EyeWorld India September 2021 Issue

CORNEA 42 EWAP SEPTEMBER 2021 by Liz Hillman EyeWorld Editorial Co-Director Recognizing, understanding, and treating conjunctivochalasis Contact information Desai: desaivision2020@gmail.com Holland: eholland@holprovision.com Hovanesian: johnhova@gmail.com Salinger: drsalinger@comcast.net Trinh: tanya.trinh@gmail.com U nderdiagnosed, often neglected, and much more common than clinicians realize is how some physicians describe conjunctivochalasis. Patients with symptomatic conjunctivochalasis often complain of dry eye and receive treatment that doesn’t resolve their symptoms. Often the system ends up pushing these patients to cornea specialists who ultimately discover the condition, make the diagnosis, and determine a course of treatment. “We [need to] start by understanding that this is a significant clinical entity. It’s not rare, and it should be in your differential diagnosis of ocular surface disease,” said Edward Holland, MD. Tanya Trinh, MBBS, FRANZCO, said a review of conjunctivochalasis concluded that the condition most commonly affects elderly patients, although it can be seen in a wide range of ages. She said its precise prevalence in the U.S. is not known, but some reports have shown higher prevalence in Asian populations. “Not all cases of conjunctivochalasis are clinically significant, and non- standardized diagnostic criteria likely contributes to the wide variance in reported prevalence rates,” Dr. Trinh said. “It is also likely underdiagnosed because patients typically will come in presenting with dry eye symptoms and ocular irritation and it is only upon examination and work-up that it is discovered; patients typically are not referred straight in with this diagnosis. “Underdiagnosis also occurs because a large proportion of patients with this condition are asymptomatic,” Dr. Trinh continued. “If patients are experiencing symptoms, they most often complain of dryness, discomfort, blurred vision, fatigue, pain and burning, foreign body sensation, and episodes of tearing,” she said. According to Nambi Nallasamy, MD, who wrote about conjunctivochalasis on the website of the American Academy of Ophthalmology, “no true etiology has been determined” for the condition. 1 He noted several studies that suggest mechanical causes, observe the overexpression of inflammatory metalloproteinases and inflammatory cytokines, and describe how conjunctivochalasis affects tear meniscus formation and blocks tear movement from the fornix. 2–5 Diagnosing conjunctivochalasis Dr. Holland called conjunctivochalasis a diagnosis of exclusion. “On the initial visit, I do not recommend the definitive treatment for conjunctivochalasis, which is surgery for most significant cases. What I recommend is to rule out the more common causes of ocular surface symptoms: Does this patient have aqueous tear deficiency? Does this patient have MGD? Any findings of allergic conjunctivitis? I will treat those conditions if they’re present because patients can have conjunctivochalasis and not have symptoms related to it. If the standard treatment of the common causes of ocular surface disease fail, then I know I have ruled out the more common diagnoses and I can be more certain that conjunctivochalasis is the cause of the patient’s symptoms and we can discuss possible surgery,” he said. Dr. Trinh said point-of-care testing might have a role in evaluating conjunctivochalasis in looking for associated ocular surface inflammation. “[T]he diagnosis of [conjunctivochalasis] is reliant on a careful slit lamp examination and especially observation of the patient during the blinking phase,” she said. John Hovanesian, MD, said a clue that a patient could have conjunctivochalasis and not just dry eye is localized pain. This article originally appeared in the July 2021 issue of EyeWorld . It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp.