In previous articles we have seen how eye irritation is associated with multiple causes, most of them linked to dry eye syndrome. One of these causes is what we know as conjunctivochalasis, a condition that often goes unrecognised on routine eyes screening and yet, we know that it has an important role in the origin of “chronic irritation” of the eyes. Here, we present the most significant aspects about conjunctivochalasis, especially diagnosis and new treatments to cure it.
Conjunctivochalasis is an eye surface condition characterized by the presence of excess folds of conjunctiva, especially of the inferior bulbar conjunctiva, causing folds of this, between the globe of the eye and the free edge of the lower eyelid, as shown in Figure 1. Usually, this condition is diagnosed in patients aged 60 onward, although it can occur also earlier.
It is not well known the cause of this process, but most studies refer to a loss of adherence of the conjunctiva to the sclera (1.2). The origin of this can be very varied: (1) physiological atrophy of Tenon’s because of age, (2) patients that often rub their eyes, as it may occur in cases of conjunctival allergy related to an inflammatory component that can accelerate the conjunctiva’s and Tenon’s degradation or, (3) in cases of dry eye, where the lack of tear causes a continuous rubbing of the bulbar conjunctiva in the eyelid, with a double negative result, the mechanical “drag ” effect and swelling of this area.
The presence of these folds in the conjunctiva causes a destabilization of the tear film, the meniscus tear and the mechanism of the tear drainage, causing foreign body sensation, and tearing; this situation may exacerbate the existing dry eye condition (1-5).
When this condition is identified, a classification of the degree of severity of dry eye will be established, that is, the grading scale LIPCOF (Lid Parallel Conjunctival Folds) proposed by Hoh (1995) (16), which applies to degrees of intensity and their relationship with dry eye, indicating the risk of appearing or worsening, as seen below in Figure 2.
|Degree||Number of folds||Increased risk of dry eye in relation to degree 0
eedeenrelación con el grado 0
|1||One fold below tear prism height||15 x|
|2|| Several folds, up to tear prism height
|3|| Several folds, over tear prism height
Figura 2.- Classification of Lid Parallel Conjunctival Folds (LIPCOF) proposed by Höh.
In many cases, in the initial phase of the process, there are no symptoms; yet as long as conjunctival folds become redundant, sensation of discomfort will increase. To identify the folds, a simple examination by means of the slit lamp will be sufficient, but stained with fluorescein dye, they will be seen more in detail and then we shall value the Tear-film breakup time (BUT), a basic test to see the negative influence of the folds on the tear stability.
We currently have more sophisticated systems to assess the tear film, the meniscus and the tear clearance, with infrared imaging topography and analysis systems to quantify the changes. They help find the diagnosis and right assessment of the established treatments (Figures 3 and 4).
The treatment is based upon the lubrication of the ocular surface with artificial tears (eye drops or ointments) and if they fail, surgery comes in. Until recently, the surgical technique of Meller and Tseng (4) was used: resection of redundant conjunctival tissue but the results were not satisfactory, especially because it did not solve the problem of non-adherence of conjunctiva and Tenon, even by cauterizing the exposed area or by implanting amniotic membrane (4-18). Recently, it has been proposed to combine the resection with the use of biological adhesives to improve adherence. The published results are very good, with a significant improvement in relieving discomfort reported by patients. (19-22).
One advantage of using fibrin glue as a biological adhesive is because of its polymerization, by which a parallel anticoagulant effect is obtained. Hence, in addition to improving the sealing of the incisions and the adherence of the underlying scleral conjunctiva, a subconjunctival haemorrhage will be avoided, and consequently the release of proinflammatory factors and delayed recovery of patients will be spared too. (23,25). .
Our experience follows this procedure, and when we examine a patient with both dry eye symptoms and conjunctivochalasis, unresponsive to medical treatment, we propose this outpatient and less traumatic surgery. It offers very good results and recovery within 24 hours.
1. Hughes WL. Conjunctivochalasis. Am J Ophthalmol. 1942;25:48–51.
2. Bosniak SL, Smith BC. Conjunctivochalasis. Adv Ophthal Plast Reconstr Surg. 1984;3:153–155.
3. Mimura T, Usui T, Yamagami S, et al. Subconjunctival hemorrhage and conjunctivochalasis. Ophthalmology. 2009;116:1880–1886.
