Dry Eye Dx and Tx
A Look at Conjunctivochalasis
By William Townsend, OD, FAAO
Conjunctivochalasis is a common anterior segment condition characterized by one or more redundant lid-parallel conjunctival folds (LIPCOFs) situated between the globe and the lower eyelid. It was described by Elschnig and others as early as 1908, but Hughes first coined the term conjunctivochalasis in 1942 (Meller and Tseng, 1998). He reported that patients with this condition often complain of sharp, intermittent pain that occurs primarily on down gaze.
Conjunctivochalasis is more common in patients who have dry eye and is associated with aging and lens wear (Mimura et al, 2009). Yokoi and coworkers (2005) addressed the impact of conjunctivochalasis on the ocular surface. The study compared 161 eyes with conjunctivochalasis to 118 control eyes. This group reported the most common symptoms and signs with conjunctivochalasis were irritation (51.7 percent), lacrimation (31.4 percent), blurred vision (8.5 percent), ocular fatigue (3.4 percent), discharge (3.4 percent), dryness (0.8 percent), and subconjunctival hemorrhage (0.8 percent).
Meller and Tseng (1998) proposed a conjunctivochalasis grading system based on location, fold height compared to tear meniscus, the presence or absence of punctal occlusion by the folds, and changes in downgaze and digital pressure. They suggested that LIPCOF found in conjunctivochalasis may lead to decreased tear clearance by partially or totally occluding the puncta.
Causes of the Condition
The pathogenesis of conjunctivochalasis is still unclear. Meller and Tseng (1998) suggested that it is linked to inflammation and collagenolytic activity. Aging is a factor; Mimura and coworkers (2009) reported that the prevalence of conjunctivochalasis is low during the first two decades of life and increases steadily after the third decade. Francis and coworkers (2005) evaluated the clinical and histopathology changes in conjunctivochalasis and found that 22 of 29 conjunctivochalasis specimens showed normal conjunctival histology.
Li et al (2000) investigated the influence of matrix metalloproteinases (MMPs) on conjunctivochalasis. MMPs are a group of enzymes that modify or degrade the extracellular matrix and are crucial in remodeling after tissue damage. Li's group found over-expression of MMP-1 and MMP-3 in the conjunctiva of individuals who have conjunctivochalasis. There is significantly higher incidence of conjunctivochalasis in individuals who have autoimmune thyroid disease. Almeida et al (2010) reported that, when compared controls, this condition occurs 59 percent more frequently in those with thyroid disease.
Managing conjunctivochalasis is dictated by signs and symptoms. In asymptomatic conjunctivochalasis, treatment is not indicated. Patients who present with ocular irritation, pain, ulceration, or subconjunctival hemorrhage may benefit from tear substitutes, lubricants, and corticosteroid drops. Patients with evidence of nocturnal exposure may benefit from overnight patching (Meller and Tseng, 1998). If these measures are unsuccessful, surgical treatment may be beneficial.
Simple conjunctival resection has been used for decades and has an established success record (Yokoi et al, 2008). Kheirkhah et al (2007) also reported success in treating recalcitrant conjunctivochalasis with amniotic membrane transplantation using fibrin glue.
What to Look For in Practice
Conjunctivochalasis is an anterior segment condition that can be asymptomatic or may cause epiphoria and discomfort. We should recognize it and manage it appropriately, or when indicated, refer for surgery. CLS
For references, please visit www.clspectrum.com/references.asp and click on document #182.
Dr. Townsend practices in Canyon, Texas and is an adjunct faculty member at UHCO. He is an advisor to TearLab Corporation, has received research funds from Alcon and B+L and is an advisory panel member of Alcon, B+L, and In spire Pharmaceuticals. You can reach him at firstname.lastname@example.org.