Conjunctivochalasis: a systematic review

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.

Effects of a Long-Acting Diquafosol Ophthalmic Solution on the Ocular Surface, Tolerability, and Usability in Dry Eye Disease

INTRODUCTION

This study aimed to investigate the tolerability of high-viscosity diquafosol tetrasodium (DQS) ophthalmic solution (DIQUAS LX; DQSLX) and examine its usability and effect on clinical findings in patients with dry eye disease (DED).

METHODS

This interventional retrospective study included 66 eyes of 66 patients with DED who switched from conventional DQS to DQSLX ophthalmic solution. Tear function assessments (tear film breakup time [BUT], keratoconjunctival vital staining [VS] score), evaluations of DED symptom relief, and a four-item usability questionnaire ("comfort upon instillation," "irritation upon instillation," "eye mucus discharge," "convenience of instillation frequency") assessed using a visual analog scale from 0 (worst) to 10 (best) were administered 4 weeks after switching to DQSLX. Factors associated with drug tolerability were assessed using multiple regression analysis.

RESULTS

The symptoms improved by 64.2% after switching to DQSLX. The BUT value, VS score, and the questionnaire items "comfort upon instillation" and "convenience of instillation frequency" were significantly improved after switching to DQSLX. DQSLX tolerability was reported as acceptable in 56 (84.8%) and unacceptable in 10 (15.2%) patients. Overall, DQSLX tolerability was significantly associated with "comfort upon instillation" and "convenience of instillation frequency" and tended to be associated with a VS score ≥ 1. DQSLX tolerability depended on symptom and VS score improvements and absence of excessive "eye mucus discharge" in patients with a VS score ≥ 1 (39 patients), but on "comfort upon instillation" and absence of excessive "eye mucus discharge" in patients with a VS score = 0 (27 patients).

CONCLUSION

The high-viscosity DQSLX ophthalmic solution was generally considered acceptable in the study population. However, drug tolerability seemingly differed between patients with DED with and without epithelial damage. The former were affected by improvements in symptoms and clinical findings, whereas the latter were affected by comfort upon instillation.

TRIAL REGISTRATION

University Hospital Medical Information Network identifier, UMIN000051390.

The Influence of Lid-Parallel Conjunctival Folds and Conjunctivochalasis on Dry Eye Symptoms with and Without Contact Lens Wear: A Review of the Literature

INTRODUCTION

Lid-parallel conjunctival folds (LIPCOF) and conjunctivochalasis (CCH) are similar conditions that seem to be related to dry eye severity. In addition, there is a lack of studies on the topic of LIPCOF and CCH on dry eye symptoms in non-contact lens and contact lens (CL) wearers. Therefore, the aim of this study is to review the relationship of LIPCOF and CCH with dry eye symptoms in non-CL and CL wearers, as well as to report the treatment of dry eye disease (DED) in non-CL and CL wearers who present LIPCOF or CCH.

METHODS

A literature review of full-length original studies in two databases, PubMed and Scopus, was performed. The search period included observational studies in humans published between April 21, 2009 and March 20, 2023.

RESULTS

A total of 26 studies were included. The studies suggest that LIPCOF and CCH are significantly related to dry eye symptoms in non-CL and CL wearers. However, the impact of CL wear on LIPCOF and CCH may be complex and may vary depending on individual factors such as lens type, lens care regimen, and pre-existing ocular conditions. Regarding LIPCOF management, tear substitutes seem to significantly reduce LIPCOF and dry eye symptoms in non-CL wearers, while vectored thermal pulsation (VTP) and microblepharoexfoliation (MBE) are suggested as promising treatment for LIPCOF and dry eye symptoms in CL wearers. Regarding CCH management, surgical interventions may be effective in reducing CCH when medical treatments have no response. In addition, an ocular examination by slit lamp is necessary to distinguish both conditions.

