Conjunctivochalasis (CCh) is a condition characterized by multiple folds in the conjunctiva, the clear covering of the white part of the eye (called the sclera). After years of eye rubbing, aging, genetic risk factors, the conjunctiva no longer adheres closely to the sclera and the conjunctiva becomes loose with redundant conjunctival folds. These folds sometimes do not cause symptoms but often cause foreign body sensation due to their presence and/or due to tear distribution [1, 2, 3]. This condition is also characterized by bloodshot eyes, subconjunctival hemorrhage (popped surface blood vessel), chronic tearing (ie, epiphora), dry eye, and corneal ulceration [1, 2, 4]. It can also cause tear meniscus disruption, impaired tear distribution, and punctal occlusion (ie, the whole that drains tears to the nose). [1, 4].
Treatment (Reference 7):
Medical therapy
The goal of medical therapy for CCH is to improve tear film stability and suppress inflammation by lubricating the surface to prevent mechanical friction making the CCH worse.
1. Topical lubricants: ie, eye drops and ointments may be used.
2. Non-steroidal drops to decrease inflammation: Xiidra, Restasis
3. Autologous serum eye drops further achieve a more functional tear status Reference 8). Furthermore, a prospective unmasked study showed that an artificial tear containing isotonic glycerol and sodium hyaluronate can in fact reduce the severity of CCH.43 Additionally, there are ongoing double-masked clinical trials on safety and efficacy of a sodium hyaluronate eye drop (LO2A) for CCH (clinicaltrials.gov, NCT02810119 and NCT02804191).
4.Topical corticosteroids: nonpreserved 1% methylprednisolone 3 times a day for 3 weeks leads to subjective (83%) and objective (80%) improvement, as well as resolution of DTC (87%).
5. Eye patching at nighttime: For patients with severe CCH associated with nocturnal lagophthalmos.
It is important to remember that CCH is frequently associated with other common ocular surface disorders such as aqueous tear deficient dry eye and meibomian gland dysfunction, which may not only contribute to its pathogenesis but also produce symptoms similar to those caused by CCH. Thus, these conditions need to be treated as well.
Surgical treatment
1. Laser Treatment with Argon: Red or Green Argon. The laser work at a wavelength of 532 nm and tries to shrink redundant conjunctiva and possibly to promote conjunctival fixation to the underlying tissue. The recovery is short and minimal risk of side effects. Repeat treatment may be needed.
2. Conjunctival cauterization: also tries to shrink redundant conjunctiva and possibly to promote conjunctival fixation to the underlying tissue. (Ref 9). The advantages of conjunctival cauterization include short operating and healing times and the elimination of suture-related complications. (Ref 10).
Conjunctival cauterization has been shown to be effective in treating refractory cases of mild-to-moderate CCH. Although different techniques have been used for conjunctival cauterization, a complete or significant improvement in ocular symptoms and signs, as well as shrinkage of conjunctiva, have been found after this procedure. (Ref 11). Importantly, cauterization does not result in removal of normal conjunctival tissue, significant scar formation, or motility restriction.
3. Conjunctival excision with or without tissue graft with or without Sutures (more painful) or Glue (less pain).
Conjunctival excision with Fibrin Glue: This is the most commonly performed procedure for CCH after Argon laser as it involves no suture and a quicker recovery time. The risk of complications is very low. The success rate depends on the extent of CCH.
4. Scleral fixation of the conjunctiva: fixation of the redundant conjunctiva to the sclera with 3 6-0 Vicryl stitches 8 mm posterior to the inferior limbus. Benefits of the scleral fixation technique include firm conjunctival adherence to the sclera from the ability of Vicryl thread to induce focal inflammation and the lack of conjunctival resection, avoiding inferior fornix shortening or ocular motility restriction.6
5. Other procedures
a. high frequency radiowave electrosurgery,92
c. conjunctival semiperitomy combined with subconjunctival cauterizarion,78
d. laterosuperior traction of the inferior lid, and
Int Ophthalmol. 2018 Jul 10. doi: 10.1007/s10792-018-0963-6. [Epub ahead of print]
Investigation of conjunctivochalasis histopathology with light and electron microscopy in patients with conjunctivochalasis in different locations.
Abstract
PURPOSE:
To investigate changes in conjunctival tissue of conjunctivochalasis (CCh) patients and to determine the relationship between pathological findings and localization of loose conjunctiva.
METHODS:
Our study included nineteen eyes of 19 patients who were referred to Cukurova University Ophthalmology Department based on ocular surface symptoms and CCh detected in ocular examination. Amniotic membrane was applied after conjunctival excision as surgical treatment. The control group was formed with five eyes of five patients who are similar in terms of age and gender distribution with our study group. Tissue samples obtained from the study and control groups were investigated with light and electron microscopy.
RESULTS:
Results of pathological examination of conjunctival tissues revealed increased inflammation in 13 patients (68%), lymphatic ectasia in 12 patients (63%), and loss of goblet cells in 17 patients (89%). Destruction of elastic fibers was detected in all cases by staining with elastic van Gieson. After semiquantitative assessment, varying degrees of light microscopic findings were noted considering the localization of CCh. No statistically significant relationship was observed between light microscopic findings and CCh location (p > 0.05 for all). Electron microscopic investigation revealed increase in intercellular spaces, increased cytoplasmic electron density, and the presence of slight vacuolization in cell cytoplasm, and heterochromatin clumping in nuclei of cells in conjunctival samples.
CONCLUSIONS:
Mechanical and inflammatory factors induce development of CCh, and signs associated with these factors can be detected with light and electron microscopy of conjunctival tissue. No relationship was observed between CCh localization and pathological changes in tissues examined in our study, and large-scale case series are required to evaluate the possible effect of CCh localization on pathological findings.
References:
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