What is Conjunctivochalasis- Mechanical Dry Eye?
Conjunctivochalasis (CCh), also know as Mechanical Dry Eye, is a common but often unrecognized condition, characterized by loose and saggy folds of the conjunctiva, which is usually found in the lower part of the eye’s outer covering. The word comes from Greek, meaning to loosen, and was first used by Hughes in 1942. CCh can cause a variety of symptoms. In its mild stages, it may cause slight discomfort. But, as it progresses to moderate stages, tear flow may become blocked. In severe stages, it can expose the cornea leading to potential vision loss.
What Causes Conjunctivochalasis- Mechanical Dry Eye?
The exact cause of Conjunctivochalasis (CCh), an eye condition, is still not completely understood. Some research suggests that this condition might be caused by the breakdown of something called elastic fibers. Elastic fibers support and provide structure to the conjunctiva, the clear, thin tissue that covers the front of the eye.
This breakdown of elastic fibers might be due to the regular rubbing of the eyelids against the conjunctiva. Eventually, this process could lead to the formation of folds in the conjunctiva, known as lid-parallel conjunctival folds (LIPCOF). These folds can interfere with tear drainage and reduce the space in the eye where the tears are stored, among other issues.
There could be other factors that speed up this process, like genes, age, wearing contact lenses, inflammation, and exposure to ultraviolet light.
Moreover, the repetitive friction can also cause inflammation, leading to damage to the conjunctiva and a layer beneath it known as the Tenon capsule. The conjunctival folds decrease tear flow, resulting in an accumulation of inflammatory substances on the surface of the eye. This activates proteins called matrix metalloproteinases (MMPs), the job of which is to breakdown and remodel the extracellular matrix, the network of materials that provide structure to the tissues. Excessive amounts of these proteins might pose harmful effects on the conjunctiva.
Risk Factors and Frequency for Conjunctivochalasis- Mechanical Dry Eye
CCh, often seen as a change related to aging, generally affects older people. A number of studies have shown that CCh becomes more common as people get older. It affects both men and women equally, although some research suggests that women may experience more severe cases of CCh and have a smaller tear meniscus area. Most of the studies conducted on this disease are from China, where there’s a high occurrence rate of CCh – 44% of people have the condition and 18% have serious cases. Research on how common this condition is in the United States is limited. However, a small study at an American Veterans Affairs hospital found that non-Hispanic patients had CCh more than others.
Signs and Symptoms of Conjunctivochalasis- Mechanical Dry Eye
Conjunctivochalasis (CCh) is a condition that can lead to a variety of symptoms, which can become more serious as the condition progresses. In the early stages, it might just worsen dry eyes. As it advances to a moderate stage, it can disrupt the flow of tears from your eyes. At its most severe stage, it can cause exposure problems in your eyes. Some of the symptoms you might experience include a feeling like there’s something in your eye, burning or pain, redness, excessive teary eyes, sensitivity to light, and blurry vision. These symptoms usually get worse when you look down, blink, or apply pressure to your eye. It is also mentioned that patients who have CCh on the nasal (nose) side tend to have more severe dry eye symptoms and find their quality of life greatly impacted.
- Dry eye sensation worsening
- Disruption in tear flow
- Feeling like there’s something in your eye
- Burning or pain in your eye
- Redness
- Excessive teary eyes
- Sensitivity to light
- Blurry vision
- Aggravation during down gaze, blinking or applying pressure on the eye
- Potentially severe impact on quality of life, particularly for those with nasal CCh
Testing for Conjunctivochalasis- Mechanical Dry Eye
CCh is a condition where the tissue lining the white part of the eye becomes excessively loose. It’s most commonly seen in both eyes, often more visible in the lower part. This is confirmed through an eye exam known as slit-lamp examination, often revealing folds specifically at the lower eyelid. These folds become more noticeable when upward pressure is applied to the lower lid or when the eye looks upwards.
Using certain tools or a slit-lamp beam, the depth of these folds can be measured. There are also studies showing that a technology called anterior segment optical coherence tomography (OCT) can help in diagnosing and monitoring CCh. OCT can measure the area of the tissue that is protruding. It has also been found that the tissue in patients with CCh is thinner than in those without the condition.
Several grading systems have been proposed to evaluate the severity of CCh. For instance, Hoh et al.’s system is based on both the number and size of folds, from Grade 0 (no persistent fold) to Grade 3 (multiple folds that rise above the tear meniscus).
Another grading system, proposed by Meller et al., considers several factors like location and height of the folds, whether the tear duct is blocked, and changes occurring when looking down or upon applying digital pressure. This system has been widely used and adapted. Notably, the folds are often located in the temporal, middle, or nasal part of the eyelid.
Lastly, the Eifrig system measures the extent of tissue rolling beneath the edge of the corner of the eye and the speed at which eye tissue or vessels return back to their usual position after blinking.
CCh often comes with dry eye syndrome or keratoconjunctivitis sicca (KCS), especially in severe cases. Additional tests like the Schirmer test, fluorescein staining, and tear break-up time can help identify this. In pure CCh cases, you can see a distinctive spot or line staining on the inside area of the eyelid edge close to where the tissue is loose. This pattern differs from what we see in patients with KCS.
One should also look for other signs, such as minor bleeding below the conjunctiva due to easily rupturable vessels, swollen tear ducts, and forward migration of the point where the skin and the internal eye lining meet. Also, it’s important to check for incomplete eye closure on blinking and forced closure.
There have been studies suggesting a correlation between the presence of a yellowish patch or bump on the white part of the eye, known as pinguecula, and the severity of CCh in the same eye region. The reasoning behind this is unclear, but it’s thought to be linked to common risk factors like aging and UV radiation. In severe cases, there is the development of a small, shallow, saucer-like depression on the eye surface, known as Dellen. Sometimes, eyelid conditions like meibomian gland dysfunction, floppy eyelid syndrome, and inward folding of the eyelid can worsen the inflammation and the distinctive folds in CCh.
Treatment Options for Conjunctivochalasis- Mechanical Dry Eye
For those without symptoms of conjunctival chalasis (CCh), treatment isn’t typically necessary. If the symptoms are mild to moderate, eye drops can be used to reduce swelling and inflammation. Because CCh often indicates dry eye syndrome, moisturizing treatments such as artificial tears and gels can help relieve symptoms by stabilizing the tear film. Some ingredients in artificial tears, like isotonic glycerol and sodium hyaluronate, can potentially reduce the severity of the condition.
Corticosteroids can also help with swelling and inflammation, but these may require a lengthier course of treatment. Eye drops containing antihistamines can help lessen any irritation caused by rubbing the eyes. In one study, patients with dry eye symptoms related to CCh experienced noticeable improvement after applying a steroid eye drop containing methylprednisolone for three weeks.
However, medical treatment may not always be enough. Other more invasive methods to deal with excess conjunctival tissue have been tried, with varying degrees of success. These tactics include removing the conjunctiva, cauterizing it, attaching it to the sclera (the white part of the eye), tying it off, reshaping it with a laser, and using radio-frequency surgery. Some of these methods may involve grafting tissue, such as from the amniotic membrane.
Let’s look at several surgical techniques used to correct CCh, along with their pros and cons:
1. Conjunctival Cauterization: This method requires less operating time because no stitches are needed. It also helps shrink excess folds of conjunctiva, reduces the risk of scar formation, and may improve attachment to the sclera. However, it’s typically reserved for milder cases, and multiple procedures may be necessary.
2. Excision of Conjunctiva: This procedure removes excess conjunctiva, reduce injuries caused by blinking, and reduces interference with tear distribution. However, removing too much tissue can lead to complications, such as shortening of the eye’s fornix (the area between the eyelid and the eyeball), inward turning of the eyelid, limited eye movement, and complications related to stitches. Recovery can also take longer.
3. Excision of Conjunctival Tissue with Amniotic Membrane Graft: This carries the same benefits as the previous procedure, but also reduces the risk of fornix shortening. However, it may cause localized inflammation of the conjunctiva, formation of scars, and issues related to stitches.
4. Scleral Fixation of Conjunctiva: This procedure helps the conjunctiva adhere to the sclera better and reinforces the Tenon layer under the conjunctiva, reducing the risk of complications like fornix shortening and issues with eye movement. But, it’s challenging to perform and can lead to complications related to stitches.
5. Laser Conjunctivoplasty, High-Frequency Radio-Wave Electrosurgery: These methods require less operating time and are less invasive. They also shrink the excess folds. However, they may not readily available and can cause side effects like chemosis (swelling of the conjunctiva), redness, and minor bleeding.
6. Recession of Conjunctiva with Amniotic Membrane: Similar to basic excision, this technique also helps restore the tear reservoir. However, the use of an amniotic membrane graft can increase the cost.
While many of these procedures involve removing or reducing the conjunctiva, they may not address the issue of reconstructing the eye’s fornix and can lead to scarring or a return of the condition. A procedure called conjunctival recession, which restores the tear reservoir in the fornix, may be more effective.
Additionally, using fibrin glue can reduce operation time and complications related to stitches. Key steps in the surgery include moving the conjunctiva away from the limbus (the border between the cornea and the sclera), removing any degenerated Tenon capsule, and replacing the Tenon and conjunctival tissue with an amniotic membrane graft to potentially reduce pain and expedite recovery.
What else can Conjunctivochalasis- Mechanical Dry Eye be?
When diagnosing vision issues, particularly those related to tears in the eyes, a variety of conditions could be causing similar symptoms. These conditions might include disorders related to the positioning or looseness of the eyelid, such as ectropion, entropion, and floppy eyelid syndrome. Irritations or conditions affecting the eyelashes, blocked tear ducts, conjunctivitis which can be caused by viruses or allergies, and nasolacrimal obstruction which affects tear drainage are also possibilities.
In people with CCh, symptoms can become more pronounced when they look down or blink often, causing the folds in the eye to spread or increase. For people with dry eyes, symptoms could get worse when they look up, for example, at a computer screen because the area between their open eyelids widens. Blinking more often can ease these symptoms.
CCh can sometimes be mistaken for another eye condition called superior limbic keratitis (SLK). However, doctors can look out for certain signs such as little bumps in the upper inside part of the eyelid, inflammation of the cornea, and corneal erosions to differentiate between the two. Another sign of SLK could be increased inflammation, like redness in the eye or swollen eyelids.
What to expect with Conjunctivochalasis- Mechanical Dry Eye
CCh, often called chronic cholestasis, usually has a positive outcome when properly treated. However, the diagnosis can often be missed or delayed. Surgery might be necessary for patients who continue to experience symptoms even after the initial medical treatment.
Research has shown notable improvement in dry eye symptoms and signs following a surgical procedure known as conjunctival recession with amniotic grafts. This points towards the need for greater attention to the early diagnosis of this condition.
Possible Complications When Diagnosed with Conjunctivochalasis- Mechanical Dry Eye
While surgical complications are rare, they can include a few different types of issues. These might involve:
- Scarring
- Cicatricial entropion, which is an inward turning of the eyelid
- Retraction of the lower fornix, or pulling back of the lower part of the eye socket
- Restricted eye movement
- Problems with the cornea, the outermost layer of the eye.
Preventing Conjunctivochalasis- Mechanical Dry Eye
Individuals with this condition may need lifestyle adjustments, especially if they have Chronic Conjunctivitis (CCh) along with eyelid inflammation (blepharitis) and Dry Eye Syndrome (KCS). This includes avoiding things that can worsen their symptoms, like fans, air conditioners, heating vents, or extensive use of digital devices. They should also consider certain dietary changes, such as reducing caffeine and alcohol intake and adding fatty acids.
Recent research indicates that a person’s quality of life when dealing with Chronic Conjunctivitis is largely affected by unstable tear-film and increased friction during blinking. Therefore, all available treatment options, including non-surgical and surgical methods, should be carefully reviewed and discussed.