CONCLUSIONS

Tear substitutes, VTP, MBE, and fitting CLs with low coefficient of friction (CoF) seem to reduce and prevent LIPCOF. However, surgical treatment options seem to be more effective in the complete elimination of CCH. An adequate evaluation and differentiation between LIPCOF and CCH are important, and they should be considered by practitioners in managing dry eye symptoms in non-CL and CL wearers.

A Review of Current Uses of Amniotic Membrane Transplantation in Ophthalmic Plastic and Reconstructive Surgery

PURPOSE

To review and summarize the existing literature on the clinical applications of amniotic membrane transplantation (AMT) in ophthalmic plastic and reconstructive surgery.

METHODS

A literature review was conducted on the PubMed database using the following search terms: "amniotic membrane" and "eyelid" or "orbit" or "fornix" or "socket" or "lacrimal".

RESULTS

In total 516 articles resulted from the search, of which 62 were included. Numerous cases and case series have been published on the use of amniotic membrane transplantation for ocular surface reconstruction, eyelid and forniceal reconstruction, and cicatricial eyelid abnormalities. Surgical methods of securing the graft vary. Few comparative studies exist; some show a similar or improved result when compared to oral mucous membrane grafting for certain indications.

CONCLUSIONS

Amniotic membrane transplantation can be a useful tool for the oculoplastic surgeon when faced with a case requiring reconstruction of the posterior lamellae, particularly in patients without other graft donor sites available, and uses of AMT continue to expand. Additional studies directly comparing AMT to other reconstructive techniques would be helpful in choosing between the available surgical techniques and standardizing best practices.

Clinical correlations and ımpact of conjunctivochalasis in soft contact lens wearers

PURPOSE

To evaluate the correlation between clinical tests, patient symptoms, and conjunctivochalasis in contact lens wearers and non-wearers.

METHODS

This study comprised 40 eyes of 40 current soft contact lens users and 40 eyes of 40 control subjects. Cross-sectional areas of conjunctivochalasis at three locations (nasal, central, temporal) during straight and downward gazes were determined using anterior segment optical coherence tomography in all participants. Tear film break up time test and Schirmer test with anesthesia were performed and for evaluation of symptoms, the participants completed ocular surface disease index questionnaire.

RESULTS

During straight gaze, the mean cross-sectional areas of conjunctivochalasis were 0.0112 ± 0.009 and 0.006 ± 0.005 mm2 at nasal, 0.0096 ± 0.007 and 0.002 ± 0.004 mm2 at central, 0.0176 ± 0.014 and 0.008 ± 0.009 mm2 at temporal in contact lens and control groups, respectively. Regardless of location and gaze direction, the mean cross-sectional conjunctivachalasis areas of the contact lens group were significantly higher than those of the controls (all, p < 0.05). Significant positive correlations between ocular surface disease index score and measured conjunctivachalasis areas (in all sites) during straight gaze and downward gaze were observed in the contact lens group (all, p < 0.05 and r > 0.450).

CONCLUSION

Wearing soft contact lenses is associated with increased conjunctivochalasis areas. Anterior segment optical coherence tomography determined conjunctivochalasis area is an objective clinical measurement value that is positively correlated with patients' symptoms in soft contact lens wearers.

Comparative evaluation of corneal and limbal epithelial thickness in brachycephalic dogs with and without corneal diseases using spectral domain optical coherence tomography

OBJECTIVE

To evaluate alterations in epithelial thickness during corneal degeneration, corneal pigmentation, and additional features observed through spectral-domain optical coherence tomography (SD-OCT) in brachycephalic dogs.

ANIMALS AND PROCEDURES

The study used 55 eyes from 49 brachycephalic dogs that underwent OCT-containing ophthalmic examinations. The examined eyes were classified into corneal degeneration, corneal pigmentation, and normal groups according to corneal lesions. For each eye, corneal epithelial thickness (CET) in the central cornea and maximum limbal epithelial thickness (maxLET) in 4 quadrants of limbus (superior, inferior, nasal, and temporal) were measured from OCT images. Additional abnormal findings on OCT images, including irregular epithelium, subepithelial hyperreflectivity, and conjunctivochalasis, were also recorded.

RESULTS

The corneal degeneration group had significantly thinner nasal and temporal maxLETs than that of the normal group (p < .001). In the central corneal OCT image of the corneal degeneration group, an irregular epithelium was observed in 70.6% and subepithelial hyperreflectivity in 82.4%, both of which were significantly higher than the normal group (p < .001). In a comparative analysis, the nasal, temporal, and inferior maxLETs were significantly thinner in the corneal pigmentation group than those in the normal group (p < .001, p < .001, and p = .01, respectively).

CONCLUSIONS

Morphological changes in the limbal epithelium were observed in dogs with corneal degeneration and corneal pigmentation. LET reduction could be associated with their pathogenesis and would be valuable as an additional parameter for corneal diseases.

Evaluation of Dry Eye Severity and Ocular Surface Inflammation in Patients with Pemphigus and Pemphigoid

PURPOSE

To evaluate ocular surface involvement, tear cytokine levels, and histopathological changes in pemphigus and pemphigoid patients.

METHODS

A total of 22 patients (15 pemphigus and 7 pemphigoids) and 21 non-diseased controls were enrolled in our study. All participants underwent ocular surface evaluation, which included ocular surface disease index test, slit lamp observation, dry eye-related examination, tear multicytokine analysis, and conjunctival impression cytology.

RESULTS

Pemphigus and pemphigoid patients presented much more severe conjunctivochalasis, corneal epithelial defects, corneal opacity, symblepharon   and dry eye. Severe ocular surface squamous metaplasia and a significant increase of tear macrophage inflammatory protein-1beta, tumor necrosis factor-alpha, interleukin (IL)-1β, IL -6, and IL-8 occurred in pemphigus and pemphigoid patients.

CONCLUSIONS

Our results revealed that ocular surface inflammation and dry eye persist in most pemphigus and pemphigoid patients, and do not occur in parallel with the systemic course. Regular ophthalmological examinations and local anti-inflammatory should be provided for pemphigus and pemphigoid patients.

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.

Collagen changes in rabbit conjunctiva after conjunctival crosslinking

This study aims to determine the ultrastructural changes in collagen fibrils in rabbit conjunctiva after conjunctival crosslinking using riboflavin and ultraviolet A (UVA) light at an irradiation intensity of 45 mW/cm². Conjunctival crosslinking may increase conjunctival stiffness. The supertemporal quadrants of the right eyes of 24 adult rabbits were treated with a topical riboflavin solution (0.25%) before irradiation with UVA light at 45 mW/cm² for 4 min. After 3 weeks, the collagen fibrils in fibril bundles were examined by electron microscopy. Immunohistochemical staining was used to detect the expression levels of collagen I and collagen III in the rabbits' conjunctiva. The diameter of the collagen fibrils in the fibril bundles varied slightly, ranging from 30 to 60 nm in the conjunctival stroma of the control group. In the treatment group, the diameter of collagen fibrils ranged from 60 to 90 nm. The thickest collagen fibrils were observed in the treatment group (up to 90 nm in diameter). In contrast, those in the conjunctival stroma of the control group were considerably smaller (up to 60 nm in diameter). However, thicknesses of collagen fibrils displayed a unimodal distribution. Both collagen I and collagen III increased after treatment with riboflavin and UVA light irradiation at 45 mW/cm². The data indicate that in rabbits, conjunctival crosslinking with riboflavin and UVA light at 45 mW/cm² for 4 min is safe and does not induce ultrastructural alterations of the conjunctival cells. The conjunctival crosslinking with riboflavin and UVA light at 45 mW/cm² can increase the diameter of collagen fibrils, but the average densities of collagen I and collagen III have no statistical significance.

