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Thermocautery for Inferior Conjunctivochalasis
Abstract
To describe a thermocautery technique to treat symptomatic inferior conjunctivochalasis.
Thirty-nine eyes of 23 patients with symptomatic inferior conjunctivochalasis were treated with thermocautery. The mean age of the patients was 78.6 ± 5.4 years (±SD) with a range of 69-89 years. Patients with symptomatic inferior conjunctivochalasis were initially treated with topical medication, and the eyes that were unresponsive underwent a ligation test. We treated those eyes in which symptoms improved or disappeared during the ligation test. The redundant bulbar conjunctival tissue was grasped with smooth forceps and cauterized with the OPTEMP variable low temperature cauterizer until the redundant conjunctival tissue was gone. The mean follow-up period was 469.5 ± 234.6 days (range, 101-823 days).
After the thermocautery, the symptoms disappeared in 36 of 39 eyes (92.3%) and improved in the remaining 3 eyes (7.7%). The conjunctival laxity disappeared in 36 of 39 eyes (92.3%) and improved in 3 eyes (7.7%). There were no recurrences of the conjunctival laxity during the follow-up period.
Thermocautery is a simple and effective treatment for symptomatic inferior conjunctivochalasis.
... The goal of surgical treatment of conjunctivochalasis is to remove the redundant tissue. Several techniques have been described, including elliptical excision, excision and amniotic membrane transplant, thermocautery, electrocautery, and a paste-pinch-cut technique [8][9][10][11][12]. In thermocautery and electrocautery, the epithelium and stroma of the conjunctiva are burnt and reduced. ...
... This study compared efficacy, histology, and post-operative inflammatory markers of thermoconjunctivoplasty performed on mouse conjunctiva by two different methods, thermocautery or a pulsed near-infrared laser. Thermocautery and high frequency radiowave electrocautery are the most commonly utilized methods to surgically treat conjunctivochalasis in a clinic setting [8][9][10]. Energy delivered to tissue from these devices can exceed 1000 °F, which burns tissue, can cause an unpleasant odor, and can ignite a fire [15]. ...
... This study compared efficacy, histology, and post-operative inflammatory markers of thermoconjunctivoplasty performed on mouse conjunctiva by two different methods, thermocautery or a pulsed near-infrared laser. Thermocautery and high frequency radiowave electrocautery are the most commonly utilized methods to surgically treat conjunctivochalasis in a clinic setting [8][9][10]. Energy delivered to tissue from these devices can exceed 1000 • F, which burns tissue, can cause an unpleasant odor, and can ignite a fire [15]. ...
Conjunctivochalasis is a degenerative condition of the conjunctiva that disrupts tear distribution and causes irritation. Thermoreduction of the redundant conjunctiva is required if symptoms are not relieved with medical therapy. Near-infrared laser treatment is a more controlled method to shrink the conjunctiva than thermocautery. This study compared tissue shrinkage, histology, and postoperative inflammation in thermoconjunctivoplasty performed on the mouse conjunctiva using either thermocautery or pulsed 1460 nm near-infrared laser irradiation. Three sets of experiments were performed on female C57BL/6J mice (n = 72, 26 per treatment group and 20 control) to assess conjunctival shrinkage, wound histology, and inflammation 3 and 10 days after treatment. Both treatments effectively shrunk the conjunctiva, but thermocautery caused greater epithelial damage. Thermocautery caused greater infiltration of neutrophils on day 3 and neutrophils and CD11b+ myeloid cells on day 10. The thermocautery group had significantly higher conjunctival expression of IL-1β on day 3. Expression of chemokine CCL2 was higher in the conjunctiva on day 3 and tear concentrations were higher on day 7 in the laser group. These results suggest that pulsed laser treatment causes less tissue damage and postoperative inflammation than thermocautery while effectively addressing conjunctivochalasis.
... Conjunctival cauterization is a simple procedure for treatment of CCH unresponsive to medical therapy. Cauterization leads to conjunctival coagulation, shrinkage, and, in some cases, adhesion to the underlying episclera [20,[22][23][24][25]. In general, it is performed under local anesthesia either with topical anesthesia or after a subconjunctival injection of lidocaine. ...
... Review of the outcomes of the aforementioned studies (Table 1) shows mostly successful results. These studies have shown symptom control in 84.6-100% of patients [24][25][26]. Four studies identified significant improvement in OSDI and Canadian Dry Eye Assessment (CDEA) scores at 1-2 months postoperatively versus the baseline preoperative scores (OSDI: 21.5 ± 14.2 versus 31.5 ± 15.2, P = 0.001, 19.1 ± 13.8 versus 50.7 ± 12.4, P < 0.001, and 7.80 ± 1.38 versus 19.5 ± 16.5, P = 0.0002; CDEA: 4.5 ± 0.78 versus 7.1 ± 2.8, P = 0.01) [20,[27][28][29]. ...
... Recurrence rates were demonstrated to be as low as 0% [24,25] and as high as 100% in cases of incomplete initial treatment [22]. Residual postoperative CCH was present in 7.6% and 100% patients in two studies due to underestimation of the conjunctiva that should have been cauterized [22,24]. ...
Conjunctivochalasis (CCH) is a bilateral conjunctival condition characterized by loose, redundant conjunctival folds, typically in the inferior bulbar conjunctiva. It is a common cause of ocular irritation, especially in older age. For asymptomatic CCH, no treatment is necessary. For treatment of symptomatic CCH, however, a variety of medical and surgical approaches are currently available, which will be thoroughly appraised in this review article. The first step in the management is medical therapy, which involves enhanced lubrication and use of anti-inflammatory medications. In refractory cases, a surgical approach may be undertaken for symptom relief. Several techniques have been described for this, with varying success rates. These include conjunctival cauterization, conjunctival excision, scleral fixation of the conjunctiva, conjunctival ligation, laser conjunctivoplasty, and radiowave electrosurgery. Among these, conjunctival cauterization and excision of the redundant conjunctiva, with or without tissue grafting, have gained popularity.
... All results were reported as mean ± Standard Division (SD) of three independent experiments. All statistical tests were analyzed using SPSS version 26 ...
... Although in clinical practice, CCh is a common ailment, there is little to no definite treatment for this disease [7]. These patients usually take artificial tears to cut down on dry eye symptoms [26], but this procedure is not satisfactory. In fact, for asymptomatic CCh, no treatment is required, while for symptomatic ones, different medical and surgical interventions are available. ...
