It’s likely that, at one point or another, every eye care provider has diagnosed dry eye and eventually discovered that the masquerader conjunctivochalasis (CCh) was actually the cause of their patient’s discomfort. How many times have we placed punctal plugs in the inferior punctum with no relief from symptoms—sometimes making the symptoms even worse? CCh is just one of several mechanical conditions that affects the ocular surface, and most providers commonly overlook it. 

As we age, CCh, or loose redundant conjunctiva, becomes a common sign of ocular surface degradation.¹ Its etiology is certainly multifactorial. In addition to age, a history of dry eye, allergies (eye rubbing), certain medications and previous surgeries are risk factors for CCh and can cause a wide variety of symptoms.² Symptoms can be non-specific with an insidious onset, which is why CCh is often confused for dry eye.² 

It’s fascinating that some of the worst cases (with significant pleating and prolapse) I’ve ever seen are totally asymptomatic, yet some with only minimal CCh inferiorly have tremendous discomfort from the mechanical irritation and disruption of their tear film.^2,3 

In its most severe forms, CCh can cause blurred vision, mucus discharge, fatigue, dryness, tearing and subconjunctival hemorrhage.² Epiphora secondary to CCh is thought to be due to two distinct causes: (1) reduplicated folds of conjunctiva disrupt the tear lake or (2) the conjunctiva causes a mechanical blockage of the inferior punctum.¹ These two cases keep inflammatory cytokines (IL-6 and IL-8) on the ocular surface, increasing the chances of MMP activation and discomfort. An additional breakdown of conjunctival elasticity and progression of CCh is possible.¹

An interesting study performed in 2015 at a Veterans Affairs hospital showed the location of CCh to be important. The study analyzed the relationship between CCh and symptoms and signs of dry eye.³ 

Patients with nasal CCh had the most severe symptoms by OSDI scores when compared with patients with CCh elsewhere or no CCh at all. Nasal CCh patients also had a more abnormal tear film with decreased Schirmer scores, increased meibomian gland dropout and increased eyelid vascularity.³ Those with nasal CCh experienced more throbbing and light sensitivity than those with non-nasal CCh.³ 

Placing a finger on the area that the patient describes as being painful and having them look up and down will reproduce the characteristic pain and aid in a helpful diagnosis.⁴

Treat and Manage

Most often, the extent of signs and symptoms that present to the office affects how we manage CCh. Some patients with very dramatic presentations might have no complaints and require no treatment, just observation. If the patient is symptomatic, topical agents, such as artificial tears, antihistamines and steroids, are a reasonable approach. 

The goal is to reduce any disruption of the tear film and inflammatory chemical mediators. Using ointment and patching at night may provide some relief if the CCh is severe.¹ Also address all additional confounders, including any ocular-related allergy, meibomian gland disease and blepharitis.

Surgery is a reasonable option when targeted medical management fails. Several approaches to offer patients are conjunctival excision with Tisseel (fibrin sealant, Baxter Healthcare), conjunctival fixation to the sclera (incisional glue), amniotic membrane transplantation and superficial thermocautery.² Radiofrequency treatment will generally be less traumatic to the ocular surface than thermocautery. Re-establishing the fornix is key to avoid scarring and the development of a cicatricial entropion.¹

So, is CCh its own clinical entity, a masquerade of dry eye or just an extension of it, since the eye can only respond with so many symptoms? Regardless of what camp you fall in, this is a condition that can’t be missed but unfortunately often is. 

CCh remains the most common reason for recurrent subconjunctival hemorrhages, causes a wide range of symptoms, including significant tearing, burning and irritation in many older patients, and is easily treated in-office. The mystique remains, but, fortunately, we have good remedies to treat CCh when not overlooked.    

1. Bert BB. How to manage conjunctivochalasis. Rev Ophthalmol. 2017;24(9):36-38. 2. Lozano AFI, Larrazaabal LI. Conjunctivochalasis. eyewiki.aao.org/Conjunctivochalasis. Last modified March, 13, 2019. Accessed April 1, 2019. 3. Chhadva P, Alexander A, McClellan, et al. The impact of conjunctivochalasis on dry eye symptoms and signs. Invest Ophthalmol Vis Sci. 2015;56(5):2867-71. 4. Hovanesian J. March 2019. Personal communication.