Conjunctivochalasis: A Report of Two Cases

Conjunctivochalasis: A Report of Two Cases
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doi.org: 10.62055/tnftzesylhmz

Abstract

Background: Conjunctivochalasis regularly shares symptomatology with multiple other common ocular surface ailments. Additionally, conjunctivochalasis can exist concomitantly with and exacerbate other ocular surface etiologies of discomfort, complicating timely and proper diagnosis and treatment.

Case Reports The two cases provided demonstrate a way to systematically manage conjunctivochalasis. Case 1 recounts how recalcitrant symptomatology necessitated surgical treatment of conjunctivochalasis. Case 2 gives an example of conjunctivochalasis as a likely contributing factor of ocular surface disease symptoms that were ultimately managed medically.

Conclusion: Conjuntivochalasis symptomatology and treatment overlaps many other ocular surface diseases. When conjunctivochalasis is present it must be considered as a contributing factor to ocular surface disease. Conjunctivochalasis causes reduced tear clearance which can result in epiphora and the increase of inflammatory cytokines, exasperating ocular surface disease.

Key Wordsconjunctivochalasis, epiphora, oculoplastic, dry eye, fornix

 

Introduction

Conjunctivochalasis is a common, age related, often overlooked, ocular surface condition. Conjunctivochalasis can be asymptomatic or contribute to several oft-heard patient complaints.1,2 When presented with a chief complaint that is familiar to many other common ocular surface maladies, the practitioner must evaluate for the presence of conjunctivochalasis. Conjunctivochalasis is a redundancy of the bulbar conjunctiva – most prevalent inferiorly –that may have multiple etiologies including: age related conjunctival elastosis, chronic inflammation, mechanical friction, and mechanical lymphatic flow obstruction.1,2,3,4,5 Conjunctivochalasis symptomatology has significant crossover with several other common ocular surface diagnoses, such as nasal lacrimal duct occlusion, punctal stenosis, dry eye syndrome, allergic and chronic conjunctivitis, meibomian gland dysfunction, blepharitis, epithelial corneal dystrophy, viral conjunctivitis, corneal-conjunctival foreign body, and eye strain, among others.1,2,3,4,7,8,9,10,11,12 When conjunctivochalasis is overlooked, the challenge to adequately treat the patients’ ailments is magnified.

 

Case Report

Patient 1: A 71-year-old white male presented to the clinic as an established patient of four years to be monitored as a low-risk glaucoma suspect. The patient gave an account of stable vision but no improvement in epiphora despite compliance with a preservative-free lubricant eye drops four times per day OU. Historically, the patient’s symptoms failed to be adequately treated with a preserved artificial tear four times per day OU, but symptoms improved once converted to a preservative-free lubricant. The epiphora complaints were inconsistent from one exam to the next. The patient’s systemic history was positive for multiple vasculopathies, including well controlled non-insulin dependent diabetes without retinopathy OU, diagnosed five years ago. The last eye examination was nine months prior and conjunctivochalasis was not diagnosed. As the patient was compliant with treatment and was again complaining of bilateral epiphora, conjunctivochalasis was specifically evaluated for and noted OU. Topical steroid pulse therapy was recommended but initially declined by the patient. However, he did agree to an oculoplastic referral for possible surgical repair. Therefore, the patient was instructed to continue the preservative-free eye drop four times per day in each eye and the referral was made. Fortunately, prior to the oculoplasty appointment being made, the patient communicated, via a phone conversation, that he would reconsider the pulse topical steroid treatment. Hence, a prescription for a steroid eye drop to be used four times per day OU was ordered, and the patient was to keep the upcoming oculoplasty appointment. Ocuoloplasty performed bilateral nasal-lacrimal duct dilation and irrigation which revealed non-occluded lacrimal ducts bilaterally. Hence, the veteran returned to oculoplasty for follow-up three months later reporting recalcitrant bilateral epiphora despite compliance with ocular lubricants and topical steroids. At that point, ophthalmology proceeded with surgical correction of the conjunctivochalasis, via conjunctival resection, resulting in resolution of the patient’s epiphora.

Patient 2: A 62-year-old black male returned to the clinic with frequent-moderate-recalcitrant bilateral epiphora. Additional symptoms included photophobia, transient blur with his glasses and mild-occasional itching. This established patient of the past 10 years had an ocular history of bilateral pinguecula, bilateral reduced tear break-up time, mild-bilateral blepharitis, and bilateral-mild-diffuse punctate keratopathy. While the patient was usually compliant with follow-ups, he unfortunately had a strong history of non-compliance with eyelid message/eyelash scrubs and preserved artificial tears, despite significant time spent on education concerning the purpose of said treatment. This patient also has a contributory systemic history of sleep apnea for which he uses a Continuous Positive Airway Pressure (CPAP) each night.