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.

Comparison of Efficacy and Inflammatory Response to Thermoconjunctivoplasty Performed with Cautery or Pulsed 1460 nm Laser

Conjunctivochalasis is a degenerative condition of the conjunctiva that disrupts tear distribution and causes irritation. Thermoreduction of the redundant conjunctiva is required if symptoms are not relieved with medical therapy. Near-infrared laser treatment is a more controlled method to shrink the conjunctiva than thermocautery. This study compared tissue shrinkage, histology, and postoperative inflammation in thermoconjunctivoplasty performed on the mouse conjunctiva using either thermocautery or pulsed 1460 nm near-infrared laser irradiation. Three sets of experiments were performed on female C57BL/6J mice (n = 72, 26 per treatment group and 20 control) to assess conjunctival shrinkage, wound histology, and inflammation 3 and 10 days after treatment. Both treatments effectively shrunk the conjunctiva, but thermocautery caused greater epithelial damage. Thermocautery caused greater infiltration of neutrophils on day 3 and neutrophils and CD11b+ myeloid cells on day 10. The thermocautery group had significantly higher conjunctival expression of IL-1β on day 3. Expression of chemokine CCL2 was higher in the conjunctiva on day 3 and tear concentrations were higher on day 7 in the laser group. These results suggest that pulsed laser treatment causes less tissue damage and postoperative inflammation than thermocautery while effectively addressing conjunctivochalasis.

Qi Jing Mingmu decoction inhibits the p38 signaling pathway in conjunctivochalasis fibroblasts by down-regulation of Th17 cell differentiation

ETHNOPHARMACOLOGICAL RELEVANCE

Qi Jing Mingmu (QJMM) decoction is a traditional Chinese medicine that has been widely used for the clinical treatment of conjunctivochalasis (CCH). It is an effective treatment to relieve ocular symptoms including improving tear film and promoting tear secretion. However, its effects and molecular mechanisms need to be elucidated.

AIM OF THE STUDY

To determine whether QJMM decoction affected T helper 17 (Th17) cell differentiation of CCH patients.

MATERIALS AND METHODS

Blood samples and conjunctival tissues were collected from CCH patients and normal controls. The fibroblasts were separately induced, and CD4⁺ T cells were incubated with increasing concentrations of QJMM decoction and co-cultured with CCH fibroblasts. Th17 cell numbers were then analyzed using flow cytometry. Serum levels of interleukin 17 (IL-17) and IL-22 were detected using enzyme-linked immunosorbent assays. The expressions of signal proteins and genes were detected using western blotting and quantitative real-time PCR.

RESULTS

Compared with normal controls, Th17 cell numbers and serum levels of IL-17 and IL-22 were elevated in patients with CCH. QJMM decoction down-regulated the expressions of IL-17, IL-22, and STAT3 of CD4⁺T cells from CCH patients, suggesting that QJMM decoction impeded Th17 cell differentiation. QJMM decoction-treated CD4⁺ T cells inhibited the expression of p38 in CCH fibroblasts.

CONCLUSION

QJMM decoction inhibited Th17 cell differentiation of CD4⁺T cells from CCH patients, and QJMM decoction-treated CD4⁺T cells down-regulated the p38 signal pathway in CCH fibroblasts. Our study showed that Th17 cells may be good candidates for clinical treatment of CCH.

