Amniotic Membrane Transplantation for Symptomatic Conjunctivochalasis Refractory to Medical Treatments

Daniel Meller, M.D., Steven L. Maskin, M.D., Renato T.F. Pires, and Scheffer C.G. Tseng, M.D., Ph.D.

Purpose. To determine whether preserved human amniotic mem- severe form causes exposure-related problems such as nocturnal brane can restore the large conjunctival defect created during sur- lagophthalmos and dellen formation.7 gical removal of conjunctivochalasis. Methods. Amniotic mem- No treatment is needed if patients with conjunctivochalasis re- brane transplantation was performed at two facilities in 40 con- main asymptomatic. Medical treatments with artificial tears, lubri- secutive patients (47 eyes) with symptomatic conjunctivochalasis cants, steroids, and antihistamines have been advised for symp- refractory to conventional treatments. Results. The majority of tomatic patients. When they fail, surgical removal of the redundant patients were elderly (73.1 ± 9.7 years) and women (75%). Over a conjunctiva becomes necessary.1,3,4,8,9 The first surgical tech- follow-up period of 6.9 ± 4.3 months, 46 (97.8%) eyes recovered 4 1,2,5,6,8 smooth, quiet, and stable conjunctival surfaces. Epithelial defects nique, described by Braunschweig and employed by others healed in 16.5 ± 7.3 days. Episodic epiphora was resolved in 24 of includes a crescent excision of the inferior bulbar conjunctiva at a 30 (83.3%) eyes and improved in five other eyes. Notable relief distance of 5 mm from the limbus followed by suture closure.2,5,8 was also noted for such symptoms as fullness or heaviness (19/19, A modified technique was proposed by Serrano and Mora9 to 100%), sharp pain (6/6, 100%), redness (14/17, 88.2%), tiredness avoid visible scarring or retraction of the inferior conjunctival (17/20, 80.9%), itching (11/13, 78.6%), blurry or decreased vision fornix. It includes a peritomy made close to the limbus followed by (6/8, 75%), burning (8/13, 61.5%), foreign body sensation (8/13, two radial relaxing incisions to excise the redundant conjunctiva9 61.5%), and crust formation (1/2, 50%). Complications included (also see review7). focal inflammation of the host conjunctiva adjacent to the graft Amniotic membrane, or amnion, i.e., the innermost layer of the (six eyes), scar formation (five eyes), and suture-induced granuloma (one eye). Conclusion. Amniotic membrane transplantation placenta, consists of a thick basement membrane and an avascular can be considered as an effective means for conjunctival surface stromal matrix. Recently, amniotic membrane has been used as a reconstruction during removal of conjunctivochalasis. successful alternative to conjunctival graft for conjunctival surface Key Words: Amniotic membrane—Amniotic membrane trans- reconstruction after removal of large lesions such as pte- plantation—Conjunctiva—Conjunctivochalasis—Epiphora— rygium,10,11 conjunctival intraepithelial neoplasia and tumors,12 Tearing—Transplantation. scars, symblepharon,12–14 and in one case of conjunctivochalasis.12 Because amniotic membrane facilitates the proliferation and differentiation of epithelial cells, maintains the original epithelial phenotype, promotes goblet cell differentiation, reduces scarring, Conjunctivochalasis, defined as a redundant, loose, nonedema- minimizes vascularization, and decreases inflammation15–20 (also tous inferior bulbar conjunctiva interposed between the globe and see reviews21,22), we examine herein in a large series of patients the lower eyelid, tends to be bilateral and is more prevalent in older whether this technique can also be used for conjunctival surface populations.1–6 Conjunctivochalasis in a mild form causes and reconstruction during removal of symptomatic conjunctivochalasis aggravates an unstable tear film by depleting the tear meniscus and refractory to medical treatments. interfering with eyelid blinking, in a moderate form it causes in- termittent epiphora by interfering with tear clearance, and in a PATIENTS AND METHODS