Since the patient’s previous eye examination, 11 months prior, he reported faithfully using distilled water with his CPAP every night and good compliance with daily lid hygiene, omega 3 FA 3 grams per day, preservative-free lubricant eye drops three times during the day in each eye (OU), and a preservative-free lubricant gel at bedtime OU. The patient stated that although his ocular comfort was mostly satisfactory, his main concern was the constant tearing and fluctuating vision in both eyes, despite compliance with and lack of adverse side effects to the current treatment regimen. Corrected vision was 20/20- OD and 20/20 OS. Intraocular pressures were 12 mmHg OU and posterior segment was unremarkable OU, except for a mild cortical cataract OD and a posterior intraocular lens implant OS. Slit-lamp evaluation did not reveal blepharitis nor meibomitis. Mild-diffuse punctate keratopathy and a mildly decreased tear break-up time were noted bilaterally. Conjunctivochalasis was noted bilaterally at this visit.

Once conjunctivochalasis is noted, addressing probable ocular surface inflammation is indicated. Considering topical anti-inflammatory therapy had yet to be attempted, cyclosporine emulsion 0.05% (Restasis) every 12 hours was added to the treatment plan. Following the initiation of the immunomodulant eye drops, this patient continues to express an improvement in bilateral epiphora symptoms with compliance to the most recent treatment regimen.  Conjunctivochalasis likely contributed to the inflammatory component of this patient’s dry eye disease that was successfully treated by adding the immunomodulant eye drops.

 

Discussion

Patients with mild conjunctivochalasis may be asymptomatic, in which case monitoring is appropriate, as subclinical conjunctivochalasis is likely benign and asymptomatic patient treatment compliance is low (i.e. early glaucoma). However, more pronounced conjunctivochalasis can result in a slew of symptoms. Grading systems for conjunctivochalasis do exist but are not widely agreed upon.1 Due to the redundant nasal bulbar conjunctiva resting upon the puncta and possibly occluding tear drainage, bilateral epiphora is a main complaint of conjunctivochalasis.1,2,4,5,9 Watering of the eyes is the most arduous symptom to treat medically and the symptom can necessitate surgical intervention when recalcitrant. While there are various documented surgical methods for correcting conjunctivochalasis, the most common means of surgical correction is via a bulbar conjunctival resection of the redundant conjunctiva, normally via conjunctival cauterization or excision.11,13,14,17 This results in proper applanation of the bulbar conjunctiva to the sclera, alleviating epiphora.1,4,9,17 Wound closure can be accomplished with suturing, graft tissue (i.e. amniotic membrane), or fibrin glue. The benefit of utilizing fibrin glue, which adheres the conjunctiva to the underlying sclera, is to negate the possible complications associated with conjunctival sutures (i.e., foreign body sensation, pyrogenic granuloma, giant papillary conjunctivitis).1,2,13,16,17

Conjunctivochalasis also reduces the tear reservoir by limiting the fornix space. Therefore, it is important to ensure natural post-surgical fornix structure, allowing for needed replenishing of tears via regular blinking.1,10,15,17 Oculoplastic surgeons will take caution to avoid post-surgical complications such as infection, scarring, fornix retraction, restricted ocular motility, and eyelid entropion.1 At times, the incorporation of amniotic membranes to aid in post-surgical healing and improved outcomes is advocated.1,2,15,16

A majority of conjunctivochalasis clinical cases will fall in between the extremes of no symptoms and oculoplastic surgical referrals. Since conjunctivochalasis disrupts the tear film homeostasis, ocular irritation is a common clinical sign and complication. When presented with complaints of foreign body sensation, transient blur with corrective lenses, stinging, burning, and/or itching, the clinician must consider all ocular surface signs as possible causal suspects. Conjunctivochalasis is often a concomitant sign with keratoconjunctivitis, dry eye syndrome, blepharitis, meibomianitis, floppy eyelid syndrome, and allergic conjunctivitis. Conjunctivochalasis can exacerbate dry eye syndrome by increasing tear inflammatory cytokines both by being inflammatory in nature and by inhibiting tear clearance.1,4,5,9,12 Therefore, conjunctivochalasis is regularly treated successfully by addressing the dry eye component of the disease, specifically that which involvs decreasing inflammation. So, the mainstay dry eye treatments of lubricants (preservative-free are advised to avoid the pooling of preservatives in the tears), immunomodulants, omega 3 fatty acids, and topical steroid pulse therapy are all appropriate treatment modalities. It is prudent to try topical steroid pulse therapy prior to referring to an ophthalmologist for surgical intervention as a steroid will likely be prescribed by the ophthalmologist prior to operating. Also, do not ignore other causes of ocular surface irritation such as meibomianitis, blepharitis, recurrent corneal erosions, allergic conjunctivitis, floppy eyelid syndrome, and others, as conjunctivochalasis may exacerbate these ailments each requiring their own unique treatments.