Purpose: The present study aimed to determine whether treating symptomatic Conjunctivochalasis (CCh) patients with Atmospheric Low-Temperature Plasma (ALTP) can stimulate inflammatory responses or not; if yes, are they in a stable state and how long do they take back to the normal range? Methods: In this study, 20 patients with definite CCh-with a grade of 3 and 4-were recruited (identifier: IRCT20181229042160N3). ALTP was generated and used to undertake the surgery; the digital camera examinations were used to follow up the clinical outcomes after surgery. Tear and serum samples were isolated from each patient at 1 week, 1 month, and 3 months after treatment, and the concentration of candidate pro-inflammatory (i.e. IL-2, IL-6, IL-17A, IFN-γ, and TNF-α) and anti-inflammatory cytokines (IL-4 and IL-10) was measured using flow cytometry. Results: In all patients, grades 3 and 4 of CCh were substantially improved to grades 1 and 2, respectively; clinically, after one month, no complications were reported in the eyes that were subjected to ALTP-based surgical procedure. Besides, the analyses revealed that the ALTP-based treatment could improve the 'Ocular Surface Disease Index' score. Interestingly, regarding the concentration of the candidate cytokines in the tear and serum samples, no differences were observed at pre-and post-surgery follow-ups. Conclusion: In sum, we reintroduced using the Plasma-Assisted Noninvasive Surgery method as a novel approach to treat CCh because of its accurate handy nature with no stimulated inflammatory responses.
... Its incidence has gradually increased in the population, due to the permanent increase of life expectancy [1,2]. To manage these folds, different surgical procedures have been described, including the conjunctival fold excision by the use of sutures [3][4][5], amniotic membrane transplantation [6], and other less invasive procedures using different types of cautery techniques, such as bipolar coagulation [7], laser thermocautery coagulation [8], and argon green laser coagulation [9]. ...
... Conjunctivochalasis is an increasingly common clinical finding in ophthalmic consultation [8,9], and it is one of the causes of chronic ocular irritation and epiphora, which is sometimes underdiagnosed in the older population. All of the surgical techniques described use surgical excision and placement of sutures, which should be avoided in order to prevent conjunctival scars that sometimes prolong postoperative recovery or create a permanent alteration of the preocular lachrymal film. ...
Aim
. To report a new surgical technique for the treatment of conjunctivochalasis.
Methods
. A new surgical technique in which specially designed bipolar electrocautery forceps facilitate the complete reduction of the conjunctival folds without creating lesions near the corneoscleral limbus was designed. A retrospective revision of the medical records of patients treated with this technique between the years 2011 and 2013 was made, and eighteen eyes of sixteen patients with conjunctivochalasis treated with this new technique were included.
Results.
All the eyes treated showed a significant improvement with no evidence of scar lesions after a mean follow-up time of 10 months.
Conclusions
. The surgical technique presented here could be a good alternative for the management of conjunctivochalasis.
... Surgical reconstruction of the tear meniscus in conjunctivochalasis leads to an improvement of ocular signs and symptoms 1,9 , tear film break up time, Schirmer's test, fluorescence clearance test, tear osmolarity 15,26,27 , and tear film inflammatory markers 5 . Superficial conjunctival cauterization has been shown to be an effective treatment for correction of conjunctivochalasis 11,12,28 . Haefliger and coworkers reported that superficial cauterization of the inferior bulbar conjunctiva results in a significant reduction of moderate conjunctivochalasis 12 . ...
... Haefliger and coworkers reported that superficial cauterization of the inferior bulbar conjunctiva results in a significant reduction of moderate conjunctivochalasis 12 . Nakasato et al showed that thermocautery could induce conjunctival shrinkage in all cases and symptom improvement in over 90% of the eyes 11 . A quantitative reduction in the cross-sectional conjunctivochalasis area has been demonstrated on anterior segment optical coherence tomography after inferior conjunctival cauterization 28 . ...
We evaluated the change in tear film lipid layer thickness, corneal thickness, volume and topography after superficial cauterization of symptomatic conjunctivochalasis. Bilateral superficial conjunctival cauterization was performed in 36 eyes of 18 patients with symptomatic conjunctivochalasis. The mean age of patients (12 males, 6 females) was 68.6 ± 10.9 years (range: 44-83 years). Preoperatively, 28 eyes (77.8%) had grade 1 conjunctivochalasis, and 8 eyes (22.2%) had grade 2 conjunctivochalasis. At 1 month postoperatively, the severity of conjunctivochalasis decreased significantly (p < 0.001) and 29 eyes (80.6%) had grade 0 conjunctivochalasis whereas 7 eyes (19.4%) had grade 1 conjunctivochalasis. The mean Ocular Surface Disease Index score decreased from 31.5 ± 15.2 preoperatively to 21.5 ± 14.2 at the end of 1 month postoperatively (p = 0.001). There was a statistically significant increase in mean tear film lipid layer thickness 1 month after the surgery (49.6 ± 16.1 nm vs 62.6 ± 21.6 nm; p < 0.001). The central corneal thickness, thinnest corneal thickness and corneal volume decreased significantly postoperatively (p < 0.001). Our study showed that superficial conjunctival cauterization is an effective technique for management of conjunctivochalasis in the short term. An increase in tear film lipid layer thickness along with a decrease in corneal thickness and volume were observed after surgical correction of conjunctivochalasis.
... [4] The main goal of these procedures is to remove or shorten the redundant conjunctiva, or to fix the conjunctiva on the underneath sclera to reduce friction. [1] In prior prospective studies, the success rate of conjunctival cauterization and conjunctival excision with sutured wound closure ranged from 84.6% to 100% [7][8][9] and 84.8% to 93.3%, [3,[10][11][12][13] respectively, with varied recurrence rates reported. Restoration of the inferior tear meniscus was achieved in 92.3%-100% of cases receiving conjunctival cauterization, [7,14] and 65.2%-100% of cases receiving conjunctival excision. ...
