CORNEAL CLARITY

Diagnosing and treating CCh

This overlooked and poorly understood ocular disease deserves clinical respect.

By Thomas John, MD

While ocular surface issues primarily reflect underlying dry eyes, allergic conjunctivitis and/or blepharitis, patients may be symptomatic of a lesser-known entity: conjunctivochalasis (CCh).

Clinical recognition of CCh is essential to focusing proper treatment avenues to relieve patient symptoms.

Here, I explain how to accurately diagnose and treat CCh.

DEFINITION

More prevalent in the elderly and often bilateral, CCh usually manifests as loose, redundant conjunctival folds that extrude over lower and/or upper eyelid margins and disrupts tear meniscus. CCh contributes to symptoms and signs of foreign body sensation, red eyes, epiphora, localized pain, irritation, tearing, blurred vision, subconjunctival hemorrhage and ulceration, which can escalate with vigorous blinking. CCh is commonly found in the inferotemporal and inferonasal regions of the lower eyelid margin.^1,2 The conjunctival folds are made more visible with fluorescein dye, or by gentle upward digital pressure through the lower eyelid onto the globe. Patients with CCh often have difficulty reading.

Conjunctival folds seen over the lower lid margin in a CCh patient.

CCh is considered to be a result of age-related, conjunctival thinning and stretching combined with the dissolution of underlying Tenon’s tissue, resulting in compromised conjunctival adhesion to the sclera. Middlemore first reported laxity of conjunctiva in quiet eyes as early as 1835.³ Subsequent reports followed, but the term “conjunctivochalasis” was not introduced until 1942.^4-7

WHAT TO LOOK FOR

With CCh, the lax conjunctiva disrupts the tear meniscus and contributes to tears overflowing the lid margin rather than exiting through the lacrimal punctum. This can result in the upregulation of inflammatory mediators — namely, elevated tear interleukin levels, interleukin-6 and interleukin-8.⁸ The clinical severity of CCh parallels the increased tear interleukin levels, and inflammation markers are more pronounced in the advanced stages of this disease.⁸ As the loose conjunctiva folds on itself over the lower lid margin, the ocular symptoms exacerbate on down gaze in CCh patients. If a wrong diagnosis of dry eyes is made and punctal plugs are placed, the patients’ symptoms will worsen. CCh should be taken into consideration in the differential diagnosis of chronic ocular irritation and epiphora.⁹

A recent study examined whether CCh interferes with tear flow from the fornix to the tear meniscus and depletes the fornix tear reservoir, which rapidly replenishes the tear meniscus under normal ocular surface conditions. The study confirmed that CCh obliterates tears in the meniscus as well as the reservoir, explaining how CCh symptoms develop.¹⁰ In CCh patients, surgical correction should restore the tear meniscus and deepen the fornix.¹⁰

CCh has been associated with certain systemic diseases. In one study, 88% of patients with thyroid disease had a higher incidence of CCh as compared to the control group.¹¹ Other conditions connected with CCh include superior limbic keratitis and Ehlers-Danlos syndrome.^12,13

The exact cause of CCh is not fully understood. Mechanical and inflammatory theories have been attributed to CCh development. In addition to Tenon’s capsule dissolution contributing to loss of conjunctival adhesion to the underlying sclera, other theories proposed include eye rubbing, lid position abnormalities and pressure from the eyelids causing impaired conjunctival lymphatic drainage. Prolonged lymphatic flow obstruction may result in lymphangiectasia and CCh. One study showed lymphangiectasia and fragmentation of elastic fibers in the absence of inflammation in CCh patients’ tissue specimens.¹⁴

TREATMENT

Asymptomatic mild CCh does not require treatment. In patients with dry eyes and CCh, begin with dry eye and anti-inflammatory treatment to see whether they control the ocular symptoms. To relieve symptoms, CCh often requires surgical intervention.

One effective approach is conjunctivoplasty combined with amniotic membrane transplantation, which can effectively reconstruct the conjunctival surface during CCh removal.¹⁵ For patients with CCh and epiphora secondary to CCh, a medial, conjunctival resection could be beneficial.¹⁶ Other surgical treatment modalities include: preserved amniotic membrane transplantation using fibrin glue; conjunctival semiperitomy combined with gentle subconjunctival cauterization; conjunctivoplasty using an argon green laser; thermocautery in inferior CCh; and paste-pinch-cut conjunctivoplasty using fibrin glue.^17-21 However, long-term effectiveness in a large clinical series with no significant postoperative complications should influence the proper choice of surgical procedure for the surgical management of CCh.

RECOGNIZING CCH

To properly diagnose CCh, listen to patient’s symptoms and scan the lid margins with the biomicroscope. In CCh patients, surgical correction is usually required to relieve symptoms. OM

REFERENCES

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. E-mail him at tjcornea@gmail.com.