CCH part 3: When do we treat CCH – and what are the non-surgical options?
A brief recap and some general observations (noting I cannot diagnose, recommend, or treat specific patients or their specific problems in a general blog like this):
- CCH can prevent a “new” tear, resting in its “well” or “reservoir” under the lower eyelid from easily coming up and replacing the older, “used up” tear with every blink. This becomes especially important if the amount of this “sprinkler system” tear is too little to begin with (typical of “Aqueous Tear Deficiency”, or ATD). In ATD, the pleats and folds of the loose membrane typical of CCH can act as a “washboard” that restricts flow – and the loose membrane shortens the reservoir, which reduces the amount of tear it can hold. Another problem exists when the new tear is a “poor tear” (as in not the good “salad dressing tear” that we should have). This is most common when the tear doesn’t have enough good oil (typical of “evaporative dry eye” – also known as “mechanical dry eye” or “Meibomian Gland Dysfunction” – also known by my preferred abbreviation, as MGD). Now the pleats and folds can “rub” back and forth with every blink, resulting in friction that abrades the membranes, causing irritation and inflammation (a major cause of dry eye and related symptoms). Add to that the twisting and shearing of the membrane that can strain and break the tiny blood vessels in that membrane and cause puddles of blood to cause red spots, splotches and even a total red coloring of the whites of the eyes (also called subconjunctival hemorrhages – these are “bruises” that can look scary but are usually not going to cause significant problems for most patients).
- The obvious goal is to restore an adequate, healthful, “salad dressing tear.” If patients have an adequate volume of healthy tears, then even a significant amount of CCH will “matter less.” Even if we need to “operate” – by removing, heating/burning or otherwise tightening the conjunctival membrane, then healing will be facilitated by having that healthy tear. So - my general advice is to work on making a great tear before doing any surgery.
- While “waiting” to get tears up to snuff, CCH can be limited in its irritating contributions by lubrication. This can be achieved with artificial tears (ATs). As you know by now, I am less a fan of ATs as a long-term answer for dry eye patients (they are at best a “Band-Aid” on the problem. If you are not actively working on making better tears, then this allows you to “feel better” even as you “get worse” from this chronic, progressive disease we call dry eye). However, when we are actively working on making better tears, I am a strong advocate of using “Preservative Free Artificial Tears” of PFATs. The exact formula I recommend would be dependent on the issues of each case (and trial and error is a common approach to find what works “best” in each case).
- Reducing inflammation is another challenge. Using steroids is the strongest approach – but as you also know by now, I don’t like using steroids for long-term control of inflammation – preferring to target “root causes,” as steroids can have many unpleasant side effects (such as increasing the risk of cataracts, glaucoma, and infections) – especially when used for the long-term. Weaker medications like Restasis (or other cyclosporine products like Cequa, some newer generics, or Ikervis and the rest) and Xiidra (lifitigrast) are both better long-term choices than steroids, but are still not primarily addressing root causes. I prefer IPL, Omegas 3-6-9 oral supplements, anti-inflammatory diets, in some cases, altered lifestyles - and generally getting the MGs back online (heated expressions, Maskin probing when indicated, lid hygiene, etc).
- Decongestants or other vasoconstrictors (like phenylephrine, brimonidine/Lumify or Upneeq/oxymetazoline ) will shrink tissues congested by swollen blood vessels (by stimulating the muscles that squeeze and constrict the vessels, thereby limiting the fluid that would otherwise swell the membrane). Because friction will injure the vessels and cause them to swell and be leaky, shrinking the vessels will have the opposite effect. The problem common to asking (or flogging) the muscles to constantly “squeeze” is that sooner or later, these overworked muscles need to “relax.” This leads to subsequent swelling and leaking – so these medications (supplied in drops) will eventually lose their effectiveness and can make the issue worse over time. They also are commonly supplied in larger vials or bottles that have preservatives - the harsh chemicals that can damage tear glands and aggravate dry eyes. For this reason, I see them as more “cosmetic” than therapeutic – and better for a hot date on certain occasions that are not more frequent than a few times a week – and then as a short-term “fix,” rather than addressing root causes.
- This brings me back to my favorite “fix” for CCH – the radiofrequency “plications” that lightly iron out the folds and then sear the base in a way that allows the membrane to “stick,” and no longer be loose or baggy. The added benefit is that the same heat can be used (off label) to heat and express the blockages in the MGs that allows the oils to flow - and to naturally fix the root cause of CCH. This fixes the problem causing the problem and is an elegant, efficient, two-step, in-office procedure that is a common part of my practice.
- If doing our best to fix MGD, ATD, (allergies, lid hygiene or the many other co-contributors of dry eye) is still unable to adequately reduce the dry eye issues and it appears some significant amount of these issues relate to CCH – then fixing that problem makes lots of sense. How much we can address making better tears is often dependent on cost considerations and the fact that insurance may not cover all the costs. Fortunately, using my technique (of RF) to plicate CCH is commonly covered by most US-based insurance companies as of this writing.
- The common “downtime” of the RF procedure to those with decent tears is typically 3-5 days of discomfort (from the small burns) – I use the example of burning your mouth with a hot pepperoni pizza bite. For a few days your mouth does not feel good, and you might avoid eating (or drinking) hot foods or beverages (so avoid hot eyelid compresses). After a few days, the discomfort diminishes to the degree that most have little to no discomfort (and are back to eating hot pizza in the case of a burned mouth – or to using hot compresses in the case of the plications). One eye is typically done before the other – so the patient and I can decide if treating the second eye makes sense. Eye drops (a bit like after cataract surgery) help with proper healing and comfort. Those with especially poor tear quality or very diminished volume will sometimes take longer to recover - but usually on the order of a few extra days, up to an extra week. It is the rare patient that doesn’t decide to have the second eye treated - and rare that we don’t see significant improvement in the signs and symptoms of dry eye disease (as I noted in my study publication in the last segment).
A recent industry journal publication on CCH relates to another common “side effect” of CCH - a “subconjunctival hemorrhage” or bruise on the white part of the eye: https://www.optometrytimes.com/view/schs-mild-trauma-or-something-more-sinister-