To observe the surgical outcome of “Tenon Excision with Fibrin Glue-Assisted Reattachment of Conjunctiva Flap” (T.E.F.A.R.C.) for the treatment of symptomatic conjunctivochalasis (CCH). This is a retrospective case series of CCH patients undergoing T.E.F.A.R.C. from January 2017 to December 2020 were reviewed. Seven patients (14 eyes) with symptomatic CCH received T.E.F.A.R.C. in both eyes. The symptoms before and after the procedures were compared and surgical complication was evaluated. The mean follow-up time was 13.7 ± 2.14 months. After the operation, resolution of the symptoms was reported in 12 eyes (86%). The grade of CCH decreased from 3 to 0 in all 14 eyes, and the restoration of inferior conjunctival surface and fornix within 1 day was also observed in all eyes. Most patients had localized injection and mild chemosis after the operation, which mostly recovered within 3 weeks. No complication or recurrence of CCH was reported after 1 year of follow-up. In conclusion, T.E.F.A.R.C. is a simple and effective treatment option for CCH with less surgical complication. Future larger studies are needed to confirm its clinical applicability.
... 3 In general, a complete or major improvement in CCH symptoms have been reported in 84%-100% of patients af-ter this procedure. 3,48,49 Compared with excisional techniques, it was shown as effective but with earlier symptom relief. However, repeated procedures may be required to achieve surgical success. ...
... By analyzing the development of symptoms in patients with conjuncticochalasis, it is indicated that surgical correction should not only restore the meniscus of the tear, but also deepen the sputum of patients with conjunctivochalasis, and these views have been confirmed in Huang et al [48] study. Moreover, despite the fact that they used thermocautery therapy to treat conjunctivochalasis, and the final mechanism is still the fornix reconstruction in Nakasato et al [49] research. It is the similarity of these studies, so we put in the same category in the cluster view called "#10 fornix reconstruction." ...
Background:
With the aging of the population and the use of video terminals, the incidence of Conjunctivochalasis is getting higher, and related research is increasing. So our research aimed to use visualization software to display the research trends of Conjunctivochalasis.
Methods:
Retrieved the document (from 1986 to 2017) of conjunctivochalasis in the web of science core collection, analyzed by Citespace V.
Results:
The main language is English. Article is the key type of document. The average annual number of publications in the time period from 2008 to 2017 was 11.6, which was significantly higher than the period from 1994 to 2007, indicating that the total number of publications has been continuously developed. The law of frequency quoted showed an upward trend yearly. Furthermore, we can find out that Japan, USA, and People's Republic of China were the most productive countries, Kyoto Prefectural University of Medicine was the most prolific institution, Shanghai Jiaotong University is a key institution. The average IF of journals was 3.0508. Cornea and Canadian Journal of Ophthalmology are core journals. Tseng SCG is the most active scholar. All cited author contributed to 5 classifications. Di PMA paper is a classic literature. Huang YK paper can be regarded as the frontier document. All cited-reference dedicated to 7 categories. Conjunctivochalasis is the hot topic, related to observe indicators, risk factors, treatment, graded diagnosis of conjunctivochalasis, etc. In addition, fibroblast was research hotspot. At length, the cluster map of keyword was divided into 7 categories.
Conclusion:
This research will help relevant clinicians and researchers to accurately and quickly grasp the research trends in the field, and continue to conduct new research on the basis.
... Furthermore, suture fixation of the conjunctiva to the sclera with 6-0 Vicryl sutures has been described [9]. Additionally, electrocoagulation represents another method, which allows local inflammation to occur and the conjunctiva to attach to the subconjunctival Tenon's capsule [14][15][16]. ...
The purpose of our study is to present a quick surgical procedure for the treatment of Conjunctivochalasis (CCH) and to evaluate its effectiveness. Thirty consecutive patients, in whom CCH was diagnosed on clinical examination, were investigated for the presence of symptoms of dry eye. The 60 eyes were evaluated according to their symptomatology and the 40 symptomatic eyes were grouped in two stages using the LIPCOF (stage 1, one small fold; stage 2, more than two folds but not higher than the tear meniscus) classification and included in the study. After a subconjunctival injection of lidocaine 20 mg/mL, a medium frequency alternating current (RF) was used, adjusted in low power. With a wide tip, redundant conjunctiva was ablated leaving space between the ablations. Postoperative treatment included eye oint.gentamicin 0.3% with dexamethasone 0.03% three times a day for 5 days. At postoperative day 10, conjunctival edema had subsided and conjunctival epithelium was intact after fluorescein staining. Symptoms had improved in all patients. During follow-up, no complication was detected. Mild conjunctival hyperemia was present in all cases but resolved with standard postoperative medications. To conclude, CCh treatment with RF appears to be a safe, quick, and effective surgical technique. Operation time is less than 10 min and can be performed in an outpatient clinic.
... Surgical means used to remove redundant conjunctival tissue is an effective way to treat conjunctivochalasis. However, the current surgical techniques, such as thermocautery or electrocautery, are not performed on a widespread basis due to the long painful healing period [7][8][9] . Both techniques reach temperatures exceeding the boiling point of water and can burn the conjunctival epithelium, underlying stroma, and surrounding tissue. ...
Conjunctivochalasis is a common cause of tear dysfunction due to the conjunctiva becoming loose and wrinkly with age. The current solutions to this disease include either surgical excision in the operating room, or thermoreduction of the loose tissue with hot wire in the clinic. We developed a near-infrared (NIR) laser thermal conjunctivoplasty (LTC) system, which gently shrinks the redundant tissue. The NIR light is mainly absorbed by water, so the heating is even and there is no bleeding. The system utilizes a 1460-nm programmable laser diode system as a light source. A miniaturized handheld probe delivers the laser light and focuses the laser into a 10x1 mm2 line. A foot pedal is used to deliver a preset number of calibrated laser pulses. A fold of loose conjunctiva is grasped by a pair of forceps. The infrared laser light is delivered through an optical fiber and a laser line is focused exactly on the conjunctival fold by a cylindrical lens. Ex vivo experiments using porcine eye were performed with the optimal laser parameters. It was found that up to 50% of conjunctiva shrinkage could be achieved.
... However, no study to date has measured changes in capillary hemodynamics alongside changes in protein expression at the level of a single vessel segment or over time. To fill this void, we modified an established vessel ligation technique 37,41 to alter blood flow in limbal vessels, and we applied this technique to the corneal neovasculature to demonstrate the ability to measure changes in capillary hemodynamics and endothelial cell protein expression in individual neovessel segments across sequential time points (Fig. 2a). By applying a surgical cautery knife to one of the arterioles feeding into the corneal network, we were able to surgically induce a redistribution of blood flow throughout the neovessel network (Fig. 2a, light blue 'x'). ...
Microvascular endothelial cell heterogeneity and its relationship to hemodynamics remains poorly understood due to a lack of sufficient methods to examine these parameters in vivo at high resolution throughout an angiogenic network. The availability of surrogate markers for functional vascular proteins, such as green fluorescent protein, enables expression in individual cells to be followed over time using confocal microscopy, while photoacoustic microscopy enables dynamic measurement of blood flow across the network with capillary-level resolution. We combined these two non-invasive imaging modalities in order to spatially and temporally analyze biochemical and biomechanical drivers of angiogenesis in murine corneal neovessels. By stimulating corneal angiogenesis with an alkali burn in Tie2-GFP fluorescent-reporter mice, we evaluated how onset of blood flow and surgically-altered blood flow affects Tie2-GFP expression. Our study establishes a novel platform for analyzing heterogeneous blood flow and fluorescent reporter protein expression across a dynamic microvascular network in an adult mammal.
... In severe cases of conjunctivochalasis that do not respond to ocular lubricants, topical cyclosporine or punctal occlusion, resection of the excessive conjunctival tissue may be considered [748]. Several approaches to reduce the excessive conjunctival folds have been reported, including electrocoagulation or thermal cauterization [749,750], simple fixation to the sclera [751], and Argon laser conjunctivoplasty [752]. In all studies (Level 3 evidence), some level of improvement in symptoms has been reported in over 75% of patients. ...
The members of the Management and Therapy Subcommittee undertook an evidence-based review of current dry eye therapies and management options. Management options reviewed in detail included treatments for tear insufficiency and lid abnormalities, as well as anti-inflammatory medications, surgical approaches, dietary modifications, environmental considerations and complementary therapies. Following this extensive review it became clear that many of the treatments available for the management of dry eye disease lack the necessary Level 1 evidence to support their recommendation, often due to a lack of appropriate masking, randomization or controls and in some cases due to issues with selection bias or inadequate sample size.
... However in the case of severe conjunctivochalasis (LIPCOF degree 3), an invasive therapy may also be necessary [14]. A spectrum of invasive therapies, like classical surgeries against conjunctivochalasis and other invasive methods, such as the treatment of the conjunctival folds with argon-laser [40] or with heat cauterization [41], are well known. There is little data on population survey of conjunctivochalasis. ...
Trial registration:
Controlled-Trials.com ISRCTN81112701 http://www.isrctn.com/ISRCTN81112701.
... Several methods have been described, including crescent resection with or without suture, suture fixation of the redundant conjunctiva to the globe, pinching the excess conjunctiva and performing bipolar cauterization, conjunctivoplasty using a simple medial conjunctival resection, conjunctivoplasty with argon green laser, paste-pinch-cut conjunctivoplasty, conjunctival semiperitomy combined with gentle subconjunctival cauterization, and conjunctivoplasty with amniotic membrane transplantation with or without the use of fibrin tissue glue. [43][44][45][46][47][48][49][50][51][52][53][54] In conclusion, the majority of patients with CCh have been diagnosed with the more common ocular surface disease conditions, such as dry eye, blepharitis, or allergic eye disease, prior to the correct diagnosis. So it is important to consider this pathology during the diagnostic work-up of chronic irritation and epiphora. ...
Purpose
To evaluate the clinical characteristics of patients with conjunctivochalasis (CCh).
Methods and materials
This retrospective study enrolled 30 subjects diagnosed with conjunctivochalasis. Complete ophthalmic examination, including visual acuity assessment, slit-lamp examination, applanation tonometry, dilated funduscopy, tear break-up time, Schirmer 1 test, and fluorescein staining were performed in all patients. Age, sex, laterality, ocular history, symptoms, and clinical findings were recorded.
Results
The study included 50 eyes from 30 cases. Ages ranged from 45 to 80 years, with a mean age of 65±10 years. CChs grading were as follows: 30 (60%) eyes with grade 1 CCh; 15 (30%) eyes with grade 2 CCh; and five (10%) eyes with grade 3 CCh. CCh was located in the inferior bulbar conjunctiva in 45 (90%) eyes, and in the remaining five (10%) CCh was located in the superior bulbar conjunctiva. Ten (33.3%) patients had no symptoms. Dryness, eye pain, redness, blurry vision, tired eye feeling, and epiphora were the symptoms encountered in the remaining twenty (63.6%) patients. Altered tear meniscus was noted in all cases. The mean tear break-up time was 7.6 seconds. The mean Schirmer 1 test score was 7 mm. Pinguecula was found in ten patients.
Conclusion
Dryness, eye pain, redness, blurry vision, and epiphora were the main symptoms in patients with CCh. Dryness, eye pain, and blurry vision were worsened during downgaze and blinking. So CCh should be taken into consideration in the differential diagnosis of chronic ocular irritation and epiphora.
Background
Conjunctivochalasis (CCh) is characterized by loose, redundant conjunctival folds that result in tear film instability. For cases that are refractory to conventional therapies, surgical treatment may be used to address the underlying pathophysiology.
Aims
The aim of this study was to assess the clinical outcome of fornix reservoir restoration surgery with cryopreserved amniotic membrane (AM) in patients with symptomatic CCh.
Setting and Design
This was an observational, retrospective, single-site study.
Materials and Methods
Retrospective review of eyes with CCh that underwent fornix deepening reconstruction with conjunctival recession and AM transplantation with at least 3 months of follow-up. Outcome measures, which were assessed at 2 ± 1 weeks postoperatively and at the last follow-up visit, included CCh severity, symptoms, tear break-up time (TBUT), corneal and conjunctival fluorescein staining, subconjunctival hemorrhage, and delayed tear clearance.
Statistical Analysis Used
Wilcoxon signed–rank test and Fisher’s exact test were used for statistical analysis.
Results
Ten eyes (76.9%) presented with Grade 3 CCh, and 3 eyes (23.1%) presented with Grade 2 CCh along with ocular irritation (100%), epiphora (84.6%), dryness (76.9%), ocular pain (38.5%), and photophobia (23.1%). Following surgical intervention, CCh severity significantly improved to Grade 0 in all eyes. This was accompanied by a significant improvement in corneal staining, symptoms, and resolution of conjunctival staining/subconjunctival hemorrhage.
