Well-documented risks contributing to the development of dry eye disease include medications, meibomian gland dysfunction, allergic conjunctivitis, and conjunctivochalasis (Yamaguchi et al, 2015; International Dry Eye WorkShop, 2007).

In 1942, Hughes coined the term conjunctivochalasis to describe a condition characterized by redundant, loose bulbar conjunctiva that often presents as lid-parallel conjunctival folds (LIPCOFs). It also often presents with ocular irritation, dryness, foreign body sensation, and increased watering (Yamaguchi et al, 2015). This condition occurs more frequently with increasing age, tends to be bilateral but may be asymmetric, and is typically localized to the lower eyelid (Németh et al, 2012).

Based on their observation of staining and inflammation adjacent to areas of conjunctivochalasis, Meller and Tseng (1988) suggested that inflammation may contribute to its pathogenesis. They noted a close association between conjunctivochalasis and epiphora. They also observed increased tearing when redundant nasal conjunctiva covers the puncta, suggesting that mechanical obstruction of the puncta leads to epiphora.

In a study designed to determine the role of inflammation, researchers excised lower conjunctival tissue in 18 subjects who had conjunctivochalasis and 24 controls who had normal-appearing conjunctiva (Francis et al, 2005). They subsequently did histological evaluations of these tissues. Only one of the study group showed typical actinic tissue damage, and four had inflammatory cells. This study suggests that inflammation, based on the absence or presence of inflammatory cells in conjunctival biopsy, is not a significant factor in conjunctivochalasis.

Tissue inflammation evaluation is also influenced by the test used. Li et all (2000) assessed fibroblasts harvested from conjunctival tissue of patients who had conjunctivochalasis versus controls. They evaluated the expression and activity of matrix metalloproteinases (MMPs) over their tissue inhibitors and noted increased expression of MMP-1 (five- to 32-fold) and MMP-3 (four- to 30-fold). A second part of the study found a 2.2-fold increase in collagenolytic activity of MMP-1 in conjunctivochalasis fibroblasts. The authors suggest that lysis of the conjunctival matrix and Tenon’s capsule degradation contribute to the breakdown of tissue in conjunctivochalasis.

Contact Lens Influence

The mere presence of a contact lens on the eye may lead to inflammation (Holden, 1988). Mimura et al (2009) conducted a large, multi-site study evaluating the relationship between contact lens wear and conjunctivochalasis. They enrolled 600 soft and rigid contact lens wearers, ranging in age from 11 to 60 years, and an age-matched control group of 579 non-lens wearers. The authors found that the incidence of conjunctivochalasis increased with age in all subjects, but its severity and prevalence were significantly greater in lens wearers. They also suggested that interaction between the lens surface and the conjunctiva may contribute to this condition.

Dry eyes and a destabilized tear film are also risk factors for conjunctivochalasis. Meller and Tseng (1988) noted that conjunctivochalasis is common in individuals who have unstable tears. The question is: Does dry eye lead to conjunctivochalasis, or vice versa?

Chhadva et al (2015) evaluated a large, multi-ethnic population from the Miami Veterans Administration clinic for conjunctivochalasis and other factors such as tear osmolarity, staining, tear breakup time, and meibomian gland function. They found that subjects who have nasal conjunctivochalasis had more tear film abnormalities (e.g., decreased Schirmer’s scores, increased meibomian gland dropout, and increased eyelid vascularity). Subjects who have nasal conjunctivochalasis also reported that dry eye symptoms moderately to severely impacted their quality of life. CLS

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