Transcript Conjunctivochalasis

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.
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?…
…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.
Conjunctivochalasis: Features 1
• Tends to be bilateral and prevalent in older patients.
• A common cause of ocular surface irritation but its clinical
significance is 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).
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 surgery e.g. peribulbar anaesthesia.
• ‘Benign’ subconjunctival hemorrhage is often due to CCh and
conjunctival redness may be mistaken for ‘conjunctivitis.’
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.
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.
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).
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?
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.
Surgical results:
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.
Conclusion
• 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.
Bibliography
Di Pascuale MA, Espana EM, Kawakita T, Tseng SC. 2004. Clinical characteristics of
conjunctiv ochalasis with or without aqueous tear def iciency .Br J Ophthalmol. 88:388-392.
Francis IC, Chan DG, Kim P, et al. 2005. Case-controlled clinical and
histopathological study of conjunctiv ochalasis. Br J Ophthalmol. 89:302-305.
Georgiadis NS, Terzidou CD. 2001. Epiphora caused by conjunctiv ochalasis:
treatment with transplantation of preserv edamniotic membrane. Cornea. 20:619-621.
Li D-Q, Meller D, Tseng SCG. 2000. Ov erexpressio
n of collagenase (MMP-1) and
stromely sin(MMP-3) by cultured conjunctiv ochalasis f ibroblasts. Invest Ophthalmo l Vis Sci.
41:404-410.
Meller D, Tseng SCG. 1998. Conjunctiv ochalasis: literature review and possible
pathophy siology. Surv Ophthalmol. 43:225-232.
Meller D, Li D-Q, Tseng SCG. 2000. Regulation of collagenase, stromely sin, and
gelatinase B in human conjunctival and conjunctiv ochalasis fibroblasts by interleukin-1 and
tumor necrosis factor. Invest Ophthalmo l Vis Sci. 41:2922-2929.
Meller D, Maskin SL, Pires RTF, Tseng SCG. 2000. Amniotic membrane
transplantation for symptomatic conjunctiv ochalasis refractory to medical treatments.
Cornea.19:796-803.
Mimura T, Usui T, Yamamoto H, Yamagami S, Funatsu H, Noma H, Honda N,
Fukuoka S and Amano S. 2009. Conjunctiv ochalasis and Contact Lenses. Am J of
Ophthalmo l.148, Issue 1, 20-25.
Y okoi N, Komuro A, Maruyama K, Tsuzuki M, Miy ajima S, Kinoshita S. 2003. New
surgical treatment f or superior limbic keratoconjunctivitis and its association with
conjunctiv ochalasis. Am J Ophthalmol. 135:303-308.