Submitted November 15, 1999. Revision received March 7, 2000. Ac- Patients cepted March 8, 2000. Forty patients (47 eyes) with conjunctivochalasis were consec- From the Ocular Surface and Tear Center Department of Ophthalmol- utively operated at two facilities from January 1998 to February ogy, Bascom Palmer Eye Institute (D.M., R.T.F.P., S.C.G.T.); the Depart- ment of Cell Biology & Anatomy, University of Miami School of Medi- 1999. Among them, 13 patients were from Bascom Palmer Eye cine, Miami (S.C.G.T.); and Tampa (S.L.M.), Florida, U.S.A. Institute, of which one (case 2, two eyes) was part of a study Address correspondence and reprint requests to Dr. S.C.G. Tseng, previously approved by the Medical Science Subcommittee for the Bascom Palmer Eye Institute, William L. McKnight Vision Research Protection of Human Subjects in Research of the University of Center, 1638 NW 10th Ave., Miami, FL 33136, U.S.A. E-mail: stseng@ bpei.med.miami.edu Miami School of Medicine. All patients remained symptomatic Proprietary interest: S.C.G.T. has a financial interest in the preparation despite conventional medical therapies including tear substitutes, and clinical uses of amniotic membrane. lubricants, and nonpreserved steroid drops. Their symptoms ob-

