This initial inflammatory stress could produce lid-parallel conjunctival folds (LIPCOF), lateral conjunctival folds located near the eyelid margin, which are likely a very early version of conjunctivochalasis.14 The presence of LIPCOF then displaces the tears, subsequently decreasing tear turnover/drainage.14
Simultaneously, the above insults are continuing to produce inflammatory molecules, which activate matrix metalloproteinases (MMPs).9,13 Decreased tear drainage would allow MMPs to stay on the ocular surface longer, allowing for compounding ocular surface damage, hence the additional irritation with dry eye and blepharitis.8
MMPs are proteins that degrade and remodel connective tissue.9 Their physiological inhibitors (TIMPs) inhibit MMPs, and a balance of MMPs and TIMPs is needed to maintain homeostatis.9 Evidence exists that conjunctivochalasis tissue overexpresses certain MMPs.9 Therefore, over time MMPs likely degrade conjunctival connective tissue, resulting in the looser and more pronounced conjunctival folds associated with conjunctivochalasis.8
The increasing severity of conjunctivochalasis likely creates a vicious cycle of more redundant tissue, worse tear flow, and even punctum blockages, which would keep more toxic tears on the ocular surface for longer.7
Furthermore, reduced tear turnover likely also cause increased tear osmolarity, additional inflammatory molecule production, and the characteristic dry eye symptoms associated with advanced conjunctivochalasis.14
Thankfully, evidence indicates that both topical and surgical intervention not only mitigates conjunctivochalasis’ disruptive folds, but surgery also reduces the inflammatory component of the condition.15
A good method to ease patient concerns is discussing the condition’s prevalence, etiology, and lack of dangerous nature while presenting multiple treatment options. Medically managing conjunctivochalasis can be frustrating and may require multiple approaches.
Topical pharmaceutical intervention can address chemosis and inflammation, allergies, and bacterial load as it relates to concurrent blepharitis and dry eye strategies. Corticosteroids such as loteprednol (Alrex, Lotemax; Bausch + Lomb) can target the chemosis and inflammation and may require extended periods of use.16-17 Topical antihistamines can assist in managing concurrent allergic conjunctivitis, whose inflammatory component can worsen chalasis symptoms.
A bacteriostatic approach meant to curtail existing blepharitis via antibiotic vehicles or lid hygiene may lessen irritation. Lubricants, including artificial tears and gels, can assist in both managing the foreign body sensation via stabilizing the tear film.
Success rates to these approaches are variable. If symptoms concur most often with contact lens use, the patient may be refit into a different modality or design. If unsuccessful, the next step would be surgical intervention.
Opportunities abound in this arena—from superficial conjunctival cauterization for mild to medium cases, to tightening the conjunctiva via excision or resection for moderate to severe cases.18 A more recently added procedure is an amniotic membrane transplantation in which an area of the conjunctiva is excised and an amniotic graft is attached to the globe via dissolvable sutures or fibrin tissue glue in place of the defect.19 Success rates of the various procedures are similar with moderate to high rates of improvement.19
Conjunctivochalasis is a complicated condition that not only can present with a variety of complaints but can also often coexists with other anterior segment disorders like dry eye. As we are seeing an increasing number of aging patients, we must keep in mind how significantly chalasis can impact a patient’s comfort and may warrant a unique treatment plan.
Related: Connecting allergy and osmolarity
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