Two minimally invasive procedures can treat conjunctivochalasis
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Welcome to another edition of CEDARS/ASPENS Debates. CEDARS/ASPENS is a society of cornea, cataract and refractive surgery specialists, here to discuss some of the latest hot topics in ophthalmology.
This month we are going to present two novel approaches for conjunctivochalasis (CCh), a common and often overlooked condition that likely results from chronic inflammation, leading to loosening and folding of conjunctival tissue. Although CCh can be almost asymptomatic in the early stages, a variety of complaints may appear over time until management through medications is no longer effective. Two minimally invasive surgical methods, effective at different stages of CCh severity, are proposed here by Neel R. Desai, MD, and Laura M. Periman, MD, who both have seen many of their patients experience significant, long-lasting relief from symptoms. Enjoy the debate.
Kenneth A. Beckman, MD, FACS
OSN CEDARS/ASPENS Debates Editor
Reservoir restoration with AmnioGraft
Conjunctivochalasis (CCh) is a degenerative ocular surface disease, with overlapping risk factors and symptoms of aqueous tear deficiency and evaporative dry eye disease but distinct anatomical findings and clinical manifestations. Patients with CCh may appear to be typical dry eye patients seemingly recalcitrant to conventional therapy. However, patients at this end of the ocular surface disease (OSD) spectrum may also unknowingly have stage 1 neurotrophic keratitis and, hence, remain physically asymptomatic — only noting visual instability and, counterintuitively, epiphora.
The disease state is defined by four pathognomonic characteristics: chronic inflammation, dissolution of Tenon’s fascia, prolapse of orbital fat and subsequent foreshortening of the forniceal reservoir with altered tear dynamics. Notably, the primary pathophysiology is not localized to the conjunctiva at all. Rather, the coincident conjunctival pathology — degeneration, dehiscence and contracture — is definitively not a redundant excess as conventional nomenclature erroneously suggests. Hence, to be effective long term, any treatment must resolve the four primary pathophysiological issues.
The TissueTuck technique for reservoir restoration, intentionally designed to address each element of underlying pathology, is reproducible and efficient (less than 20 minutes) by any surgeon and avoids the long-term pitfalls of other approaches. The technique involves sutureless reconstruction of the inferior cul-de-sac with a redundantly folded cryopreserved amniotic membrane (AmnioGraft, BioTissue) following Tenon’s dissection and light excision and cauterization of prolapsed orbital fat. There is little in the way of conjunctival excision; there is already a deficiency of healthy conjunctiva to reform the fornix. To the contrary, we utilize a 25 mm × 20 mm cryopreserved amniotic membrane to serve as an anti-inflammatory, antifibrotic, regenerative scaffold for Tenon’s replacement and conjunctival re-epithelialization over the entire inferior scleral bed and inferior fornix. Impression cytology has shown that this newly regenerated conjunctiva demonstrates a threefold increase in epithelial cell density and tenfold increase in goblet cell density — a clear benefit to the patients with undiagnosed mucin deficiency as part of their OSD spectrum and a distinct advantage over many other CCh treatments.
Unfortunately, poor nomenclature has led to a variety of treatment modalities that cause contracture of loose conjunctiva or remove what is erroneously thought to be redundant conjunctiva. These approaches may, indeed, result in patient and physician perception of short-term improvement, as the physical sensation of loose conjunctiva is reduced. However, these approaches risk long-term exacerbation of the inflammatory disease state, conjunctival deficiencies and foreshortening of the fornix, while simultaneously failing to address orbital fat prolapse or improve conjunctival epithelial phenotype.
Reservoir restoration has been adopted by more than 400 surgeons nationwide thus far, with more being trained each month at the ocular surface biologics course offered at our practice. I remain hopeful and optimistic that passionate and innovative clinicians such as Dr. Laura Periman will find even more effective and easily implemented treatments for our patients with this misunderstood and underdiagnosed manifestation of OSD.
- For more information:
- Neel R. Desai, MD, of The Eye Institute of West Florida, Largo, Florida, can be reached at desaivision2020@gmail.com.
Plasma Pen CCh-plasty
Conjunctivochalasis (CCh) is the consequence of long-standing inflammation breaking down the delicate collagen and elastin fibers of the subconjunctival connections to Tenon’s. It is more common than we realize and is often overlooked. The grade of severity often correlates with specific dry eye symptoms.
For severe CCh, the excellent technique developed by Neel Desai is necessary and helpful for patients, but not enough surgeons are able to currently offer this procedure. Meanwhile, less severe yet symptomatic cases remain unserved. Pharmacologic approaches with Lumify (brimonidine tartrate ophthalmic solution 0.025%, Bausch + Lomb) temporarily reduce CCh folds, according to Melissa Toyos at the American Society of Cataract and Refractive Surgery meeting in 2019, and based on clinical observations, Miebo (perfluorohexyloctane ophthalmic solution, Bausch + Lomb) can relieve symptoms and reduce friction.
For patients in between the pharmacologic approach for symptom relief and the clinical severity that warrants a trip to the operating room for the excellent Desai technique, a rapid in-office treatment method is needed. Along with Frank Bowden, MD, and Sarah Darbandi, MD, we have piloted treating intermediate CCh with Plasma Pen CCh-plasty, using the NuVissa Plasma Pen.
This handheld device generates a controlled plasma arc that induces tissue contraction and triggers fibroblast collagen remodeling. It is used extensively in aesthetics and dermatology for facial rejuvenation and noninvasive treatment of skin tags, angiomas, telangiectasias, acne scars and moles. It is also used for “non-surgical blepharoplasty,” in which it tightens the eyelids by causing shrinkage of the top layer of the skin.
Off label, we have been using the Plasma Pen to treat CCh. Plasma energy induces a highly controlled contraction of the conjunctiva with minimal thermal damage, gently shrinking the CCh folds.
Before the procedure, eyelid scrub is performed, and topical anesthesia is applied using pledgets soaked in proparacaine solution. Brimonidine as well as moxifloxacin or TobraDex drops (tobramycin and dexamethasone ophthalmic suspension, Novartis) are administered.
Then, holding the Plasma Pen just above the conjunctival surface, individual noncontact superficial spots of plasma energy are delivered until slight shrinkage of the conjunctiva is seen. Care is taken to avoid the limbus by at least 3 mm and to avoid treatment down to Tenon’s or overlying ocular muscle insertions. Approximately three curvilinear parallel lines of plasma energy are usually required to achieve adequate CCh fold reduction.
After the procedure, antibiotic-steroid drops, Miebo and Tylenol (acetaminophen, Johnson & Johnson) for pain control are administered.
Healing time is fast. Patients report relief in CCh symptoms starting from day 3, and the effect is enduring, with re-treatment rates in a small percentage of patients 2 to 3 years out in our early clinical experience.
Plasma Pen CCh-plasty is a gentle, effective treatment that limits the coagulative necrosis induced by thermal cautery techniques, as well as the potential goblet cell loss caused by pinch-and-glue excisional techniques. While formal clinical studies are needed, the early experience with Plasma Pen CCh-plasty for less severe cases of CCh appears to have good treatment safety and efficacy.
- For more information:
- Laura M. Periman, MD, of Periman Eye Institute in Seattle, can be reached at dryeyemaster@perimaneyeinstitute.com.
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