796 AMNIOTIC MEMBRANE TRANSPLANTATION FOR CONJUNCTIVOCHALASIS 797 tained by a questionnaire are summarized in Table 1. In Table 2, TABLE 2. Preexisting ocular surface and tear disorders the frequency of pre-existing ocular surface and tear disorders Diagnosis Number of eyes (%) associated with conjunctivochalasis is listed. Meibomian gland disease and aqueous tear deficiency were found to be associated Aqueous tear deficiency 33 (70.2) Meibomian gland disease 25 (53.2) with conjunctivochalasis in 25 (53.2%) and 33 (70.2%) eyes, re- Floppy eyelid syndrome 14 (29.8) spectively. In addition, 14 (29.8%) eyes had floppy eyelid syn- Inflamed pingueculae 12 (25.5) drome and four (8.5%) eyes had ocular allergy. In 12 (25.5%) Inflamed semilunar folds 7 (14.9) Ocular allergy 4 (8.5) eyes, conjunctivochalasis was associated with inflamed pinguecula Essential blepharospasm 2 (4.25) (Figs. 1A and B) and in seven (14.9%) eyes with an inflamed Exposure keratopathy 1 (2.1) semilunar fold; five of such eyes were part of the aforementioned 12 eyes. Only, three of 47 eyes (6.4%; two patients) were diag- 9-O or 10-O Vicryl or nylon sutures (Ethicon Inc., Johnson & nosed as having conjunctivochalasis alone and did not reveal any Johnson, Somerville, NJ, U.S.A.) (Figs. 2E and F). Attention was associated ocular surface or tear disorder. Twenty-nine eyes given to flattening the membrane tightly onto the scleral surface (61.7%) had received punctal occlusion before the surgery. In nine and approximate to or underneath the epithelial edge. This was patients, symptomatic conjunctivochalasis refractory to conven- followed by topical application of Maxitrol ointment (neomycin tional medications was noted on both eyes. Seven patients of the sulfate, polymyxin B sulfate, and dexamethasone; Alcon Labora- latter were operated bilaterally. tories, Inc., Fort Worth, TX, U.S.A.). Seven patients were operated on bilaterally. In eyes associated with inflamed pinguecula and/or Amniotic Membrane Transplantation (AMT) semilunar fold, the crescent strip of conjunctiva was extended to Informed consent was obtained from all patients. In this study, include the inflamed conjunctival area. In 11 eyes, AMT was all except for one patient (two eyes) from a previously approved combined with the removal of inflamed pinguecula (Figs. 1A and study used amniotic membranes obtained from Bio-Tissue (South B). In seven eyes, excision of the redundant conjunctiva was ex- Miami, FL, U.S.A.), where procurement includes screening tended to include the inflamed semilunar fold. After surgery, all against human immunodeficiency virus types 1 and 2, human T- patients received prednisolone acetate 1% eyedrops every 2 hours lymphoma virus type 1, hepatitis B and C viruses, and syphilis at while awake and Maxitrol ointment nightly for 1 week, tapering the time of cesarean delivery and 6 months post partum. off within 3–4 weeks. Sutures were removed at 3 weeks. All surgeries were performed by S.L.M. or S.C.G.T. at two different facilities following the steps depicted in Figure 2. A simple crescent excision as described before was used to remove Data Analysis the redundant inferior conjunctival tissue (Fig. 2A). Owing to the All pre- and postoperative data were sent to the Bascom Palmer looseness and dissolution of Tenon’s capsule, this invariably left a Eye Institute, Miami, FL, and were analyzed with the help of the bare sclera. The amniotic membrane was then removed from the Department of Biostatistics. storage medium, peeled off the nitrocellulose filter paper (Fig. 2B), transferred to the recipient eye (Fig. 1C), and fitted to cover the entire defect by trimming off excess edges. The size of created RESULTS defect in the temporal and nasal inferior bulbar conjunctiva was then determined in upgaze and measured approximately 2.5 cm in Thirty patients were female and 10 were male. The mean age length by 1.0–1.5 cm in width. However, the amount of conjunc- was 73.1 ± 9.7 years (range, 59–94). All patients showed symp- tiva excised differed in individual cases (see below). The amniotic tomatic conjunctivochalasis that was refractory to conventional membrane was placed with the basement membrane surface up. therapies, and nine of them were bilateral. The symptoms before The basement membrane side could be distinguished from the AMT are summarized in Table 1. These included tearing (30/47, stromal side by touch with a sponge, i.e., Weckcel (Edward Weck 63.8%), tiredness (20/47, 42.6%), fullness or heaviness (19/47, & Company, Inc., Research Triangle Park, NC, U.S.A.); the stro- 40.4%), redness (17/47, 36.2%), itching (13/47, 27.7%), burning mal side being sticky (Fig. 2D). The membrane was secured to the (13/47, 27.7%), foreign body sensation (13/47, 27.7%), sharp pain surrounding conjunctival edge with episcleral bites by interrupted (6/47, 12.8%), and crust formation (2/47, 4.3%). The symptoms after AMT are also found in Table 1. Interestingly, blurry or decreased vision was observed in eight (17%) eyes, of which six TABLE 1. Symptoms before and after AMT (75%) showed improvement after surgery. Besides refractory symptoms (Table 1), most patients showed Before Resolved Better Resolved and Persistent (eyes) (eyes) (eyes) better (%) (eyes/%) abnormal findings on their ocular surfaces and lid margins. A representative case is illustrated in Figure 3. The redundant con- Fullness, heaviness 19 16 3 100 0/0 Pain 6 5 1 100 0/0 junctival tissue interposed between the lid margin and the eye Tearing 30 24 5 96.6 1/3.4 globe impeded the formation of a proper tear meniscus (Fig. 3B). Redness 17 10 4 88.24 3/11.76 As a result, rose Bengal staining could be seen on the lid margin Tiredness 21 14 3 80.9 4/19.1 Itching 14 8 3 78.6 3/11.4 where the redundant conjunctiva was prominent, and this area Blurry/decreased exhibited focal inflammation and anterior expansion of the tarsal vision 8 — 6 75 2/25 Burning 13 7 1 61.5 5/38.5 conjunctival surface toward the skin, leading to the anteriorly dis- Foreign body placed mucocutaneous junction (i.e., gray line). Frequently, the sensation 13 4 4 61.5 5/38.5 bulbar conjunctiva adjacent to this region was also stained, and the Crust formation 2 0 1 50 1/50 staining was continuous with the stained lid margin. The staining

Cornea, Vol. 19, No. 6, 2000 798 D. MELLER ET AL.

