Kristiana D. Neff

Introduction

Conjunctivochalasis (CCh) is a characteristically bilateral condition where redundant, nonedematous conjunctiva causes a spectrum of clinical findings ranging from exacerbation of an unstable tear film to mechanical disruption of tear flow. The origination of the term conjunctivochalasis came from W. L. Hughes in 1942; however, descriptions of this same entity were noted as early as 1908 by Elschnig and by Braunschweig and Wollenberg in 1921 and 1922, respectively.¹ They described the more severe spectrum of findings in CCh of subconjunctival hemorrhage, pain, and exposure keratopathy. Later work described the more mild symptomatology of CCh, including dry eye to the more moderate symptoms of excess lacrimation by impeding tear clearance.²

Because CCh can be asymptomatic, it is often overlooked as a normal variant of aging. However, it is an important clinical diagnosis that must be considered in the evaluation of patients with ocular irritation and tearing. CCh typically presents as loose inferior conjunctiva, that disrupts the inferior tear meniscus; however, it is thought to also involve the superior conjunctiva in some cases.3,4 Aside from the most common symptoms of irritation and lacrimation, other associated complaints include blurred vision, discharge, dryness, ocular fatigue, subconjunctival hemorrhage, and eye stiffness on awakening.⁵ The severity of CCh symptoms tends to worsen with both downgaze and digital pressure.

Slit lamp biomicroscopy can show prolapse of the conjunctiva over the lower lid margin in the temporal, medial or nasal regions, or any combination of these regions (Fig. 20.1). This conjunctival prolapse can impede tear outflow through the inferior punctum, resulting in epiphora. Mechanical trauma can also cause recurrent subconjunctival hemorrhage in this sector (Fig. 20.2).

The diagnostic dilemma in managing CCh lies in the fact that other more common etiologies of tearing and ocular irritation must be ruled out as causative or contributory agents to the tear flow disruption or tear instability. The same symptom constellation can be seen in isolated dry eye syndrome, isolated CCh or a mixed presentation of these diseases. Lid pathology, as well as systemic entities, such as ocular allergy and thyroid eye disease can also present with similar symptoms. One must be able to determine how much the presence of redundant conjunctiva contributes to the patient’s irritation. This can be particularly challenging in cases of mild CCh.

Epidemiology

Conjunctivochalasis has been identified to be an age-dependent phenomenon by several studies.4,6–8 It has been seen in patients as early as the first decade of life and tends to increase in prevalence and severity with age. The Zhang study estimated the prevalence to be 44.08% in a senile Chinese population, while Mimura noted an even higher prevalence in a hospital-based Japanese population. There was no increase in grade of severity of CCh based on gender in Mimura’s study. The location of CCh is most frequently found in the nasal and temporal regions of inferior conjunctiva, versus middle zone of inferior conjunctiva or superior conjunctiva.^4,7,8 Conjunctivochalasis has also been noted to be more frequent in patients with thyroid disease and with contact lens wear.^6,9

Pathophysiology

Information regarding the pathogenesis of conjunctivochalasis is minimal and often conflicting. The earliest publications suggested senile changes involving the subcutaneous, elastic or supporting tissue, in the conjunctiva. Eye rubbing, mechanical irritation or trauma to conjunctiva, and abnormal eyelid position, were all implicated in development of CCh; however, no true etiology has been determined. More recent studies have offered a more mechanistic approach to evaluating the pathogenesis of CCh.

Francis et al., in a prospective clinical and histopathological study of 29 CCh patients, showed that 22 of 29 specimens displayed normal conjunctival histology, while only four specimens showed inflammatory changes and three specimens showed elastosis (Fig. 20.3).¹⁰ They hypothesized, based on these results, that the pathogenesis of CCh is therefore, multifactorial, including local trauma, ultraviolet radiation and delayed tear clearance as inciting factors. Watanabe et al. demonstrated microscopic lymphangiectasia of the subconjunctiva in 39 of 44 specimens taken from patients with severe CCh, with no evidence of inflammation.¹¹ They also noted loss of typical fiber patterns with fragmented elastic fibers and sparse assemblages of collagen fibers in all 44 specimens. Their conclusion was that mechanical forces between the lower eyelid and conjunctiva gradually impaired lymphatic flow, resulting in lymphatic dilation and clinical CCh. Immunostaining by Yokoi et al. supported the negligible role of inflammation in CCh, by comparing conjunctival samples in CCh patients to those of known normal and known inflammatory ocular surface disease.⁵

