A Quick Surgical Treatment of Conjunctivochalasis Using Radiofrequencies

healthcare

Article A Quick Surgical Treatment of Conjunctivochalasis Using Radiofrequencies

Alexandra Trivli * ID , Georgios Dalianis and Chryssa Terzidou

Department of Ophthalmology, Konstantopouleio-Patission General Hospital, Agias Olgas 3–5, Nea Ionia, 14233 Athens, Greece; [email protected] (G.D.); [email protected] (C.T.) * Correspondence: [email protected]; Tel.: +30-6945047506

Received: 3 January 2018; Accepted: 11 February 2018; Published: 12 February 2018

Abstract: The purpose of our study is to present a quick surgical procedure for the treatment of Conjunctivochalasis (CCH) and to evaluate its effectiveness. Thirty consecutive patients, in whom CCH was diagnosed on clinical examination, were investigated for the presence of symptoms of dry eye. The 60 eyes were evaluated according to their symptomatology and the 40 symptomatic eyes were grouped in two stages using the LIPCOF (stage 1, one small fold; stage 2, more than two folds but not higher than the tear meniscus) classiﬁcation and included in the study. After a subconjunctival injection of lidocaine 20 mg/mL, a medium frequency alternating current (RF) was used, adjusted in low power. With a wide tip, redundant conjunctiva was ablated leaving space between the ablations. Postoperative treatment included eye oint.gentamicin 0.3% with dexamethasone 0.03% three times a day for 5 days. At postoperative day 10, conjunctival edema had subsided and conjunctival epithelium was intact after ﬂuorescein staining. Symptoms had improved in all patients. During follow-up, no complication was detected. Mild conjunctival hyperemia was present in all cases but resolved with standard postoperative medications. To conclude, CCh treatment with RF appears to be a safe, quick, and effective surgical technique. Operation time is less than 10 min and can be performed in an outpatient clinic.

Keywords: Conjunctivochalasis; radiofrequencies; dry eye syndrome

1. Introduction Conjunctivochalasis (CCH) is defined as a redundant, loose, nonedematous inferior bulbar conjunctiva. It is most often located between the globe and the lower eyelid, but not always limited to the inferior bulbar conjunctiva. CCH can be found in the superior and even the whole bulbar conjunctiva [1]. Several theories regarding its etiology have been described, but the exact etiology is still unknown [2–4]. CCH is a common cause of ocular surface irritation. It might lead to decreased tear film stability, delayed tear clearance, and therefore an increased concentration of inflammatory markers on the ocular surface and subsequent ocular surface disease. Its clinical significance tends to be overlooked [5,6]. For symptomatic patients, treatment can be either medical or surgical. Medical treatment aims to suppress ocular surface inflammation. Surgical treatment, to remove the redundant conjunctiva, is necessary when the medical approach is unsuccessful. Traditional surgical techniques include excision of the bulbar conjunctiva, suture fixation of the conjunctiva to the sclera, and electrocoagulation of excessive conjunctiva [7–10]. Amniotic membrane transplantation has been successfully used in the reconstruction of the conjunctival surface after removal of the loose conjunctiva [7,11]. In the framework of this study, we sought to present a new technique to treat CCH, aiming to minimize surgical time without compromising patient outcome.