FIG. 1. A: A crescent excision was performed to remove the redundant conjunctiva down to the bare sclera. B: The amniotic membrane was then removed from the storage medium peeled off the nitrocellulose filter paper. C: The amniotic membrane was fitted to cover the entire defect by trimming off excess edges. D: The amniotic membrane was placed with the basement membrane side up. The orientation was tested using the Weckcel test in which the basement membrane side does not adhere to the Weckcel sponge, but the stroma of the amniotic membrane usually does. E, F: The membrane was then secured to the surrounding conjunctival edge by interrupted sutures.

of the bulbar conjunctiva expanded and fell to the inferior fornix to brane were rapidly epithelialized within a mean time of 16.5 ± 7.3 cover a much larger area when the lower lid was pulled down days (range, 6–37). Forty-six (98%) eyes recovered a smooth, wet, during examination (Figs. 3A, C, and D). and noninflamed conjunctival surface within 1 month and re- All epithelial defects created by the denuded amniotic mem- mained stable for a follow-up period of 6.9 ± 4.3 months. Five

FIG. 2. A: Rose Bengal staining of the lid margin where the redundant conjunctiva was noted at the adjacent ocular surface (arrow). B: The redundant conjunctiva interferes with the tear meniscus (arrow). C: Typically, in moderate cases with conjunctivochalasis, staining in the nonexposure zone, i.e., inferior limbus and adjacent conjunctiva, is observable (asterisks). D: The bulbar conjunctiva adjacent to the lid margin (encircled by asterisks) that constitutes the pattern of a nonexposure staining with rose Bengal.

Cornea, Vol. 19, No. 6, 2000 AMNIOTIC MEMBRANE TRANSPLANTATION FOR CONJUNCTIVOCHALASIS 799

FIG. 3. AMT for conjunctivochalasis in five illustrative cases. All patients demonstrated a complete recovery of the ocular surface. A, B: Case 1. A: Preoperative appearance. Note the redundant conjunctival tissue (white arrow) and associated pinguecula nasal (black arrow) and temporal (not shown). B: Two months after AMT. C, D: Case 2. C: One month after AMT, a smooth, quiet, and noninflamed bulbar conjunctiva was seen. D: The epithelial defect healed completely. E, F: Case 3. One and half months after AMT. G, H: Case 4. G: Eight months after AMT, a smooth, quiet, and noninflamed bulbar conjunctiva was seen without defects (H). I, J: Case 5. I: OD, 5 months after AMT. J: OS, 6 months after AMT.

representative eyes are shown in Figure 1. As a result, episodic symptoms were attributed to pre-existing ocular surface and tear epiphora, a major symptom of moderate conjunctivochalasis, was disorders such as Meibomian gland disease, aqueous tear defi- resolved in 24 of 30 (83.3%) eyes and improved in five other eyes, ciency, floppy eyelid syndrome, and ocular allergy (Table 2). The resulting in total relief of symptoms in 96.6% of the eyes. There two patients with conjunctivochalasis alone without any other ocu- was a marked relief or improvement of other symptoms such as lar surface and tear disorder complained about tearing and redness fullness or heaviness (19/19, 100%), sharp pain (6/6, 100%), red- in one case and tearing in the other case. All these symptoms were ness (14/17, 88.2%), tiredness (17/20, 80.9%), itching (11/13, relieved after AMT. 78.6%), burning (8/13, 61.5%), foreign body sensation (8/13, In this series, we noted the following complications. Six eyes 61.5%), and crust formation (1/2, 50%) (Table 1). The remaining showed focal inflammation on the host conjunctiva adjacent to the

Cornea, Vol. 19, No. 6, 2000 800 D. MELLER ET AL. amniotic membrane graft, although the membrane-covered area DISCUSSION remained noninflamed. Two such examples are shown in Figure 4. Conjunctivochalasis is a common finding, but its pathogenic This complication could be successfully managed by subconjunc- 7 tival injection of 20–40 mg of Kenalog (triamcinolone, Westwood role is often overlooked. As recently reviewed, depending on its Squibb, Buffalo, NY, U.S.A.) (Figs. 4C–H). In addition, we ob- severity, conjunctivochalasis can present with a variety of symp- served suture-induced granuloma in one eye and scar formation in toms. Exposure problems caused by severe conjunctivochalasis are the fornix in two eyes and at the host-graft border in three eyes relatively rare and are generally not missed, but moderate and mild (Figs. 4A and B). Other scarring-induced complications such as conjunctivochalasis are often trivialized as normal variation in cicatricial entropion of the lower lid, retraction of the lower fornix, older populations. Mild conjunctivochalasis may disturb tear film and restricted motility were not found. stability whereas moderate conjunctivochalasis causes additional

