Conjunctival Chalasis: A Sneaky Cause of Ocular Pain

When I evaluate patients for ocular surface disease, I always inquire about the main symptom. “If you could describe your main symptom with one word, what would it be? Redness, itching, pain, something in it, dryness, anything like that?” I liken this question to “point to where it hurts” when your child is sitting on the ground sobbing from an accident no one saw, and you have no idea what might be the cause of the emotional outburst. They probably don’t know, and if they did, they are only 5 years old, and can’t tell you anyway. 

Most dry eye patients don’t know what the problem is and have probably been told at least once that nothing is wrong. They won’t know what to tell you, either. But if you can resolve their primary complaint, they will be your patient forever.    

When a patient presents complaining of eye pain, conjunctival chalasis needs to be on your differential diagnosis list. Conjunctival chalasis is a loose, redundant tissue on the inferior conjunctiva, typically found temporally between the globe and lower lid. It is thought to be associated with increased collagenolytic activity and loss of epithelial cohesiveness. It is easily overlooked as a normal, senile change but may increase ocular surface disease symptoms. 

While it rarely causes vision-threatening problems, it may be the cause of your patient’s symptoms. It may disturb tear outflow if occluding the puncta, create an unstable tear film, increase tear osmolarity resulting in inflammation and irritation, tearing and fluctuating vision. It may be a precursor to pterygium and may be more prevalent in contact lens wearers.

Patients are more likely to report foreign body sensation and point to the temporal area when talking about the sensation. They may pull the lids away from the offending tissue, reporting “It feels better when I do this” while demonstrating.  They often report, “something is pulling” or “sticking” when voluntarily looking in different positions of gaze.

Wang, et al evaluated patients with nasal conjunctivochalasis occluding the puncta as well as those with temporal conjunctivochalasis. They performed enzyme-linked immunosorbent assay for inflammatory tear cytokines, tear film break-up time (BUT), Schirmer I test measurements, and fluorescein and rose bengal vital staining and impression cytologic and brush cytologic analysis for real-time reverse-transcriptase polymerase chain reaction analysis of MUC5AC messenger ribonucleic acid (mRNA) in 21 eyes with conjunctivochalasis, and 16 eyes of healthy controls. 

Those with nasal conjunctivochalasis that occluded the puncta had significantly delayed tear clearance. Inflammatory cytokines and rose bengal scores were increased, and goblet cell density decreased, in eyes with significant nasal conjunctivochalasis compared to eyes without nasal chalasis. Authors concluded that inflammation plays an important role in the pathogenesis of conjunctivochalasis, and theorized the pooling of inflammatory cytokines in tears of patients with nasal chalasis associated with delayed tear clearance negatively affects ocular surface health.

Le, et al, investigated the impact of conjunctivochalasis on quality of life. In the study, 198 patients in Shanghai diagnosed with conjunctivochalasis, 86 with dry eye syndrome without conjunctivochalasis, and 76 controls completed the Chinese version of the National Eye Institute Visual Functioning Questionnaire (NEI VFQ-25) and Ocular Surface Disease Index Questionnaire (OSDI). 

OSDI scores of both the conjunctivochalasis and dry eye groups were significantly higher than those of controls, while the VFQ-25 composite scores of the conjunctivochalasis and dry eye groups were significantly lower. Reduced TBUT was found in participants with a higher grade of conjunctivochalasis, and analysis of Grade 2 subgroup revealed chalasis in the middle and nasal sides disturbed the stability of the tear film more than chalasis at the temporal side. 

Decreased tear film stability was associated with chalasis folds higher than tear meniscus height, chalasis with punctal occlusion, and increased extent of chalasis in downgaze.  Median OSDI scores reported by participants with nasal chalasis and punctal occlusion were significantly higher than others. The following characteristics were associated with more ocular pain: chalasis folds higher than tear meniscus height, nasal chalasis with punctal occlusion, and increased extent of chalasis upon downgaze or upon digital pressure. 

Authors theorized redundant conjunctiva occupying the tear meniscus at the lower lid margin partially or completely may disrupt the normal function of the tear meniscus. They further theorized this occurred by affecting the reservoir for retaining tears, the route for tears along the lid margin, and delivery of tears to the ocular surface at the time of blinking.

Typical OSD assessment methods are recommended to assess conjunctivochalasis.  Slit lamp biomicroscopy examination with fluorescein and lissamine green staining, tear break up time, lid expression at a minimum.  Inflammadry (Quidel, San Diego, CA) may be of value to determine the level of inflammation, which may be low despite pain being the chief complaint.

When considering treatment, remember that chalasis does not typically respond to regular use of artificial tears or punctual occlusion. (Le) Addressing inflammation is beneficial, and loteprednol may be considered. If a patient fails to respond to loteprednol as expected, chalasis may be the etiology of their pain. Topical NSAIDs may be beneficial in reducing the foreign body sensation and pain. 

Surgical intervention is the only direct method to treat the problem. Surgery may be performed using cautery in mild to moderate cases, or in more severe cases, resection. Resection may be performed using an amniotic membrane to promote healing, but AMT increases the cost of the surgery. Amniotic membrane may be sutured in place or glued using fibrin blue, but this may be an issue for ASC’s who do not want to pay for the amniotic tissue and fibrin glue. Post-operative medications typically include topical antibiotics, steroids, and NSAIDs. 

Remembering to evaluate the conjunctivae for chalasis in patients reporting pain, foreign body sensation, and other dry eye complaints will keep this from falling below your radar.

Qihua Le, Xinhan Cui, Jun Xiang, Ling Ge, Lan Gong, and Jianjiang Xu.  Impact of Conjunctivochalasis on Visual Quality of Life: A Community Population Survey. PLoS One. 2014; 9(10): e110821. Published online 2014 Oct 20. doi: 10.1371/journal.pone.0110821

Wang Y, Dogru M, Matsumoto Y, Ward SK, Ayako I, Hu Y, Okada N, Ogawa Y, Shimazaki J, Tsubota K. The impact of nasal conjunctivochalasis on tear functions and ocular surface findings. Am J Ophthalmol. 2007 Dec;144(6):930-937. Epub 2007 Oct 4.

Qihua Le, Xinhan Cui, Jun Xiang, Ling Ge, Lan Gong, and Jianjiang Xu. Impact of Conjunctivochalasis on Visual Quality of Life: A Community Population Survey. PLoS One. 2014; 9(10): e110821. doi: 10.1371/ journal.pone.0110821.

DN Cunningham, WO Whitley. The Challenge of Chalasis: It’s more common than you may realize, and responds well to surgical intervention. Review of Optometry, July 16, 2013