Eyeworld

JULY 2021 | EYEWORLD | 109 C Relevant disclosures Desai: Bio-Tissue Holland: None Hovanesian: Katena Salinger: Bio-Tissue Trinh: None "My surgical technique is to not resect too much conjunctiva that you have a defect you need to fill in because I'd rather leave con- junctiva than put in amniotic membrane. Only resect the amount of conjunctiva you need and advance the remaining conjunctiva to close the defect," he said. Dr. Trinh said her preferred technique is "the paste-pinch-cut conjunctivoplasty," which she noted was reported by Linden Doss, MD, and colleagues in 2012. 6 "It involves the use of a fibrin sealant that is injected under the conjunctiva in a linear fashion below the limbus," she explained. "The conjunctiva is then 'pinched' together with a pair of curved tying forceps where the excess conjunctiva is gathered into a ridge while the sealant polymerizes. The now everted ridge of excess conjunctiva and sealant is resected with Westcott scissors. "We prefer this technique because it allows a pleasing cosmetic outcome as well as reduced bleeding. Care should be taken to adequately assess the amount of excess conjunctiva that is to be resected to avoid forniceal shortening." Dr. Hovanesian described other methods. One can be done in the office with topical anesthetic. He said using low-temperature cautery to burn a grid pattern in the conjunctiva a few millimeters apart in the area of looseness creates scarring that tethers the conjunctiva to the underlying globe. For patients with a limited amount of conjunctivochalasis, this can be effective, he said. For more extensive con- junctivochalasis, Dr. Hovanesian described his technique, which includes covering the area of excised conjunctiva with dehydrated amniotic membrane (Ambio2, Katena). Dr. Salinger prefers to use a cryopreserved amniotic membrane product (Bio-Tissue) for his surgical management of conjunctivochalasis. He said when he performed surgery without the cryopreserved amniotic membrane, the areas of resection were slow to heal and there were large areas of bare sclera that could develop del- len or scleral melting. His pearls for surgical management include: 1) Start 2–3 mm peripheral to the corneal limbus, avoiding the limbal stem cells, and making a semicircular incision, dissect deep into the inferior cul-de-sac. 2) Remove as much loose Tenon's fascia as possible with the goal of reforming the inferior cul-de-sac, paying special attention to the area of the inferior puncta that might have been blocked by loose, redundant conjunctival folds draped over the punctal opening. 3) After resection, cauterize with bipo- lar cautery to seal the gap, similar to excision of pterygium with amniotic membrane and ocular reconstruction. Dr. Salinger credited Neel Desai, MD, with the importance of cautery in this step, as it prevents prolapsed orbital fat from getting in the way when it's time to place the amniotic membrane. 4) Cut the amniotic membrane into a smaller and a larger piece. Dr. Salinger glues the smaller piece in position over the inferior rectus muscle, then places the larger piece of the amniotic membrane covering the entire area of resection and inferiorly deep into the inferior cul-de-sac, gluing the larger piece in position, first the nasal half, then the temporal half. He gently pulls the edge of the resected conjuncti- va forward over the amniotic membrane, and places a few absorbable sutures around the periphery and inferiorly through both the con- junctiva and the amniotic membrane to anchor everything in place and inferiorly to reform the inferior cul-de-sac. "What we're left with is a broad horizontal band of exposed amniotic membrane measuring approximately 6–8 mm vertically," Dr. Salinger said. A change in understanding Dr. Desai said just the term conjunctivochalasis creates some misunderstandings as to what it is and how he thinks it should be treated. The first part of the name suggests an issue with the conjunctiva and the second half suggests excess. Dr. Desai said conjunctivochalasis is a misnomer for the condition, which at its root is an issue with the underlying Tenon's fascia becoming dissolved and atrophic due to chronic inflammation, such as factors like MMP-9 and other inflammatory mediators common in pa- tients with chronic dry eye. As Tenon's becomes dissolved, the conjunctiva becomes loose and slides around, he explained. The normal tissue barriers that would prevent orbital fat prolapse are dissolved as well. This fat can prolapse into the fornix causing it to become foreshortened and filled by loose conjunctiva and orbital fat. "Chalasis" suggests an excess of conjunctiva when there's not, in fact, "extra," it's just loose, continued on page 110

• Blank Page
• Blank Page (1)