Contact Lens Case Reports

Conjunctival Prolapse, Hooding, Chalasis or…

BY PATRICK J. CAROLINE, FAAO, & MARK P. ANDRÉ, FAAO

The rebirth of scleral contact lenses is a topic that continues to pique the interest of contact lens specialists around the world. With this renaissance has come a number of new and interesting complications that we as a community need to properly name, understand, and ultimately treat. One such complication has been called a number of names: conjunctival prolapse, conjunctival hooding, or conjunctival chalasis.

Conjunctival Changes

Let’s start from the beginning. With advancing age, we begin to see minor alterations in the morphology of the conjunctiva that include conjunctival thinning and a loss of tissue transparency. Additionally, the conjunctival vessels become more prominent, particularly in the interpalpebral area, and we frequently see tortuosities, varicosities, and small telangiectase of the conjunctival vessels.

Another morphologic change associated with the aging conjunctiva is its apparent loss of attachment to the underlying Tenon’s capsule, a condition clinically referred to as conjunctival chalasis. In reality, the bulbar conjunctiva “attaches” only at the limbus, and the remaining tissue is elastic enough that it simply stretches across the globe, resulting in a very loose (and poorly defined) so-called attachment to Tenon’s capsule.

Add a Scleral Lens and…

When we fit scleral lenses that completely vault the cornea and limbus and come to rest on the sclera (more specifically, on the bulbar conjunctiva), we occasionally see the conjunctival tissue being drawn up (prolapsing) beneath the lens at the limbus (Figures 1 through 3). We see this condition most frequently in our elderly patients or in patients who have undergone multiple ocular surgeries, i.e. strabismus or retinal reattachment surgeries. Our clinical experience has suggested that this may be a benign event and, despite its somewhat disconcerting look, it appears to carry with it no apparent long-term ramifications.

Figure 1. Conjunctival prolapse.

Figure 2. Conjunctival prolapse.

Figure 3. Conjunctival prolapse.

We believe that it would be advantageous for the scleral lens community to provide some consensus on the most appropriate nomenclature to describe the physiologic, mechanical and tissue-related changes taking place beneath contemporary scleral lenses. Therefore, is this condition best referred to as conjunctival prolapse, conjunctival hooding, conjunctival chalasis, or some other name? CLS

The authors wish to thank Dr. Michelle N. Lee at Weill Cornell Medical College Department of Ophthalmology for a number of her images and for her assistance with this manuscript.

Patrick Caroline is an associate professor of optometry at Pacific University. He is also a consultant to Paragon Vision Sciences. Mark André is an associate professor of optometry at Pacific University. He is also a consultant for CooperVision.