Article

DRY EYE DX AND TX

CONJUNCTIVOCHALASIS AND DRY EYE REVISITED

In 2017, Contact Lens Spectrum published an article titled, “Conjunctivochalasis, Contact Lenses, and Dry Eye: Is There a Connection?” You might ask why I would revisit this subject only two years later! Recent research directed at this ubiquitous condition confirms the tremendous impact that it may have on the ocular surface, specifically dry eye disease. It was first described by Anton Elschnig in 1908, but remained unnamed until 1942 when Wendell Hughes, MD, coined the term conjunctivochalasis (CCh), i.e., “relaxed conjunctiva.”

Conjunctivochalasis is a chronic, progressive, and typically bilateral condition characterized by loosely adhered or non-adherent folds of conjunctiva. It is often asymmetric, typically more evident in the lower portion of the eye, and is increasingly prevalent with advancing age. Because this condition is encountered more frequently in older populations (Gumus and Pflugfelder, 2013), the underlying cause was thought to be a simple loss of elasticity as occurs in other connective tissues such as skin. That hypothesis may be oversimplified; new information suggests that the immune system may play a crucial role in the pathogenesis of CCh. Partial or total obstruction of the nasal puncta may also lead to reduced tear film stability and an increased concentration of inflammatory markers.

In addition, Xiang et al (2019) identified the genome of individuals who had confirmed CCh. They reported 175 upregulated genes and 582 downregulated genes compared to individuals who did not have CCh. Many of the down-regulated genes in CCh were related to cell cycle and proliferation. The results suggest that the overall effect of gene downregulation may be a key factor in the development of CCh.

Effects of CCh

The redundant folds of conjunctiva that occur in CCh exert several effects on the eye and lacrimal system. Chhavda et al (2015) conducted a hospital-based study that included tear osmolarity (TOSM), tear breakup time (TBUT), corneal staining, meibomian gland assessment, and eyelid vascularity. They found that subjects who had nasal conjunctivochalasis (NCCh) had higher rates of dry eye pain, symptoms, and signs. Those patients also had higher Schirmer’s test scores, increased meibomian gland dropout, and increased eyelid vascularity. The bulk of tears normally resides in the lower cul-de-sac, but redundant conjunctiva may block or reduce tear access to this potential reservoir, thereby reducing the volume of tears available to maintain a healthy ocular surface and provide clear vision.

Treatment Options

Given the negative impact that CCh may exert on the ocular surface, it is encouraging to review some of the existing and new treatments for this condition. Asymptomatic CCh does not require treatment; however, it may exist concurrently with other conditions that are symptomatic. It is incumbent on practitioners to determine the underlying etiology of the symptoms.

Conjunctival cauterization is a simple, proven therapy for CCh performed under topical anesthesia (Marmalidou et al, 2019). The procedure is done using electric cautery forceps and typically results in shrinkage of the conjunctiva and, in some cases, scarring to the episclera. A high percentage of subjects develop restoration of the inferior meniscus following this procedure.

Surgical excision of the conjunctiva followed by the use of sutures or fibrin glue has a proven track record (Marmalidou et al, 2019). Conjunctiva excision followed by suturing has between an 85% and a 93% wound closure rate. The use of fibrin glue after excision has also been very effective in aiding postoperative wound healing.

Meller et al (2000) used amniotic membrane tissue postoperatively to aid in wound healing following conjunctival excision. They reported a 96% improvement in symptoms 6.9 months following surgery.

In Conclusion

Conjunctivochalasis is a common, annoying, and sometimes painful condition that is often ignored or tolerated. With new technology and procedures, these patients can be safely and effectively treated. CLS

For references, please visit www.clspectrum.com/references and click on document #284.