The Dry EyePublication Exclusive

Dry eye can be a surgical disease

If there is a physical problem, it will need a physical solution.

For some reason I get all confessional with you here. Doubtless it has something to do with our shared experience in the trenches, stomping out dry eye wherever it threatens our patients. Here is my latest: I would really rather be in the operating room.

There. I said it.

That may seem a bit weird coming from a dry eye guy, but after all, this is a column in Ocular Surgery News. Although I do enjoy my work taking care of dry eye patients, when people ask me what I do for a living, I tell them that I am an eye surgeon. I like John Hovanesian’s premise that dry eye can be thought of as the “new glaucoma,” and as long as we are using that analogy, we should probably also realize that the new paradigm is that glaucoma is becoming more and more of a surgical disease. While this is unlikely to be the case in dry eye, there are two specific surgical interventions that we should all become comfortable recommending to those patients who qualify.

Surgery for ectropion

The first of these is an entity that we see in a large percentage of our patients regardless of age or gender: ectropion. We all fight gravity every day; gravity always wins. As I noted in a previous column on computer vision syndrome (Computer vision syndrome: Does looking at a screen cause dry eye?, Ocular Surgery News, February 25, 2015, page 8), exposure of the ocular surface while doing office work or other near tasks is an inflammatory stimulus. Depending on the degree of ectropion involved and the extent to which the lower lid has ceased to function normally, one can see large areas of conjunctiva that would normally be covered but are now exposed to the air. No amount of medicine will fix this. You could prescribe enough fish oil to depopulate every aquarium in North America, and your patient would still be uncomfortable.

It is a physical problem, and it therefore requires a physical solution. Someone needs to fix that lid.

Reasonable people can disagree on the specifics on how to address a loose, malpositioned lower eyelid, but there are just a couple of endpoints that you should strive for. Most cases of ectropion involve a significant loosening of the lid with an associated loss of elasticity. In and of itself, this will have a negative effect on the pump function of the lower lid. After surgery, the lid should be snug against the globe.

The position of the punctum is key. Your endgame includes not only normal tear production but also normal tear drainage. It is important to make sure that the inferior punctum is in contact with the tear lake. By the same token, by re-establishing the lateral canthal angle, you not only create a more attractive contour but also reduce the area of inferotemporal conjunctiva that is exposed between blinks.

While it is slightly more difficult technically to perform a tarsal strip, in my experience the outcome both cosmetically and functionally is superior to a simple wedge resection. In addition, quite often it is possible to rotate the lid margin with just this one technique. If the punctum stubbornly remains aimed more toward the slit lamp than the tear lake, excising an ellipse of tarsal conjunctiva nasally and then suturing or cauterizing the edges together will likely do the trick. If you, like me, don’t like the sight of blood, this is an excellent time to get chummy with your local ophthalmic plastic surgeon. (Mark Levine: Don’t retire.)

Surgery for conjunctival chalasis

It is on the conjunctiva itself that the sexy, cutting-edge surgical stuff is happening. How many times have you seen the following? Your patient had a high tear osmolarity, and now it is smack dab in the middle of normal. The InflammaDry (RPS) was fire engine red, and now it is as white as a blank page before a poet. The tear breakup time is so long you took a nap, and if there is a single superficial punctate keratitis, it is findable only by Sherlock Holmes, MD. Just as your hand is beginning to cramp from reaching around to pat yourself on the back, you hear something like this: “I still have a constant gritty sensation.” You sit at the slit lamp, and there it is: conjunctival chalasis.

After years of inflammation and dryness, loose, redundant conjunctiva flops all over the sclera, often coming to rest on the lower lid margin. Even after you have repaired that pesky ectropion, there it lies. Each blink brings another wiggle and with it the grittiness that comes from constant exposure to the atmosphere. No amount of lubrication, no anti-inflammatory regimen is going to resolve these symptoms. Once again, you are presented with a physical problem, and it demands a physical solution.

