Conjunctivochalasis

Conjunctivochalasis, also sometimes referred to as conjunctival chalasis, is a loosening and wrinkling of the conjunctiva, the clear tissue that covers the white of the eye and the underside of the eye lid. Conjunctivochalasis occurs when the eye lid causes excessive friction during a blink, due to a lack of moisture or lubrication in the eyes (i.e., aqueous deficiency or evaporative dry eye).

Inflamed or obstructed meibomian glands (a sign of meibomian gland dysfunction or MGD) can also stress the conjunctiva during a blink causing chalasis, wrinkling. The wrinkles usually occur in the lower half of the eye, known as anterior conjunctivochalasis. But conjunctivochalasis is also seen in the upper half of the eye, posterior conjunctivochalasis.

Conjunctivochalasis may be present without symptoms (asymptomatic) or may be present with symptoms that vary in degrees of severity, from mild to severe.

With chalasis, the surface of the eye is not smooth and the tear film does not distribute properly across the eye. This may lead to dry eye symptoms. Someone with conjunctivochalasis may also suffer from recurrent pink eye, because the bacteria that causes the redness hides among the folds of the wrinkled tissue, rendering antibiotics ineffective.

Diagnosing and Misdiagnosing Conjunctivochalasis

The condition can be seen under a slit lamp with staining. It is sometimes diagnosed based on symptoms and the sensation felt when the eye lid is pulled gently away from the eye.

Sadly, and for reasons we do not understand, conjunctivochalasis is frequently missed or misdiagnosed. Thankfully, at least one study published in Investigative Ophthalmology and Visual Science recommends that clinicians “look for conjunctivochalasis in patients with symptoms of dry eye.” We are hopeful that more clinicians will adopt this recommendation.

Sometimes conjunctivochalasis is misdiagnosed as ocular neuropathy, unspecific nerve pain in the eyes. Treatment for ocular neuropathy may include prescriptions for pain medications. Although the medication may relieve the pain, prescription pain medications do not treat or address the underlying condition, the wrinkling of the conjunctiva. Sometimes serum tears are prescribed, another ineffective remedy for a wrinkled conjunctiva.

As with other diseases in the Dry Eye spectrum, sometimes a patient with conjunctivochalasis is told the pain is psychosomatic or “all in your head.”

If this has happened to you or a love one — being diagnosed with ocular neuropathy for eye pain or discomfort; or if you are told there is nothing wrong with your eyes and that you are imagining the symptoms (or that the symptoms are “all in your head”) — then we recommend that you seek another opinion with an ophthalmologist specializing in ocular surface and external diseases. Ask to be examined for conjunctivochalasis.

Symptoms
Conjunctivochalasis can be asymptomatic or symptomatic. Symptoms may be mild or severe. Many symptoms may indicate the presence of conjunctivochalasis, including:

Burning
Dry Eyes
Eye Pain
Feeling of Tissues Stuck Under the Eye Lids
Foreign Body Sensation
Gritty or Scratchy Eyes
Red Eyes
Menthol Around the Eyes
Recurrent Pink Eye
Short Tear Break-up Time (TBUT)
The Slightest Breeze is Bothersome or Excruciatingly Painful to the Eyes
Watery Eyes

Behaviors to watch for:

Difficulty or No Driving
Difficulty or No Reading
Frequent Blinking, every one or two seconds
Frequent Use of Eye Drops, more than once every hour and as often as every 5 minutes
Keeping Eyes Closed for Long Periods
Not Participating in Normal Daily Activities
Thoughts of Enucleation (removing the eyes)
Thoughts of Suicide

Classification system
Meller and Tseng (1998) created the following system for classifying the severity of conjunctivochalasis.

Grade Number of folds and relationship to the tear meniscus height
1 No persistent fold
2 Single, small fold
3 More than two folds and not higher than the tear meniscus
4 Multiple folds and higher than the tear meniscus

Conjunctivochalasis: literature review and possible pathophysiology. Meller D, Tseng SC. Survey of Ophthalmology. 1998; 43: 225-232. View the full report

Treatment
When it is asymptomatic, treatment for the condition is not always necessary; although without treatment, the tear film may still be compromised, worsening the condition. When it is symptomatic, the only sure treatment is surgery in the same way that plastic surgery is the only permanent solution to wrinkles on the face.

Reference

The impact of conjunctivochalasis on dry eye symptoms and signs
Chhadva P, Alexander A, McClellan AL, McManus KT, Seiden B, Galor A.
Investigative ophthalmology & visual science
2015 May;56(5):2867-71. doi: 10.1167/iovs.14-16337.
View the full report