Mechanism of Akt regulation of the expression of collagens and MMPs in conjunctivochalasis

Akt is a central node of many signaling pathways, which plays important roles in cell survival, proliferation, migration, metabolism and collagen synthesis. Conjunctivochalasis (CCH) is one of the most common age-related ocular superficial diseases related to abnormalities in conjunctival extracellular matrix. Here, we studied the role of Akt regulating collagens and MMPs in the pathogenesis of CCH. Primary conjunctival fibroblasts were obtained from CCH patients (n = 13) and age-matched normal controls (n = 10). The levels of Akt, collagen type I, collagen type III, MMP1, and MMP3 were determined by Western blot, qRT-PCR, immunohistochemistry, and immunofluorescence staining. Normal control conjunctival fibroblasts were treated with Akt inhibitor A6730, and CCH fibroblasts were transfected with Akt overexpression vector. The expression of Akt in CCH was significantly lower than that in normal control of conjunctival tissues and cultured fibroblasts. Blocking Akt signaling with Akt inhibitor could inhibit the expression of collagen type I and collagen type III and upregulate the expression of MMP1 and MMP3. Meanwhile, compared with CCH fibroblasts transfected with control mimics, the protein and mRNA expression of collagen type I and collagen type III were increased significantly in Akt overexpression group, while the results of MMP1 and MMP3 in transfected fibroblasts were opposite. Taken together, Akt upregulated the expression of collagen type I and collagen type III and downregulated the expression of MMP1 and MMP3. Akt signaling pathway could provide a direct negative contribution to CCH and might be an attractive target for CCH therapy.

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.

Measurement of the Lid Margin Thickness in Meibomian Gland Dysfunction with Vernier Micrometer

Introduction

To investigate the lid margin thickness (LMT) from the posterior lash line to the mucocutaneous junction at the middle position in adults with and without meibomian gland dysfunction (MGD) by vernier micrometer (VM).

Methods

This is a cross-sectional, observational study. A hundred eyes from 100 volunteers aged 20 to 79, including 56 normal participants and 44 participants with MGD, were recruited. Measurements of the LMT by VM were performed by the same person.

Results

The mean age of 56 normal subjects (24 males and 32 females) and 44 MGD subjects (16 males and 28 females) was 40.0 ± 13.2 years and 42.7 ± 17.1 years, respectively. There was a significant difference in the upper LMT between normal and MGD subjects (1.36 ± 0.25 vs. 1.60 ± 0.27 mm, P < 0.001), but not in the lower LMT (1.0 ± 0.23 vs. 1.10 ± 0.28 mm, P = 0.07). In both normal and MGD subjects, the upper or lower LMT was significantly positively correlated with age (P < 0.05), and the upper LMT was greater than the lower LMT (P < 0.001). In addition, the lower LMT in MGD subjects was significantly positively correlated with meibum expressibility (r_s = 0.35, P = 0.02).

Conclusions

The LMT was closely related to age and could be an important indicator for detecting MGD. Furthermore, we found that the upper LMT was greater than the lower LMT, and the lower LMT in MGD subjects seemed to be related to meibum expressibility.

Measurement of the Lower Lid Margin Thickness by Oculus Keratograph

OBJECTIVES

To investigate the lower lid margin thickness (LLMT) from the posterior lash line to the anterior edge of tear meniscus with Oculus Keratograph 4 (K4).

METHODS

This was a prospective, single-center, observational study. A total of 90 volunteers aged 18 to 79 years with no ocular diseases were included in this study. The LLMT of 90 subjects was measured twice by the same person with K4. To determine the reliability of K4, measuring the LLMT of 30 normal subjects was separately performed by two operators.

RESULTS

The LLMT measurements with K4 between two operators demonstrated a good reproducibility (0.94±0.18 vs. 0.96±0.16 mm; intraclass correlation coefficient=0.88; P=0.18). The mean age of 90 volunteers (42 men and 48 women) was 45.5±14.1 years. The LLMT was 0.95±0.17 mm, which was a significant positive correlation with age (rs=0.57; P<0.001). In addition, there was no significant difference in the LLMT between genders (0.97±0.16 vs. 0.93±0.18 mm; P=0.32).

CONCLUSIONS

We found that K4 was a reliable tool in the LLMT measurements, and the LLMT seemed to be closely related to age but not to gender.

