EyeWorld India September 2021 Issue

CORNEA 44 EWAP SEPTEMBER 2021 second visit, Dr. Salinger addresses aqueous production, performing a Schirmer’s test and considering punctal occlusion or immunomodulator medications like Cequa (cyclosporine, Sun Ophthalmics), Xiidra (lifitegrast, Novartis), or Restasis (cyclosporine, Allergan). After 3–4 visits, and possibly 4–6 months of treatment, if significant symptoms still persist, that’s when Dr. Salinger revisits a formal discussion about surgical options. Surgical management Dr. Holland resects the inferior conjunctiva 180 degrees or, if needed, will do a full 360-degree resection. He won’t do a 360 resection if the patient has glaucoma and might need glaucoma surgery in the future. Dr. Holland said he takes out the strip of loose conjunctiva, taking care to avoid the limbus. He’ll often do the patient’s second eye as well because it’s frequently a bilateral condition. He said that he doesn’t use amniotic membrane but knows other surgeons advocate for it. “My surgical technique is to not resect too much conjunctiva that you have a defect you need to fill in because I’d rather leave conjunctiva than put in amniotic membrane. Only resect the amount of conjunctiva you need and advance the remaining conjunctiva to close the defect,” he said. Dr. Trinh said her preferred technique is “the paste- pinch-cut conjunctivoplasty,” which she noted was reported by Linden Doss, MD, and colleagues in 2012. 6 “It involves the use of a fibrin sealant that is injected under the conjunctiva in a linear fashion below the limbus,” she explained. “The conjunctiva is then ‘pinched’ together with a pair of curved tying forceps where the excess conjunctiva is gathered into a ridge while the sealant polymerizes. The now everted ridge of excess conjunctiva and sealant is resected with Westcott scissors. “We prefer this technique because it allows a pleasing cosmetic outcome as well as reduced bleeding. Care should be taken to adequately assess the amount of excess conjunctiva that is to be resected to avoid forniceal shortening.” Dr. Hovanesian described other methods. One can be done in the office with topical anesthetic. He said using low- temperature cautery to burn a grid pattern in the conjunctiva a few millimeters apart in the area of looseness creates scarring that tethers the conjunctiva to the underlying globe. For patients with a limited amount of conjunctivochalasis, this can be effective, he said. For more extensive conjunctivochalasis, Dr. Hovanesian described his technique, which includes covering the area of excised conjunctiva with dehydrated amniotic membrane (Ambio2, Katena). Dr. Salinger prefers to use a cryopreserved amniotic membrane product (Bio-Tissue) for his surgical management of conjunctivochalasis. He said when he performed surgery without the cryopreserved More from Dr. Hovanesian Dr. Hovanesian described conjunctivochalasis, its diagnosis, and management in a video (bit.ly/2SGz4Ho) . Surgically, after the physician has identified where the areas of loose conjunctiva are, Dr. Hovanesian showed how to excise a small strip of conjunctiva 1 mm from the limbus so as to not disturb limbal stem cells. He then cuts dehydrated amniotic membrane to the same shape of the conjunctival defect, making it 1–2 mm larger on all sides except the corneal side. “We use dehydrated amniotic membrane because of the ease of cutting with the packaging and the ease of application directly on to the eye in its dry state,” he said. From there, fibrin adhesive is applied in two layers. After applying the second adhesive, the graft is applied and placed under the surrounding conjunctiva. Postop, Dr. Hovanesian prescribes prednisolone acetate 1% QID, fluoroquinolone antibiotic QID, and a topical nonsteroidal. In before and after pictures, Dr. Hovanesian noted less inflammation and complete coverage of surface epithelium after healing. He also said a review of his patients over the course of a year identified eight patients with conjunctivochalasis. All patients were older than 5 years, had a history of prior eye surgery, and previous diagnosis of severe dry eye. Dr. Hovanesian said all of these patients had excision of the affected conjunctiva and placement of the dehydrated amniotic membrane, which resulted in complete resolution of the symptoms following surgery. “We encourage our colleagues to consider conjunctivochalasis in patients who have been previously diagnosed with unremitting dry eye that is associated with pain. Naturally, making every effort with nonsurgical therapy is an appropriate first step in this condition, but when conservative treatment fails, we have had very good success using the described technique,” Dr. Hovanesian said in the video. amniotic membrane, the areas of resection were slow to heal and there were large areas of bare sclera that could develop dellen or scleral melting. His pearls for surgical management include: 1) Start 2–3 mm peripheral to the corneal limbus, avoiding the limbal stem cells, and making a semicircular incision, dissect deep into the inferior cul-de- sac. 2) Remove as much loose Tenon’s fascia as possible