Conjunctivochalasis (CCh), defined as a redundant, loose, nonedematous inferior bulbar conjunctiva interposed between the globe and the lower eyelid, tends to be bilateral and is more prevalent in older populations.1,2 Patients vary in the degree of their symptomology ranging from asymptomatic to experiencing ocular irritation, pain, subconjunctival hemorrhage, epiphora, dry eye, and/or ulceration.3–5 Treatment of conjuntivochalasis varies depending on the severity of symptoms. Asymptomatic eyes can be left untreated and followed up periodically for signs of progression. If symptoms continue despite topical treatment, surgery may be needed to remove the segments of redundant conjunctiva. With regard to surgical procedures, crescent-shaped conjunctiva resection, first introduced by Hughes,5 successfully treats CCh by removing crescent-shaped conjunctiva under the lower eyelid and closing the conjunctival incision with a continuous silk suture. This approach has been widely used and demonstrated to be successful.4,6 However, it is difficult to design how much conjunctival tissue should be excised before the operation as well as in the operation phase. This is usually more complicated with attendant subconjunctival hemorrhage. So if a tool could be applied to facilitate the excision of conjunctiva, it may optimize this procedure. Herein we introduce a quantitative locator for conjunctiva resection and performed it on 46 patients with bilateral symptomatic CCh.
Design of locator
The quantitative locator used in this study is made of poly β-hydroxyethyl methacrylate resin/β-hydroxyethyl methacrylate (HEMA). It consists of a circle at the centre with a diameter of 12 mm and two arcs 5 mm posterior from the circle. A slit between the two arcs was made as an access of loose conjunctiva to the surface of the locator. Five holes each with a diameter in 1 mm at the 2, 4, 6, 8, 10-o'clock positions of the outer arc are made for the micro-forceps to pull out the conjunctiva beneath the inner face of the locator after it is placed on the eyeball (Figure 1).
Forty-six patients (20 males, 26 females; mean age, (70.77±9.42) years) with bilateral symptomatic CCh but without other ocular surface diseases were included in this study. All patients provided informed consent according to the Tenets of the Declaration of Helsinki. While the right eye underwent the popularly used crescent-shaped conjunctiva resection (group Ð†), the left eye was treated with conjunctiva resection assisted by the quantitative locator (group II). This study was approved by the Ethnic Committee of Putuo Hospital, Shanghai Chinese Traditional Medicine University.
Conjunctiva excision assisted by quantitative locator
Before surgery, 0.5% Alcaine eye drops (Alcon, USA) were administered to anesthetize the conjunctiva. After the eye was exposed with a speculum, the locator (Figure 2) was placed on the eyeball with its centre coincident with the centre of cornea. A forceps was used to pull out the loose conjunctiva from the little holes located at the edge of the outer arc and next from the slit between the two arcs. In this way, loose conjunctiva can be laid on the surface of the locator without sliding, and therefore can be easily excised. After excision of the conjunctiva, the locator was lifted and the cut was sutured with a 10–0 silk suture (Johnson& Johnson, USA). Artificial tear eye drops and 0.5% gentamicin were administered 4 times per day for two weeks.
Crescent-shaped conjunctiva resection procedure
After topically anesthetized with 0.5% Alcaine eye drops, the eye was exposed with a speculum and loose conjunctiva was pushed downward and the folded conjunctiva was kept 5 mm posterior from the limbus. Redundant conjunctiva was gathered together without influence on the eye movement and the gathered conjunctiva was excised like a crescent. The cut was approximated with a 10–0 nylon silk suture. The duration of keeping sutures should be 10–14 days during which 0.5% gentamicin and artificial eye drops were administered 4 times per day.
Ocular surface symptoms evaluations
OSDI was used to evaluate the ocular symptoms7 as described by Li et al.2
Loose conjunctiva excision evaluation
At 2, 4, and 8 weeks after surgery, patients were examined under the slit lamp microscope. The score was recorded as 0 with no loose conjunctiva, whereas it was recorded as 1 score with grade I conjunctival fold and recorded as 2, 3, and 4 scores as such.
Conjunctival wound healing evaluation
Conjunctival wound healing was evaluated by healing scores. Grade A healing was recorded as 3 scores when the conjunctiva was demonstrated to be fine with healing line and no scar formation; Grade B healing was recorded as 2 scores with little conjunctival scar or swelling but with no infection; and Grade C healing was recorded as 1 score with infection of conjunctiva. This classification and healing scores were respectively documented at 2, 4, and 8 weeks after surgery.
The main complications after CCh surgery are as follows: conjunctival fold remaining, roughness of conjunctival cut, scar, restriction of eye movement, shallow conjunctival sac, cut break, and infection. If one complication occurred, a score of 1 was recorded; two complications occurred, a score of 2 was recorded; if no complication was recorded, the score was 0.
Tear meniscus and BUT evaluation
Height of tear meniscus was measured by micro-scale in the slit lamp and defined as abnormal when it was lower than 0.3 mm or the tear meniscus was irregular, dry or broken. BUT was measured and evaluated as described in the ophthalmic textbook.
Lacrimal duct function evaluation
Tasting chloromycetin test (TCT), described by Zhang et al in their early report,8 was used to evaluate how the lacrimal duct worked.
Data were presented as mean ± standard deviation (SD) and analyzed by χ2 and t-test, using a statistics program SAS 6.0 (SAS, Corp., USA). P <0.05 was considered as statistically significant.
Evaluation of ocular surface symptoms
OSDI scores in group II were significantly lower than those in group I at all time points. There was a decrease in OSDI scores from a mean value of 30.28 at baseline before surgery to 8.82 at 8 weeks after surgery in group II, and were from 30.43 to 14.67 in group I (Table 1).
