SPOTLIGHT ON TECHNOLOGY & TECHNIQUE

A surgical option for dry eye induced by conjunctivochalasis

Reservoir restoration uses cryopreserved amniotic membrane to replace Tenon’s fascia and conjunctiva.

By Bill Kekevian, Senior Associate Editor

Patients presenting with dry eye symptoms have more testing and treatment options today than ever before. Few of those options involve surgery. However, conjunctivochalasis is an anatomical cause of dry eye cause that now can be treated surgically with the reservoir restoration procedure by Bio-Tissue (Doral, Fla. www.biotissue.com).

THE PROBLEM WITH CONJUNCTIVOCHALASIS

“Conjunctivochalasis is a factor that contributes to some degree in probably more than 50% of dry eye patients,” says Clifford Salinger, MD, of VIP Laser Eye Center, Palm Beach Gardens, Fla.

The blue area (left) represents a normal tear reservoir vs. a deteriorated tear reservoir (right) in conjunctivochalasis. Notice the wrinkled conjunctiva. As the conjunctiva wrinkles and loosens, it also shortens the depth of the fornix.
COURTESY: CLIFFORD SALINGER, MD, AND BIO-TISSUE

Reservoir restoration may be the best option for patients who have conjunctivochalasis and do not respond to medical treatment, punctual occlusion, which can worsen symptoms, or other treatment options, Dr. Salinger says.

IDENTIFYING THE PROBLEM

Too often, clinicians overlook conjunctivochalasis in the differential diagnosis of dry eye, according to Dr. Salinger. It’s not on every doctor’s radar. “You have to have your antenna up to even think to look for it,” he says.

The work-up for conjunctivochalasis involves fluorescein staining and cobalt blue light. “If you don’t use the dye and the blue light combined, you’re just not going to appreciate the significance of how much redundant conjunctiva there is,” Dr. Salinger says.

When using only a white light, he adds, “often I am fooled. The condition is not so readily obvious.” This process reveals the redundant conjunctiva just above the lower lid margin, where the tear meniscus is supposed to reside. But that is only the tip of the iceberg, so to speak, of what lies under the eyelid, interfering with the inferior fornix and the anatomy of the inferior cul-de-sac.

PATIENT EDUCATION

It’s important not only to identify this issue within a dry eye patient’s first two visits, but to present the concept of possible surgery early on, according to Dr. Salinger. “I hand patients a brochure and explain that if, four to six months down the road, despite comprehensive medical treatment, their symptoms are still significant, we’ll talk about going forward with the procedure,” he says.

GOALS OF THE PROCEDURE

“Any surgeon who surgically manipulates the conjunctiva would be comfortable performing this procedure,” Dr. Salinger says. The technique involves several steps, but has four goals:

• Aggressively remove deteriorated Tenon’s fascia.

• Rearrange and minimally trim the conjunctiva, if necessary.

• Deepen the fornix, restoring the anatomy of the inferior cul-de-sac “pouch.”

• Use multiple-layer cryopreserved amniotic membrane, not dehydrated membrane, to replace the Tenon’s fascia and conjunctiva.

“The cryopreservation method maintains the anti-inflammatory factors within the tissues much better than the dehydrated tissue,” says Dr. Salinger. The dehydration process destroys the anti-inflammatory factors within the membrane, he says.

“As well, there are growth factors, nutrients within the membrane that are also more well-preserved with the cryopreserved than the dehydrated form,” he says.

RESPONSE

The response from patients has been “overwhelmingly positive,” Dr. Salinger says. Hey says reservoir restoration is a vast improvement over other procedures to minimize redundant conjunctiva, which he calls “inadequate to address the problem of the obliteration of the inferior fornix.” OM