Consider both conditions when treating coexisting conjunctivochalasis, pterygium
Conjunctivochalasis and pterygium, two common ocular conditions associated with inflammatory changes and elastic tissue abnormalities, often occur simultaneously, according to Tong and colleagues.
Successfully treating the coexisting conditions depends on considering them together, rather than separately, and understanding the impact of each on the patient before choosing a treatment strategy (Zhang and colleagues). Conjunctivochalasis (CCH) is characterized by loose and non-edematous folds of excess conjunctiva, generally in the inferior bulbar conjunctival area (Marmalidou and colleagues). As the tissue grows, it can obstruct tear outflow or roll over the lower lid, resulting in epiphora, or it may even impede lid closure and cause exposure. Pterygium, on the other hand, refers to a fibrovascular overgrowth of conjunctiva that is related to exposure to ultraviolet light (Shahraki and colleagues). Patients with significant CCH or pterygium usually present with ocular surface symptoms including irritation, dryness, foreign body sensation, burning, pain and epiphora (Zhang and colleagues; Marmalidou and colleagues; Shahraki and colleagues).
Source: Zeba A. Syed, MD
Nonsurgical treatment
As tear film instability is a primary source of symptoms in CCH or pterygium, treatment of the ocular surface in mild cases may involve preservative-free artificial tears, lubricating ointment, eyelid hygiene, and avoidance of dust, sand or other irritants that can aggravate symptoms (Yvon and colleagues). In cases involving symptomatic inflammation, topical cyclosporine or short courses of topical corticosteroids may be used.
Surgical approaches
If symptoms of CCH or pterygium are not adequately controlled with conservative medical therapy or if pterygium overgrowth has caused significant astigmatism, surgical intervention may be considered. The surgical treatment plan will depend on various factors, including symptom severity, the extent of conjunctival or ocular surface involvement, and the patient’s tolerance for in-office procedures.
Broadly, surgical techniques for CCH include shrinking excess tissue, excising excess tissue and enhancing adhesion of tissue to the conjunctiva. Shrinking tissue can be performed in the office and is often the first procedure I consider. After anesthetizing the ocular surface, I use forceps to mobilize excess conjunctiva in the inferior fornix and then use handheld cautery to shrink this area. Patients may experience minor ocular surface irritation or hyperemia after the procedure.
In more severe disease or in cases that do not respond to in-office cautery, I prefer to bring patients to the operating room to excise the excess conjunctival tissue. During this surgery, I mark out a crescentic area of redundant conjunctiva in the inferior fornix, remove the tissue with scissors and use absorbable sutures to close the exposed edges. It is critical not to remove too much tissue, as that can result in forniceal shortening. Another surgical strategy is to improve adhesion of the conjunctiva to the underlying sclera using fixation with sutures, which also helps minimize the risk of forniceal shortening.
A recent study compared surgical methods for CCH and pterygium, assessing same-stage trapezoidal conjunctival flap transplantation, pterygium excision and scleral fixation surgery vs. staged pterygium excision, crescentic conjunctival excision and scleral fixation surgery (Zhang and colleagues). There were no significant differences between techniques, and neither significantly improved the symptoms and quality of life of patients. Overall, it is important to remember that there is no single correct technique — many of us approach treatment based on training or institutional practice patterns, and outcomes can be excellent regardless of the particular surgery used.
Use of amniotic membrane
Amniotic membrane also plays an important role in the treatment of CCH and pterygium. My personal preference is amniotic membrane that has been cryopreserved, as this preservation method retains many of the original biomechanical properties of amniotic membrane, making it easy to shape and manipulate surgically (Cooke and colleagues).
In the surgical removal of CCH, the risk of forniceal shortening can be reduced by using a cryopreserved amniotic membrane graft to cover the remaining bare sclera. It is also useful in the treatment of pterygium, particularly in patients with large or double pterygia in which adequate healthy conjunctiva is not available to obtain autografts for both areas of bare sclera.
In cases of double pterygia, I use a conjunctival autograft for one area of bare sclera and amniotic membrane for the other area. The results have been excellent, with low rates of pterygium recurrence. Many surgeons use amniotic membrane transplantation in all pterygium surgery. Recurrence rates are low, but as with conjunctival autografting, they are variable and depend on geographic region and patient adherence to their postoperative steroid regimen.
Regardless of the approach we use, successful treatment of coexisting CCH and pterygium depends on fully considering the impact of both conditions rather than treating them separately or only considering one disease (Zhang and colleagues). Appreciating the effect of both of these common ocular conditions is key to optimizing visual outcomes as well as quality of life.
- References:
- Cooke M, et al. J Wound Care. 2014;doi:10.12968/jowc.2014.23.10.465.
- Marmalidou A, et al. Ocul Surf. 2019;doi:10.1016/j.jtos.2019.04.008.
- Shahraki T, et al. Ther Adv Ophthalmol. 2021;doi:10.1177/25158414211020152.
- Tong L, et al. Med Hypotheses. 2013;doi:10.1016/j.mehy.2013.08.017.
- Yvon C, et al. Conjunctivochalasis. In: StatPearls [Internet]. StatPearls Publishing. Updated April 3, 2023.
- Zhang N, et al. Altern Ther Health Med. 2024;30(6):188-195.
- For more information:
- Zeba A. Syed, MD, a cornea, cataract and refractive surgery specialist who serves as an associate professor of ophthalmology at Sidney Kimmel Medical College at Thomas Jefferson University and as the director of the cornea fellowship at Wills Eye Hospital in Philadelphia, can be reached at zsyed@willseye.org.
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