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Healthcare 2018, 6, x FOR PEER REVIEW 2 of 5 2. Materials and Methods 2. Materials and Methods Thirty consecutive patients (60 eyes) were recruited, while admitting for general ophthalmological examinationThirty atconsecutive our service, patients when CCH (60 waseyes) apparent were onrecruited, clinical examination. while admitting Twenty-one for patientsgeneral (40ophthalmological eyes) were included examination in the study. at our Patients’ service, age wh rangeden CCH between was apparent 49 and 85 on years clinical (mean examination. 77.1 years). PatientsTwenty-one with patients any kind (40 of eyes) anterior were surface included or lid in inflammationthe study. Patients’ as well age as obstructionranged between of the 49 lacrimal and 85 drainageyears (mean apparatus 77.1 years). were Patients excluded with from any the kind protocol. of anterior We alsosurface excluded or lid inflammation patients who as had well been as surgicallyobstruction treated of the for lacrimal CCH indrainage the past. apparatus were excluded from the protocol. We also excluded patientsPatients who werehad been examined surgically for thetreated presence for CCH of CCH in the symptomatology: past. epiphora, pain during eye movementsPatients or were blinking, examined and common for the symptomspresence of dryCCH eye symptomatology: (foreign body sensation, epiphora, burning, pain during grittiness). eye movementsUpon clinical or blinking, examination, and common CCH symptoms was evaluated of dry and ey documentede (foreign body by sensation, number of burning, conjunctival grittiness). folds and positionUpon clinical on the examination, lid margin (nasal, CCH medial,was evaluated temporal). and Mechanical documented lacrimal by number punctum of conjunctival obstruction duefolds to and the nasalposition folds on was the evaluatedlid margin with (nasal, slit lampmedial, examination, temporal). fluorescein Mechanical staining, lacrimal fluorescein punctum clearanceobstruction test due (FCT), to the and nasal the folds presence was ofevaluated epiphora. with In patientsslit lamp with examination, pathological fluorescein FCT or epiphora, staining, wefluorescein evaluated clearance the patency test (FCT), of the and lacrimal the presence system to of rule epiphora. out any In obstruction. patients with Finally, pathological tear break-up FCT or timeepiphora, (TBUT) we was evaluated documented. the patency (Table of1) the lacrimal system to rule out any obstruction. Finally, tear break-up time (TBUT) was documented. (Table 1) Table 1. Patient’s data documented on clinical examination. Table 1. Patient’s data documented on clinical examination. Symptoms Findings Tests Symptoms Findings Tests Non-typical (itching, burning, foreign body sensation) CCH severity (number of conjunctival folds) TBUT Non-typicalPain (during (itching, blinking burning, or with foreign eye movement)body sensation) Epiphora CCH severity (punctum (number occlusion of conjunctival by overlapping folds) folds) TBUT FCT Pain (duringEpiphora blinking or or pleolacrimal with eye movement) Epiphora (punctum occlusion by overlapping folds) FCT Epiphora or pleolacrimal

For thethe gradinggrading ofof CCHCCH wewe usedused thethe LIPCOFLIPCOF (stageclassification, 1, one small dividing fold; stageCCH 2,into more four than stages two where folds but(0) is not no higher conjunctival than the fold, tear (1) meniscus) is one small classiﬁcation, fold, (2) denotes dividing more CCH than into two four folds stages but not where higher (0) isthan no conjunctivalthe tear meniscus, fold, (1)and is (3) one indicates small fold, multiple (2) denotes folds higher morethan than twothe tear folds meniscus. but not higher than the tear meniscus,Topical and anesthesia (3) indicates with multiple eye drops folds of higherproxymet thanacaine the tear hydrochloride meniscus. 5 mg/mL was performed 5 minutesTopical prior anesthesia to the procedure. with eye A drops subconjunctival of proxymetacaine injection hydrochloride of lidocaine 20 5 mg/mLmg/mL waswas performedperformed 5with min a prior 25-g toneedle. the procedure. A medium A subconjunctivalfrequency alternatin injectiong current of lidocaine (RF) was 20 mg/mL used, adjusted was performed in low power with a 25-g(Figure needle. 1). With A medium a wide frequencytip, redundant alternating conjunctiva current was (RF) ablated, was used, leaving adjusted space in between low power the(Figure ablations1). With(Figure a wide 2). tip, redundant conjunctiva was ablated, leaving space between the ablations (Figure2).

Figure 1. Radiofrequency (RF) cautery equipment used in the procedure. Figure 1. Radiofrequency (RF) cautery equipment used in the procedure.