Although there is little histopathologic support of inflammation playing a role in CCh, mechanistic evidence suggests a shift in the normal balance of conjunctival matrix metalloproteinases (MMPs) and tissue inhibitors (TIMPs). These enzymes serve to degrade extracellular matrix, possibly contributing to the pathogenesis of CCh.¹² Specifically, Li, et al. showed overexpression of MMP-1 and MMP-3 mRNA in tissue cultured conjunctivochalasis fibroblasts, versus normal human conjunctival fibroblasts. No difference was noted in MMP-2, TIMP-1, TIMP-2, and urokinase plasminogen activator in the same study. Further studies then showed that inflammatory mediators tumor necrosis factor-α (TNF-α) and interleukin-1β (IL-1β) may increase expression of MMP-1 and MMP-3 in conjunctivochalasis fibroblasts.¹³ Other proinflammatory cytokines, tear IL-6 and IL-8, were shown to be increased in the tear film of CCh patients.¹⁴ It has been suggested that this interaction of MMPs and their inhibitors, which normally participate in connective tissue degradation and remodeling, may offer some insight into the clinical manifestation of loose, redundant conjunctiva.

Symptoms

Conjunctivochalasis is one of the most common underdiagnosed and misdiagnosed ocular surface diseases. The difficulty in diagnosing CCh is that the symptoms are non-specific and the onset is insidious. Initial symptoms include foreign body sensation, burning, ‘dryness’ and discomfort. These non-specific symptoms together with the intermittent clinical findings of conjunctival edema often lead to misdiagnosis. The majority of patients with CCh have been diagnosed with the more common ocular surface disease conditions, such as dry eye, anterior blepharitis, meibomian gland disease or allergic eye disease, prior to the correct diagnosis. Another problem in the diagnosis of CCh, is that many clinicians do not recognize the significance of the conjunctival findings or are unaware of CCh as a significant clinical entity.

As the clinical findings progress and the conjunctival redundancy increases, the puncta can be blocked, thus leading to the later symptoms of epiphora. It is at this later stage that many patients are first diagnosed.

Grading Systems

Several grading systems have been developed to describe conjunctivochalasis. The first group to categorize CCh was Höh et al., who looked at the number of lid-parallel conjunctival folds (LIPCOF).¹⁵ They noted the number of LIPCOF had a high predictive value for diagnosis of keratoconjunctivitis sicca (Table 20.1). At present, the most widely used grading system was proposed by Meller and Tseng in 1998 (Table 20.2) who adapted the scale by Höh and associates and included the extent of CCh, changes with downgaze and digital pressure, and presence of punctual occlusion.² This system has been utilized in the majority of studies to define extent of CCh. The newest grading system proposed by Zhang et al. in 2011 (Table 20.3) further modified Meller and Tseng’s approach by including three symptoms (epiphora, feeling of dryness, and foreign body sensation) and unstable tear film-break up time (BUT).⁸ The authors felt these modifications were necessary to flesh out those ‘asymptomatic, normal older people’ they felt added to the very high prevalence rates of CCh noted in some epidemiologic studies. The validity of this scale needs to be proven in future studies.

Therapeutic Options

No intervention for asymptomatic conjunctivochalasis is required. Once a patient becomes symptomatic, medical therapy is initiated with trials of lubrication or topical corticosteroids. Any other components of ocular surface disease, such as allergic conjunctivitis, meibomian gland disease, dry eye syndrome, and allergic eye disease, should concurrently be addressed. As the clinical findings may fluctuate, several clinical exams may be required to confirm the diagnosis. When other ocular surface disease has been ruled out and conservative medical management fails to control the patient’s symptoms, surgical intervention is then indicated.

