I recently read that the restaurant in Tampa, which licenses the name Hogan’s Beach from the professional wrestler Hulk Hogan, is under fire for its controversial dress code. One area of concern for us optometrist is the fourth item on this controversial dress code: “No excessively baggy attire.” You may be questioning how this is germane to comanagement or, frankly, what this has to do with the doctoring of the eyes. Well, we are enablers to the excessive bagging of our patient’s eyes, the lids, and the conjunctiva. Chalasis is the relaxation of a bodily opening, and our patients need the 411 on how to care for their lids and conjunctival chalasis (CCh).
In order for us to prepare our patients for patronage at Hogan’s Beach, we have to determine the medical necessity of the lids and/or the conjunctiva. Both conditions seem to be overlooked and underdiagnosed, leaving our patients with sad, red eyes that are not accurately allowing the superior visual fields to be seen. The etiology of the dermatochalasis is not unlike the normal aging changes of the skin seen elsewhere in the body. There is thinning of the epidermal tissue with a loss of elastin, resulting in laxity, redundancy, and hypertrophy of the skin. Thus the normal facial expression, such as smiling, laughing, squinting, crying, etc.—combined with the action of gravity—over many years induces the drooping. Unlike the natural forces, the conjunctiva becomes loose as a result of the loss of Tenon’s fascia.
In the case of the lids, dermatochalasis describes a common, physiologic condition seen clinically as sagging of the upper eyelids, and to some degree, the lower lids. It is typically bilateral and most often seen in patients over 50 years of age, but it may infrequently occur in some younger adults. Inspection of these patients’ lids reveals redundant, lax skin with poor adhesion to the underlying muscle and connective tissue. Dermatochalasis patients are Allergan’s best clients because the frontalis muscle is working overtime to pull up the lids, avoiding a ptosis, and in turn creating a furrowed forehead; can you say Botox?. The dermatochalasis itself presents a cosmetic challenge for some patients, but the loss of field is the real medical necessity. On rare occasion the loose skin will cause entropian, induce some trichiasis, and induce some discomfort.
The diagnosis of CCh is not nearly as straightforward as having to lift the folds of tissue to see what is underneath. Although CCh is relatively common and asymptomatic, the risk factors include age greater than 50 years, dry eye history, and prior surgery, particularly if a peribulbar or retrobulbar anesthetic was used. Some have theorized that the use of peribulbar or retrobulbar anesthetic causes chemosis, which may lead to loosening of tethering of Tenon's fascia between the globe and conjunctiva.1
Patients tend to describe a pain in their eye that is often misdiagnosed as dryness. However, we do not tend to assign pain as the common symptom for dry eye. Thus, in the presence of CCh, you can localize the discomfort by asking the patient to describe where it is emanating. The clinician can apply gentle pressure on that same area to further substantiate the CCh diagnosis. This must be done when there is no anesthetic in the eye. This maneuver can reproduce the characteristic pain that the patient has experienced with CCh. The classic sign of CCh is redundancy of the conjunctiva at the lower lid margin. Most typically, this occurs on the temporal side. Naturally, this redundancy occurs in some asymptomatic individuals.