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Figure 2. Wide tip used in the procedure. Figure 2. Wide tip used in the procedure. Postoperative treatment included eye oint.gentamicin 0.3% with dexamethasone 0.03% three timesPostoperative a day for 5 days, treatment as well includedas frequent eye installation oint.gentamicin of artificial 0.3% tears. with Prior dexamethasone to the procedure, 0.03% risks, three alternatives,times a day forand 5 benefits days, as were well asexplained frequent to installation the patients of and artificial a signed tears. consent Prior toform the was procedure, obtained. risks, alternatives,The Ethics and Committee benefits were for Human explained Research to the patients of the ho andspital a signed approved consent the study. form wasEthical obtained. approval code:The 14104/22,05,2017. Ethics Committee Date for of Human approval: Research 22/05/2017. of the The hospital data approvedwere collected the study. by the Ethical clinicians approval who reportedcode: 14104/22,05,2017. the medical records, Date of approval:including 22/05/2017.surgical procedures The data wereand findings. collected byA thewritten clinicians informed who consentreported form the medical was obtained records, by including all participants. surgical procedures and findings. A written informed consent form was obtained by all participants. 3. Results 3. Results Patients’ age ranged between 49 and 85 years with a mean age of 77.1 years. Follow-up time Patients’ age ranged between 49 and 85 years with a mean age of 77.1 years. Follow-up time ranged from 2 to 14 months with a mean of 8 months. ranged from 2 to 14 months with a mean of 8 months. From the total of 60 eyes examined, atypical symptomatology was present in the 40 eyes included From the total of 60 eyes examined, atypical symptomatology was present in the 40 eyes included in the study, pain was present in 25 eyes (41.6%), and epiphora was present in 25 eyes (41.6%). in the study, pain was present in 25 eyes (41.6%), and epiphora was present in 25 eyes (41.6%). CCH was evaluated according to the LIPCOF classification system. In this way, 29 eyes were CCH was evaluated according to the LIPCOF classification system. In this way, 29 eyes were categorized as stage I CCH and 11 eyes were categorized as stage II. (Table 2). categorized as stage I CCH and 11 eyes were categorized as stage II. (Table2). Table 2. CCH staging. Table 2. CCH staging. No. of Eyes CCH Stage Percentage Pain Epiphora No. of Eyes0 CCH Stage0 Percentage0% Pain0 Epiphora0 029 0I 72.5% 0% 15 0 16 0 2911 III 72.5%27.5% 10 15 9 16 110 IIIII 27.5%0% 100 0 9 0 III 0% 0 0 4040 25 25 25 25

At 24 hours postoperative, all eyes showed mild conjunctival hyperemia and edema (Figure 3), whichAt resolved 24 hours in postoperative, all of the patients all eyes 10 days showed latermild with conjunctivalour standard hyperemia postoperative and treatment edema (Figure (Figure3), which4). resolved in all of the patients 10 days later with our standard postoperative treatment (Figure4).

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Figure 3. Mild conjunctival hyperemia 24 h postoperative. Figure 3. Mild conjunctival hyperemia 24 h postoperative. Figure 3. Mild conjunctival hyperemia 24 h postoperative.

