Conjunctivochalasis (CCh)

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• Diagnosis of Conjunctivochalasis

  Slit Lamp Examination

  The loose conjunctiva can be demonstrated as follows:

  • Ask the patient to blink vigorously.
  • Press the eyelid against the conjunctiva with an upward motion (Fig. 1).
  • Fluorescein staining will help visualize the wrinkles as well as obliterate tear meniscusby the redundant conjunctival folds (Fig. 2).
  • Rose Bengal staining may show punctate staining on the bulbar conjunctiva adjacent to the lid margin (Fig. 3).

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    Figure 1
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    Figure 2
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    Figure 3

   
• Supplies for Conjunctivochalasis Surgery

  AmnioGraft® from Bio-Tissue (1-888-296-8858):

  • AG-2015 if CCh involves the inferior temporal bulbar conjunctiva.
  • AG-2520 if CCh involves the entire inferior bulbar conjunctiva.
  • AG-3535 if CCh involves the entire inferior and superior bulbar conjunctiva.

  Traction Sutures: use 7-0 Vicryl sutures.

  For sutureless surgery: use fibrin glue; TISSEEL from Baxter Biologics (1-877-TISSEEL) 2.0 mL (Catalog # 1501236) or Evicel from Ethicon from Johnson & Johnson (1-800-255-2500) 1 mL (NDC # 63713-390-11).

  For surgery with sutures, 10-0 nylon and 7-0 Vicryl sutures are recommended.
• Surgical Techniques for Inferior Conjunctivochalasis
  • Insert a 15 mm solid blade Speculum (K1-5014 Katena), apply
  • Epinephrine (1:1000) for hemostasis and 2% lidocaine gel (Astra Zeneca) for Topical Anesthesia.
  • Identify the location of CCh by grabbing the conjunctiva with 0.12 forceps (Fig. 4).
  • Create an arc like conjunctival peritomy from 4 to 8 o'clock positions 1-2 mm posterior to the limbus (Fig. 5).
  • Place 7-0 Vicryl Traction Suture 1-2 mm posterior to the limbus at the 6 o'clock position. Rotate the eye upward to allow the conjunctiva posterior to the peritomy to retract and expose the bare sclera.
  • Excise a strip of fragile and wrinkled conjunctival tissue along with any underlying movable Tenon's capsule (Fig. 6).
  • Transplant Cryopreserved Amnion Graft with Fibrin Glue: Place the cryopreserved AmnioGraft on the bare sclera with the sticky/stromal surface facing down. Secure the membrane using fibrin glue while tucking the graft underneath the conjunctival edge and sealing the conjunctiva over the graft (Fig.7).

   

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    Figure 4
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    Figure 5
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    Figure 6
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    Figure 7
• Conjunctivochalasis with Pinguecula

  Remove any pinguecula during the surgery to avoid progression into a pseudopterygium. AM should cover the entire denuded area (Figure 8). 

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    Figure 8
• Conjunctivochalasis with Fat Prolapse

  (Fig. 9A)Anchor the recessed remaining conjunctival tissue to the fornix   using 7-0 Vicryl mattress sutures to the sclera (Fig. 9B).

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    Figure 9a
  • 
    Figure 9b
• Pterygium Post-Operative Care

  Create a limbal based conjunctival flap about 5 mm posterior to the superior limbus. Rotate the eye down using a 7-0 traction suture 1-2 mm posterior to limbus at the 12 o'clock position. Remove all mobile Tenon's capsule (Fig. 10A) prior to laying down and adhering AM on the bare sclera with fibrin glue (Fig. 10B). Remove the traction suture and secure the conjunctival flap on top of AM with bipolar cautery.

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    Figure 10a
  • 
    Figure 10b
• Post Operative Care

  Begin topical Prednisolone four times and Ocuflox three times a day for 4 weeks. Epithelialization will be completed in 2 to 3 weeks. If the surrounding conjunctiva is not inflamed, stop Ocuflox and taper off PF on a weekly schedule from four times a day. If, however, the surrounding conjunctiva is inflamed, give subconjunctival injection of 0.1 cc Kenalog (40 mg/ml) per site in the office. Symptoms related to CCh will be quickly resolved. The residual symptoms due to aqueous tear deficiency, meibomian gland dysfunction (MGD), or excessive blinking can be managed accordingly.
• Frequently Asked Questions

  Why not just remove the excess conjunctiva? Why use an amnion graft?

  CCh is not caused by excessive or redundant conjunctiva. Instead it is caused by poor adhesion between the Tenon's capsule and the sclera. Simple excision may not prevent fat prolapse and may aggravate a pinguecula, if present. Covering the bare sclera with cryopreserved amniotic membrane reinforces such adhesion without stirring up unnecessary inflammation or scarring based on the important biologic actions preserved in cryopreserved amnion grafts. These include anti-inflammation, anti-scarring, anti-angiogenesis and the promotion of healing while reducing patient pain.

  Why are cryopreserved amnion grafts recommended over other amniotic membrane products?

  AmnioGraft® is the only cryopreserved amnion graft available and approved by the FDA for commercial use in the United States. The cryopreserved method of preserving amniotic membrane is the only method for use in ocular surface wound repair and wound healing because this method retains the biologic actions of the tissue in utero (anti-scarring, anti-inflammation, anti-angiogenesis, and promotion of healing).

  What happens if ocular irritation persists after CCh surgery?

  If the conjunctivochalasis has been corrected, the remaining irritation might come from aqueous tear deficiency dry eye, MGD blepharitis, or delayed tear clearance, which can then be successfully treated by punctal occlusion, lid scrub, or non-preserved steroid drops.

  Should CCh correction surgery be performed before blepharoplasty?

  Yes. If an eye had CCh and the lid is tightened through blepharoplasty, then the symptoms will get worse.

  If the patient has entropion with CCh, should both corrective surgeries be performed at the same time?

  Operate on the entropion first to see if CCh persists. If so, then CCh will be managed accordingly.

  Can this procedure be performed on both eyes in the same surgical session?

  Yes, because topical anesthesia makes it possible