Conjunctivochalasis in 2011: A common yet uncommonly diagnosed condition

1. 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.

2. 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?…

3. …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.

4. Conjunctivochalasis: Features 1 • Tends to be bilateral and prevalent in older patients. • A common cause of ocular surface irritation but its clinical significanceis 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).

5. 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 surgerye.g.peribulbar anaesthesia. • ‘Benign’ subconjunctival hemorrhageis often due to CCh and conjunctival redness may be mistaken for ‘conjunctivitis.’

6. 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.

7. 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.

8. 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).

9. 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?

10. 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.

11. Surgical results: Conclusion 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. • 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.

12. Bibliography