Diagnosis and Treatment of Conjunctival Chalasis

Diagnosis and Treatment of Conjunctival Chalasis

Diagnosis and Treatment of Conjunctival Chalasis
John A. Hovanesian, MD, FACS

If correctly diagnosed, conjunctival chalasis can  usually be treated successfully with lubricants, topical NSAIDs, or amniotic membrane surgery.

---

In eyes with conjunctival chalasis, a loss of Tenon’s fascia causes the development of loose, redundant bulbar conjunctiva. Because this loose tissue can move independently when patients blink or move their eye, it may become pinched and fold over on itself, causing a foreign body sensation, usually near the limbus. While not sight-threatening, this condition can cause persistent discomfort.

With appropriate treatment, however, complete and permanent resolution of symptoms is often possible. For some patients, lubricants and/or topical nonsteroidal anti-inflammatory drugs (NSAIDs) are sufficient to achieve this goal; if not, amniotic membrane surgery is almost always effective.

Diagnosing Conjunctival Chalasis

Although relatively easy to diagnose once clinicians look for it, conjunctival chalasis often goes unrecognized. In part, this is because its clinical presentation is similar to dry eye, and many patients may have both conditions. Correctly identifying patients with conjunctival chalasis is important for treatment, however, since therapies that specifically address this condition can provide benefit beyond that offered by dry eye therapies.

To identify patients with conjunctival chalasis, clinicians should keep in mind several risk factors which seem to be associated with this condition, including dry eye disease, increased age, and a history of ocular surgery. Specifically, use of a peribulbar or a retrobulbar anesthetic may cause chemosis, which could stretch the Tenon’s fascia and potentially exacerbate chalasis.

In addition to the patient’s history, clinicians should also consider how patients describe their discomfort. While dry eye patients and patients with conjunctival chalasis both report some sort of ocular surface irritation, dry eye patients do not typically complain of pain. Patients with conjunctival chalasis, on the other hand, not only report pain, but they can often point to the precise area of the eye where it is localized.

In these patients, a simple test can help to confirm the presence of conjunctival chalasis. By applying a finger to the eyelid near the area the patient indicates and then having the patient look up and down, the clinician can exacerbate any pinching of the tissue that might occur. Not only will this trigger the discomfort that patients are describing, it can also sometimes show where the conjunctival tissue is loose.

While a positive result on this “finger test” is usually diagnostic for conjunctival chalasis, other possible causes of corneal pain must be ruled out, including recurrent corneal erosions, corneal filaments, keratitis, or pain associated with dry eye disease. Also, clinicians should keep in mind that redundancy of the conjunctiva can occur without symptoms, in which case treatment is not required. Nearly all older people have some degree of redundancy of the conjunctiva, particularly at the lower eyelid margin, but not all of these patients are symptomatic.

Treatment Options

For patients who do require treatment, I recommend starting with lubricants and/or NSAIDs. In most cases, patients with conjunctival chalasis have already tried artificial tears or other lubricants without much success, but occasionally a different product or type of lubricant can provide the necessary relief. By reducing the amount of friction between the conjunctiva and the eyelids, lubrication can minimize the discomfort this condition causes.

When lubrication alone is insufficient, I also frequently recommend an NSAID—my personal preference is bromfenac (Xibrom™; ISTA Pharmaceuticals). NSAIDs are quite effective for this type of ocular surface pain and safe for long-term use. For patients who achieve adequate relief with an NSAID, I recommend that they continue using it twice daily as needed—indefinitely if necessary—and a number of patients do well with NSAIDs alone.

Amniotic Membrane Surgery

Given that artifical tears and NSAIDs are safe and often effective, I always try these conservative therapies first. For patients who continue to experience symptoms, however, I then present surgery as an alternative. As part of this discussion, I show patients a short video that I developed to explain conjunctival chalasis surgery.1 After learning about the surgery and seeing the results it can achieve, many patients elect to undergo this procedure.

When performing this surgery, clinicians must first identify the area of loose conjunctiva. After anesthetizing the eye—I usually use a very conservative peribulbar anesthetic, although topical anesthetic is sufficient—I use a Q-tip or Weck-Cel® sponge to probe the conjunctiva and see where it is loose. Since the conjunctival tissue is thin enough to be transparent, it is also possible to observe the sclera and see where the Tenon’s fascia are absent.

Once the area of loose conjunctiva has been identified and marked, it can then be excised (Figure 1). I usually remove a crescent-shaped strip of conjunctiva about 2 or 3 millimeters wide, starting at least a millimeter beyond the limbus in order to preserve the limbal stem cells. Generally, it is better to go a little ways outside of the area of redundant tissue so you have a healthy margin. Because this tissue is no longer anchored to the sclera, it is usually very easy to remove, and excision typically causes minimal bleeding. Cautery can be applied sparingly to stop any bleeding that does occur. Next, dehydrated amniotic membrane is cut to the shape of the excised area, leaving an extra 1 to 2 millimeters on each side of the graft. I prefer to use freeze dried AmbioDry2™ (IOP Inc.), but this procedure can also be performed with other types of amniotic membrane.

The amniotic membrane is then attached to the eye with fibrin adhesive. First, the thrombin component of the adhesive is applied to the bare sclera. Then, holding the amniotic membrane nearby, the fibrinogen component is applied on top of the thrombin solution. The amniotic membrane is then immediately applied to the sclera, where it becomes hydrated by the adhesive, making it pliable enough to apply to the globe (Figure 2).

The edges of the graft are then tucked under the surrounding conjunctiva, except for the area near the limbus (Figure 3). Finally, smooth forceps are used to squeegee out the excess adhesive from underneath the amniotic membrane.

Following surgery, patients are treated with a topical antibiotic, a topical NSAID, and a topical steroid for 2 to 3 weeks. Most patients have minimal discomfort postoperatively, and many feel much more comfortable within just a few days after surgery. As healing progresses, the area of excised conjunctiva becomes epithelialized, and the new ocular surface is firmly secured with fine subconjunctival scar tissue. 

THE BOTTOM LINE

Occurring when a loss of Tenon’s fascia allows bulbar conjunctiva to become loose, conjunctival chalasis can cause persistent discomfort due to the loose tissue being pinched and folding over on itself. The diagnosis of conjunctival chalasis if often missed, largely due to an overlap in symptoms with dry eye disease, but when diagnosed, proper treatment can often result in complete resolution of symptoms. In some patients, lubricants and/or NSAIDs are sufficient to relieve discomfort, and I always try these therapies before proceeding to surgery. If necessary, removing the redundant conjunctival tissue and replacing it with an amniotic membrane graft also achieves excellent outcomes.

---

John A. Hovanesian, MD, FACS, is clinical assistant professor at UCLA Jules Stein Eye Institute and a specialist in refractive surgery, cataracts, cornea, and external disease at Harvard Eye Associates in Laguna Hills, CA. He is a consultant with the following companies: Allergan, Advanced Medical Optics, Bausch & Lomb Surgical, Inspire, IOP Inc., ISTA Pharmaceuticals, Therapeutics, Ivantis, Revision Optics, Sirion Therapeutics, Visiogen, and Vistakon. Refractive Eyecare senior editor Kay Downer assisted in the preparation of this manuscript.

References
1.John A. Hovanesian, MD, Discusses Conjunctival Chalasis, A Cause of Eye Pain that Mimicks Dry Eye. Available online at http://www.youtube.com/watch?v=BNI8dZ55v1I. Accessed August 5, 2009.