Conclusion
Surgical treatment using the reservoir restoration procedure addresses the pathophysiology of CCh as demonstrated by improved symptoms, TBUT, and corneal and conjunctival staining.
PURPOSE: To assess the extent of inferior fornix shortening in conjunctivochalasis (CCh) and to evaluate whether fornix deepening reconstruction can restore the fornix tear reservoir in patients with CCh.
MATERIALS AND METHODS: This was a retrospective review of five patients (3 unilateral and 2 bilateral eyes, total 7 eyes) with CCh who underwent fornix deepening reconstruction with conjunctival recession and amniotic membrane transplantation. Postsurgical outcome measures included changes in fornix depth with correlation to basal tear volumes, symptoms, corneal staining, and conjunctival inflammation.
RESULTS: For the three patients with unilateral surgery, both the fornix depth (8.3 ± 1.5 mm) and wetting length (9.3 ± 8.5 mm) of the operative eyes were less than the fellow eyes (10.3 ± 1.5 mm and 10.3 ± 8.5 mm, respectively). At 5.3 ± 2.7 months (range 1.7–8.7) postoperatively, the fornix depth increased significantly by 2.0 ± 1.1 mm (P = 0.02). Deepening of the fornix depth was accompanied by overwhelming symptomatic relief (91.5%) that could be subdivided into complete relief (87.5%) and partial relief (4%) of symptoms, with blurred vision being the most notably relieved symptom (P = 0.03). Furthermore, superficial punctate keratitis and conjunctival inflammation were significantly improved at follow-up (P = 0.008 and 0.05, respectively).
CONCLUSION: Deepening of the fornix to restore the tear reservoir is an important surgical objective that may change the tear hydrodynamic state to provide a stable tear film and improve outcomes in CCh.
The treatment of patients with dry eye disease is based upon the severity of the patient's disease and symptoms. In addition, since there are several factors that can contribute to dry eye symptoms, it is critical to address the underlying cause including evaporative dry eye, aqueous deficiency, and inflammation. The treatment of dry eye should follow a stepwise approach based upon the patient's symptoms and the underlying physiology of their condition. The goals of treating dry eye disease are to improve patients' symptoms and quality of life, decrease inflammation, and prevent ocular surface damage. There has been a large expansion in treatment modalities available to treat the different causes of dry eye disease. For patients with symptoms that are refractory to conservative measures and lubricants, there are several prescription medications that can be utilized including antiinflammatory agents and antibiotics. In addition, blood products are increasingly being used that have shown relief in symptoms and signs of dry eye disease. In-office procedures can also play a helpful role in managing evaporative dry eye disease. For patients with advanced disease, contact lenses, amniotic membrane transplant, and neurostimulation can be considered. Furthermore, surgical procedures can help ameliorate symptoms for certain patients. Lastly, there is ongoing research on devices and novel therapeutics that are currently in clinical trials. While dry eye disease affects millions of patients, the advances that have been made in treating dry eye disease help decrease the burden of disease on patients' lives.
Despite being a common presenting symptom to eye-care clinics, many ophthalmologists have difficulty diagnosing and managing ocular surface pain. The purpose of this review is to discuss potential causes of ocular surface pain, focusing on both nociceptive and neuropathic aetiologies. Specifically, we outline an approach to the diagnosis of ocular surface pain and focus on various management strategies, providing supporting evidence on the efficacy of various treatments. © 2020, This is a U.S. government work and its text is not subject to copyright protection in the United States; however, its text may be subject to foreign
Conjunctivochalasis is defined as a redundant, nonedematous conjunctiva that causes a wide variety of symptoms. Excess conjunctival tissue may not cause any symptoms and may cause some symptoms like subconjunctival hemorrhage, epiphora, dry eye findings and corneal ulceration. Disturbance of tear meniscus, impaired tear distribution and punctal occlusion play a role in the onset of symptoms. Although the etiopathogenesis of the disease is not yet clearly understood, several theories have been proposed. According to the mechanical theory, age-related mechanical changes in the conjunctiva lead to a chronic obstruction of the lymphatic flow and lymphatic dilatation after this chronic obstruction leads to conjunctivochalasis. According to inflammatory theory, collagenolytic activity increases as a result of inflammation on the ocular surface, causing degeneration of elastic fibers. As a result, degeneration of elastic fibers lead to alterations in the extracellular components of the conjunctival tissue. This inflammatory changes resulting in conjunctival laxity. Although conjunctivosalasis (CCh) is a clinical diagnosis, it is often overlooked by clinicians. CCh patients are can be symptomatic or asymptomatic. Medical and / or surgical treatment is generally needed in symptomatic patients, whereas treatment is not necessary in asymptomatic patients. Medical treatment is the first choice in the treatment of conjunctivochalasis. Artificial tear preparations are widely used in the treatment of CCh due to the deterioration of the tear film layer and dry eye symptoms. In clinical practice, topical anti-inflammatory eye drops are often preferred to reduce ocular surface inflammation. In cases where medical treatment is not sufficient, surgical treatment should be performed. Today, there are many studies showing that surgical treatment is effective in reducing ocular symptoms and ocular surface damage in patients with CCh and in cases with and without dry eye.The surgical treatment plan should include the loose conjunctival tissue located in the lower part, as well as the excess conjunctival tissue located in the nasal and temporal regions and aim to correct the tear meniscus along the entire lower lid margin. The most preferred surgical method is crescent excision of CCh tissue and primary suture of the conjunctiva. Other surgical approaches include fibrin glue and amniotic membrane transplantation and direct scleral suture of CCh tissue. Another surgical method is electrocauterization of the conjunctival tissue. It is applied 5 mm away from limbus and there is no harm to fornixes.
Conjunctivo chalasis (CCh) presents as loose and redundant conjunctival folds interspersed between the globe and eyelids and may cause a variety of ocular symptoms that mimic dry eye. It disturbs the preocular tear film by blocking the tear drainage, disrupting the tear meniscus, and obliterating the fornix tear reservoir to interfere tear flow from the fornix reservoir to the tear meniscus. Elimination of intrinsic irritative stimuli/inflammation by topical preservative-free dexamethasone is the initial treatment for delayed tear clearance (DTC) associated CCh. After differentiating dry eye caused by CCh from that caused by aqueous tear deficiency (ATD) and determining that CCh is the cause of ocular symptoms, restoration of the fornix tear reservoir by fornix reconstruction with conjunctival recession and amniotic membrane transplantation is an effective surgical procedure to treat CCh. After elimination of CCh, punctal occlusion remains ultimate and specific management of genuine ATD dry eye. Identification of DTC, symptomatic CCh and evaluation of genuine ATD dry eye that is independent of CCh led physicians to adopt an effective treatment algorithm to restore the integrity of the ocular surface.
