Increasing prevalence and severity of conjunctivochalasis with aging detected by anterior segment optical coherence tomography

Clinical outcomes of conjunctivochalasis treatment with a new ophthalmic radiofrequency device

PURPOSE

To investigate the safety and efficacy of a new micro-controlled radiofrequency device for treatment of conjunctivochalasis (Cch).

METHODS

Data of 127 patients (230 eyes) who underwent ophthalmic radiofrequency treatment for Cch from January 2020 to June 2023 were analyzed retrospectively. Cch coagulation was performed with a radiofrequency electrode tip (OcuRF®, Ilooda, Korea) and a high-frequency radio-wave electric unit (0.6 ~ 0.8 watts, 2 MHz, Acutron™, Ilooda, Korea). Pre- and postoperative Cch grading, slit-lamp photography, tear film break-up time (TBUT), and bulbar conjunctival hyperemia using Keratograph 5 M (Oculus, Wetzlar, Germany) were evaluated. Cch grade 0 or 1 after surgery was regarded as 'success'. Complications, recurrence, and additional treatment rates were analyzed.

RESULTS

In 227 (98.7%) eyes, the radiofrequency treatment led to marked improvement of Cch, with 224 (97.4%) eyes achieving grade 0 or 1 at 2 months postoperatively. Eight eyes (3.5%) received additional treatment. TBUT improved from 3.17 ± 0.82 s to 5.28 ± 1.10 s after surgery (P < 0.001). The total bulbar conjunctival hyperemia value showed an improvement from 1.7 ± 0.6 to 1.4 ± 0.6 postoperatively (P < 0.05). No serious complications were observed.

CONCLUSION

The novel ophthalmic radiofrequency device led to a marked improvement of Cch with no serious adverse events during the entire follow-up period. Our results suggest that the radiofrequency device presents a safe and efficacious treatment option for Cch.

Study of IL-17 and Intercellular Adhesion Molecule-1 in Conjunctivochalasis Using Correlation Analysis

PURPOSE

The aim of this study was to observe the expression of interleukin (IL)-17 and intercellular adhesion molecule (ICAM)-1 in conjunctivochalasis (CCH) and to analyze the correlations between cytokines and the severity of CCH.

METHODS

Serum samples were collected from 22 patients with CCH and 18 normal controls (NCs). The Ocular Surface Disease Index, tear film break-up time, Schirmer I test, and corneal fluorescein staining were used to evaluate the ocular surface signs and symptoms. The concentrations of IL-17, IL-23, and ICAM-1 in serum and cellular supernatants were measured by enzyme-linked immunosorbent assays, and the gene expression levels of cytokines were measured by a quantitative real-time polymerase chain reaction. The relationships between serum concentrations of IL-17, IL-23, and ICAM-1 with clinical ocular surface parameters in CCH were analyzed using the Spearman correlation analysis.

RESULTS

The concentrations of IL-17 and ICAM-1 in serum and cellular supernatants of CCH were significantly higher than those of NCs (all P < 0.001). The concentrations of IL-23 in serum and cellular supernatants of CCH showed no significant difference from those of NCs ( P > 0.05). The mRNA expression levels of IL-17 and ICAM-1 in conjunctival fibroblasts of CCH were significantly higher than those of NCs (all P < 0.001). The mRNA expression of IL-23 in conjunctival fibroblasts of CCH was higher than that of NCs, without a significant difference ( P > 0.05). Furthermore, the serum concentrations of IL-17 and ICAM-1 were positively correlated with Ocular Surface Disease Index and fluorescein staining (all P < 0.05), and negatively correlated with break-up time and Schirmer I test of CCH (all P < 0.05).

CONCLUSIONS

The expression levels of IL-17 and ICAM-1 were significantly increased in CCH serum and associated with the disease severity. We postulate that IL-17 and ICAM-1 may play a role in the pathogenesis of CCH. IL-17 and ICAM-1 antagonists may be a potential treatment option for CCH in the future.

The mechanism of Qijing Mingmu decoction on cellular senescence of conjunctivochalasis

BACKGROUND

Qijing Mingmu decoction (QJMM), a compound Chinese medicine preparation, which consists of Lycium barbarum, Polygonatum, Ophiopogon japonicus, Poria cocos, Glycyrrhiza, Eclipta prostrata and Ligusticum striatum, has been confirmed to be effective for the treatment of conjunctivochalasis (CCH) in clinic and reduce cellular senescence. However, the underlying mechanism is still unknown. Our previous study revealed that p38-mediated cellular senescence contributed to the pathogenesis of CCH.

METHODS

To explore whether p38 might be the potential therapeutic target of QJMM for CCH, CCH fibroblasts were treated with QJMM granule and then the effect of QJMM granule on the expression and promoter activity of p38α was determined by western blot and dual luciferase reporter gene assay, respectively. Meanwhile, the influence of QJMM granule on cell proliferation, oxidative stress, cellular senescence and the expression of the cellular senescence-associated genes were measured by corresponding methods.

RESULTS

QJMM granule significantly decreased the protein expression of p38α and p-p38α in CCH fibroblasts in a dose-dependent manner and inhibited p38α promoter activity. QJMM granule as well as the p38 inhibitor SB203580 reduced the level of reactive oxygen species and increased the activity of superoxide dismutase in CCH fibroblasts. QJMM granule and SB203580 promoted cell proliferation and reduced the percentage of SA-β-Gal-positive cells. The mRNA and protein expression of p53 and p21 was remarkably down-regulated by QJMM granule as well as SB203580 and that of SMP30 was up-regulated in CCH fibroblasts.

CONCLUSIONS

Our findings demonstrated that QJMM granule was effective for alleviating cellular senescence of CCH fibroblasts by p38 MAPK signaling and the followed p53/p21 signaling.

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.

TFOS lifestyle: Impact of societal challenges on the ocular surface

Societal factors associated with ocular surface diseases were mapped using a framework to characterize the relationship between the individual, their health and environment. The impact of the COVID-19 pandemic and mitigating factors on ocular surface diseases were considered in a systematic review. Age and sex effects were generally well-characterized for inflammatory, infectious, autoimmune and trauma-related conditions. Sex and gender, through biological, socio-economic, and cultural factors impact the prevalence and severity of disease, access to, and use of, care. Genetic factors, race, smoking and co-morbidities are generally well characterized, with interdependencies with geographical, employment and socioeconomic factors. Living and working conditions include employment, education, water and sanitation, poverty and socioeconomic class. Employment type and hobbies are associated with eye trauma and burns. Regional, global socio-economic, cultural and environmental conditions, include remoteness, geography, seasonality, availability of and access to services. Violence associated with war, acid attacks and domestic violence are associated with traumatic injuries. The impacts of conflict, pandemic and climate are exacerbated by decreased food security, access to health services and workers. Digital technology can impact diseases through physical and mental health effects and access to health information and services. The COVID-19 pandemic and related mitigating strategies are mostly associated with an increased risk of developing new or worsening existing ocular surface diseases. Societal factors impact the type and severity of ocular surface diseases, although there is considerable interdependence between factors. The overlay of the digital environment, natural disasters, conflict and the pandemic have modified access to services in some regions.

Does the conjunctivochalasis accompanied by pseudoexfoliation syndrome affect the ocular surface and anterior segment structures?

PURPOSE

The probability of the coexistence of conjunctivochalasis and pseudoexfoliation syndrome (PES) in the same individual may increase with aging. We investigated the effects of conjunctivochalasis accompanied by PES on the ocular surface (OS) and anterior segment (AS) structures.

METHODS

Cases with only conjunctivochalasis were determined as Group 1 (n = 62), cases with conjunctivochalasis accompanied by PES as Group 2 (n = 45), and healthy individuals as Group 3 (n = 56). The OS and AS parameters of the groups were compared.

RESULTS

There were a higher grade-3 conjunctivochalasis rate (17.7% vs. 46.7%, p = 0.039), a greater "mean grade of conjunctivochalasis" value (1.72 ± 0.24 vs. 2.29 ± 0.32, p = 0.036), and a higher "total conjunctivochalasis score" (4.27 ± 1.13 vs. 6.12 ± 1.35, p = 0.025) in Group 2 than in Group 1. Additionally, Group 2 had a shorter tear film break-up time (TBUT) (9.17 ± 2.53 vs. 5.41 ± 1.32, p = 0.010) and a greater OS disease index (OSDI) score (16.28 ± 3.15 vs. 27.36 ± 4.12, p = 0.037) than Group 1. Moreover, both Group 1 and Group 2 had shorter TBUTs (Group 1-3: p = 0.004; Group 2-3: p < 0.001) and greater OSDI scores (Group 1-3: p = 0.042; Group 2-3: p = 0.019) compared to Group 3. The groups' ocular surface staining scores, Schirmer 1 tests, central corneal thicknesses, keratometries, axial lengths, anterior chamber depths, lens thicknesses, and intraocular pressures were similar (p > 0.05).

CONCLUSIONS

To our knowledge, this was the first study comprehensively investigating the effects of conjunctivochalasis accompanied by PES on the OS and AS structures together. We found that conjunctivochalasis might cause the OS disease, while the presence of PES in conjunctivochalasis cases might worsen both the OS disease and conjunctivochalasis findings.

CLEAR - Effect of contact lens materials and designs on the anatomy and physiology of the eye

This paper outlines changes to the ocular surface caused by contact lenses and their degree of clinical significance. Substantial research and development to improve oxygen permeability of rigid and soft contact lenses has meant that in many countries the issues caused by hypoxia to the ocular surface have largely been negated. The ability of contact lenses to change the axial growth characteristics of the globe is being utilised to help reduce the myopia pandemic and several studies and meta-analyses have shown that wearing orthokeratology lenses or soft multifocal contact lenses can reduce axial length growth (and hence myopia). However, effects on blinking, ptosis, the function of Meibomian glands, fluorescein and lissamine green staining of the conjunctiva and cornea, production of lid-parallel conjunctival folds and lid wiper epitheliopathy have received less research attention. Contact lens wear produces a subclinical inflammatory response manifested by increases in the number of dendritiform cells in the conjunctiva, cornea and limbus. Papillary conjunctivitis is also a complication of all types of contact lenses. Changes to wear schedule (daily disposable from overnight wear) or lens materials (hydrogel from SiHy) can reduce papillary conjunctivitis, but the effect of such changes on dendritic cell migration needs further study. These changes may be associated with decreased comfort but confirmatory studies are needed. Contact lenses can affect the sensitivity of the ocular surface to mechanical stimulation, but whether these changes affect comfort requires further investigation. In conclusion, there have been changes to lens materials, design and wear schedules over the past 20+ years that have improved their safety and seen the development of lenses that can reduce the myopia development. However, several changes to the ocular surface still occur and warrant further research effort in order to optimise the lens wearing experience.

The correction of conjunctivochalasis using high-frequency radiowave electrosurgery improves dry eye disease

We aimed to determine the clinical impact of conjunctivochalasis (CCh) and its correction using high-frequency radiowave electrosurgery (HFR-ES), for signs and symptoms of dry eye disease (DED). Forty patients diagnosed with symptomatic CCh were prospectively enrolled. As a result, patients with CCh had moderate to severe DED and most of them exhibited meibomian gland dysfunction (MGD). Corneo-conjunctival fluorescein staining score (CFS) and all lid-parallel-conjunctival-folds scores (LIPCOFs) were positively correlated. Nasal LIPCOF significantly correlated with symptoms and tear volume. Central, temporal, and total LIPCOF significantly correlated with MG loss, MGD stage, and lipid layer thickness. Independent significant factors associated with total LIPCOF included CFS, tear break-up time, and MGD stage. One month following HFR-ES, CCh was completely resolved in all cases. Patient age and preoperative nasal LIPCOF were determinants of outcomes associated with postoperative improvements in symptoms. Ocular surface parameters significantly improved, but MGD-related signs did not. Collectively, CCh associated with MGD severity deteriorates not only tear film stability and reservoir capacity, leading to DED exacerbation. Therefore, CCh should be corrected in patients with DED and MGD. Younger patients with nasal CCh are likely to experience more symptomatic relief after HFR-ES. Particularly, management for MGD should be maintained after CCh correction.

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.

Fourier-Domain OCT Imaging of the Ocular Surface and Tear Film Dynamics: A Review of the State of the Art and an Integrative Model of the Tear Behavior During the Inter-Blink Period and Visual Fixation

In the last few decades, the ocular surface and the tear film have been noninvasively investigated in vivo, in a three-dimensional, high resolution, and real-time mode, by optical coherence tomography (OCT). Recently, OCT technology has made great strides in improving the acquisition speed and image resolution, thus increasing its impact in daily clinical practice and in the research setting. All these results have been achieved because of a transition from traditional time-domain (TD) to Fourier-domain (FD) technology. FD-OCT devices include a spectrometer in the receiver that analyzes the spectrum of reflected light on the retina or ocular surface and transforms it into information about the depth of the structures according to the Fourier principle. In this review, we summarize and provide the state-of-the-art in FD-OCT imaging of the ocular surface system, addressing specific aspects such as tear film dynamics and epithelial changes under physiologic and pathologic conditions. A theory on the dynamic nature of the tear film has been developed to explain the variations within the individual compartments. Moreover, an integrative model of tear film behavior during the inter-blink period and visual fixation is proposed.

The expression of MAPK signaling pathways in conjunctivochalasis

This study investigated the potential role of MAPK signaling pathways in conjunctivochalasis (CCH). Twenty loose conjunctival biopsy samples from 20 CCH and 15 conjunctival biopsy samples from 15 normal controls (CON) were collected. The conjunctival fibroblasts were cultured in vitro. Immunofluorescence, ELISA, Western blot and reverse transcription-polymerase chain reaction (RT-PCR) were used. Our results showed that the expression of p-ERK, p-JNK, and p-p38 in CCH conjunctiva was significantly higher than that in CON group. The expression of p38 MAPK, JNK, and ERK proteins in CCH fibroblasts was significantly higher than that in CON group. The total expression of MAPK mRNA in CCH fibroblasts was significantly higher than that in CON group. The activated forms of p38 MAPK, JNK, and ERK proteins and mRNAs might up-regulate the expression of MMPs in CCH loose conjunctival tissue and fibroblasts, causing the degradation of collagen fibers and elastic fibers and promoting the occurrence of CCH. Our results deepen the understanding of CCH pathological mechanism.

Presbyopia and the aging eye: Existing refractive approaches and their potential impact on dry eye signs and symptoms

Every part of the human body is subject to aging, including the eye. An increased prevalence of dry eye disease with age is widely acknowledged. Aging threatens ocular surface homeostasis, altering the normal functioning of the lacrimal functional unit and potentially leading to signs and symptoms of dry eye. Additional age-related processes take place within the crystalline lens, leading to presbyopia and cataractogenesis. Correction strategies for presbyopia and cataracts may directly or indirectly challenge the ocular surface. Contact lenses disturb the normal structure of the tear film and can interact negatively with the ocular surface, further deteriorating an already unbalanced tear film in presbyopes, however, newer contact lens designs can overcome some of these issues. Moreover, cataract and corneal refractive surgeries sever corneal nerves and disrupt the corneal epithelium and ocular surface, which can influence surgical outcomes and aggravate dryness symptoms in older age groups. This review summarises the current understanding of how the invasive nature of contact lens wear and cataract and refractive surgery influence signs and symptoms of ocular dryness in an aging population.

Lid-parallel conjunctival fold (LIPCOF) morphology imaged by optical coherence tomography and its relationship to LIPCOF grade

PURPOSE

Lid-parallel conjunctival folds (LIPCOF) are a well-accepted clinical sign in dry eye diagnosis. Commonly, LIPCOF is classified by grading the number of folds observed by slit-lamp microscope. This study investigated the relationship between subjective grading scale and LIPCOF morphology imaged by optical coherence tomography (OCT).

METHODS

Temporal and nasal LIPCOF of 42 subjects (mean age 27.3 ± 8.4 (SD) years; 13 M, 29 F) were observed and classified by an experienced optometrist using the Pult LIPCOF grading scale (0: no permanent, lid-parallel conjunctival fold; 1: one fold; 2: two folds, 3: three or more folds). Additionally, LIPCOF cross-sectional area (LIPCOF-A) and fold count (LIPCOF-C), as imaged by OCT (Cirrus HD; Carl Zeiss Meditec, Jena, Germany), were analysed with ImageJ 1.50 (http://rsbweb.nih.gov/ij). Correlations between subjective grading and LIPCOF-A and LIPCOF-C were analysed by Spearman correlation, differences between subjective grading and LIPCOF-C were analysed by Wilcoxon test.

RESULTS

For temporal and nasal sectors, mean subjective LIPCOF grade was 1.43 ± 0.86 grade units and 0.57 ± 0.80 grade units, mean LIPCOF-C was 1.67 ± 0.82 folds and 0.69 ± 0.78 folds, and mean LIPCOF-A was 0.0676 ± 0.0236mm² and 0.0389 ± 0.0352 mm², respectively. Subjective temporal and nasal LIPCOF grade was significantly correlated to LIPCOF-C (r = 0.610, p < 0.001 and r = 0.645, p < 0.001, respectively), and to LIPCOF-A (r = 0.612, p < 0.001 and r = 0.583, p < 0.001, respectively). LIPCOF-C was not statistical different to subjective LIPCOF grade (p = 0.07 and p = 0.239; temporal and nasal sectors, respectively).

CONCLUSIONS

OCT allows for better imaging of finer details of LIPCOF morphology, and especially of LIPCOF area. OCT evaluation of LIPCOF area correlated well with subjective grading and appears to be a promising objective method for LIPCOF classification.

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.

[Ocular surface aging: Pathophysiology and consequences for management]

All the components of the ocular surface and the lacrimal system are affected by aging. Aging induces lacrimal gland fibrosis, Meibomian gland dysfunction, loss of corneal sensitivity, decreased corneal cell density, impairment of immune defences, increased local inflammation associated with hormonal changes, conjunctivochalasis, lid abnormalities, etc. Furthermore, homeostasis of the ocular surface may be altered by various age-related systemic comorbidities and iatrogenic interventions. Altogether, aging is considered the most predominant risk factor for dry eye disease. The increasing knowledge of the pathophysiology of aging of the ocular surface allows for refinement of the management of ocular surface disease in the elderly.

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.

Update in Current Diagnostics and Therapeutics of Dry Eye Disease

Dry eye disease (DED) represents a heterogeneous group of conditions with tear film insufficiency and signs and/or symptoms of ocular surface irritation. The clinical manifestations of DED can be highly variable; hence the diagnosis is often based on a combination of symptoms, signs, and clinical tests, given that any one of these alone would miss a significant number of patients. Similarly, the treatment must often be tailored to each patient by targeting the specific mechanisms involved in his or her disease. The purpose of this review is to summarize recent advances that have allowed us to better recognize, categorize, and treat patients with DED. The most notable new diagnostic tests in DED are tear film osmolarity, inflammatory biomarkers, and meibomian gland imaging. Therapeutically, anti-inflammatory therapy, meibomian gland heating and expression, and scleral contact lenses are some of the latest options available for treating DED.

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.

Usability and reproducibility of tear meniscus values generated via swept-source optical coherence tomography and the slit lamp with a graticule method

Purpose

To investigate the usability and the reproducibility of the tear meniscus values via swept-source optical coherence tomography (SS-OCT) and the conventional slit lamp microscope method with a graticule.

Methods

The right eye was examined in 90 healthy adult subjects who were grouped according to age (group 1: 20–39 years; group 2: 40–59 years; group 3: ≥60 years). The tear meniscus height (TMH) and tear meniscus area were measured using SS-OCT and TMH by the slit lamp microscope method. The reproducibility of each method was calculated using intraclass correlation coefficients (ICCs) in additionally enrolled 30 healthy young subjects. We also evaluated TMH at 3 mm from the corneal center in both temporal and nasal directions using SS-OCT.

