John A. Hovanesian
Age, dry eye history and previous ocular surgery are three risk factors
for conjunctivochalasis that should be considered when diagnosing cases of
apparent dry eye with pain, John A. Hovanesian, MD, FACS, said.
Conjunctivochalasis can masquerade as dry eye syndrome, but pain is not
generally associated with milder cases of dry eye, Dr. Hovanesian said at
Hawaiian Eye 2010. Physicians often diagnose dry eye without also considering
conjunctivochalasis because the two frequently occur together.
Its very easy to mistake these patients for dry eye patients
because in our mind, we make the diagnosis very often before we hear the
patients full complaint. We have to avoid doing that, he said.
A simple surgical procedure to fix loosened conjunctiva could
effectively resolve symptoms, according to Dr. Hovanesian.
Dr. Hovanesian conducted a review of patients who had the condition and
subsequent surgery. After the surgical procedure, patients had complete
resolution of symptoms.
In a video shown during the presentation, a patient described his ocular
pain as resembling an eyelash in my eye and said the sensation was
irritating. Its driving me crazy because we look, I use eye wash,
Ive used everything I could. And nothing helps, the patient said in
The point that this patient illustrates is that there is a
specific point of sensitivity on the eye, Dr. Hovanesian said.
There is pain involved, and I think it is that distinct difference that
helps us differentiate this from just symptoms of dry eye.
Dr. Hovanesian said an easy test can be used to help identify
conjunctivochalasis. With a finger, pressure should be gently placed externally
on the eye in the area with pain. The patient should be instructed to look up
and then down. Doing so will place pressure on the affected conjunctiva and
reproduce the characteristic pain that they feel, he said. Patients
should not receive anesthetic before the examination.
Dr. Hovanesian conducted a 1-year review of eight patients with the
condition, all of whom were older than 50 years and had prior ocular surgery,
including cataract, LASIK and a lid blepharoplasty. The patients were
originally diagnosed with refractory dry eye and were later diagnosed with
He found that age, dry eye and prior ocular surgery were risk factors
Previous ocular surgery could play a major role in the condition. Dr.
Hovanesian hypothesized that chemosis during surgery could loosen Tenons
fascia, causing conjunctivochalasis to occur because the conjunctiva is
loosened and redundant.
Conjunctival chalasis occurs most commonly at the inferior border
of the conjunctiva, where it meets the lower eyelid, he said.
Physicians can treat conjunctivochalasis with nonsurgical
therapies,including lubricants and anti-inflammatories. If those approaches do
not work, a simple surgical procedure could potentially produce full resolution
of symptoms, Dr. Hovanesian said.
How many of our dry eye patients leave our practice feeling 100%
relief? Thats very rare. And its often because theres
something else going on, he said.
The surgical technique removes the loose conjunctiva, keeping a tag at
the limbus so limbal stem cells are not harmed. An amniotic membrane is used to
re-graft, which can help facilitate fast healing, Dr. Hovanesian said. Fibrin
adhesive is used to hold the site together.
When performing the surgical procedure, he first finds the loose
conjunctiva and excises the tissue there in a small area, not going as far as
back as the fornix. He then cuts dried amniotic membrane to be slightly larger
than the excised area on which it will be placed.
He applies thrombin glue and fibrinogen on the area, followed by the
I simply lift the edges of the conjunctiva around the area,
allowing the amniotic membrane to fall into place, and in a couple of areas,
you may need to tuck it in, he said. We then finally squeegee, with
forceps, the amniotic fluid in order to ensure that theres a thin
interface of adhesive. This allows the best adhesion with the glue when you
have a very thin interface of glue. And thats it. Thats the end of
surgery. No sutures.
After completion of surgery, the eye is patched over antibiotic drops.
Patients receive prednisolone acetate 1% drops four times a day,
fluoroquinolone antibiotic four times a day and a topical nonsteroidal.
Postoperatively, youll see a fine reticular scar tissue that
shows you that you have a firmly adherent epithelium, right down to the sclera.
The patients tend to be asymptomatic, Dr. Hovanesian said.
A video showing techniques for diagnosing and treating conjunctival
chalasis can be found at
by Erin L. Boyle
- John A. Hovanesian, MD, FACS, can be reached at Harvard Eye
Associates, 24401 Calle De La Louisa, Suite 300, Laguna Hills, CA 92653;
949-951-2020; fax: 949-380-7856; e-mail: