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October 2011
 

CORNEA
 

Conjunctivochalasis: An overlooked—but common—ailment


by Michelle Dalton EyeWorld Contributing Editor
 

 

 

Treatment varies, but surgery is usually necessary


The excess conjunctival folds (stained) indicative of conjunctivochalasis Source: Steven G. Safran, M.D.
Conjunctivochalasis is easier to identify after Lissamine green staining Source: Steven G. Safran, M.D.

Although not uncommon, conjunctivochalasis may be overlooked or mistaken for an age-related change comprising redundant conjunctival folds between lower lid margins and the globe. "Many times I have sat in the room listening to patients complain of vague on again/off again foreign body sensation, typically after cataract surgery, and have been unable to give an answer for their problems other than dry eye. However, some of these patients presented without the typical corneal signs of dryness and had adequate tear film stability," said Gary Wortz, M.D., private practice, Bluegrass Eye Surgery, Lebanon, Ky. "This subset of patients bothered me, and through further research and careful examination, I have been able to identify conjunctivochalasis as a common yet often overlooked culprit." When there is refractory conjunctivochalasis, surgical resection with or without amniotic graft transplantation is typical. The issue with chalasis "is that there is a deficiency of Tenon's capsule, and thus the conjunctiva is not just redundant but does not have the proper adherence to the underlying tissue," said Steven G. Safran, M.D., private practice, Lawrenceville, N.J. He has "been treating conjunctival chalasis surgically for many years. My current approach is to use the Ellman (Oceanside, N.Y.) radio surgical unit with a Teflon-tipped white 0.04-mm probe. This technique has been published,1 and I've been using it since. It shrinks the conjunctiva in a series of applications under/through the conjunctiva, and it's fast, easy, and reasonably effective. If that fails, I do resection with an amniotic membrane graft that works very effectively but in a few cases can lead to fibrosis/redness that persists for months and may not be cosmetically acceptable. It's also far more expensive and bothersome to take patients to the OR for this than to fix it in the office."
Dr. Safran said resecting and in-office suturing used to be his preferred treatment strategy, but he abandoned that technique when persistent chemosis "took months to resolve" in rare instances. In Dr. Safran's experience, radio-wave electrosurgery addresses both the deficiency and the adherence issue. "In severe cases, resection will still be required, and amniotic grafts work well in these cases most of the time," he said. In his amniotic graft technique, surgery is performed under topical anesthesia with lidocaine gel and "straight epinephrine drizzled on the eye for hemostasis," he said. He noted surgeons should expect "very little bleeding" when they cut into the loose conjunctivochalasis tissue. Also, moisten the cornea "every now and then," but not to the point where it might disturb the amniotic graft or the tissue glue. Although he's performing more of these types of treatments, Dr. Safran maintains his "go-to" surgery is radiosurgery. He is now performing a "more aggressive procedure" on cases with a lot of excess tissue.
"I've been grabbing the excess tissue with a clamp [a modified foldable IOL forceps] and using the Ellman with a pointed cautery tip to 'melt away' the excess conjunctiva while the clamp creates a new 'seal' at the base," Dr. Safran said. "I can get a greater reduction of excess tissue in moderate to severe cases with this technique without resorting to surgical removal in the OR. This is a modified version of the technique described by Stephen Pflugfelder, M.D.2 In his technique he uses cautery and calls it 'thermoreduction.' In my technique I use the Ellman and find it works better and with less inflammation and more control than cautery."
A "great pearl" for minimizing bleeding during conjunctival surgery is to "drop topical epinephrine on the ocular surface before dissection. There is almost no bleeding except from the limbal vessels. It was astonishing to me when I first did it because I didn't think it had enough time to react, but it works great," said D. Brian Kim, M.D., in private practice, Professional Eye Associates, Dalton, Ga. He said he learned this technique from Scheffer C.G. Tseng, M.D., director, Ocular Surface Center, Miami, Fla.; medical director, Ocular Surface Research & Education Foundation (OSREF), Miami, Fla.; and director of research & development, Tissue Tech, Miami, Fla. Videos and discussions of the topic are available on OSREF's website: www.osref.org/conjunctivochalasis-cch.aspx.


At the 2010 World Cornea


Congress and American Academy of Ophthalmology conference, Linden Reed Doss, R. Philip Doss, M.D., and E. Lauren Doss described a new surgical technique for the treatment of conjunctivochalasis in which the redundant conjunctiva is precisely resected. The AAO video ("Paste-Pinch-Cut: A novel surgical repair for conjunctivochalasis") was awarded Best of Show in the Cornea, External Disease topic. Basically, the technique involved creating an arc-like guideline that is demarcated inferior to the limbus. A small buttonhole is made in the temporal bulbar conjunctiva at the edge of the marking line. Fibrin glue is injected through the buttonhole along the line. The conjunctiva is pinched with modified (curved) ptosis forceps gathering the excess conjunctiva into a ridge at the top of which lies the marking line. The authors noted the forcep curve follows the globe line. This ridge is excised after 20 seconds (the amount of time needed for the glue to coagulate), leaving a sealed wound. The authors also said that in 139 eyes of 70 patients, conjunctivochalasis resolved in all patients, and 91.5% reported improvement in symptoms. More work is being done to understand the underlying causes of conjunctivochalasis. A recent study3 analyzed protein profiles in the tears of healthy patients and those with conjunctivochalasis and found 24 spots were "significantly upregulated in conjunctivochalasis compared with that in controls," the authors wrote, adding that some of the proteins are markers of inflammation and oxidative processes.



References

1. Youm DJ, Kim JM, Choi CY. Simple Surgical Approach with High-Frequency Radio-Wave Electrosurgery for Conjunctivochalasis. Ophthalmology. 2010;117:2129–2133.
2. Gumus K, Crockett CH, Pflugfelder SC. Anterior segment optical coherence tomography: a diagnostic instrument for conjunctivochalasis. Am J Ophthalmol. 2010;150(6):798-806.
3. Acera A, Suarez T, Rodriguez-Agirretxe I, Vecino E, Duran JA. Changes in tear protein profile in patients with conjunctivochalasis. Cornea. 2011;30(1):42-9.



Editors' note: The doctors interviewed have no financial interests related to their comments.



Contact information

Kim: 706-226-2020, kim@professionaleye.com
Safran: 609-896-3931, safran12@comcast.net
Wortz: 270-692-0047, 2020md@gmail.com







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