Results

The mean of the TMH values measured by SS-OCT was significantly higher than those measured by the slit lamp method (328 vs. 212 μm, P < 0.001, respectively). High reproducibility was observed for each method (ICC > 0.75 for both). No statistically significant differences were found in TMH among the age groups using both SS-OCT and slit lamp methods (P = 0.985, 0.380, respectively). TMH values at both sides of the corneal center were significantly smaller than those at the corneal center (P < 0.0001).

Conclusions

TMH values obtained by the slit lamp method were lower than those obtained by SS-OCT. However, both methods yielded highly reproducible TMH measurements, suggesting that they are clinically useful. Tear meniscus values did not vary by age but by measurement points in our cohort.

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.

Therapeutic Strategies to Treat Dry Eye in an Aging Population

Dry eye (DE) is a prevalent ocular disease that primarily affects the elderly. Affecting up to 30% of adults aged 50 years and older, DE affects both visual function and quality of life. Symptoms of DE, including ocular pain (aching, burning), visual disturbances, and tearing, can be addressed with therapeutic agents that target dysfunction of the meibomian glands, lacrimal glands, goblet cells, ocular surface, and/or neural network. This review provides an overview of the efficacy, use, and limitations of current therapeutic interventions being used to treat DE.

The impact of conjunctivochalasis on dry eye symptoms and signs

PURPOSE

The purpose of this project was to study the relationship between conjunctivochalasis (Cch) and ocular signs and symptoms of dry eye.

METHODS

Ninety-six patients with normal eyelid and corneal anatomy were prospectively recruited from a Veterans Administration hospital over 12 months. Symptoms (via the dry eye questionnaire 5 [DEQ5]) and signs of dry eye were assessed along with quality of life implications. Statistical analyses comparing the above metrics among the three groups included χ(2), analysis of variance, and linear regression tests.

RESULTS

Participants were classified into three groups: nasal conjunctivochalasis (NCch; n = 31); nonnasal conjunctivochalasis (non-NCch; n = 41); and no conjunctivochalasis (no-Cch; n = 24). Patients with NCch had more dry eye symptoms than those with non-NCch (DEQ5: NCch = 13.8 ± 5.0, non-NCch = 10.2 ± 5.0, no-Cch = 11.6 ± 5.8; P = 0.014), and more ocular pain than those with Non-NCch and no-Cch (numerical rating scale [NRS]: NCch = 4.5 ± 3.0, non-NCch = 2.3 ± 2.8, no-Cch = 3.3 ± 2.6; P = 0.008). They also had worse dry eye signs compared to those with no-Cch measured by Schirmer score with anesthesia (NCch = 14.5 ± 6.9, non-NCch = 16.8 ± 8.2, no-Cch = 19.9 ± 6.4; P = 0.039); meibomian gland dropout (NCch 1.8 ± 0.9, non-NCch = 1.4 ± 1.0, no-Cch = 1.0 ± 1.0; P = 0.020); and eyelid vascularity (NCch = 0.84 ± 0.8, non-NCch = 0.74 ± 0.7, no-Cch = 0.33 ± 0.6; P = 0.019). Moreover, those with NCch more frequently reported that dry eye symptoms moderately to severely impacted their quality of life (NCch = 87%, non-NCch = 51%, no-Cch = 58%; P = 0.005).

CONCLUSIONS

The presence of NCch associates with dry eye symptoms, abnormal tear parameters, and impacts quality of life compared with non-NCch and no-Cch. Based on these data, it is important for clinicians to look for Cch in patients with symptoms of dry eye.

In vivo evaluation of the cornea and conjunctiva of the normal laboratory beagle using time- and Fourier-domain optical coherence tomography and ultrasound pachymetry

OBJECTIVE

To obtain normative data for the canine cornea and conjunctiva using high-resolution time- and Fourier-domain optical coherence tomography (TD-OCT and FD-OCT) and ultrasound pachymetry (USP).

ANIMALS

One hundred sixty-eight eyes of 133 healthy young intact laboratory beagles.

PROCEDURES

The cornea and conjunctiva of 16 eyes of 8 healthy young intact female beagles were imaged using FD-OCT. Corneal thickness was measured with FD-OCT and USP, while corneal epithelial thickness and conjunctival epithelial thickness were measured with FD-OCT. The central corneal thickness (CCT) was determined in 152 eyes of 125 healthy young adult intact female (35) and male (90) beagles using TD-OCT. Mixed effects linear regression was used for statistical analysis.