Loose conjunctiva excision evaluation
The amount of conjunctiva fold remaining in group II was less than that in group I. Scores of remnant conjunctiva fold in group I were significantly higher than that in group II (t=31.85, P <0.01). At 2 weeks after surgery, among patients underwent locator-assisted conjunctiva excision, 42 in grade 0 CCh, 4 in grade I, none in grade II or III; while in patients underwent crescent-shaped conjunctiva resection, 37 in grade 0 CCh, 6 in grade I, 3 in grade II and none in grade III. At 4 weeks after surgery, among patients underwent locator-assisted conjunctiva excision, 43 in grade 0 CCh, 3 in grade I, none in grade II or III; while in patients underwent crescent-shaped conjunctiva resection, 39 in grade 0 CCh, 5 in grade I, 2 in grade II and none in grade III. At 8 weeks after surgery, among patients underwent locator-assisted conjunctiva excision, 44 in grade 0 CCh, 2 in grade I, none in grade II or III; while in patients underwent crescent-shaped conjunctiva resection, 39 in grade 0 CCh, 5 in grade I, 2 in grade II and none in grade III (Table 2). A normal conjunctival surface with no folded conjunctiva was observed at 8 weeks after locator-assisted conjunctiva excision (Figure 3).
Evaluation of conjunctival wound healing
Scores of conjunctival wound healing evaluation between the two groups at 2 weeks after surgery were not significantly different (t=1.43, P=0.159), while those at 4 weeks (t=3.760, P <0.01) and 8 weeks (t=5.62, P <0.01) were significantly different (Table 3). A smooth conjunctiva surface with no evident cut line was observed at 8 weeks after locator-assisted conjunctival excision.
Evaluation of the height of tear meniscus and BUT
There were no significant differences in BUT (χ2=0.031, P=0.985), as well as the height of tear meniscus (χ2=0.48, P=0.780) between the two groups. While there was a normal height of tear meniscus in 40 eyes (86.9%) and a normal BUT (≥10 seconds) in 33 eyes (71.7%) in group II at 8 weeks after surgery, the height of tear meniscus and BUT were normal in 32 eyes (69.5%) and 30 eyes (65.5%) respectively in group I at the same time point (Tables 4 and 5).
Evaluation of complications
Scores of complications in group I were significantly higher than those in group II (t=89.60, P <0.01). Fewer complications occurred in locator-assisted conjunctiva excision (Table 6).
Evaluation of lacrimal duct function
There was no significant difference in TCT between the groups (χ2=0.14, P=0.930) (Table 7). Larimal duct function respectively resumed in 23 eyes (50.0%) in group II and 20 eyes (43.4%) in group I at 8 weeks after surgery.
Mean surgery time in group II (17.11±2.08) minutes) was significantly shorter than that in group I (25.22±4.78) minutes) (t=13.84, P <0.01).
The crescent excision of the inferior bulbar conjunctiva has been advised as a surgical procedure in the management of conjunctivochalasis refractory to medical treatments.9,10 In this procedure, it is of vital importance to delicately design how much bulbar conjunctiva should be excised. As Liu4 has cautioned, overzealous resection of the conjunctival tissue may result in a compromised lower fornix, which may restrict motility or cause incision broken and corneal problems whereas underestimated resection would cause loose conjunctiva to remain.
This study highlighted an instrument termed as a quantitative locator for conjunctiva resection. This locator is made of β-hydroxyethyl methacrylate acetate/HEMA (water gel) with chemical stability, bringing no stimulations. As it becomes soft in water, it is easy to be implanted into the conjunctival sac without scratching. By using the locator, the operator can accurately design how much conjunctiva tissue should be excised. Since excessive or insufficient conjunctiva excision could possibly be avoided, this procedure is superior to currently used crescent-shaped conjunctiva resection as evidenced by an array of clinical evaluations in this report. OSDI are widely accepted and used as a method for the study concerned with ocular surface disease. Scores of OSDI is lower in locator-assisted conjunctiva excision than those in crescent-shaped resection. This might be attributable to the improvement in relatively accurate loose conjunctiva excision as shown by evaluations of remnant conjunctiva fold and wound healing in this study. As for the insignificant differences in evaluations of the height of tear meniscus, BUT, and TCT between the two surgical procedures, this may lie in the similar resolving of mechanical problems caused by the interposed conjunctiva fold between the globe and the lower eyelid. Among the advantages of locator-assisted conjunctiva excision, its fewer complications may encourage a most liberal use. However, this procedure is limited by its inevitable suturing of the conjunctiva cut which may carry risks of suture-related disadvantages and complications such as postoperative discomfort, abscesses, granuloma formation, and giant papillary conjunctivitis. In this regard, suture-related complications could be reduced by amniotic membrane transplantation after conjunctiva is approximated by suture.11 Also, fibrin glue may offer a novel way of repairing conjunctival defects and has been shown to avoid suture-related complications, decrease surgical time, and decrease ocular inflammation and discomfort postoperatively.12,13 The use of fibrin glue has been proven to be rather safe, but the potential side effects can not be ruled out given that many of the constituents are derived from human blood plasma.14 Both these two approaches may achieve a good therapeutic result for CCh when used as adjunctive methods for conjunctiva excision to better reconstruct the conjunctival surface. Further studies are warranted to investigate if the locator-assisted conjunctiva excision would be more effective in treating CCh under the help of amniotic membrane transplantation or fibrin glue.
In conclusion, a quantitative locator can be used as an effective, safe, and less time-consuming instrument to facilitate conjunctival excision for symptomatic CCh treatment.
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Keywords:© 2011 Chinese Medical Association
conjunctivochalasis; conjunctiva resection; treatment