EyeWorld Asia-Pacific September 2021 Issue

CORNEA EWAP SEPTEMBER 2021 45 with the goal of reforming the inferior cul-de-sac, paying special attention to the area of the inferior puncta that might have been blocked by loose, redundant conjunctival folds draped over the punctal opening. 3) After resection, cauterize with bipolar cautery to seal the gap, similar to excision of pterygium with amniotic membrane and ocular reconstruction. Dr. Salinger credited Neel Desai, MD, with the importance of cautery in this step, as it prevents prolapsed orbital fat from getting in the way when it’s time to place the amniotic membrane. 4) Cut the amniotic membrane into a smaller and a larger piece. Dr. Salinger glues the smaller piece in position over the inferior rectus muscle, then places the larger piece of the amniotic membrane covering the entire area of resection and inferiorly deep into the inferior cul-de-sac, gluing the larger piece in position, first the nasal half, then the temporal half. He gently pulls the edge of the resected conjunctiva forward over the amniotic membrane, and places a few absorbable sutures around the periphery and inferiorly through both the conjunctiva and the amniotic membrane to anchor everything in place and inferiorly to reform the inferior cul-de-sac. “What we’re left with is a broad horizontal band of exposed amniotic membrane measuring approximately 6–8 mm vertically,” Dr. Salinger said. A change in understanding Dr. Desai said just the term conjunctivochalasis creates some misunderstandings as to what it is and how he thinks it should be treated. The first part of the name suggests an issue with the conjunctiva and the second half suggests excess. Dr. Desai said conjunctivochalasis is a misnomer for the condition, which at its root is an issue with the underlying Tenon’s fascia becoming dissolved and atrophic due to chronic inyammation, such as factors like *- and other inyammatory mediators common in patients with chronic dry eye. As Tenon’s becomes dissolved, the conjunctiva becomes loose and slides around, he explained. The normal tissue barriers that would prevent orbital fat prolapse are dissolved as well. This fat can prolapse into the fornix causing it to become foreshortened and filled by loose conunctiÛa and orbital fat. “Chalasis” suggests an excess of conjunctiva when there’s not, in fact, “extra,” it’s just loose, Dr. Desai said. For this reason (and several others), Dr. Desai uses amniotic membrane in his surgical management for conjunctivochalasis. If one were to remove a strip of conjunctiva and not replace it with amniotic membrane or another platform, he said there might be short- term improvement, as loose conjunctiva would no longer create a foreign body sensation. Over the long term, however, Dr. Desai said it doesn’t improve adherence of the conjunctiva, doesn’t address prolapsed orbital fat, doesn’t improve the inyammatory condition of the eye and goblet cell deficiency, and can eÝacerbate a conunctiÛal deficiency. Dr. Desai said that amniotic membrane allows for reconstruction of the cul-de- sac, creates a barrier against prolapsed orbital fat, addresses Tenon½s insufficiency, and allows for regenerative healing with the biologics inherent in the membrane. Continued need for education Dr. Hovanesian said there’s still a need for simple awareness about conjunctivochalasis. “Every eyecare provider is seeing conjunctivochalasis and needs to be aware of it so you can optimally treat these patients because otherwise, they tend to go from doctor to doctor unhappy with their treatment and having their problem unsolved,” he said. Dr. Desai said awareness about the condition in general is still needed, as is a better understanding of what the condition is and the right approach to its management. “We are facing an uphill battle in terms of making more surgeons aware of even looking for it, understanding what the condition is, and having the right approach to it. All three of those need a lot of work,” Dr. Desai said. EWAP References 1. Nallasamy N. Conjunctivochalasis. American Academy of Ophthalmology. eyewiki. aao.org/Conjunctivochalasis. Accessed Nov. 16, 2020. 2. Chan DG, et al. Clinicopathologic study of conjunctivochalasis. Cornea . 2005;24:634. 3. Watanabe A, et al. Clinicopathologic study of conjunctivochalasis. Cornea . 2004;23:294–298. 4. Huang Y, et al. Conjunctivochalasis interferes with tear yow from forniÝ to tear meniscus. Ophthalmology . 2013;120:1681–1687. 5. Holland E, et al. Ocular Surface Disease: Cornea, Conjunctiva and Tear Film . 2013. Saunders Elsevier. 6. Doss LR, et al. Paste-pinch-cut conjunctivoplasty: subconjunctival fibrin sealant inection in the repair of conjunctivochalasis. Cornea . 2012;31:959–962. Editors’ note: Dr. Desai practices at the Eye Institute of West Florida, Tampa, Florida, and has interests with Bio-Tissue. Dr. Holland is Professor of Ophthalmology, University of Cincinnati, Cincinnati, Ohio, and `isclse` n relevant financial interests. Dr. Hovanesian practices at Jules Stein Institute, University of California, Los Angeles, Los Angeles, California, has interests with Katena. Dr. Salinger practices at VIP Laser Eye Center, Palm Beach Gardens, Florida, and has interests with Bio-Tissue. Dr. Trinh practices at Mosman Eye Centre, Sydney Eye Hospital, Sydney, Australia, and `isclse` n relevant financial interests.