RESULTS

The CCT was (mean ± standard deviation) 497.54 ± 29.76, 555.49 ± 17.19, and 594.81 ± 33.02 μm as measured by FD-OCT, USP, and TD-OCT, respectively. The central, superior paraxial, superior perilimbal corneal epithelial thickness and superior bulbar conjunctival epithelial thickness were 52.38 ± 7.27, 56.96 ± 6.47, 69.06 ± 8.84 and 42.98 ± 6.17 μm, respectively. When comparing techniques used for measuring CCT (USP vs. FD-OCT and FD-OCT vs. TD-OCT), USP and TD-OCT generated significantly greater values in comparison with FD-OCT (both P < 0.001). For all dogs, CCT increased with increasing age and body weight (both P < 0.001) and was higher in intact males vs. females using TD-OCT (P = 0.034).

CONCLUSION

High-resolution FD-OCT and TD-OCT provide detailed noninvasive evaluation of in vivo canine anterior segment structures. Normative values of the canine cornea and conjunctiva are reported.

Clinical characteristics of patients with conjunctivochalasis

Purpose

To evaluate the clinical characteristics of patients with conjunctivochalasis (CCh).

Methods and materials

This retrospective study enrolled 30 subjects diagnosed with conjunctivochalasis. Complete ophthalmic examination, including visual acuity assessment, slit-lamp examination, applanation tonometry, dilated funduscopy, tear break-up time, Schirmer 1 test, and fluorescein staining were performed in all patients. Age, sex, laterality, ocular history, symptoms, and clinical findings were recorded.

Results

The study included 50 eyes from 30 cases. Ages ranged from 45 to 80 years, with a mean age of 65±10 years. CChs grading were as follows: 30 (60%) eyes with grade 1 CCh; 15 (30%) eyes with grade 2 CCh; and five (10%) eyes with grade 3 CCh. CCh was located in the inferior bulbar conjunctiva in 45 (90%) eyes, and in the remaining five (10%) CCh was located in the superior bulbar conjunctiva. Ten (33.3%) patients had no symptoms. Dryness, eye pain, redness, blurry vision, tired eye feeling, and epiphora were the symptoms encountered in the remaining twenty (63.6%) patients. Altered tear meniscus was noted in all cases. The mean tear break-up time was 7.6 seconds. The mean Schirmer 1 test score was 7 mm. Pinguecula was found in ten patients.

Conclusion

Dryness, eye pain, redness, blurry vision, and epiphora were the main symptoms in patients with CCh. Dryness, eye pain, and blurry vision were worsened during downgaze and blinking. So CCh should be taken into consideration in the differential diagnosis of chronic ocular irritation and epiphora.

New testing options for diagnosing and grading dry eye disease

PURPOSE

To describe new options for diagnosis and severity grading of dry eye disease.

DESIGN

Perspective on technological advancements to identify tear dysfunction and their value in diagnosing and grading dry eye disease.

METHODS

Evidence is presented on new and evolving technologies to measure tear stability, composition, and meniscus height and their role in dry eye diagnosis and therapeutic efficacy grading is assessed.

RESULTS

Evolving concepts regarding pathogenesis and new technologies to evaluate the tears and ocular surface have improved the ability to diagnose, classify, and grade the severity of dry eye disease. New technologies include noninvasive imaging of tear stability and tear meniscus height as a measure of tear volume and tear composition (osmolarity, lacrimal factors, inflammatory mediators, growth and differentiation factors). Approved tests, such as tear osmolarity and tear imaging, are being integrated into clinical practice and may eventually supplant certain traditional tests that have greater variability and less sensitivity. Other tests, such as molecular assays of tears and conjunctival cells, are currently being used in studies investigating pathogenesis and therapeutic mechanism of action. They may eventually translate to routine clinical practice.

CONCLUSIONS

New technologies have emerged that can noninvasively evaluate the tears and measure disease-associated compositional changes. These tests are being integrated into clinical practice and therapeutic trials for diagnosis, classification, and severity grading of dry eye disease.