Surgical options include a variety of methods to reduce the amount of redundant conjunctival folding. The most commonly employed procedure involves simple conjunctival excision of the redundant tissue. Conjunctival resection was initially described using a crescentic excision of conjunctiva 5 mm posterior to the limbus and closed with absorbable suture.¹

The author’s preferred conjunctival resection technique involves customizing the resection to each individual’s specific degree of conjunctival laxity. The areas of redundant conjunctiva are identified, and a limbal peritomy is created, 1 mm posterior to the limbus in the involved sectors. The freed conjunctiva is then advanced centrally with the help of radial relaxing incisions, allowing the surgeon to visualize the extent of excess tissue folding. The visualized tissue redundancy extending past the limbal peridomy is then excised. Fibrin glue can then be utilized to appose the wound margins. This sutureless technique can be adapted to all cases of conjunctivochalasis, from mild to severe. It is important to eliminate only excess tissue, so as to avoid contracture of the inferior fornix. For the majority of cases, the redundant conjunctival is most visible inferiorly and this is the area that is resected. However, in many cases the redundant tissue involves all the bulbar conjunctiva and the resection is carried out for 360 degrees.

Several other techniques have shown to decrease or resolve symptoms of CCh; however, there have not been prospective comparative analysis to determine the relative efficacy of these different surgical procedures. These other procedures include conjunctival fixation to sclera with three 6-0 Vicryl sutures¹⁶ and elliptical excision of redundant conjunctiva.³ Serrano and Mora modified the excision technique by creating a peritomy, just posterior to the limbus with two radial, relaxing incisions to avoid scarring or retraction of the inferior fornix.¹⁷ Amniotic membrane transplantation for CCh has been described as a treatment with either suture fixation of the amniograft^18–20 or fixation through the use of fibrin glue.²¹ However, CCh is a condition of redundant conjunctiva, so most clinicians feel that the addition of other tissue, such as amniotic membrane is not warranted. Fibrin glue has also been used as an adjunctive step to conjunctival resection and has been shown to be effective (Fig. 20.4).²²

The more minimally invasive superficial thermocautery of the inferior conjunctiva, has also shown to improve symptoms of CCh and improve conjunctival laxity.23,24 Nakasato and colleagues described a novel technique where ligation testing was used to predict appropriate candidates to undergo thermocautery of the inferior bulbar conjunctiva. This allowed them to treat symptomatic patients with CCh in an outpatient setting and to stratify patients into groups that were more likely to respond to therapy. The ligation test technique describes an 8-0 silk suture formed into a loop, with forceps used to grasp redundant conjunctiva through the loop 3–4 mm inferior to the limbus until the CCh disappears. The loop is then tightened to ligate the excess tissue. Once anesthesia has worn off, patients were evaluated for improvement or resolution of CCh symptoms, and if some improvement is noted, they were selected for thermocautery treatment. Following thermocautery, disappearance of symptoms was noted in 92.3% of treated eyes, and symptoms improved in the remaining 7.7% of eyes.²³ Because the severity of CCh increases with digital pressure and downward gaze, lid tightening procedures tend to worsen the symptoms of CCh-related dry eye.⁷ Extensive conjunctival resections should also be avoided in order to minimize complications, such as contraction of the fornices, cicitricial entropion, and restriction of extraocular movement. When sutures are employed in the technique, increased foreign body sensation, suture-induced granulomas, and prolonged inflammatory reactions can be seen. Other early complications include chemosis, hyperemia, subconjunctival hemorrhage, and infection. Late complications, such as scar formation and residual or recurrent CCh are possible.

Conclusion

Conjunctivochalasis is a prevalent disease process in the older population. It should not be overlooked as an etiology of ocular irritation and tearing. In some cases, CCh can cause significant symptoms that may require surgical treatment. Treatment should proceed in a stepwise fashion, starting with non-invasive, medical therapies, followed by surgical intervention if medical management fails to control the patient’s symptoms.

References