The Effect of Age and Conjunctivochalasis on Conjunctival Thickness

The association between conjunctival and scleral thickness and ocular surface ultraviolet autofluorescence

Ultraviolet autofluorescence (UVAF) imaging is used to visualise ocular surface changes due to sunlight exposure and so is considered to be a biomarker for UV damage. The conjunctival and scleral thicknesses of participants with and without ocular surface UVAF were measured to examine the UVAF associated tissue thicknesses. The presence of UVAF on the ocular surface was associated with significant differences in tissue thickness including thinner conjunctival epitheliums and thicker scleras but predominantly thickening of the conjunctival stroma. Participants were also classified into four groups according to the presence and absence of UVAF on both the temporal and nasal conjunctivas. It was noted that for those that had only nasal UVAF, the temporal conjunctival stroma was significantly thicker even without the presence of UVAF. Some participants with temporal UVAF had signs of pinguecula observed with slit lamp examination and some had OCT SLO enface imaging darkening. These findings highlight the potential of techniques other than slit lamp examination, including tissue thickness measurement and UVAF photography, in the detection of early UV-related changes to the ocular surface.

Conjunctiva and Tenon's Capsule Handling in the Port Delivery System with Ranibizumab Implant Insertion Procedure: Surgical Pearls

OBJECTIVES

To describe conjunctiva and Tenon's capsule handling during the Port Delivery System with ranibizumab (PDS) implant insertion procedure including up-front assessments, planning, and instrumentation, with emphasis placed on the peritomy, scleral dissection, and closure steps.

METHODS

Surgical pearls based on experience accumulated in the PDS clinical trial program in patients with retinal diseases.

RESULTS

Preoperative preparation, specific instruments, and meticulous techniques are key to optimizing surgical outcomes. Before surgery, assessment of factors that affect conjunctival integrity and an in-office conjunctiva examination are conducted. Gentle, purposeful conjunctiva and Tenon's capsule handling with nontoothed forceps and suturing with a BV needle are recommended to prevent tissue damage. The peritomy is 6 mm by 6 mm, centered around the planned implant location in the superotemporal quadrant. A complete sub-Tenon's capsule dissection is achieved using a wide, robust lateral and posterior dissection technique to free tissue from the sclera and minimize tension. The globe is stabilized during scleral cutdown by grasping the sclera with fine-toothed forceps away from the incision edge to prevent tissue delamination. When closing the peritomy, both the conjunctiva and Tenon's capsule are completely captured and sutured with scleral anchoring at the apex of the peritomy to help prevent conjunctival retraction and erosion. Mitigation and detection of adverse events is critical to successful surgical outcomes.

CONCLUSIONS

The PDS implant insertion procedure is straightforward, but it requires planned preoperative preparation, specific instruments, and meticulous techniques. The surgical pearls described here offer insights for optimizing outcomes. [Ophthalmic Surg Lasers Imaging Retina. 2022;53:266-273.].

Anatomical and physiological considerations in scleral lens wear: Conjunctiva and sclera

While scleral lenses have been fitted using diagnostic lenses or impression moulding techniques for over a century, recent advances in anterior segment imaging such as optical coherence tomography and corneo-scleral profilometry have significantly improved the current understanding of the anatomy of the anterior eye including the morphometry of the conjunctiva, sclera, and corneo-scleral junction, as well as the ocular surface shape and elevation. These technological advances in ocular imaging along with continual improvements and innovations in scleral lens design and manufacturing have led to a global increase in scleral lens prescribing. This review provides a comprehensive overview of the conjunctiva and sclera in the context of modern scleral lens practice, including anatomical variations in healthy and diseased eyes, the physiological impact of scleral lens wear, potential fitting challenges, and current approaches to lens modifications in order to minimise lens-induced complications and adverse ocular effects. Specific topics requiring further research are also discussed.

Limbal and Conjunctival Epithelial Thickness in Ocular Graft-Versus-Host Disease

PURPOSE

To compare the thickness of the limbal epithelium (LE) and the bulbar conjunctival epithelium (BCE) between patients with dry eye disease (DED) with and without ocular graft-versus-host disease (GVHD).

METHODS

This cross-sectional study enrolled 40 patients with moderate to severe DED including 20 with and 20 without chronic ocular GVHD. All patients had a comprehensive clinical ophthalmic assessment. Moreover, the thickness of the LE and BCE in both nasal and temporal regions of both eyes was measured using spectral domain optical coherence tomography.

RESULTS

The average LE thickness in all patients with dry eye (GVHD and non-GVHD) was 65.8 ± 11.9 μm temporally and 69.7 ± 11.1 μm nasally (P = 0.02). The average BCE thickness was 55.8 ± 11.4 μm temporally and 60.1 ± 11.0 μm nasally (P = 0.03). There were no statistically significant differences between GVHD and non-GVHD groups in LE thickness (69.6 ± 11.7 vs. 66.1 ± 6.2 μm, respectively, P = 0.31) or BCE thickness (58.9 ± 9.6 vs. 57.3 ± 9.8 μm, respectively, P = 0.82). There was a significant correlation between LE thickness and BCE thickness (P = 0.01, Rs = 0.41). A statistically significant negative correlation was also observed between LE thickness and age (P = 0.002, Rs = -0.35). There were no significant correlations between the thickness of the LE or BCE and other clinical parameters.

