Conjunctivochalasis I. Describe the approach to establishing the diagnosis

A. Describe the etiology of this disease 1. Age related process 2. Thought to be due to elastotic degeneration and collagenolysis that

leads to laxity of the adherence of the conjunctiva to the underlying connective tissue

3. Suggested that enzyme accumulation in the tear film due to delayed tear clearance may lead to degradation of the conjunctiva.

B. Define the relevant aspects of epidemiology of the disease 1. Occurs more frequently with age 2. Prevalence low prior to age 30 3. Prevalence may be higher in patients with autoimmune thyroid disease

C. List the pertinent elements of the history 1. Tearing 2. Tired feeling eyes 3. Pain 4. Blurred vision 5. Foreign body sensation 6. Irritation

D. Describe pertinent clinical features 1. Loose conjunctival folds interposed between the inferior globe and the

lid margin of the lower eyelid a. Folds may be located temporally, centrally, and/or nasally. b. If the chalasis is nasally located it may cause punctal occlusion

and delayed tear clearance 2. Folds may be single or multiple, and may be lower than, equal to, or

higher than the tear meniscus 3. Localized injection of the redundant conjunctiva may be seen

E. Describe appropriate testing and evaluation for establishing the diagnosis 1. Slit lamp examination 2. With fluorescein or Rose Bengal stain discreet areas of staining may

be present on the redundant bulbar conjunctiva, the adjacent lid margin, and tarsal conjunctiva. These features may help distinguish symptoms due to conjunctivochalasis from other causes

II. Define the risk factors

A. Age B. Thyroid disease

III. List the differential diagnosis

A. Entropion B. Ectropion C. Punctal stenosis D. Nasolacrimal obstruction

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E. Lid laxity F. Tear film abnormalities G. Aqueous tear deficiency H. Meibomian gland dysfunction I. Conjunctival edema, chemosis, lymphangiectasis J. Superior limbic keratoconjunctivitis

IV. Describe patient management in terms of treatment and follow-up

A. Describe the natural history, outcome and prognosis 1. Conjunctivochalasis is common with age 2. It may be asymptomatic in which case no treatment is required. 3. Symptoms such as intermittent epiphora, dry eye type symptoms, and

exposure related pain and irritation can occur and require treatment 4. Medical therapy may improve symptoms. If not, surgical intervention

may be indicated B. Describe medical therapy options

1. Ocular lubricants 2. Topical corticosteroids 3. Topical antihistamines 4. Patching at bedtime with ointment to protect the exposed conjunctiva

C. Describe surgical therapy options 1. Most surgical methods include excision of the area of

conjunctivochalasis. 2. A crescentic excision of the inferior bulbar conjunctiva 5mm away from

the limbus followed by closure with absorbable sutures may be performed

a. Fibrin glue can be used in lieu of sutures to reduce suture related granuloma formation and inflammation

b. Amniotic membrane can be placed over the defect created after the crescentic excision of conjunctiva. This can be sutured or glued into place

3. Suture can be placed to tighten the conjunctiva 4. Transconjunctival cautery can be applied

V. List the complications of treatment, their prevention and management

A. Complications 1. Recurrence 2. Conjunctival scarring 3. Cicatricial entropion 4. Retraction of the lower fornix 5. Motility restriction 6. Corneal complications

B. Prevention and management 1. Conjunctival area of excision should be limited as much as possible to

avoid these complications

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2. Use of amniotic membrane may reduce the likelihood of these complications

VI. Describe disease-related complications

A. Delayed tear clearance may lead to an increase in ocular surface irritation, inflammation and pain

B. Epiphora secondary to blocking access to lid puncta VII. Describe appropriate patient instructions

A. Appropriate use of topical therapy B. If indicated, proper instruction on patching at bedtime

Additional Resources

1. AAO, Basic and Clinical Science Course. Section 8: External Disease and Cornea, 2013-2014.

2. Erdogan-Poyraz C et al. Delayed Tear Clearance in Patients with Conjunctivochalasis Is Associated With Punctal Occlusion. Cornea 26:290–293, 2007.

3. Yokoi N. Clinical Impact of Conjunctivochalasis on the Ocular Surface. Cornea 24(Suppl. 1):S24–S31, 2005.

4. Meller D, Tseng SCG. Conjunctivochalasis: Literature Review and Possible Pathophysiology. Survey of Ophthalmology 43(3): 225-32, Nov-Dec 1998.

5. Meller D et al. Amniotic Membrane transplantation for symptomatic conjunctivochalasis refractory to medical treatments. Cornea 19(6): 796-803, 2000.

Cornea/External Disease 44 © 2013, AAO