 

Conclusion

Conjunctivochalasis is a common ocular surface clinical finding that can contribute to multiple ocular surface related symptoms, especially bilateral epiphora. Due to the effects conjunctivochalasis has on the ocular surface, namely decreased tear drainage and replenishing, and increasing inflammatory markers, it is not unusual for patients to also have signs and symptomatology consistent with dry eye syndrome, allergic conjunctivitis, and other ocular surface complications.1,2,3,4,5,6,7,8,9,10,15 Not all patients with conjunctivochalasis are symptomatic and many more will be successfully treated with ocular lubrication, anti-allergy eye drops, and anti-inflammatory eye drops. Because tears may pool on the ocular surface, it is advisable to incorporate preservative-free eye drops in your treatment plan (including preservative-free glaucoma eye drops) when addressing conjunctivochalasis.4 Other patients will be bothered enough by their recalcitrant epiphora to warrant an oculoplastic surgical referral. Remember to initiate a topical steroid pulse therapy prior to the specialist referral, as this is likely to be implemented by the surgeon prior to surgical intervention. Some patients with unresolved epiphora will decline surgical intervention of conjunctivochalasis, but at minimum a proper diagnosis will be made that explains the persistent symptoms.

 

References

  1. Marmalidou A., Kheirkhah A., Dana R. Conjunctivochalasis: a systematic review. Survey of Ophthalmology. 2018; Vol.63, Issue 4, 554-564
  2. Meller, D., Tseng,S.C.G.Conjunctivochalasis: literature review and possible pathophysiology. Surv Ophthalmol. 1998; 43:225-232
  3. Liu, D. Conjunctivochalasis (A cause of tearing and its management). Ophthal Plast Reconstr Surg. 1986; 2:25-28
  4. Wang, Y., Dogru, M., Matsumoto, Y. et al, The impact of nasal conjunctivochalasis on tear functions and ocular surface findings. Am J Ophthalmol. 2007; 144:930-937
  5. Francis, I.C., Chan, D.G., Kim, P. et al, Case-controlled clinical and histopathological study of conjunctivochalasis. Br J Ophthalmol. 2005; 89:302-305
  6. Watanabe, A., Yokoi, N., Kinoshita, S. et al, Clinicopathologic study of conjunctivochalasis. Cornea. 2004; 23:294-298
  7. Hughes, W.L. Conjunctivochalasis. Am J Ophthalmol. 1942; 25:48-51
  8. Erdogan-Poyraz, C., Mocan, M.C., Bozkurt, B. eta al, Elevated tear interleukin-6 and interleukin-8 levels in patients with conjunctovochalasis. Cornea. 2009; 28:189-193
  9. Erdogan-Poyraz, C., Mocan, M.C., Irkec, M., Orhan, M. Delayed tear clearance in patients with conjunctivochalasis is associated with punctal occlusion. Cornea. 2007; 25:290-293
  10. Di Pascuale, M.A., Espana, E.M., Kawakita, T., Tseng, S.C. Clinical characteristics of conjunctivochalasis with or without aqueous tear deficiency. Br J Ophthalmol. 2004; 88:388-392
  11. Georgiadis, N.S., Terzidou, C.D. Epiphora caused by conjunctivochalasis: treatment with transplantation of preserved human amniotic membrane. Cornea. 2001; 20:619-621
  12. Yokoi, N., Komuro, A., Nishii, M. et al, Clinical impact of conjunctivochalasis on the ocular surface. Cornea. 2005; 24:S24-S31
  13. Kheirkhah, A., Casas, V., Blanco, G. et al, Amniotic membrane transplantation with fibrin glue for conjunctivochalasis. Am J Ophthalmol. 2007; 144:311-313
  14. Youm, D. J., Kim, J. M., Choi, C. Y., Simple surgical approach with High-Frequency Radio-Wave Electrosurgery for conjunctivochalasis. Ophthalmology 2010; 117(11): 2129-2133
  15. Huang, Y., Sheha, H., Tseng, S.C.G., Conjunctivochalasis interferes with tear flow from fornix to tear meniscus. Ophthalmology 2013; 120(8):1681-1687
  16. Meller, D., Maskin, S.L., Pires, R.T., Tseng, S.C. Amniotic membrane transplantation for symptomatic conjunctivochalasis refractory to medical treatments. Cornea. 2000; 19:796-803
  17. Marmalidou A., Palioura S., Dana R., Kheirkhah A. Medical and surgical management of conjunctivochalasis. Ocular Surface 2019 Vol. 17, Issue 3, 393-399

 

Lt. Col. Luke Weathers, Jr. VAMC | Jackson, TN

Dr. Lee is a 2006 Southern College of Optometry graduate and completed his residency in Primary Eye Care the following year at the Memphis VAMC. He is an AAO Fellow and ABCMO certified. Dr. Lee has been an attending optometrist at the Jackson CBOC since 2009.

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