CONCLUSIONS

No difference exists in the thickness of the ocular surface epithelia between dry eyes with and without ocular GVHD, which would suggest that these epithelial changes may be independent of the underlying etiology and possibly only reflect the disease severity. Furthermore, there are regional variations in the thickness of the ocular surface epithelia in patients with DED.

Effect of long-term topical latanoprost medication on conjunctival thickness in patients with glaucoma

AIM

To investigate the effect of long-term use of topically administered latanoprost on conjunctival thickness (CT) and conjunctival epithelium thickness (CET) in the patients with glaucoma.

METHODS

A series of 106 glaucomatous patients were included. Of the 106 eyes, 55 eyes were treated with latanoprost eye drops once a day (latanoprost group), while 51 eyes were treated with carteolol hydrochloride eye drops (carteolol group). All the included patients completed a 2-year follow-up. CT and CET were measured with optical coherence tomography (OCT) in all patients at presentation and at 2-year visit, respectively. Statistical analysis was then performed to compare the change in CT and CET.

RESULTS

At presentation, there was no difference in CET (t=0.400, P=0.689) or CT (t=1.14, P=0.259) between the two groups. No significant difference was found in CET (61.65±5.35 µm at baseline, 60.36±6.36 µm at 2-year follow-up, respectively; t=1.977, P=0.0531), while there was a significant decrease in CT from 201.45±14.99 µm at baseline to 167.81±14.57 µm at 2-year visit (t=14.1407, P<0.001) in the latanoprost group. At 2-year follow-up, no statistically difference was found in CET (62.24±5.27 µm; t=1.086, P=0.282) or CT (201.23±12.45 µm; t=1.44, P=0.154) compared to it at baseline (CET: 61.23±5.42 µm; CT: 198.76±13.68 µm, respectively) in the carteolol group.

CONCLUSION

A significant decrease in conjunctival thickness is found in glaucoma patients treated with long-term topical latanoprost; its potential effect on the outcome of filtration surgery should be considered.

A preliminary study on the establishment of an animal model of conjunctivochalasis

AIM

To explore a feasible method on the establishment of an animal model of conjunctivochalasis (CCH).

METHODS

Twelve clean-grade New Zealand white rabbits were divided into four groups (n=3/group): the control group (one received no interventions, and the others underwent subconjunctival injection of sterile water), the matrix metalloproteinases (MMPs) group (administered subconjunctival injection of MMP-3), the aging group (administered subcutaneous injection of D-galactose), the tumor necrosis factor-α (TNF-α) solution group (administered eye drops of TNF-α). Anterior segment photography, conjunctival tissue light microscopy and transmission electron microscopy (TEM) were performed after 12wk.

RESULTS

Among all groups, the MMPs group had the following changes: the looser connection between the inferior bulbar conjunctiva and sclera; the more disordered collagen fibers (Trichrome staining) and the broken elastic fibers (Aldehyde-fuchsin staining); the focal necrosis of fibroblasts (TEM).

CONCLUSION

Administration of MMPs may be a feasible method for the establishment of an animal model of CCH.

Conjunctivochalasis: a systematic review

Conjunctivochalasis (CCH) is a conjunctival condition characterized by loose, redundant conjunctival folds, most typically in the inferior bulbar conjunctiva of both eyes. Although CCH is a common cause of ocular irritation and discomfort, especially in the elderly, it is often overlooked in clinical practice. CCH may be associated with various ocular and nonocular conditions; however, the most important risk factor is aging. Although often asymptomatic, CCH may cause symptoms related to tear film instability and/or delayed tear clearance. Pathogenesis of CCH remains largely unknown but may involve different elements such as aged conjunctiva, unstable tear film, mechanical friction, ocular surface inflammation, and delayed tear clearance. Contradictory results have been reported on histopathologic changes in CCH, with some studies showing a normal microscopic structure. For symptomatic CCH, medical treatment may include lubrication and anti-inflammatory medications. For symptomatic patients who fail to respond to medical treatment, a surgical procedure may be considered. Although various surgical procedures have been used for CCH, more often, it consists of conjunctival cauterization or excision of the redundant conjunctiva, with or without amniotic membrane transplantation.

The role of elastic fibers in pathogenesis of conjunctivochalasis

The PubMed, MEDLINE databases and China National Knowledge Infrastructure (CNKI) were searched for information regarding the etiology and pathogenesis of conjunctivochalasis (CCh) and the synthesis and degradation of elastic fibers. After analysis of the literature, we found elastic fibers was a complex protein molecule from the structure and composition; the degradation of elastic fibers was one of the histopathological features of the disease; the vast majority of the factors related to the pathogenesis of CCh ultimately pointed to abnormal elastic fibers. By reasonably speculating, we considered that abnormal elastic fibers cause the conjunctival relaxation. In conclusion, we hypothesize that elastic fibers play an important role in the pathogenesis of CCh. Studies on the mechanism of synthesis, degradation of elastic fibers are helpful to clarify the pathogenesis of the disease and to find effective treatment methods.