FIG. 4. A–H: Complications after AMT for conjunctivochalasis in four illustrative cases. A: Case 2. Focal scar formation in the lower fornix ex- tending to bulbar conjunctiva between the host and graft junction (arrows). B: Case 6. Small symblepharon formation (white and black arrows). C–F: Case 7. Postoperative inflammation of the ocular surface and management. C, D: Inflammation of nasal (C) and temporal (D) bulbar conjunctiva extend from incompletely excised pinguecula (C) and semilunar fold (D) was noted at the host-graft border (arrows). E: One week after subconjunctival injection of Kenalog, the inflammation of the bulbar conjunctiva was completely (temporal shown here) diminished. The asterisks indicate the subconjunctival de- posit of Kenalog. F: After an additional 2.5 months, the ocular surface remained stable without signs of inflammation. G–J: Case 8. Postopera- tive inflammation and management. G: Preoperative appearance shows redundant conjunctiva (white arrow). H: After AMT, diffuse inflammation was noted at the host conjunctiva. I: Such inflammation was presumably triggered by suture-induced granulomatous reaction (arrows). J:One week after subconjunctival injection of Kenalog (see supratemporal de- posit), inflammation was markedly decreased.

Cornea, Vol. 19, No. 6, 2000 AMNIOTIC MEMBRANE TRANSPLANTATION FOR CONJUNCTIVOCHALASIS 801 delayed tear clearance. An unstable tear film, i.e., the hallmark of vations were also noted in the present study. A modified technique various forms of dry eye,23 and delayed tear clearance are two was proposed by Serrano and Mora.9 to avoid visible scarring or major causes leading to ocular surface irritation.24,25 The former retraction of the inferior conjunctival fornix; however, no detailed gives rise to symptoms characteristic of dry eye with burning, outcome was provided. A comparison of these two traditional foreign body sensation, tiredness upon reading or prolonged use of techniques and AMT is not possible owing to the lack of details the eye, and sharp pain and photophobia in severe cases. The latter provided by published reports regarding symptoms before and af- tends to cause inflammatory symptoms of redness, itching, mucus ter surgery, the size of excised conjunctiva, follow-up period, out- accumulation, and sticky lids in the morning.24 Unstable tear film come measures, and complications.1,2,4,5,8,9 Future prospective can trigger reflex tearing and in the presence of delayed tear clear- studies are needed to determine the relative efficacy of these sur- ance, episodic epiphora manifests as a predominant symptom as- gical procedures including AMT for treating conjunctivochalasis. sociated with conjunctivochalasis. Besides delayed tear clearance, After AMT, all epithelial defects healed rapidly within 3 weeks, we wonder whether the sensation of heaviness and fullness may in a finding similar to those previously reported for other indica- part be caused by the friction generated by eyelid blinking super- tions.10,12 The rapid healing rate can be attributed to the thick imposed on the redundant tissue. Depending on the severity of basement membrane of the amniotic membrane because it has conjunctivochalasis and associated diseases, a colossal amount of been known that the basement membrane in general promotes the aforementioned complaints at variable frequencies was found epithelial proliferation.29–31 A recent study noted that the laminin in our patients (Table 1). It has been recognized that rose Bengal subchain type of amniotic membrane is identical to that of the staining is typically found in the interpalpebral conjunctiva, i.e., conjunctival epithelium in humans32 after healing, all but one eye the exposure zone, in keratoconjunctivitis sicca caused by pure recovered a smooth and noninflamed conjunctival surface (Fig. 4), aqueous tear deficiency. Owing to the superimposition of delayed suggesting the return of normal conjunctival epithelial phenotype. tear clearance and the location of redundant conjunctiva, rose Ben- This notion is supported by the finding that amniotic membrane gal staining was found in the conjunctiva close to the lid margin of promotes nongoblet epithelial cell differentiation of the conjunc- conjunctivochalasis (Fig. 3), a pattern previously defined as a tival epithelium in culture.33,34 By means of impression cytology, “nonexposure” zone.24,26 Furthermore, the adjacent lid margin was we also noted that amniotic membrane–reconstructed conjunctival