Tear meniscus dimensions in tear dysfunction and their correlation with clinical parameters

PURPOSE

To evaluate relationships between tear meniscus dimensions and parameters of ocular surface disease in a variety of tear dysfunction conditions.

DESIGN

Single-institution prospective observational study.

METHODS

This study from the Baylor College of Medicine included 128 eyes of 64 subjects. Cross-sectional lower tear meniscus height and tear meniscus area were measured using optical coherence tomography and were compared with tear break-up time (TBUT), corneal staining, conjunctival staining, and an irritation symptom questionnaire (Ocular Surface Disease Index). Study groups included meibomian gland disease (MGD), aqueous tear deficiency (ATD), Sjögren syndrome, non-Sjögren syndrome ATD, and control subjects. Statistical analyses were performed using the Pearson correlation and Student's t test.

RESULTS

When compared with mean tear meniscus height in controls (345 μm), mean tear meniscus height was lower in all tear dysfunction (234 μm; P = .0057), ATD (210 μm; P = .0016), and Sjögren syndrome groups (171 μm; P = .0054). For tear meniscus height ≤210 μm, relative risk ratio for developing corneal staining ≥10 was 4.65. Tear meniscus height correlated with corneal staining for all subjects (R = -0.32; P = .0008), MGD (R = +0.40; P = .059), and ATD (R = -0.36; P = .04). Tear meniscus area showed similar trends in MGD (R = +0.55; P = .006) and ATD (R = -0.40; P = .018). Tear meniscus height correlated with TBUT for all subjects (R = +0.39; P < .0001) and ATD (R = +0.37; P = .018).

CONCLUSIONS

In tear dysfunction conditions, lower tear volume correlates with worse corneal epithelial disease in ATD and Sjögren syndrome, conditions with lacrimal gland dysfunction. In contrast, higher tear volume is associated with corneal epithelial disease in MGD. These findings may improve the ability to identify patients at risk for corneal epithelial disease.

Defining the limits of normal conjunctival fornix anatomy in a healthy South Asian population

PURPOSE

Quantifying the extent of conjunctival fibrosis for documentation of progression in conjunctival scarring disease is a clinical challenge. Measurement of forniceal foreshortening facilitates monitoring of these disorders. This study aims (1) to define the limits of the normal human conjunctival fornices and how these alter with age and (2) to provide normative data for upper and lower fornix depths (FDs) and fornix intercanthal distance (FICD) within a healthy South Asian, racially distinct population.

DESIGN

Epidemiologic, cross-sectional study.

PARTICIPANTS

A total of 240 subjects with national origins from South Asia, with no known ocular history and normal adnexal and conjunctival examination, aged 20 to 80 years.

METHODS

An FICD modification of a custom-designed fornix depth measurer (FDM) was validated and used for measurement of both lower and upper FDs together with FICDs in 480 healthy eyes with no ocular comorbidities. Data were analyzed using repeated-measures analysis of variance and presented as means with 95% confidence intervals (CIs).

MAIN OUTCOME MEASURES

Mean lower and upper FDs and FICD for the entire cohort, stratified according to age decade and sex.

RESULTS

For this South Asian population, the overall upper and lower FDs were 15.3 mm (95% CI, 14.9-15.6) and 10.9 mm (95% CI, 10.7-11.1), respectively, with FICD defined as 32.9 mm (95% CI, 32.5-33.4) (upper) and 31.7 mm (95% CI, 31.3-32.1) (lower). With increasing age, a progressive reduction of all measured parameters (P < 0.001) was noted, with female subjects having significantly shallower fornices (upper FD, P < 0.001; lower FD, P < 0.001; upper FICD, P = 0.081; and lower FICD, P = 0.015).

CONCLUSIONS

This is the first study to define the limits of normal upper FD and FICDs in any population group. Our study demonstrates sex variations and progressive conjunctival shrinkage with age. Although it provides important, objective data for normal forniceal anatomy, further study is recommended in other populations to confirm the generalizability of these data or to enable normal comparative datasets for the assessment of conjunctival scarring disorders among all anthropological groups.