Objective:
The aim of this study was to evaluate the outcomes of paste-pinch-cut conjunctivoplasty and cautery conjunctivoplasty for the treatment of symptomatic conjunctivochalasis.
Design:
This was a prospective cohort study.
Participants:
Sixteen patients (32 eyes) with bilateral conjunctivochalasis that was symptomatic after medical therapy were enrolled in the study.
Methods:
This was a single-centre, contralateral eye, prospective study. Paste-pinch-cut conjunctivoplasty was performed in the left eye, and thermal cautery conjunctivoplasty was performed in the right eye. The outcomes of each procedure were compared preoperatively and at the 1-month follow-up by using the Canadian Dry Eye Assessment (CDEA) scoring system, standard conjunctivochalasis grading, and corneal staining. Intraoperative discomfort and immediate postoperative discomfort were assessed by using a 10-point scale.
Results:
The mean age of patients was 72.4 ± 8.67 years. Conjunctival redundancy was absent in 14 of 16 patients postoperatively. The mean CDEA score improved after both procedures (7.1 ± 2.8 preoperatively versus 4.5 ± 0.78 at the 1-month follow-up for cautery conjunctivoplasty, 7.4 ± 2.5 versus 4.9 ± 3.1 for paste-pinch-cut conjunctivoplasty). This improvement was statistically significant in the cautery conjunctivoplasty group (p = 0.012). Mean intraoperative discomfort was 2.6 ± 2.1 with the use of paste-pinch-cut conjunctivoplasty and 3.5 ± 3.2 with the use of cautery conjunctivoplasty; however, the difference was not statistically significant. No intraoperative or postoperative complications were observed with either technique.
Conclusions:
Paste-pinch-cut and thermal cautery conjunctivoplasty are both safe and effective surgical treatments for the repair of conjunctivochalasis, with patients reporting greater improvement in symptoms after the cautery technique.
Purpose:
To determine whether conjunctivochalasis (CCh) obliterates the fornix tear reservoir and to discern whether there is concomitant aqueous tear deficiency (ATD) dry eye.
Methods:
Retrospective review of 18 eyes of 12 patients with CCh and ATD (CCh + ATD) and 18 eyes of 13 patients with CCh without ATD (CCh - ATD). Changes were compared before and after fornix reconstruction regarding symptoms, basal tear volumes, use of medications, conjunctival inflammation, and corneal staining.
Results:
Fornix reconstruction with conjunctival recession and amniotic membrane transplantation effectively restored the fornix tear reservoir as evidenced by a significant increase of the basal tear volume in both CCh - ATD and CCh + ATD groups. Multivariate regression analysis confirmed that such improvement was significantly correlated with symptomatic resolution (r = 1, P < 0.001), which was also accompanied by significant resolution of corneal staining, conjunctival inflammation, and reduction of topical medications. Intriguingly, the prior diagnosis of ATD was no longer existent in 10 of the 18 eyes (56%) with CCh + ATD suggesting that ATD could be secondary to obliteration of the fornix tear reservoir by CCh.
Conclusions:
Obliteration of the fornix tear reservoir is a common pathogenic process regardless of whether CCh is associated with ATD dry eye. Restoration of the tear reservoir by fornix reconstruction with conjunctival recession and amniotic membrane transplantation results in significant resolution of symptoms and signs associated with ATD that is secondary to CCh and helps identify genuine ATD dry eye that is independent of CCh.
Purpose:
Evaluation of the tearing patient is often distilled to a search for ocular surface problems causing reflex hypersecretion versus lacrimal drainage problems. The literature does not typically emphasize conditions affecting the function of the tear distribution system, but neglect of these important factors can lead to suboptimal treatment outcomes. The intent of this review is to provide a systemic evaluation of frequently overlooked conditions that can influence the distribution system and to offer a mnemonic to ensure an orderly sequence of inspection during clinical examination.
Methods:
Review of clinical literature and experience from 1957 to 2014.
Results:
Tearing complaints attributable to problems with the distribution system can be evaluated, classified, and managed according to the mnemonic BLICK, which stands for Blink dynamics, Lid malposition, Imbrication, Conjunctivochalasis, and Kissing puncta.
Conclusion:
The BLICK mnemonic is a useful adjunct to the workup of epiphora.
Objective:
The purpose of our study is to investigate the effect of episcleral cauterization during conjunctival autograft surgery on subconjunctival fibrovascular reaction in rabbit eyes.
Methods:
Twenty-four healthy male New Zealand white rabbits were divided into Control Group (n = 12) and Cautery Group (n = 12). In the Control Group, a 4 × 4 mm free conjunctival graft was elevated, the underlying Tenon's capsule was excised, and the free graft was sutured back to its original place with 10-0 nylon sutures. In the Cautery Group, in addition to the same surgical steps, the episclera was cauterized with six gentle touches before the conjunctival graft was sutured back to its original place. The scleroconjunctival block of the operated area was excised at the first month. The sections were stained with hematoxylin and eosine and Masson trichrome and were evaluated using light microscopy.
Results:
Subconjunctival collagen fibers were increased, and the fibroblast density increased more significantly in the Cautery Group than in the Control Group. The groups were similar regarding vascularization, lymphocytic, and plasmocytic infiltration. Macrophage density was normal in all animals in both groups.
Conclusion:
Our histopathological examinations indicate that cauterization seems to lead to an increase in subconjunctival fibrosis at the first postoperative month in rabbit eyes.
Conjunctivochalasis is an age-dependent redundancy or laxity of the conjunctiva. It may result in epiphora (tearing) through mechanical disruption of the normal tear flow or exacerbate dry eye symptoms by disruption of an already unstable tear film. In this study, the authors performed a retrospective analysis of the benefits of a simple medial conjunctival resection for tearing associated with conjunctivochalasis.