Figure 4. Normal appearance of conjunctiva 10 days postoperative. Figure 4. Normal appearance of conjunctiva 10 days postoperative. Figure 4. Normal appearance of conjunctiva 10 days postoperative. Symptoms resolved in all patients with stage I CCH and improved significantly for those with stageSymptoms II CCH regarding resolved duration in all patients and intensity. with stage Stag I CCHe II CCH and improvedpatients reported significantly that theyfor those remained with Symptoms resolved in all patients with stage I CCH and improved significantly for those with stagesymptom-free II CCH regarding for most ofduration the day and and intensity. that their Stag symptomse II CCH werepatients mild reported and tolerated. that they All remained patients stage II CCH regarding duration and intensity. Stage II CCH patients reported that they remained symptom-freereported satisfaction for most with of thethe result. day and During that follow-up,their symptoms no major were complication mild and tolerated. was detected. All patients symptom-freereported satisfaction for most with of the the result. day and During that follow-up, their symptoms no major were complication mild and tolerated. was detected. All patients reported satisfaction with the result. During follow-up, no major complication was detected. 4. Discussion 4. Discussion 4. DiscussionConjunctivochalasis is a conjunctival disorder with a poorly understood etiology. Its clinical Conjunctivochalasis is a conjunctival disorder with a poorly understood etiology. Its clinical significanceConjunctivochalasis is often underestimated is a conjunctival and it can disorder cause withvarious a poorlysymptoms understood in patients. etiology. These symptoms Its clinical significance is often underestimated and it can cause various symptoms in patients. These symptoms significanceare associated is oftenwith underestimatedDry Eye Syndrome and and it can can cause occur various mechanically symptoms due in to patients. the folded These conjunctiva. symptoms are associated with Dry Eye Syndrome and can occur mechanically due to the folded conjunctiva. areSuch associated symptoms with are: Dry foreign Eye Syndromebody sensation, and can epiphora, occur mechanically and occlusion due of tothe the inferior folded punctum conjunctiva. by Such symptoms are: foreign body sensation, epiphora, and occlusion of the inferior punctum by Suchconjunctival symptoms folds are: on foreignthe margin body ofsensation, the lower epiphora,eyelid. Ocular and occlusionsurface disease of the can inferior occur punctum due to the by conjunctival folds on the margin of the lower eyelid. Ocular surface disease can occur due to the conjunctivaldelayed tear folds clearance on the [12]. margin CCH of theis loweran increa eyelid.singly Ocular common surface clinical disease finding can occur and due is tooften the delayed tear clearance [12]. CCH is an increasingly common clinical finding and is often delayedunderdiagnosed tear clearance in older [12]. patients. CCH is an increasingly common clinical finding and is often underdiagnosed underdiagnosed in older patients. in olderThere patients. are many CCH classification systems proposed in the literature. We used the LIPCOF There are many CCH classification systems proposed in the literature. We used the LIPCOF classificationThere are in many which CCH CCH classification is divided into systems four stages: proposed stage in (0), the no literature. conjunctival We fold; used stage the LIPCOF(1), one classification in which CCH is divided into four stages: stage (0), no conjunctival fold; stage (1), one classificationsmall fold; stage in which (2), more CCH than is divided two folds into but four not stages: higher stage than (0), the no tear conjunctival meniscus; fold; and stagestage (1), (3), one multiple small small fold; stage (2), more than two folds but not higher than the tear meniscus; and stage (3), multiple fold;folds stagehigher (2), than more the than tear two meniscus folds but [13]. not higher than the tear meniscus; and stage (3), multiple folds folds higher than the tear meniscus [13]. higherVarious than the surgical tear meniscus methods [13 ].have been reported for the treatment of CCH. According to the Various surgical methods have been reported for the treatment of CCH. According to the literature,Various Hughes surgical was methods the first have to been successfully reported fortreat the this treatment condition of CCH. by removing According a to section the literature, of the literature, Hughes was the first to successfully treat this condition by removing a section of the Hughesconjunctiva was under the first the to lower successfully eyelid treatand thisclosing condition the incision by removing with a acontinuous section of the black conjunctiva silk suture under [1]. conjunctiva under the lower eyelid and closing the incision with a continuous black silk suture [1]. theFurthermore, lower eyelid suture and closingfixation the of incision the conjunctiva with a continuous to the sclera black silkwith suture 6-0 Vicryl [1]. Furthermore, sutures has suture been Furthermore, suture fixation of the conjunctiva to the sclera with 6-0 Vicryl sutures has been fixationdescribed of the[9]. conjunctivaAdditionally, to theelec scleratrocoagulation with 6-0 Vicrylrepresents sutures anot hasher been method, described which [9]. Additionally,allows local described [9]. Additionally, electrocoagulation represents another method, which allows local electrocoagulationinflammation to occur represents and the anotherconjunctiva method, to attach which to the allows subconjunctival local inflammation Tenon’s tocapsule occur [14–16]. and the inflammation to occur and the conjunctiva to attach to the subconjunctival Tenon’s capsule [14–16]. conjunctivaWe previously to attach toreported the subconjunctival another approach Tenon’s capsulewhere, [after14–16 ].surgical removal of the excess We previously reported another approach where, after surgical removal of the excess conjunctiva,We previously preserved reported human another amniotic approach membrane where, was after placed surgical over removal and sutured of the excesswith a conjunctiva, 10-0 nylon conjunctiva, preserved human amniotic membrane was placed over and sutured with a 10-0 nylon preservedcontinuous human suture amniotic to the membranefree conjunctival was placed ed overges and[11]. suturedIn the with current a 10-0 study, nylon continuoussimilar to continuous suture to the free conjunctival edges [11]. In the current study, similar to sutureelectrocoagulation, to the free conjunctival our surgical edges procedure [11]. In the using current radiofrequenci study, similares toachieves electrocoagulation, conjunctival ourshortening surgical electrocoagulation, our surgical procedure using radiofrequencies achieves conjunctival shortening procedureby burning using excessive radiofrequencies conjunctiva. achieves The operation conjunctival is performed shortening in by an burning outpatient excessive clinic conjunctiva. setting, is byapplicable burning to excessive the conjunctival conjunctiva. folds Theat any operation location, isand performed patients experiencein an outpatient minimal clinic intraoperative setting, is applicableand postoperative to the conjunctival ocular irritation. folds at any location, and patients experience minimal intraoperative and postoperative ocular irritation.

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The operation is performed in an outpatient clinic setting, is applicable to the conjunctival folds at any location, and patients experience minimal intraoperative and postoperative ocular irritation.

5. Conclusions No recurrence of CCH was noted during our follow-up period. Moreover, surgery usually takes less than 10 min, which is a significant advantage compared to previous procedures reported in the literature. In conclusion, RF treatment of CCH has a high success rate, a short operation and recovery time, and can be considered a treatment easily accessible for both patients and medical staff.

Author Contributions: Chryssa Terzidou conceived and designed the experiment, Georgios Dalianis performed the experimentand Alexandra Trivli analyzed the data and wrote the paper. Conﬂicts of Interest: The authors declare no conﬂict of interest.

References

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