Until recently, there has been little talk about conjunctival “reduction” surgery. I, likely like you, have concentrated mainly on treating dry eye medically. My frustration level has reached the point at which I have begun to more aggressively attend to conjunctival chalasis in patients of all ages. In my research, I have been impressed by fellow NYU grad Steve Safran’s approach and techniques. A Google search for Steve (and John Hovanesian) rewards you with a plethora of information and video on this topic.

Your surgical approach to the conjunctiva begins with a simple question: whether to attack the problem at the limbus or in the fornix. In the fornix, you can reduce the amount of loose conjunctiva by contraction (Steve Safran has an elegant technique using an Ellman radiofrequency probe) or by excising an ellipse of loose inferior bulbar conjunctiva. In this location, you can leave the margins open or use a thin, dissolvable suture.

If you opt to solve the problem of chalasis at the limbus, you come across some of the coolest science in extraocular surgery today. Once again, the procedure begins with the excision of a generously measured ellipse of loose conjunctiva. After gentle cautery, a measured and shaped piece of preserved amniotic membrane, such as that from Bio-Tissue, is placed to cover the bare sclera after the application of activated tissue glue. Typically, tissue glue is then activated on top of the amniotic membrane. The edge of the conjunctiva sits at the inferior margin of the amniotic membrane graft. Steve Safran has had some success replacing tissue glue with autologous blood to secure the conjunctiva at the end of the procedure.

Once upon a time, I exhorted you to stand tall and proclaim: “I am a red eye doctor, and I am proud!” (Anterior segment experts: You are red eye doctors, Ocular Surgery News, June 25, 2014, page 8). You and I both know the truth, though. We are anterior segment surgeons, and when we see a physical problem, we look for a physical solution to fix it. Here is your chance, especially when dealing with conjunctival chalasis. These techniques are part of the skill set we already have. When presented with a red, irritated eye that is resistant to medical solutions, you have the answer.

I am a dry eye surgeon. I can fix that.

Disclosure: White reports he is a consultant for Bausch + Lomb, Allergan, Shire and Eyemaginations and on the speakers board for Bausch + Lomb, Allergan and Shire.

For some reason I get all confessional with you here. Doubtless it has something to do with our shared experience in the trenches, stomping out dry eye wherever it threatens our patients. Here is my latest: I would really rather be in the operating room.

There. I said it.

That may seem a bit weird coming from a dry eye guy, but after all, this is a column in Ocular Surgery News. Although I do enjoy my work taking care of dry eye patients, when people ask me what I do for a living, I tell them that I am an eye surgeon. I like John Hovanesian’s premise that dry eye can be thought of as the “new glaucoma,” and as long as we are using that analogy, we should probably also realize that the new paradigm is that glaucoma is becoming more and more of a surgical disease. While this is unlikely to be the case in dry eye, there are two specific surgical interventions that we should all become comfortable recommending to those patients who qualify.

Surgery for ectropion

The first of these is an entity that we see in a large percentage of our patients regardless of age or gender: ectropion. We all fight gravity every day; gravity always wins. As I noted in a previous column on computer vision syndrome (Computer vision syndrome: Does looking at a screen cause dry eye?, Ocular Surgery News, February 25, 2015, page 8), exposure of the ocular surface while doing office work or other near tasks is an inflammatory stimulus. Depending on the degree of ectropion involved and the extent to which the lower lid has ceased to function normally, one can see large areas of conjunctiva that would normally be covered but are now exposed to the air. No amount of medicine will fix this. You could prescribe enough fish oil to depopulate every aquarium in North America, and your patient would still be uncomfortable.

It is a physical problem, and it therefore requires a physical solution. Someone needs to fix that lid.

Reasonable people can disagree on the specifics on how to address a loose, malpositioned lower eyelid, but there are just a couple of endpoints that you should strive for. Most cases of ectropion involve a significant loosening of the lid with an associated loss of elasticity. In and of itself, this will have a negative effect on the pump function of the lower lid. After surgery, the lid should be snug against the globe.

The position of the punctum is key. Your endgame includes not only normal tear production but also normal tear drainage. It is important to make sure that the inferior punctum is in contact with the tear lake. By the same token, by re-establishing the lateral canthal angle, you not only create a more attractive contour but also reduce the area of inferotemporal conjunctiva that is exposed between blinks.

While it is slightly more difficult technically to perform a tarsal strip, in my experience the outcome both cosmetically and functionally is superior to a simple wedge resection. In addition, quite often it is possible to rotate the lid margin with just this one technique. If the punctum stubbornly remains aimed more toward the slit lamp than the tear lake, excising an ellipse of tarsal conjunctiva nasally and then suturing or cauterizing the edges together will likely do the trick. If you, like me, don’t like the sight of blood, this is an excellent time to get chummy with your local ophthalmic plastic surgeon. (Mark Levine: Don’t retire.)

Surgery for conjunctival chalasis

It is on the conjunctiva itself that the sexy, cutting-edge surgical stuff is happening. How many times have you seen the following? Your patient had a high tear osmolarity, and now it is smack dab in the middle of normal. The InflammaDry (RPS) was fire engine red, and now it is as white as a blank page before a poet. The tear breakup time is so long you took a nap, and if there is a single superficial punctate keratitis, it is findable only by Sherlock Holmes, MD. Just as your hand is beginning to cramp from reaching around to pat yourself on the back, you hear something like this: “I still have a constant gritty sensation.” You sit at the slit lamp, and there it is: conjunctival chalasis.

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After years of inflammation and dryness, loose, redundant conjunctiva flops all over the sclera, often coming to rest on the lower lid margin. Even after you have repaired that pesky ectropion, there it lies. Each blink brings another wiggle and with it the grittiness that comes from constant exposure to the atmosphere. No amount of lubrication, no anti-inflammatory regimen is going to resolve these symptoms. Once again, you are presented with a physical problem, and it demands a physical solution.

Until recently, there has been little talk about conjunctival “reduction” surgery. I, likely like you, have concentrated mainly on treating dry eye medically. My frustration level has reached the point at which I have begun to more aggressively attend to conjunctival chalasis in patients of all ages. In my research, I have been impressed by fellow NYU grad Steve Safran’s approach and techniques. A Google search for Steve (and John Hovanesian) rewards you with a plethora of information and video on this topic.

Your surgical approach to the conjunctiva begins with a simple question: whether to attack the problem at the limbus or in the fornix. In the fornix, you can reduce the amount of loose conjunctiva by contraction (Steve Safran has an elegant technique using an Ellman radiofrequency probe) or by excising an ellipse of loose inferior bulbar conjunctiva. In this location, you can leave the margins open or use a thin, dissolvable suture.

If you opt to solve the problem of chalasis at the limbus, you come across some of the coolest science in extraocular surgery today. Once again, the procedure begins with the excision of a generously measured ellipse of loose conjunctiva. After gentle cautery, a measured and shaped piece of preserved amniotic membrane, such as that from Bio-Tissue, is placed to cover the bare sclera after the application of activated tissue glue. Typically, tissue glue is then activated on top of the amniotic membrane. The edge of the conjunctiva sits at the inferior margin of the amniotic membrane graft. Steve Safran has had some success replacing tissue glue with autologous blood to secure the conjunctiva at the end of the procedure.

Once upon a time, I exhorted you to stand tall and proclaim: “I am a red eye doctor, and I am proud!” (Anterior segment experts: You are red eye doctors, Ocular Surgery News, June 25, 2014, page 8). You and I both know the truth, though. We are anterior segment surgeons, and when we see a physical problem, we look for a physical solution to fix it. Here is your chance, especially when dealing with conjunctival chalasis. These techniques are part of the skill set we already have. When presented with a red, irritated eye that is resistant to medical solutions, you have the answer.

I am a dry eye surgeon. I can fix that.

Disclosure: White reports he is a consultant for Bausch + Lomb, Allergan, Shire and Eyemaginations and on the speakers board for Bausch + Lomb, Allergan and Shire.