Superior limbic keratoconjunctivitis: a comprehensive review

Superior limbic keratoconjunctivitis (SLK) is characterized by chronic inflammation of the superior limbus and superior bulbar and tarsal conjunctivae. Patients also often have fine punctate staining of the limbus and adjacent area, superior limbic proliferation seen as thickening of the limbal epithelium and surrounding conjunctiva, and occasionally filaments at the superior limbus and upper cornea. SLK frequently presents with ocular irritation, foreign body sensation, and photophobia. SLK can be associated with other ocular and non-ocular conditions, such as thyroid disease. Although the pathogenesis of SLK is still unknown, it is thought to be related to mechanical injury, tear film instability, or an autoimmune/inflammatory etiology. Many patients with SLK can be asymptomatic or have symptoms that resolve or remit spontaneously. For symptomatic SLK, patients are managed medically with treatments such as lubricants, topical anti-inflammatory or immunomodulatory medications, punctal occlusion, and bandage contact lenses. Patients with symptoms refractory to medical management may need surgical interventions. We detail the current literature on the epidemiology, clinical manifestations, associated conditions, histopathology, pathogenesis, and treatment of SLK.

Impression cytology and meibomian glands in conjunctivochalasis

PURPOSE

To evaluate the tear parameters, meibomian glands and lid margin and tarsal conjunctival impression cytology in patients with conjunctivochalasis (CCH).

METHODS

The study included 57 patients diagnosed with CCH and 35 healthy volunteers. Tear break-up time (TBUT) was measured and Schirmer test was performed. Meibomian gland morphologies, dropout rates, and meiboscores were evaluated using meibography. Finally, impression cytology samples were taken by pressing the impression filters on the lower lid margin and lower tarsal conjunctiva. The samples were evaluated according to the Nelson grading system.

RESULTS

Schirmer test was longer and TBUT was shorter in the study group (p = 0.035 and p < 0.001, respectively). The median of meibomian gland dropout rate was 33.45% (Interquartile range [IQR]; 23.17%-49.75%) and 18.80% (IQR; 12.35%-26.50%) in the study and control groups, respectively (p < 0.001). There was no significant difference in terms of lid-margin cytology between the two groups (p = 0.481). In tarsal conjunctiva cytology, the median value of Nelson grade of the study group was 2 (IQR; 1-2) and that of the control group was 1 (IQR; 1-2) (p = 0.040). When Nelson grade-2 and above was accepted as the pathological limit, it was found that 27.5% of the study group and 15.2% of the control group showed pathological findings (p = 0.204).

CONCLUSIONS

In patients with CCH, damage occurs in the tarsal conjunctiva with the effects of redundant conjunctival folds. In these patients, atrophy occurs in the meibomian glands and tear stability is impaired. Therefore, CCH should not be overlooked in clinical practice.

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.

The Relationship between Subjective Symptoms and Quality of Life in Conjunctivochalasis Patients

The purpose of this study was to evaluate the differences in subjective symptoms between patients with conjunctivochalasis (CCh) and dry eye (DE), and examine the relationship between subjective symptoms and quality of life (QOL). In 75 eyes of 75 CCh patients and 122 eyes of 122 DE patients, 12 subjective symptoms classified into four groups depending on the mechanisms associated with symptoms (ITF: instability of tear film, IF: increased friction, R: reflex, and DTC: delayed tear clearance) were evaluated by use of a visual analogue scale (VAS). Fifteen items related to DE symptoms and their influence on daily life were evaluated by use of the dry eye-related quality-of-life score (DEQS) questionnaire, with overall degree of QOL impairment calculated as a QOL score. The correlation between the Total VAS score and QOL score were evaluated. Between the CCh and DE patients, significant differences in subjective symptoms were found in eye dryness, pain, tearing sensitivity to light, and heavy eyelids, while tearing was higher in CCh. A significant strong correlation was found between QOL score and Total VAS score, ITF, and IF in CCh patients. The QOL of CCh patients is strongly determined by decreased tear-film stability and increased friction during blinking.

