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Conjunctivochalasis

Conjunctivochalasis (CCh) is defined as redundant conjunctiva. Hughes first coined this entity in 1942; [1] however the description of loose, nonedematous conjunctiva had been first reported as early as 1908 by Elschnig.[2] It is most often evident between the globe and the lower eyelid, but in more advanced cases can be evident around the entire globe.

The majority of cases are bilateral, and often conjunctivochalasis is overlooked as a normal variant associated with the aging process if the patient is asymptomatic. In cases where the patient is symptomatic, common symptoms include: tearing, foreign body sensation, ocular irritation, and blurriness, especially in down gaze. It is important to keep this condition in the differential of chronic ocular irritation and epiphora.The majority of cases are bilateral, and often conjunctivochalasis is overlooked as a normal variant associated with the aging process if the patient is asymptomatic. In cases where the patient is symptomatic, common symptoms include: tearing, foreign body sensation, ocular irritation, and blurriness, especially in down gaze. It is important to keep this condition in the differential of chronic ocular irritation and epiphora.  

Conjunctivochalasis is a common finding among older adults. Studies suggest that conjunctivochalasis is more common in patients who have dry eye and meibomian gland disease/blepharitis and is associated with contact lens wear.[3] The etiology of conjunctivochalasis is not well understood. Theories include that it could be a natural aging process of the conjunctiva or that it could be due to lid position abnormalities, ocular movements, ocular irritation, and eye rubbing. Some histopathologic studies demonstrate elastosis, chronic, nongranulomatous inflammation, fragmentation of the elastic fibers, and loss of collagen. Matrix metalloproteinases (MMPs) are enzymes that modify or degrade the extracellular matrix. MMP-1 and MMP-3 enzymes have been noted to be overexpressed in conjunctivochalasis fibroblasts in tissue culture, while the enzyme levels of tissue inhibitors of metalloproteinases (TIMPs) are unchanged. The change in the balance between these two groups of enzymes may facilitate the breakdown of the extracellular changes and lead to the clinically evident changes observed in conjunctivochalasis.[4] Another hypothesis is that pressure from the eyelids may lead to impaired lymphatic drainage of the conjunctiva, which is supported by findings of lymphangiectasia, fragmentation of the elastic fibers, and no signs of inflammation on histopathology.[5]

If the patient has conjunctivochalasis but is asymptomatic, no treatment is necessary. For symptomatic patients, medical treatment is recommended as the initial step. Medical management includes the use of ocular lubricants, antihistamines (if there is a component of allergic conjunctivitis), and topical steroids. In cases where medical management is insufficient in improving the patient's symptoms, surgical intervention may be necessary. Surgical management is directed at resecting the redundant conjunctival tissue. Several methods have been described in the literature. The most common methods of surgical intervention include a crescent-shaped conjunctival resection with or without sutures, resection with placement of an amniotic membrane graft (with either sutures or fibrin tissue glue or both), or suture fixation of the redundant conjunctiva to the globe (without resection). During procedures where the conjunctiva is resected, a crescent of tissue can be marked, excised, and left to heal or closed with absorbable suture. Another method of resection is to make a limbal peritomy, extend posteriorly with relaxing incisions, and then pull the conjunctiva anteriorly, resecting the excess tissue that extends past the limbus.[6] The conjunctiva is then re-approximated near the limbus. Lastly, amniotic membrane grafting is an option. Once the area of conjunctiva is excised, an amniotic membrane graft is secured to the globe corresponding to the excised conjunctival defect, secured with fibrin tissue glue or absorbable suture, or a combination of the two.[7,8]

Success rates of the various methods appear to be similar. Moderate to high rates of improvement in symptoms have been reported. In a study by Yokoi and colleagues, an improvement of symptoms was found in 88.2% of patients that underwent resection of symptomatic conjunctivochalasis.[6] Similar success rates were reported by Tseng and colleagues.[8]

 

 

Differential Diagnosis: 

  • Chemosis
  • Conjunctival infection or inflammation
  • Entropion
  • Meibomian gland disease

References: 

  1. Hughes WL. Conjunctivochalasis. Am J Ophthalmology 1942;25:48-51.
  2. Elschnig A. Beitrag zur Aethiologie und Therapie der cronischen Konjunctivitis. Dtsch Med Wochenschr 1908; 26: 1133-1155.
  3. Mimura T, Yamagami S, Usui T, et al. Changes of conjunctivochalasis with age in a hospital-based study. Am J Ophthalmology. 2009;147:171-177.
  4. Li DQ, Meller D, Liu Y, Tseng SC. Overexpression of MMP-1 and MMP-3 by cultured conjunctivochalasis fibroblasts. Invest Ophthalmol Vis Sci. 2000;41:404-410.
  5. Wattanabe A, Yokoi N, Kinoshita S, et al. Clinicopathologic study of conjunctivochalasis. Cornea. 2004;23:294-298.
  6. Yokoi N, Komuro A, Nishii M, et al. Clinical impact of conjunctivochalasis on the ocular surface. Cornea. 2005;24:524-531.
  7. Serrano F, Mora LM. Conjunctivochalasis: a surgical technique. Ophthalmic Surgery. 1989;20:883-884.
  8. Meller D, Maskin SL, Pires RT, Tseng SC. Amniotic membrane transplantation for symptomatic conjunctivochalasis refractory to medical treatments. Cornea. 2000;19:796-803.
  9. Meller D, Tseng SC. Conjunctivochalasis: literature review and possible pathophysiology. Survey of Ophthalmology. 1998; 43: 225-232.

 

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