet fully understand the exact etiology of conjunctivochalasis. However, theories range from the natural aging process of the bulbar conjunctiva to eye rubbing, abnormalities in eyelid position, and even ocular movement. Some authors have posited that a gradual dissolution of the Tenon’s capsule leads to an adhesion loss between the conjunctiva and the underlying sclera that combines with an age-related conjunctival thinning and stretching, causing conjunctivochalasis. The result is a loose, excess conjunctiva that folds on itself close to the lid margin.

Risk factors include previous eye surgery, age, eyelid issues (blepharitis, meibomian gland secretion) and dry eyes. Contact lens wear — gas permeable more so than soft contact lenses — is an additional risk factor for conjunctivochalasis, ⁵ as is hyperopia.⁶

In a recent study, patients with autoimmune thyroid disease (88%) presented with higher rates of conjunctivochalasis than the control group, thus establishing a possible association between thyroid disease and conjunctivochalasis with thyroidism.⁹ Further studies are required to explore this association between the two disease processes.

Patient presentation

Conjunctivochalasis can result in a spectrum of ocular symptoms, ranging from aggravation of a dry eye at the mild stage to disturbance of tear outflow at the moderate stage, and exposure problems at the severe stage. ⁷

Besides being more prevalent in the elderly, conjunctivochalasis is usually bilateral. Symptoms range from ocular irritation, dry eye, and epiphora, to eye pain, ulceration and subconjunctival hemorrhage. Eye pain can be more severe than in dry eye syndrome. Ocular irritation can result from an unstable tear film and delayed tear clearance. Biomicroscopy will reveal redundant, conjunctival folds, perhaps along the lower or upper eyelid margins or circumferentially. It usually involves the temporal conjunctiva along the lower lid margin.

Use of topical fluorescein dye along with localized digital pressure on the globe through the eyelid in an upward direction can further augment the clinical appearance of these conjunctival folds. Depending on the severity, the eye may have more than one conjunctival fold. These excess conjunctival folds can disrupt the tear film and cause dry eye symptoms. If they occlude the punctal opening, they can lead to compromised tear outflow and tearing.

Additionally, the conjunctival wrinkling can misdirect the tear flow toward the outer corner of the eye. Table 1 shows some of the differences between dry eye syndrome and conjunctivochalasis, while Table 2 (page 20) shows the classification of conjunctivochalasis.

Table 1: Signs of dry eye syndrome vs. conjunctivochalasis*

* Modified from DiPascuale MA, et al, Br. J. Ophthalmol. 2004;88:388-392.

Unlike the boggy conjunctiva of an allergic reaction, the extent of this redundant tissue in conjunctivochalasis is small, well localized and unresponsive to antihistamine drops. Before contemplating extensive surgery, such as dacryocystorhinostomy, eyelid surgery or silicone intubation of the lacrimal system, rule out and, if necessary, treat conjunctivochalasis.⁸

Histopathology and other tests

Conjunctivochalasis tissue specimens may reveal non-granulomatous inflammation along with elastosis¹⁰ and, possibly, an over-expression of matrix metalloproteinases (MMPs). MMPs are enzymes that modify or degrade the extracellular matrix. Researchers have noted that MMP-1 and MMP-3 enzymes have been overexpressed in conjunctivochalasis fibroblasts in tissue cultures, while the enzyme levels of tissue inhibitors of metalloproteinases have been unchanged. The altered balance between these two groups of enzymes may facilitate the breakdown of the extracellular matrix and lead to the clinically evident changes in conjunctivochalasis.¹¹

Additionally, increased tear inflammation may coexist with the loss of conjunctival epithelial cohesiveness and increased collagenolytic activity, all of which may contribute to the conjunctival laxity of conjunctivochalasis.¹² An alternative hypothesis is that pressure from the eyelids may lead to impaired lymphatic drainage of the conjunctiva, leading to changes seen in conjunctivochalasis.

Management options

Asymptomatic, mild conjunctivochalasis does not usually require treatment. However, if the patient is symptomatic from conjunctivochalasis, you may initiate ocular lubricants and anti-inflammatory treatment similar to that of dry eye syndrome. When such medical treatment fails, then you may consider surgery, namely conjunctivoplasty. Surgical approaches include:

• Conjunctivoplasty with amniotic membrane transplantation. This has been an effective surgical option in symptomatic conjunctivochalasis. Carry out a crescent-shaped conjunctival resection complemented by amniotic membrane transplantation. Fibrin glue can make the procedure sutureless or decrease the number of sutures used, thus reducing the overall surgical time.¹³

• Conjunctival fixation to sclera. Three 6-0 Vicryl (Johnson & Johnson, New Brunswick, N.J.) sutures can accomplish this.¹⁴

• Conjunctivoplasty using a simple medial conjunctival resection. This is indicated in patients with conjunctivochalasis-related epiphora.¹⁵

• Pinching the excess conjunctiva and performing bipolar cauterization. This is done after subconjunctival injection of a local anesthetic agent. Twenty-two patients (84.6%) reported symptom relief immediately after this procedure.¹⁶

• Conjunctivoplasty with argon green laser. This approach may be considered in select patients to treat mild-to-moderate grade symptomatic conjunctivochalasis. ¹⁷ However, additional studies need to confirm long-term benefit from this procedure.

“Pinching the excess conjunctiva with bipolar cauterization has been shown to provide immediate relief in most patients.”

Table 2: Classification of conjunctivochalasis.⁷

• Paste-pinch-cut conjunctivoplasty. This involves first injecting fibrin sealant subconjunctivally in a line inferior to the limbus, followed by pinching and grasping the conjunctiva using a curved ptosis forceps. This creates a ridge with the excess, redundant conjunctiva and allows time for the sealant to polymerize. Finally, resect the ridge of excess conjunctiva along with the sealant. At three-month follow-up, 91.4% of patients reported improvement in symptoms.¹⁸

• Conjunctival semiperitomy combined with gentle subconjunctival cauterization. This approach resects the redundant conjunctiva and reestablishes adhesion between the conjunctiva and the underlying sclera.¹⁹

You cannot leave it out

We must include conjunctivochalasis in the differential diagnosis of dry eye syndrome. When dealing with symptomatic conjunctivochalasis with treatment failure, consider surgery with amniotic membrane transplantation to break the cycle of symptoms, re-establish normal tear film dynamics, improve tear stability, and relieve patient symptoms for an improved quality of life. OM

REFERENCES

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2. Elschnig A. Beitrag zur Aethiologie und Therapie der cronischen Konjunctivitis. Dtsch Med Wochenschr. 1908; 26: 1133- 1155.

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15. Petris CK, Holds JB. Medial conjunctival resection for tearing associated with conjunctivochalasis. Ophthal Plast Reconstr Surg. 2013;29:304-307.

16. Kashima T, Akiyama H, Miura F, Kishi S. Improved subjective symptoms of conjunctivochalasis using bipolar diathermy method for conjunctival shrinkage. Clin Ophthalmol. 2011;5:1391-1396.

17. Yang HS, Choi S. New approach for conjunctivochalasis using an argon green laser. Cornea. 2013;32:574-578.

18. Doss LR, Doss EL, Doss RP. Paste-pinch-cut conjunctivoplasty: subconjunctival fibrin sealant injection in the repair of conjunctivochalasis. Cornea. 2012;31:959-962.

19. Wang S, Ke M, Cai X, et al. An improved surgical method to correct conjunctivochalasis: conjunctival semiperitomy based on corneal limbus with subconjunctival cauterization. Can J Ophthalmol. 2012;47:418-422.