Conjunctivochalasis possible diagnosis in dry eye cases with pain, previous surgery

After diagnosis, conjunctivochalasis can be effectively treated with a surgical procedure that repairs loosened conjunctiva.

John A. Hovanesian

Age, dry eye history and previous ocular surgery are three risk factors for conjunctivochalasis that should be considered when diagnosing cases of apparent dry eye with pain, John A. Hovanesian, MD, FACS, said.

Conjunctivochalasis can masquerade as dry eye syndrome, but pain is not generally associated with milder cases of dry eye, Dr. Hovanesian said at Hawaiian Eye 2010. Physicians often diagnose dry eye without also considering conjunctivochalasis because the two frequently occur together.

“It’s very easy to mistake these patients for dry eye patients because in our mind, we make the diagnosis very often before we hear the patient’s full complaint. We have to avoid doing that,” he said.

A simple surgical procedure to fix loosened conjunctiva could effectively resolve symptoms, according to Dr. Hovanesian.

Dr. Hovanesian conducted a review of patients who had the condition and subsequent surgery. After the surgical procedure, patients had complete resolution of symptoms.

In a video shown during the presentation, a patient described his ocular pain as resembling an “eyelash in my eye” and said the sensation was irritating. “It’s driving me crazy because we look, I use eye wash, I’ve used everything I could. And nothing helps,” the patient said in the video.

“The point that this patient illustrates is that there is a specific point of sensitivity on the eye,” Dr. Hovanesian said. “There is pain involved, and I think it is that distinct difference that helps us differentiate this from just symptoms of dry eye.”

Diagnosing condition

Dr. Hovanesian said an easy test can be used to help identify conjunctivochalasis. With a finger, pressure should be gently placed externally on the eye in the area with pain. The patient should be instructed to look up and then down. Doing so will place pressure on the affected conjunctiva and “reproduce the characteristic pain that they feel,” he said. Patients should not receive anesthetic before the examination.

Dr. Hovanesian conducted a 1-year review of eight patients with the condition, all of whom were older than 50 years and had prior ocular surgery, including cataract, LASIK and a lid blepharoplasty. The patients were originally diagnosed with refractory dry eye and were later diagnosed with conjunctivochalasis.

He found that age, dry eye and prior ocular surgery were risk factors for conjunctivochalasis.

Previous ocular surgery could play a major role in the condition. Dr. Hovanesian hypothesized that chemosis during surgery could loosen Tenon’s fascia, causing conjunctivochalasis to occur because the conjunctiva is loosened and redundant.

“Conjunctival chalasis occurs most commonly at the inferior border of the conjunctiva, where it meets the lower eyelid,” he said.

Surgical procedure

Physicians can treat conjunctivochalasis with nonsurgical therapies,including lubricants and anti-inflammatories. If those approaches do not work, a simple surgical procedure could potentially produce full resolution of symptoms, Dr. Hovanesian said.

“How many of our dry eye patients leave our practice feeling 100% relief? That’s very rare. And it’s often because there’s something else going on,” he said.

The surgical technique removes the loose conjunctiva, keeping a tag at the limbus so limbal stem cells are not harmed. An amniotic membrane is used to re-graft, which can help facilitate fast healing, Dr. Hovanesian said. Fibrin adhesive is used to hold the site together.

When performing the surgical procedure, he first finds the loose conjunctiva and excises the tissue there in a small area, not going as far as back as the fornix. He then cuts dried amniotic membrane to be slightly larger than the excised area on which it will be placed.

He applies thrombin glue and fibrinogen on the area, followed by the amniotic membrane.

“I simply lift the edges of the conjunctiva around the area, allowing the amniotic membrane to fall into place, and in a couple of areas, you may need to tuck it in,” he said. “We then finally squeegee, with forceps, the amniotic fluid in order to ensure that there’s a thin interface of adhesive. This allows the best adhesion with the glue when you have a very thin interface of glue. And that’s it. That’s the end of surgery. No sutures.”

After completion of surgery, the eye is patched over antibiotic drops. Patients receive prednisolone acetate 1% drops four times a day, fluoroquinolone antibiotic four times a day and a topical nonsteroidal.

“Postoperatively, you’ll see a fine reticular scar tissue that shows you that you have a firmly adherent epithelium, right down to the sclera. The patients tend to be asymptomatic,” Dr. Hovanesian said.

A video showing techniques for diagnosing and treating conjunctival chalasis can be found at http://www.osnsupersite.com/view.aspx?rid=%2039498. – by Erin L. Boyle

• John A. Hovanesian, MD, FACS, can be reached at Harvard Eye Associates, 24401 Calle De La Louisa, Suite 300, Laguna Hills, CA 92653; 949-951-2020; fax: 949-380-7856; e-mail: drhovanesian@harvardeye.com.