A review of medical records identified 18 patients (25 eyes) who underwent a medial conjunctivoplasty for tearing between 2000 and 2012. The degree of epiphora was graded for each patient from 0 (no tearing) to 3 (persistent tearing requiring surgical correction). All patients were given an initial preoperative score of 3. Patients were excluded from the study if more than 1 eyelid procedure that would affect the lacrimal pump function was performed at the time of conjunctivoplasty or if clinically significant entropion, ectropion, or nasolacrimal duct obstruction was present at the time of conjunctivoplasty.
At an average of 2.7 months post-conjunctivoplasty (range 4 weeks to 12 months), 80% of patients improved to a score of 2 or better and 60% improved to 1 or better. Six patients ultimately needed an additional surgical procedure for unresolved or recurrent tearing.
The data suggest that conjunctivoplasty using a simple medial conjunctival resection is an effective treatment for patients with epiphora secondary to conjunctivochalasis.
Conjunctivochalasis is an isolated bilateral condition in which redundant conjunctival tissue overlies the lower eyelid margin or covers the lower punctum. It causes tearing by mechanically disrupting the normal flow of tears. Unlike the boggy conjunctiva seen in an allergic reaction, the extent of this redundant tissue is small, well-localized, and unresponsive to antihistamine drops. During the 40-month period from May 1981 through September 1984, 15 patients complaining of epiphora were found to have this problem. Simple local surgical excision relieved their symptoms. Follow-up period ranged from 10 to 40 months, with an average of 27 months. Conjunctivochalasis can be recognized by a thorough ocular examination and managed by simple excision of the redundant tissue. Consequently, before extensive surgery such as dacryocystorhinostomy, eyelid surgery, or silicone intubation of the lacrimal system is contemplated, Conjunctivochalasis should be ruled out and corrected. (C)1986The American Society of Opthalmic Plastic and Reconstructive Surgery, Inc.
To assess the relationship between age and the incidence and severity of conjunctivochalasis by using the grading system for conjunctivochalasis proposed by Meller and Tseng.
Prospective, nonrandomized, consecutive case study.
A total of 1,416 patients aged one to 94 years were enrolled. The age, gender, medical history, ocular history, and grade and parameters of conjunctivochalasis at three locations (nasal, middle, and temporal) were determined in all subject.
The prevalence of conjunctivochalasis increased dramatically with age (one to 10 years, 6.8%; 11 to 20 years, 36.2%; 21 to 30 years, 61.5%; 31 to 40 years, 71.4%; 41 to 50 years, 90.2%; 51 to 60 years, 94.2%; 61 to 70 years, 98.0%; 71 to 80 years, 99.0%; 81 to 90 years, 98.5%; and 91 to 100 years, 100.0%). The mean grade of conjunctivochalasis was higher in female patients than in male patients (nasal area, P = .0229; temporal area, P = .0078) and was higher for the temporal conjunctiva than the nasal conjunctiva (P < .0000001). Parameters such as the downward gaze- or digital pressure-dependent changes of conjunctivochalasis and the presence of superficial punctate keratitis all increased with age. These conjunctivochalasis-related parameters were correlated with the severity of conjunctivochalasis (P < .00001), especially of the middle bulbar conjunctiva.
We report the grade of conjunctivochalasis in a large series of consecutive patients. Our results strongly suggest that conjunctivochalasis is an age-dependent eye disease that occurs in young adulthood and thereafter. The present grading system should be useful for future clinical studies of conjunctivochalasis.
To report on the novel use of fibrin glue in the treatment of conjunctival resection for conjunctivochalasis.
A 78-year-old woman with bilateral, symptomatic conjunctivochalasis had a conjunctival resection by using fibrin glue, as a suture substitute, to attach the conjunctiva.
The use of fibrin glue facilitated the surgical procedure, was well tolerated by the patient, and produced excellent results with relief of symptoms.
The use of fibrin glue during the conjunctival resection was effective in simplifying the procedure and theoretically decreased the risk of suture-related complications and the postoperative irritation related to the presence of sutures in situ.
Conjunctivochalasis is an isolated bilateral condition in which redundant conjunctival tissue overlies the lower eyelid margin or covers the lower punctum. It causes tearing by mechanically disrupting the normal flow of tears. Unlike the boggy conjunctiva seen in an allergic reaction, the extent of this redundant tissue is small, well-localized, and unresponsive to antihistamine drops. During the 40-month period from May 1981 through September 1984, 15 patients complaining of epiphora were found to have this problem. Simple local surgical excision relieved their symptoms. Follow-up period ranged from 10 to 40 months, with an average of 27 months. Conjunctivochalasis can be recognized by a thorough ocular examination and managed by simple excision of the redundant tissue. Consequently, before extensive surgery such as dacryocystorhinostomy, eyelid surgery, or silicone intubation of the lacrimal system is contemplated, conjunctivochalasis should be ruled out and corrected.
Conjunctivochalasis, defined as a redundant conjunctiva typically located between the globe and the lower eyelid, is not uncommon. However, it is often overlooked, as it may be considered a normal senile change. Conjunctivochalasis can cause a spectrum of symptoms, ranging from aggravation of a dry eye at the mild stage, to disturbance of tear outflow at the moderate stage, and exposure problems at the severe stage. Clinical recognition of its pathogenic role helps differentiate conjunctivochalasis from other diseases that may generate similar symptoms. For symptomatic patients, topical lubricants can be tried, but they are frequently unsuccessful, and surgical excision may be required. To guide future investigation into the clinical significance of conjunctivochalasis, a comprehensive grading system and a hypothetical pathophysiology are proposed. Special attention is given to the relationship of conjunctivochalasis to tear dynamics.
Conjunctivochalasis, defined as a redundant conjunctiva typically located between the globe and the lower eyelid, is not uncommon. However, it is often overlooked, as it may be considered a normal senile change. Conjunctivochalasis can cause a spectrum of symptoms, ranging from aggravation of a dry eye at the mild stage, to disturbance of tear outflow at the moderate stage, and exposure problems at the severe stage. Clinical recognition of its pathogenic role helps differentiate conjunctivochalasis from other diseases that may generate similar symptoms. For symptomatic patients, topical lubricants can be tried, but they are frequently unsuccessful, and surgical excision may be required. To guide future investigation into the clinical significance of conjunctivochalasis, a comprehensive grading system and a hypothetical pathophysiology are proposed. Special attention is given to the relationship of conjunctivochalasis to tear dynamics.
To present a new surgical technique for severe, symptomatic conjunctivochalasis and our hypothesis of the pathogenesis of this condition.