4. Meller D, Tseng SC. Conjunctivochalasis: literature review and possible pathophysiology. Surv Ophthalmol. 1998;43:225–232.
5. Liu D. Conjunctivochalasis. A cause of tearing and its management. Ophthal Plast Reconstr Surg. 1986;2:25–28.
6. Li DQ, Meller D, Liu Y, et al. Overexpression of MMP-1 and MMP-3 by cultured conjunctivochalasis fibroblasts. Invest Ophthalmol Vis Sci. 2000;41:404–410.
7. Francis IC, Chan DG, Kim P, et al. Case-controlled clinical and histopathological study of conjunctivochalasis. Br J Ophthalmol. 2005;89:302–305.
8. Di Pascuale MA, Espana EM, Kawakita T, et al. Clinical characteristics of conjunctivochalasis with or without aqueous tear deficiency. Br J Ophthalmol. 2004;88:388–392.
9. Otaka I, Kyu N. A new surgical technique for management of conjunctivochalasis. Am J Ophthalmol. 2000;129:385–387.
10. Meller D, Maskin SL, Pires RT, et al. Amniotic membrane transplantation for symptomatic conjunctivochalasis refractory to medical treatments. Cornea. 2000;19:796–803.
11. Kruse FE, Meller D. Amniotic membrane transplantation for reconstruction of the ocular surface [in German]. Ophthalmologe. 2001;98:801–810.
12. Kheirkhah A, Casas V, Blanco G, et al. Amniotic membrane transplantation with fibrin glue for conjunctivochalasis. Am J Ophthalmol. 2007; 144:311–313.
13. Kheirkhah A, Casas V, Esquenazi S, et al. New surgical approach for superior conjunctivochalasis. Cornea. 2007;26:685–691.
14. Serrano F, Mora LM. Conjunctivochalasis: a surgical technique. Ophthalmic Surg. 1989;20:883–884.
15. Tseng SC, Prabhasawat P, Lee SH. Amniotic membrane transplantation for conjunctival surface reconstruction. Am J Ophthalmol. 1997;124:765–774.
16. Hoh H, Schirra F, Kienecker C, et al. Lid-parallel conjunctival folds are a sure diagnostic sign of dry eye [in German]. Ophthalmologe. 1995;92: 802–808.
17. Haefliger IO, Vysniauskiene I, Figueiredo AR, et al. Superficial conjunctiva cauterization to reduce moderate conjunctivochalasis. Klin Monbl Augenheilkd. 2007;224:237–239.
18. Watanabe A, Yokoi N, Kinoshita S, et al. Clinicopathologic study of conjunctivochalasis. Cornea. 2004;23:294–298.
19. Brodbaker E, Bahar I, Slomovic AR. Novel use of fibrin glue in the treatment of conjunctivochalasis. Cornea. 2008;27:950–952.
20. Chan SM, Boisjoly H. Advances in the use of adhesives in ophthalmology. Curr Opin Ophthalmol. 2004;15:305–310.
21. Bhatia SS. Ocular surface sealants and adhesives. Ocul Surf. 2006;4: 146–154.
22. Linden R. Doss, MS,* E. Lauren Doss, MS,† and R. Philip Doss, MD, FACS‡. Paste-Pinch-Cut Conjunctivoplasty: Subconjunctival Fibrin Sealant Injection in the Repair of Conjunctivochalasis. Cornea 2012;31:959–962
23. Koranyi G, Seregard S, Kopp ED. Cut and paste: a no suture, small incision approach to pterygium surgery. Br J Ophthalmol. 2004;88: 911–914.
24. Duchesne B, Tahi H, Galand A. Use of human fibrin glue and amniotic membrane transplant in corneal perforation. Cornea. 2001;20:230–232.
25. Hattori R, Otani H, Omiya H, et al. Fate of fibrin sealant in pericardial space. Ann Thorac Surg. 2000;70:2132–2136. Doss et al Cornea _ Volume 31, Number 8, August 2012 962.