Conjunctivochalasis in 2011: A common yet uncommonly diagnosed condition ASCRS Symposium & Congress - San Diego 2011 Mr J Aboshiha1 & Mr C Claoué2 1 - Moorfields Eye Hospital, London, UK. 2 - Queen’s University Hospital, London, UK The authors have no financial interest in the subject matter of this e-poster.

A typical case history: 72 year old female. Longstanding “dry eyes,” no other ocular history. On examination: Redundant folds of conjunctiva bilaterally (inferior lid margins). Emphasized by rigorous blinking. Interrupted tear meniscus and wrinkled bulbar conjunctiva with fluorescein. DIAGNOSIS?…

…Conjunctivochalasis (CCh) Etymology: conjunctiva + Grk. Chalasis; a loosening. First described by Hughes in 1942. Also noted by Duke-Elder as “conjunctival hyperplasia which may require surgical removal or reduction by electrocoagulation.” Defined as a redundant, loose, non-oedematous conjunctiva between the globe and eyelid.

Conjunctivochalasis: Features 1 Tends to be bilateral and prevalent in older patients. A common cause of ocular surface irritation but its clinical significance is often overlooked. Usually temporal conjunctiva on lower lid margin, but can spread (e.g. is superior in Superior Limbic Keratoconjunctivitis). Often mixed (or confused) with dry eye. CCh is the predominant diagnosis when dry eye cannot be managed by conventional treatments. Tends to be more painful than dry eye. CCh increases with age. Contact lens wear also seems to be a risk factor for CCh (HCL > SCL) (Mimura et al. 2009).

Conjunctivochalasis: Features 2 Ocular irritation is caused by 2 main features: Unstable tear film Symptoms of dry eye Delayed tear clearance - conjunctival wrinkling misdirects the tear flow toward the outer corner of the eye: Inflammatory symptoms & epiphora. Prevents the eye from clearing irritants, etc. from the ocular surface. This ‘dry eye’ patient may not be a good candidate for punctal plugs. Can be worsened by surgery e.g. peribulbar anaesthesia. ‘Benign’ subconjunctival hemorrhage is often due to CCh and conjunctival redness may be mistaken for ‘conjunctivitis.’

Conjunctivochalasis: Aetiology Underlying cause is unknown. CCh is not a result of conjunctival redundancy but rather a loosening of Tenon’s layer between the globe and conjunctiva. Non-granulomatous inflammation and elastotic degeneration are found in some histopathologic sections. CCh is characterized by over-expression of matrix metalloproteinases (Li et al. 2000). This contributes to blink-related micro-trauma.

Conjunctivochalasis: Diagnosis 1 Tear deficiency Dry Eye Table from: Di Pascuale MA, Espana EM, Kawakita T, Tseng SC. 2004. Clinical characteristics of conjunctivochalasis with or without aqueous tear deficiency. Br J Ophthalmol. 88:388-392.

Conjunctivochalasis: Diagnosis 2 Vigorous blinking and pressing a finger to the lid against the globe extenuates conjunctival folds (and worsens symptoms). Use forceps to raise redundant conjunctival folds. Wrinkled pattern & interrupted tear meniscus with fluorescein, and Rose-Bengal staining of non-exposed conjunctiva (c.f. tear deficiency dry eye).

Conjunctivochalasis: Diagnosis 3 Grading of CCh (Meller & Tseng 1998) : Grade 0 - no persistent fold Grade 1 - a single, small fold Grade 2 - 2 or more folds, but not higher than the tear meniscus Grade 3 - multiple folds and higher than the tear meniscus Also classify: the extent of CCh None; 1 or 2 locations (temporal, middle or nasal); the whole eyelid? the effect of downward gaze Improved, unchanged or worsened with downward gaze? the effect of digital pressure Worse or unchanged with digital pressure? Any presence of superficial punctate keratitis?

Conjunctivochalasis: Management No treatment is needed for asymptomatic CCh. For symptomatic CCh: Tear substitutes/lubricants Corticosteroid drops Antihistamine drops Patch before sleep to reduce nocturnal exposure Exclude other causes of excessive tearing. Obstruction of the naso-lacrimal system: syringe and probe. If CCh remains symptomatic after exhausting all medical treatments, proceed to surgical treatment by: Simple excision OR additional reconstruction with amniotic membrane Amniotic membranes stimulate differentiation and proliferation of conjunctival cells and suppress scar formation and inflammation.

Conclusion Surgical results: Meller et al (2000): Successful reconstruction of conjunctival surface following the removal of conjunctivochalasis in 46/47 eyes (98%) with resolution of ocular irritation. Georgiadis et al (2001): Resolution of symptoms in 12/12 patients with chronic epiphora caused by conjunctivochalasis, after removal of the excess of conjunctiva followed by amniotic membrane transplantation. Conclusion Consider CCh as a diagnosis, especially in recalcitrant cases of ‘dry eye.’ Look for its signs and symptoms. If conservative management fails then surgery seems to offer a successful outcome in many cases.

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