Intraocular Pressure After 2 Hours of Small-Diameter Scleral Lens Wear

OBJECTIVES

Compression of episcleral veins or deformation of tissue in the Schlemm's canal beneath the landing zone of scleral lenses could elevate intraocular pressure (IOP). We examined the effect of 2 hr of small-diameter scleral lens wear on IOP.

METHODS

Twenty-nine participants, 29 ± 6 years old (mean ± SD) who experienced no history of eye disease or scleral lens wear, were included in the study. Each participant was fitted with a 15-mm Jupiter scleral lens on one eye (study eye). Intraocular pressure was measured in both eyes by pneumatonometry centrally on the cornea and peripherally on the sclera. The lens was then placed on one eye and was worn for 2 hr. Intraocular pressure was remeasured immediately after lens placement, at 1 and 2 hr of lens wear, and immediately after lens removal. Intraocular pressure after removal of the scleral lens was compared with IOP before placing the lens and to IOP in the control eye using paired t tests.

RESULTS

Immediately after removing the scleral lens, mean central IOP in the study eye (13.9 ± 3.1 mm Hg) was not different from mean central IOP in the control eye (13.5 ± 2.2 mm Hg, P = 0.4) or in the same eye before lens wear (13.6 ± 1.9 mm Hg, P = 0.6). There were also no differences in IOP measured peripherally at 2 hr of lens wear (P = 0.8).

CONCLUSIONS

Neophyte scleral lens wear of a 15-mm scleral lens for 2 hr does not increase IOP in healthy eyes.

A New Surgical Approach for the Treatment of Conjunctivochalasis: Reduction of the Conjunctival Fold with Bipolar Electrocautery Forceps

Aim. To report a new surgical technique for the treatment of conjunctivochalasis. Methods. A new surgical technique in which specially designed bipolar electrocautery forceps facilitate the complete reduction of the conjunctival folds without creating lesions near the corneoscleral limbus was designed. A retrospective revision of the medical records of patients treated with this technique between the years 2011 and 2013 was made, and eighteen eyes of sixteen patients with conjunctivochalasis treated with this new technique were included. Results. All the eyes treated showed a significant improvement with no evidence of scar lesions after a mean follow-up time of 10 months. Conclusions. The surgical technique presented here could be a good alternative for the management of conjunctivochalasis.

Histopathology of Conjunctivochalasis Compared to Normal Conjunctiva

Purpose:

To evaluate the histopathologic changes in the conjunctiva of patients with conjunctivochalasis (CCh) compared to age-matched controls.

Methods:

This cross-sectional, controlled study included 27 eyes of 27 patients with CCh and 16 eyes of 16 age-matched controls. A biopsy of the bulbar conjunctiva was performed along the temporal lower lid margin before cataract surgery in both groups. Histopathologic evaluation of the specimens was done with light microscopy using staining with hematoxylin/eosin, periodic acid Schiff, and van Gieson elastic stain. Various histopathologic features of the conjunctival epithelium and stroma were compared between the two groups.

Results:

The mean age of patients was 62.4 ± 6.9 years in the CCh group and 65.1 ± 6.3 years in the control group (P = 0.54). No significant differences were noted between the two groups in terms of conjunctival epithelial changes including papillomatosis, epithelial clefts, epithelial goblet cells, or infiltration of inflammatory cells. Mean thickness of the conjunctival stroma was 0.21 ± 0.08 mm in the CCh group and 0.26 ± 0.21 mm in the control group (P = 0.10). For the conjunctival stroma, there were no significant differences between the two groups in terms of elastosis, fibrosis, lymphangiectasia, or infiltration of inflammatory cells.

Conclusion:

No noticeable differences were found in the histopathologic features by light microscopy between eyes with CCh and those of age-matched controls. Therefore, the primary pathology of CCh may not be within the conjunctiva itself. Instead, loose attachment of the conjunctiva to the underlying tissue may be the reason for the redundant folds in the bulbar conjunctiva.

The BLICK mnemonic for clinical-anatomical assessment of patients with epiphora

PURPOSE

Evaluation of the tearing patient is often distilled to a search for ocular surface problems causing reflex hypersecretion versus lacrimal drainage problems. The literature does not typically emphasize conditions affecting the function of the tear distribution system, but neglect of these important factors can lead to suboptimal treatment outcomes. The intent of this review is to provide a systemic evaluation of frequently overlooked conditions that can influence the distribution system and to offer a mnemonic to ensure an orderly sequence of inspection during clinical examination.

METHODS

Review of clinical literature and experience from 1957 to 2014.

RESULTS

Tearing complaints attributable to problems with the distribution system can be evaluated, classified, and managed according to the mnemonic BLICK, which stands for Blink dynamics, Lid malposition, Imbrication, Conjunctivochalasis, and Kissing puncta.

CONCLUSION

The BLICK mnemonic is a useful adjunct to the workup of epiphora.