Comparison of two measurements for the lower lid margin thickness: vernier micrometer and anterior segment optical coherence tomography

PURPOSE

To investigate the reliability of using anterior segment optical coherence tomography (AS-OCT) to measure the lower lid margin thickness (LLMT) from the posterior lash line to the Marx's line by comparing with a vernier micrometer.

METHODS

This was a prospective, single-center, diagnostic test study. Sixty volunteers aged between 20 and 79 without ocular diseases were recruited. A vernier micrometer and AS-OCT were, respectively, used to measure the same lid margin thickness at the central lower lid.

RESULTS

The mean age of volunteers was 39.1 ± 13.7 years. The LLMT in 60 subjects (25 males and 35 females) measured by a vernier micrometer and AS-OCT was 1.03 ± 0.25 mm and 0.82 ± 0.21 mm, respectively. There was a significant difference between two measurements (P < 0.001). In addition, intraclass correlation coefficient (ICC) was engaged to evaluate the reliability and agreement of two measurements (ICC = 0.83). Bland-Altman plots demonstrated that 57 of 60 spots were within 95% limits of agreement. No adverse events were detected in all subjects after the measurements.

CONCLUSION

Although the LLMT measured by AS-OCT was less than that measured by a vernier micrometer, AS-OCT providing quantitative measurements and imaging data was also seemed to be a reliable method with a good agreement. It could be a substitute for a vernier micrometer in clinical practice in the future.

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.

Amniotic membrane, clinical applications and tissue engineering. Review of its ophthalmic use

The use of amniotic membrane in ophthalmology has been increasing in recent years due to its multiple biological and tectonic properties, improvement in the process of obtaining, ease of use, and advancement in tissue engineering. The amniotic membrane has become one of the main adjuvant treatments, in ophthalmic surgery as well as in other medical-surgical specialties. The development of tissue engineering has allowed it to be used, not only in its classic form, but also by the use of drops and other presentations. The different steps prior to its use (preparation and conservation), the different surgical techniques, and their main clinical applications are described throughout the article.

P38-Mediated Cellular Senescence in Conjunctivochalasis Fibroblasts

Purpose

Conjunctivochalasis (CCH) is a common ocular disease and has received extensive attention recently. However, its exact pathogenesis remains largely unknown. Owing to the high morbidity of CCH in older people, this study aimed to investigate whether cellular senescence contributes to CCH progression and the underlying mechanism.

Methods

Loose conjunctival tissues from CCH patients (n = 13) and normal conjunctival tissues from age-matched persons (n = 12) were obtained and the fibroblasts were separately induced and obtained. Cellular senescence, and the expression of senescence-associated genes (p53 and p21) and p38 in CCH conjunctival tissues and normal controls, were determined by senescence-associated β-galactosidase (SA-β-Gal) staining and quantitative (q)RT-PCR, respectively. To explore the effects of p38 on cellular senescence in CCH fibroblasts, small interfering RNA (siRNA) targeting p38 (siP38) and p38-specific inhibitor SB203580 was performed in CCH fibroblasts. Then, cellular senescence, cell viability, reactive oxygen species (ROS) production, and gene expression were detected according to the corresponding methods.

Results

CCH conjunctival tissues had significantly more senescent cells, evidenced by more SA-β-Gal-positive cells, and higher expression of senescence-associated genes (p53 and p21) and p38. CCH fibroblasts transfected with siP38 or treated with SB203580 had obviously reduced numbers of senescent cells, decreased ROS production, and increased cell viability, as well as reduced expression of senescence-associated genes. Meanwhile, blocking p38 signaling decreased the expression of p53 and p21.

Conclusions

Therefore, these findings indicate that cellular senescence might be a causative factor for CCH. P38 signaling might play an important role in the progress of cellular senescence in CCH fibroblasts via manipulation of p53/p21 signaling.

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.