Conjunctival chalasis, or conjunctivochalasis (Cch), is a commonly observed condition in our everyday patient care experiences. Because it is so common, and because a majority of patients are asymptomatic, optometrists seldom feel the need treat.
However, some patients may break from the typical mold and present with a myriad of complicated complaints, which could not only merit further investigation but also discussion and treatment.
Conjunctivochalasis, an age-dependent, bilateral condition of redundant conjunctiva, is seen in over 98 percent of individuals over the age of 60.1 Within that age range, we may see it more often in patients who have concurrent dry eye or meibomian gland disease, though those often go hand in hand with the aging population and can all cause similar symptoms.
As our median population and patient base increases in age, we may be seeing it with increasing frequency. It now becomes more important to keep this condition and its various presentations and treatments nearer the forefront of our differential diagnosis list.
Slit-lamp examination of the bulbar conjunctiva reveals loose, redundant, nonedematous tissue most often located between the globe and the lower eyelid margin.2 Conjunctivochalasis typically begins at the limbus and though mostly observed inferiorly and temporally on the bulbar conjunctiva, it can be found superiorly and 360 degrees around the globe.3
There are in fact a few diagnostic classification systems available to grade the severity of the conjunctivochalasis. An older one, the Meller system, has five levels of severity and allows for a wider berth of diagnosis. The more recent and more commonly used is the four-tier Zhang system.4
This classification ranges from G1, meaning no persistent conjunctival folds, to G2, with a single, small fold, to G3, which signifies more than two folds and not standing higher than the tear meniscus, to G4, with multiple folds and reaching higher than the tear meniscus.5
Generally, examination with a slit lamp under both diffuse light and slit beam is adequate to visualize and potentially grade the severity of the chalasis, with the patient in primary gaze (Figure 1). Fluorescein dye instillation could be helpful in further visualizing tear movement and finer conjunctival folds. Advanced examination with anterior segment optical coherence tomography (OCT) is possible, which could aid in assessing tear meniscus height over the conjunctivochalasis.