Sagging lids and conjunctiva are an OD’s responsibility

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).

Managing the non-surgical aspect of comanagement

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.

Conjunctival chalasis

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.

Ocuplastic surgeon referral

So, we have identified our patients, and we are prepared to take the first step of initiating management of these excessive conditions. The referral is destined for the ocuplastic surgeon to provide the necessary steps to reduce the burden that the bagginess is creating for your patients. To prepare for the referral, a visual field is needed to determine the extent of the field loss. This is performed in the lid’s natural position and with taped lids to demonstrate the difference. Another good practice would be to take a photo of your patient’s lids. I like to show the patient the picture before and after her procedure, thus solidifying your investment in the welfare of your patient’s appearance and vision. 

Comanging with confidence

Bilateral upper lid blepharoplasty (BULB) is an outpatient procedure that can be performed to remove the excess skin, or hooding, seen in dermatochalasis, as well the removal of fat and muscle that may cause bulging. BULB does not address asymmetrical eyebrows, however. Surgeons measure the excess tissue and can use a scalpel or a laser to remove the disparaging tissue. A single running suture (often dissolvable) is made to bring the tissue back, and the patient is sent home. Postoperatively, the use of an antibiotic-steroid ointment is applied until fully healed. I will see these patients back in the office at the one-week mark to assess the healing and remove any sutures that may still be in place. Swelling may persist for a few more weeks, and the use of cool compresses and lubricating drops can be essential. A return visit in another month to further assess the patient is advised.

CCh surgery is an outpatient procedure as well and involves the use of amniotic tissue. Optometrists have just started working with this placental tissue to stimulate the healing of recalcitrant corneal conditions. Its use in CCh surgery is designed to stimulate the regrowth of the Tenon’s fascia that is inducinged by the redundant conjunctiva. The surgeon will identify the relaxed conjunctiva and, with the aid of a peri-bulbar anesthetic, excise the tissue. A dehydrated amniotic membrane is cut to the same shape, slightly larger, and a fibrin adhesive is then applied prior to the insertion of the amniotic membrane. The eye is patched, and the patient is sent home with a shield. Postoperatively, the patient will use a antibiotic, steroid, and non-steroidal topical drops. I see these patients back at the one-week visit to assess the extent of the swelling and to provide verbal Valium. The one-month visit is when you can expect to see significant reduction in the swelling and start to assess the pain level of these patients.

When I think of comanagement, I always look to the benefit that is provided to both the patient and the provider. The appearance of excessive hooding is not just cosmetic and needs our vocal intervention to get the excessive skin excised. The same is to be said for those wrinkly looking conjunctival tissues. These patients most likely have been treated for dry eye, and with the fornix filled with excessive conjunctival tissue, that treatment is not helping. The use of the amniotic membrane and your comanagement can make a significant difference in your patients’ well being. And of course, they can now enter Hogan’s Beach, well, unless they are breaking the other 13 dress code violations. On second thought, maybe just fix the bagginess and skip Hogan’s Beach.

Reference

1. Hovanesian JA. Conjunctival chemosis during cataract surgery. Available at http://www.healio.com/ophthalmology/blogs/hovanesian/conjunctival-chemosis-during-cataract-surgery. Accessed 10/16/2014.