Conjunctivochalsis (CCh) is characterized by the presence of redundant, nonedematous folds of the bulbar conjunctiva. The frequency of CCh increases dramatically with age, affecting between 44% and 98% of individuals 60 years old and older, with many cases thought to be unreported (Marmalidou et al, 2019). Previously regarded as a normal, age-related change in the conjunctiva, CCh is no longer considered innocuous; it presents with symptoms similar to dry eye disease (DED) (Chhadva et al, 2015). CCh results in persistent discomfort and a form of “mechanical dry eye.”

CCh interferes with normal tear film dynamics through several mechanisms:

1. Tear film instability: redundant folds disrupt smooth tear spreading, reducing tear breakup time (TBUT) and increasing tear osmolarity (Yokoi et al, 2005).

2. Reduction of the tear reservoir: excess tissue fills the inferior fornix, diminishing tear storage capacity and causing tear overflow (Huang et al, 2013).

3. Obstruction of tear drainage: CCh is worse nasally and can block the inferior puncta or impede flow toward it, delaying tear clearance and causing epiphora (Erdogan-Poyraz et al, 2007).

4. Promotion of ocular surface inflammation: stagnation of tears allows inflammatory cytokines and matrix metalloproteinases to accumulate (Li et al, 2000), perpetuating the cycle of inflammation, worsening DED symptoms, and causing tissue laxity.

Identification

CCh is primarily diagnosed at the slit lamp by looking for redundant conjunctival tissue in the inferior fornix. Vital dyes such as fluorescein and lissamine can help visualize the subtle folds and assess the tear film. The folds can also be more easily visualized by applying upward pressure on the lower lid to see whether the tissue bunches and the folds disappear in upgaze. It’s also essential to pull down the lower lid, which can reveal folds that might otherwise be tucked out of sight.

Unlike symptoms of DED, which can be improved with blinking, CCh discomfort typically worsens with blinking due to lid friction against redundant tissue. Patients may localize the pain or foreign-body sensation, and the “thumb test”—placing gentle pressure on the lower lid while the patient moves their eyes—can reproduce pain, supporting the diagnosis (Hillman, 2021).

Management in 2026

Topical therapy: Initial treatments are aimed at reducing inflammation (ie, topical steroids, immunomodulators), reducing friction (preservative-free artificial tears), and stabilizing the tear film (perfluorohexylpentane).

In-office procedures: Topical therapy typically doesn’t treat moderate to severe cases, as it does not address tissue laxity. Tightening the tissue can be performed in the office with minimally invasive procedures such as plasma pen conjunctivoplasty, which uses ionized gas to “tighten” redundant tissue, conjunctival cautery, or radiofrequency electrosurgery.

Surgical intervention: Conjunctival resection with amniotic membrane is generally reserved for recalcitrant cases where the fornix needs to be surgically restored and the ocular surface smoothed.

Conclusion

Identifying CCh is a crucial step in managing DED, especially in patients who have persistent symptoms unresponsive to treatment. CCh generally becomes a structural issue in its advanced stages. Although conservative medical therapy is usually the first step, ultimately, tightening or removing excess conjunctiva might be necessary to address the underlying cause. As with many other areas of eye care, significant innovation is underway in CCh treatment, with important implications for patient comfort. Practitioners need to be vigilant in identifying this coconspirator with DED and proactively educate patients about this finding, because it may help them better understand why they’re still symptomatic despite improvements in other DED signs.

References

1. Marmalidou A, Palioura S, Dana R, Kheirkhah A. Medical and surgical management of conjunctivochalasis. Ocul Surf. 2019;17(3):393-399. doi: 10.1016/j.jtos.2019.04.008

2. Chhadva P, Alexander A, McClellan AL, McManus KT, Seiden B, Galor A. The impact of conjunctivochalasis on dry eye symptoms and signs. Invest Ophthalmol Vis Sci. 2015;56:2867-2871. doi: 10.1167/iovs.14-16337

3. Yokoi N, Komuro A, Nishii M, et al. Clinical impact of conjunctivochalasis on the ocular surface. Cornea. 2005;24:S24–S31. doi: 10.1097/01.ico.0000178740.14212.1a

4. Huang Y, Sheha H, Tseng SC. Conjunctivochalasis interferes with tear flow from fornix to tear meniscus. Ophthalmology. 2013;120(8):1681-1687. doi: 10.1016/j.ophtha.2013.01.007

5. Erdogan-Poyraz C, Mocan MC, Irkec M, et al. Delayed tear clearance in patients with conjunctivochalasis is associated with punctal occlusion. Cornea. 2007;26(3):290-293. doi: 10.1097/ICO.0b013e31802e1e24

6. Li DQ, Meller D, Liu Y, Tseng SC. Overexpression of MMP‑1 and MMP‑3 by cultured conjunctivochalasis fibroblasts. Invest Ophthalmol Vis Sci. 2000;41:404‑410. https://iovs.arvojournals.org/article.aspx?articleid=2199870

7. Hillman L. Recognizing, understanding, and treating conjunctivochalasis. EyeWorld. 2021 Jul. https://www.eyeworld.org/2021/recognizing-understanding-and-treating-conjunctivochalasis/