Eyeworld

108 | EYEWORLD | JULY 2021 C ORNEA they're not happy, and when I finally surgically manage their conjunctivochalasis, their symp- toms vastly improve," he said. Dr. Hovanesian said his first line of defense is lubrication, followed by optimizing any dry eye conditions that can coexist with conjuncti- vochalasis. He said he's had limited success with nonsteroidals, Prolensa (bromfenac, Bausch + Lomb) in particular. Dr. Salinger explains to each patient the diagnosis at the outset, using pictures of their own eye to help the patient visualize the problem. While surgical options are not prima- ry treatment, he at least informs the patient of the potential for future surgery to mitigate symptoms. His first step in treating conjunc- tivochalasis is educating the patient, teaching them about environmental triggers to avoid, addressing inflammation and any meibomian gland dysfunction/blepharitis. For inflamma- tion, Dr. Salinger said he prefers loteprednol products, and for MGD he recommends hot compresses, lid massage, gentle lid cleaning, adding Avenova (hypochlorous acid, NovaBay Pharmaceuticals) when indicated, HydroEye (ScienceBased Health), an omega-3/omega-6 supplement, azithromycin or doxycycline either topically or systemically, and/or LipiFlow (Johnson & Johnson Vision). If symptoms are not improved with these treatments by the second visit, Dr. Salinger addresses aqueous production, performing a Schirmer's test and considering punctal occlu- sion or immunomodulator medications like Cequa (cyclosporine, Sun Ophthalmics), Xiidra (lifitegrast, Novartis), or Restasis (cyclosporine, Allergan). After 3–4 visits, and possibly 4–6 months of treatment, if significant symptoms still persist, that's when Dr. Salinger revisits a formal discussion about surgical options. Surgical management Dr. Holland resects the inferior conjunctiva 180 degrees or, if needed, will do a full 360-degree resection. He won't do a 360 resection if the patient has glaucoma and might need glaucoma surgery in the future. Dr. Holland said he takes out the strip of loose conjunctiva, taking care to avoid the lim- bus. He'll often do the patient's second eye as well because it's frequently a bilateral condition. He said that he doesn't use amniotic membrane but knows other surgeons advocate for it. symptoms and we can discuss possible surgery," he said. Dr. Trinh said point-of-care testing might have a role in evaluating conjunctivochalasis in looking for associated ocular surface inflamma- tion. "[T]he diagnosis of [conjunctivochalasis] is reliant on a careful slit lamp examination and especially observation of the patient during the blinking phase," she said. John Hovanesian, MD, said a clue that a patient could have conjunctivochalasis and not just dry eye is localized pain. "Often patients can point with one finger where it hurts. … Of course, that can be a num- ber of different things, but when you see that, you have to pay attention. They'll often report it when they blink," he said. Dr. Hovanesian described his "thumb test" where he'll put his thumb on the patient's lower eyelid below the lashes in the area where they're reporting pain and ask them to look around. If they say that's producing pain, it's a clue into conjunctivochalasis. Clifford Salinger, MD, said that fluorescein stain and a yellow filter are his most helpful tools in visualizing the rugae and redundant conjunctival folds, and punctate conjunctival staining, which he thinks are the causes of many of the symptoms associated with this condition. Dr. Salinger described conjunctivochalasis as a form of "mechanical dry eye" where the normal position of the inferior tear meniscus is blocked by the redundant conjunctival folds, and the tear reservoir in the inferior cul-de-sac is also compromised by the presence of loose Tenon's fascia and redundant conjunctiva. Without an area for the tear meniscus and tear reservoir to reside, there is not enough reserve tears and lu- bricants for the eyelid to pull up over and across the eye with each complete blink, thus contrib- uting to the dry eye condition. Medical management Dr. Holland said unless the conjunctivochalasis is severe and very symptomatic, he recommends treating other common ocular surface disease is- sues first because almost all of his patients with conjunctivochalasis have some degree of MGD. "What I find is when I manage their MGD, a lot of their symptoms go away, and we don't surgically manage their conjunctivochalasis in many cases. On the other hand, a lot of patients have been on dry eye therapy for years and References 1. Nallasamy N. Conjunctivo- chalasis. American Academy of Ophthalmology. eyewiki. aao.org/Conjunctivochalasis. Accessed Nov. 16, 2020. 2. Chan DG, et al. Clinicopatho- logic study of conjunctivochala- sis. Cornea. 2005;24:634. 3. Watanabe A, et al. Clinico- pathologic study of conjunctivo- chalasis. Cornea. 2004;23:294– 298. 4. Huang Y, et al. Conjunctivo- chalasis interferes with tear flow from fornix to tear meniscus. Ophthalmology. 2013;120:1681– 1687. 5. Holland E, et al. Ocular Surface Disease: Cornea, Conjunctiva and Tear Film. 2013. Saunders Elsevier. 6. Doss LR, et al. Paste-pinch-cut conjunctivoplasty: subconjuncti- val fibrin sealant injection in the repair of conjunctivochalasis. Cornea. 2012;31:959–962. continued from page 106

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