Conjunctival Chalasis (CCH) part 2 - How do we fix it?

CCH is a common co-contributor to dry eyes and related dry eye signs and symptoms. A recent study shows that 98% of patients over the age of 60 have CCH – or, Mechanical Dry Eye (MDE) - and in my experience, it can begin very early in the course of dry eye disease (and at a much earlier age). While not clear what exactly is the cause, I think it is widely understood that the friction from poor tear quality and poor tear volume can aid in loosening the membrane - and the inflammation associated with friction and with the dry eye disease process itself, can also promote it. T., Yamagami, S., Usui, T., Funatsu, H., Mimura, Y., Noma, H., … & Amano, S. (2009). Changes of conjunctivochalasis with age in a hospital-based study. American journal of ophthalmology, 147(1), 171-177.

Because of the association with friction (the result of the “mechanical rubbing of the eyelid” against the rough surface of a dry eye), CCH is commonly also called “Mechanical Dry Eye” and a short video was created by a company (BioTissue) marketing a biologic tissue (amnion) used to help heal from a surgical procedure used to correct it. See this link: https://youtu.be/Z6Us18F5QwY

When it comes to surgically dealing with CCH, there are a number of options available. 

1- cut it off and let it grow back. This approach leaves a relatively large defect that heals like an open sore with granulation tissue and a degree of scar tissue. The final result will gradually convert to conjunctival tissue, but I’m not aware how well the related “sprinkler system” tear-producing cells are restored. It also doesn’t deal with the problem commonly thought to cause the CCH (that being the obstructive MGD and resulting mechanical dry eye, inflammation and friction relating to a lack of oil).

2- same, but glue in a segment of amnion as a biological Band-Aid or attempt to sew portions of the membrane and/or amnion together. This hastens healing but leaves us in the same position. (This is the company with the great video I linked above).

3- burn the loose folds of CCH with a hot wire. This leaves a scaffold of unburned tissue to help in the repair and even the burned membrane leaves some cover (avoiding the open sore over the underlying sclera). The red-hot wire tends to char the tissue which tends to leave more scar tissue than what I experience with the lighter coagulation from RF. It also fails to deal with the friction issues noted above. 

4-use a laser to burn or singe the loose folds. This is similar in some respects to RF, but I’m wary of damaging the eye with light that might injure the light-sensitive structure of the eye. I also find CCH seems to recur more rapidly than with other technology and it also fails to fix the problem causing the problem. 

5- MY FAVORITE! - use Radio Frequency (RF) to “burn” (or more lightly singe) the membrane, causing it to shrink, tighten and then “stick” to the eyeball beneath the membrane (recreating the nice “shrink-wrap” effect that restores the smooth reservoir referenced in the video above) - and then use the same energy to do a heated expression of the waxy obstructions of the MGs. This fixes the problem causing the problem. I published a study using this technology here: https://jdryeyedisease.com/index.php/JDED/article/view/35

In difficult cases, after the RF procedure, one can apply the biologic tissue (amnion) - referenced in the first video, but applied as a kind of contact lens “Band-Aid” (Prokera) which can hasten the healing and help ensure a deep “reservoir” is maintained.

Perhaps one of the reasons any of these techniques work to any degree, is that it really helps to have a smooth surface for the tears to easily come up from the “gutter” (or reservoir) of the lower lid and replace the old, used up tear on the surface of the cornea.

An interesting and - probably relevant aside, is that RF (along with lasers and other thermal treatments) is now commonly used (by GYN doctors) to promote vaginal restoration and lubrication. The lining of the vagina is similar to the conjunctiva and since ocular lubrication is similar, there may be similar benefits to RF in both cases.