Six eyes of three patients with conjunctivochalasis (average age +/-SD, 70.0 +/- 9.6 years; range, 56-78 years) were treated with a conjunctival fixation to sclera with three 6-0 Vicryl (Johnson & Johnson, New Brunswick, New Jersey) stitches.
With a mean follow-up period of 209.5 days (range, 181-219 days), we achieved successful treatment in all eyes, with no recurrence of conjunctival folds.
We successfully treated conjunctivochalasis with conjunctival fixation to sclera, which strongly suggests that conjuctival folds are caused by the folding and the elevating of loosely adherent bulbar conjunctiva of the lower eyelid.
To report the clinical impact of conjunctivochalasis on the ocular surface by evaluating the effect of a new concept of conjunctivochalasis operation on the resolution of patients' symptoms and corneal epithelial damage. Also, the association of inflammation with conjunctivochalasis is examined.
A total of 168 eyes of 131 conjunctivochalasis patients with (50 eyes) or without (118 eyes) dry eye who received the newly designed conjunctivochalasis operation were enrolled. All patients had prominent conjunctivochalasis at the lower tear meniscus and their ocular symptoms were not sufficiently controlled by the usual eyedrop therapy. Subjective symptoms of patients were assessed before and after the operation by questionnaires. Scores of corneal fluorescein staining were evaluated before and after the operation in patients with dry eye. Four samples of the lower part of conjunctiva from non-dry eye conjunctivochalasis patients were investigated by immunostaining and compared with samples from 4 normal conjunctiva and 3 conjunctiva showing inflammation due to Mooren ulcer, ocular cicatricial pemphigoid, and alkali burn.
The most frequent chief subjective symptoms before the operation were irritation (51.7%) and lacrimation (31.4%) in conjunctivochalasis patients without dry eye and irritation (80.0%) in those with dry eye. Improvement of the chief symptoms was obtained in 88.2% and 78.0% of these 2 patient groups, respectively. Furthermore, in patients with dry eye, corneal fluorescein staining scores (mean+/-SD) were significantly improved after the operation compared with before the operation: A (area), 0.6+/-0.7 and D (density), 0.8+/-0.9 versus A, 1.3+/-0.5 and D, 1.9+/-0.9; P<0.0001. Based on the immunostaining study, conjunctival samples from eyes with conjunctivochalasis and normal eyes showed negligible inflammation compared with those from inflamed conjunctiva.
This study suggests that conjunctivochalasis has a great clinical impact on the ocular surface, and the newly developed operation is very effective in resolving patient complaints and also ocular surface damage in conjunctivochalasis with dry eye. It may also be suggested that the conjunctivochalasis has a negligible association with conjunctival inflammation.
We report here a simple surgical approach to reduce moderate conjunctivochalasis.
A non-comparative prospective interventional case series study of fifteen consecutive patients with moderate conjunctivochalasis was carried out. On the inferior bulbar conjunctiva 10 to 20 superficial burns were performed with an electrical bipolar cauter to reduce moderate conjunctivochalasis. Before and around a mean time of six months after surgery digital photographs of the conjunctivochalasis were taken at the slit lamp. The maximal height of the conjunctivochalasis above the lower eyelid margin measured before surgery was compared with the height of the conjunctivochalasis measured after surgery around the same location (one eye per patient).
In each patient, gentle and superficial cauterization induced contraction of the bulbar conjunctiva and reduction of the conjunctivochalasis. No complications were noted during or after the procedure. Mean (+/- SD) maximal conjunctivochalasis height above the lower eyelid margin was higher before (2.3 +/- 0.9 mm) than after surgery (0.8 +/- 0.6 mm). Preoperative values of conjunctivochalasis height were significantly (p < 0.001) different from the postoperative ones (Wilcoxon rank signed test).
Gentle superficial cauterization of the inferior bulbar conjunctiva can induced significant reduction of a moderate conjunctivochalasis.
To show poor adhesion between the conjunctiva and the sclera in eyes with superior conjunctivochalasis (CCh) and to introduce a new surgical approach by reinforcing adhesion between the conjunctiva and the sclera for correcting this deficiency.
After conjunctival peritomy and removal of the loose Tenon remnants, "Tenon reinforcement" for conjunctival adhesion to the underlying sclera was achieved by transplantation of cryopreserved amniotic membrane with fibrin glue (group A, 9 eyes of 6 patients) or 10-0 nylon sutures (group B, 8 eyes of 6 patients) in 17 eyes of 12 patients with refractory superior CCh.
The mean age of patients was 68.2 +/- 9.8 years (range, 54-80 years). Superior CCh was associated with a superior limbic keratoconjunctivitis (SLK)-like clinical feature before surgery and found to exhibit dissolved Tenon capsule during surgery in all patients. During a mean follow-up of 3.7 +/- 1.9 months after surgery, all eyes achieved smooth conjunctival surface without any sign of CCh. Complete resolution of symptoms was seen in 9 eyes (52.9%) and significant resolution in 8 eyes (47.1%). There was no significant difference between groups A and B in improvement of symptoms and signs. No complications related to surgery were noted during follow-up.
We propose that loose and dissolved Tenon tissue is correlated with the development of superior CCh, which may result in an SLK-like appearance by blink-related microtrauma. Reinforcement of conjunctival adhesion onto the sclera by amniotic membrane with either fibrin glue or sutures is effective in alleviating symptoms and signs in eyes with superior CCh.
To evaluate the feasibility of performing sutureless amniotic membrane transplantation (AMT) using fibrin glue for conjunctivochalasis.
Noncomparative interventional case series.
In 25 eyes of 16 patients with refractory conjunctivochalasis (CCh), AMT using fibrin glue was performed to cover the bare sclera.
The mean age was 55.2 +/- 18.5 years with nine patients (56.2%) younger than 60 years. The Tenon capsule was dissolved in all eyes. Fibrin glue was effective in securing the amniotic membrane to the sclera. For a mean follow-up of 10.6 +/- 4.3 months, all eyes achieved a smooth conjunctival surface with complete or significant improvement of symptoms in 44% and 56%, respectively. Complications included focal conjunctival inflammation in four eyes and pyogenic granuloma in one eye.
AMT using fibrin glue can be performed for refractory CCh resulting in alleviating its symptoms and signs.
Conjunctivochalasis.
- Hughes