Liquid nitrogen cryotherapy an effective surgical alternative for treating conjunctivochalasis

In this technique, redundant conjunctiva is tacked down to the underlying globe via a cryogenic burn.

Thomas John

Conjunctivochalasis is a less-recognized, age-related clinical entity, and symptomatic patients do not get adequate relief without definitive treatment for this condition. These patients are often misdiagnosed as having dry eye and do not get symptomatic relief from dry eye treatment. It is important for the clinician to make the correct diagnosis and institute appropriate treatment for patients with conjunctivochalasis.

Elschnig initially described conjunctivochalasis as early as 1908, but Hughes did not use the term until 1942. Symptomatic patients may complain of ocular irritation, pain, fatigue, dryness, blurred vision, epiphora, discharge and redness from subconjunctival hemorrhage. Clinically, redundant folds of conjunctiva can be observed between the globe and the eyelid. These conjunctival folds may be accentuated by vigorous blinking or by pressing the lid against the globe, upward for the lower lid and downward for the upper lid. The folds hamper normal tear distribution, causing secondary dry eye and delayed tear clearance, resulting in epiphora.

It is important to view these regions with a slit lamp to confirm the diagnosis of conjunctivochalasis. Unlike chemosis, conjunctivochalasis does not spontaneously resolve. While vigorous blinking usually improves dry eye symptoms, it worsens the ocular symptoms in conjunctivochalasis. It is also important to note that punctal occlusion worsens the symptoms in conjunctivochalasis. Unlike dry eye symptoms, which worsen in the evening and in the upward gaze, conjunctivochalasis symptoms are often uniform throughout the day and worsen on downward gaze.

The exact etiology of conjunctivochalasis is not fully established. It is thought to be the result of an aging process that causes gradual thinning and stretching of the conjunctiva along with possible Tenon’s capsule dissolution, resulting in a compromised conjunctival-scleral adhesion. Conjunctival histopathology often reveals a normal-appearing epithelium with mild inflammation. Associated research has revealed overexpression of MMP-1 and MMP-3 in the conjunctiva. Matrix metalloproteinases, or MMPs, are a group of enzymes that degrade or modify the extracellular matrix and play a role in post-damage tissue remodeling.

Surgical intervention may be considered in symptomatic patients when medical management fails. Techniques vary from simple excision to tacking down the redundant conjunctiva using sutures, tissue adhesives or amniotic membrane transplantation.

In this column, Dr. Fraunfelder describes the use of liquid nitrogen cryotherapy for the surgical management of conjunctivochalasis.

Thomas John, MD
OSN Surgical Maneuvers Editor

by Frederick W. Fraunfelder, MD

The surgical technique of excision and cryotherapy of conjunctivochalasis (Figure 1) is relatively simple and straightforward. Prior to cryotherapy, an incision is made in the involved conjunctiva with 0.12-mm forceps and sharp Westcott scissors. A 1-mm² to 2-mm² portion of tissue can be excised and sent in formalin for pathologic diagnosis (Figures 2 to 5). The clinical suspicion of conjunctivochalasis can be confirmed by an ophthalmic pathologist. Cryotherapy is performed using a Brymill CRY-AC-3 liquid nitrogen unit (Brymill Cryogenic Systems). A 1.5-mm Teflon-coated cryoprobe is used to perform a double freeze-thaw of the involved conjunctiva for 1 to 2 seconds in two freeze-thaw cycles. Thawing takes approximately 5 to 10 seconds. Erythromycin eye ointment is placed on the eye after the procedure. Patients are seen at 1 day, 6 weeks and 6 months for routine follow-up (Figure 6).

Figure 1. Conjunctivochalasis of the right eye.

Figure 2. Tenting of the conjunctiva before an incisional biopsy with Westcott scissors. Images: Fraunfelder FW

Figure 3. Cotton swab-assisted expression of subconjunctival fluid.

Figure 4. Liquid nitrogen cryotherapy with a 1.5-mm cryoprobe.

Figure 5. Multiple areas of cryotherapy applied over the bulbar conjunctiva.

Figure 6. Postoperative appearance after excision and cryotherapy.

Currently, surgical treatment of conjunctivochalasis varies and includes resection of the conjunctiva, replacement of resected conjunctiva with an amniotic membrane graft, suturing the remaining conjunctiva together to decrease the redundancy, or gluing down excess conjunctiva with fibrin glue after resection. There are also reports of electrocautery with good success.

Liquid nitrogen cryotherapy likely works for conjunctivochalasis by tacking down redundant conjunctiva to the underlying globe through a cryogenic burn. Liquid nitrogen cryotherapy has been proven safe and effective for conjunctival malignancies and also appears to be efficacious in the treatment of various other benign ocular conditions, including benign conjunctival vascular tumors, advancing wavelike epitheliopathy, superior limbic keratoconjunctivitis, pterygia, conjunctival amyloidosis, conjunctival sarcoidosis and conjunctival lymphangiectasia. Liquid nitrogen cryotherapy using the described surgical technique could be considered an effective surgical alternative in the treatment of conjunctivochalasis.

References:

• Fraunfelder FW. Liquid nitrogen cryotherapy for conjunctival lymphangiectasia: a case series. Trans Am Ophthalmol Soc. 2009;107:229-232.
• Fraunfelder FW. Liquid nitrogen cryotherapy for surface eye disease (an AOS thesis). Trans Am Ophthalmol Soc. 2008;106:301-324.
• Fraunfelder FW. Liquid nitrogen cryotherapy of conjunctival lymphangiectasia: a case series. Arch Ophthalmol. 2009;127(12):1686-1687.
• Fraunfelder FW, Dhoot DS. Successful treatment of conjunctival sarcoidosis with local cryotherapy. Ophthalmic Surg Lasers Imaging. 20102:1-4.
• Kashima T, Akiyama H, Miura F, Kishi S. Improved subjective symptoms of conjunctivochalasis using bipolar diathermy method for conjunctival shrinkage. Clin Ophthalmol. 2011;5:1391-1396.
• Kheirkhah A, Casas V, Blanco G, et al. Amniotic membrane transplantation with fibrin glue for conjunctivochalasis. Am J Ophthalmol. 2007;144(2):311-313.
• Meller D, Tseng SCG. Conjunctivochalasis: literature review and possible pathophysiology. Surv Ophthalmol. 1998;43(3):225-232.
• 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(6):930-937.
• Watanabe A, Yokoi N, Kinoshita S, Hino Y, Tsuchihashi Y. Clinicopathologic study of conjunctivochalasis. Cornea. 2004;23(3):294-298.

• Frederick W. Fraunfelder, MD, can be reached at Casey Eye Institute, 3375 SW Terwilliger Blvd., Portland, OR 97239-4197; 503-494-4318; fax: 503-418-2284; email: eyedrug@ohsu.edu.
• Edited by Thomas John, MD, clinical associate professor at Loyola University at Chicago and in private practice in Oak Brook, Tinley Park and Oak Lawn, Ill. He can be reached at 708-429-2223; fax: 708-429-2226; email: tjcornea@gmail.com.
• Disclosures: Dr. Fraunfelder’s research was supported in part by an unrestricted grant to Casey Eye Institute from Research to Prevent Blindness. Dr. John has no relevant financial disclosures.