Eyeworld

EW CORNEA 42 October 2011 Treatment varies, but sur- gery is usually necessary A lthough not uncommon, conjunctivochalasis may be overlooked or mis- taken for an age-related change comprising redun- dant conjunctival folds between lower lid margins and the globe. "Many times I have sat in the room listening to patients complain of vague on again/off again foreign body sensation, typically after cataract surgery, and have been un- able to give an answer for their prob- lems other than dry eye. However, some of these patients presented without the typical corneal signs of dryness and had adequate tear film stability," said Gary Wortz, M.D., private practice, Bluegrass Eye Sur- gery, Lebanon, Ky. "This subset of patients bothered me, and through further research and careful exami- nation, I have been able to identify conjunctivochalasis as a common yet often overlooked culprit." When there is refractory conjunctivochala- sis, surgical resection with or with- out amniotic graft transplantation is typical. The issue with chalasis "is that there is a deficiency of Tenon's cap- sule, and thus the conjunctiva is not just redundant but does not have the proper adherence to the underlying tissue," said Steven G. Safran, M.D., private practice, Lawrenceville, N.J. He has "been treating conjuncti- val chalasis surgically for many years. My current approach is to use the Ellman (Oceanside, N.Y.) radio surgical unit with a Teflon-tipped white 0.04-mm probe. This tech- nique has been published, 1 and I've been using it since. It shrinks the conjunctiva in a series of applica- tions under/through the conjunc- tiva, and it's fast, easy, and reasonably effective. If that fails, I do resection with an amniotic mem- brane graft that works very effec- tively but in a few cases can lead to fibrosis/redness that persists for months and may not be cosmeti- cally acceptable. It's also far more expensive and bothersome to take patients to the OR for this than to fix it in the office." Dr. Safran said resecting and in- office suturing used to be his pre- ferred treatment strategy, but he abandoned that technique when persistent chemosis "took months to resolve" in rare instances. In Dr. Safran's experience, radio-wave elec- trosurgery addresses both the defi- ciency and the adherence issue. "In severe cases, resection will still be required, and amniotic grafts work well in these cases most of the time," he said. In his amniotic graft technique, surgery is performed under topical anesthesia with lidocaine gel and "straight epinephrine drizzled on the eye for hemostasis," he said. He noted surgeons should expect "very little bleeding" when they cut into the loose conjunctivochalasis tissue. Also, moisten the cornea "every now and then," but not to the point where it might disturb the amniotic graft or the tissue glue. Although he's performing more of these types of treatments, Dr. Safran maintains his "go-to" surgery is radiosurgery. He is now perform- ing a "more aggressive procedure" on cases with a lot of excess tissue. "I've been grabbing the excess tissue with a clamp [a modified fold- able IOL forceps] and using the Ellman with a pointed cautery tip to 'melt away' the excess conjunctiva while the clamp creates a new 'seal' at the base," Dr. Safran said. "I can get a greater reduction of excess tis- sue in moderate to severe cases with this technique without resorting to surgical removal in the OR. This is a modified version of the technique described by Stephen Pflugfelder, M.D. 2 In his technique he uses cautery and calls it 'thermoreduc- tion.' In my technique I use the Ellman and find it works better and with less inflammation and more control than cautery." A "great pearl" for minimizing bleeding during conjunctival surgery is to "drop topical epinephrine on the ocular surface before dissection. There is almost no bleeding except from the limbal vessels. It was aston- ishing to me when I first did it be- cause I didn't think it had enough time to react, but it works great," said D. Brian Kim, M.D., in private practice, Professional Eye Associates, Dalton, Ga. He said he learned this technique from Scheffer C.G. Tseng, M.D., director, Ocular Surface Center, Miami, Fla.; medical direc- tor, Ocular Surface Research & Edu- cation Foundation (OSREF), Miami, by Michelle Dalton EyeWorld Contributing Editor Conjunctivochalasis: An overlooked—but common—ailment for it, it will become more attractive to practitioners as well." Clinically speaking, dry eye severity "is a range of values," Dr. Nichols said. "Symptoms are heavily weighted, and we have few clinical tests that correlate well with them." She noted those with aqueous deficient dry eye "will have more variability in their signs from one visit to another," and in the mild form, the two main subtypes (aque- ous deficient and evaporative dry eye) tend to present similarly. "In the early stages, test results are variable, but as the patient pro- gresses to more severe levels of the disease, certain tests become more uniform," she said. "Osmolarity can help us identify severity earlier on and when used with the patient's symptomatology, will help us diag- nose and treat more efficiently." EW Reference 1. Sullivan BD, Whitmer D, Nichols KK, et al. An objective approach to dry eye disease severity. Invest Ophthalmol Vis Sci. 2010 Dec;51(12):6125-30. Epub 2010 Jul 14. Editors' note: Drs. Nichols and Sullivan have financial interests with TearLab. Contact information Nichols: 614-688-5381, knichols@optometry.osu.edu Sullivan: 760-224-4595, bdsulliv@tearlab.com Tear continued from page 41 The excess conjunctival folds (stained) indicative of conjunctivochalasis Source: Steven G. Safran, M.D. Conjunctivochalasis is easier to identify after Lissamine green staining Source: Steven G. Safran, M.D. 40-45 Cornea_EW October 2011-dl2_Layout 1 9/29/11 3:43 PM Page 42

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