also stained (Figs. 3A and C). Such a staining pattern can be used surfaces maintain the normal conjunctival epithelial phenotype clinically to differentiate an unstable tear film caused preferen- with an increased goblet cell density.16 We now have evidence to tially by conjunctivochalasis from that by pure aqueous tear defi- show that goblet cell differentiation can be further promoted in ciency or exposure keratopathy. Previously, the grading of con- conjunctival epithelial cells when cocultured with their own fibro- junctivochalasis was used as a reliable parameter for diagnosing blasts on the amniotic membrane20 (Meller and Tseng, unpub- keratoconjunctivitis sicca.27 It remains unclear whether this is be- lished observation, 1998). The restoration of a proper tear menis- cause there is a high association of aqueous tear deficiency in cus also explains why blurry vision was resolved in six eyes. patients with conjunctivochalasis or simply because conjunctivo- The crescent defect created by excision was not closed by su- chalasis can cause an unstable tear film as discussed above. In this tures but rather covered by amniotic membrane as a free graft. This series, we noted that 70.2% of the eyes also carried a diagnosis of difference might explain in part why such scarring-induced com- aqueous tear deficiency based on Schirmer tests or the fluorescein plications as cicatricial entropion of the lower lid, retraction of the clearance test.24 Furthermore, 53.2% of them were associated with lower fornix, and restricted motility noted in previous reports5,9 Meibomian gland dysfunction, which might have caused lipid tear were not noted in this series. Our recent laboratory data further deficiency. For this reason, we treated all patients with symptom- corroborate that human corneal and limbal fibroblasts in contact atic conjunctivochalasis first with frequent artificial tears and lu- with amniotic membrane matrix rapidly turn off transforming bricants as advised by others.4,28 Twenty-nine (61.7%) eyes had growth factor ␤ signaling so the myofibroblast transformation is also received punctal occlusion before the surgery. Because mod- prohibited.19 This action may help explain why AMT helps reduce erate conjunctivochalasis can cause delayed tear clearance, we had scar formation during conjunctival surface reconstruction,12 pre- also treated every symptomatic conjunctivochalasis with topical vent recurrent scarring after pterygium removal,10 and reduce cor- nonpreserved 1% methylprednisolone three times a day for a neal haze after phototherapeutic keratectomy and photorefractive course of 3 weeks as recently reported.24 We noted that 87% of keratectomy.35,36 conjunctivochalasis patients experienced relief of symptoms after Intriguingly, conjunctivochalasis is frequently associated with the methylprednisolone treatment, a finding consistent with our pinguecula (Fig. 1A).37 We noted that 25.5% of eyes were asso- previous report for the treatment of delayed tear clearance24 ciated with inflamed pinguecula and 14.9% of eyes with an in- (Meller and Tseng, unpublished observation). flamed semilunar fold of the nasal caruncle. In these cases, we When symptomatic conjunctivochalasis is resistant to the above noted that excision to include these latter lesions was necessary to medical and surgical treatments, we advise surgical removal of the achieve a better postoperative appearance. As shown in case 2, redundant conjunctiva. Herein we demonstrated that AMT could failure to do so made the pinguecular lesion more inflamed post- effectively reconstruct the conjunctival surface after its removal. operatively, leading to scarring that invaded the amniotic mem- Previously, the crescent excision of the inferior bulbar conjunctiva brane-covered area (Fig. 4A, OD of case 2). With nasal and tem- has been advised as a surgical procedure in the management of poral pinguecula included during excision, the resultant conjunc- 5 conjunctivochalasis refractory to medical treatments.1,2,4,5,8,9 Liu tival defect could not be closed by suturing alone, and the use of described in 15 patients with conjunctivochalasis complaining of amniotic membrane became a necessary alternative (Figs. 1C and epiphora a successful outcome after simple excision of an elliptical D, OS of case 2). Owing to the recovery of a smooth and tight area of 3–5 mm width and 10–12 mm length of redundant con- conjunctival surface, patient complaints related to conjunctivocha- junctiva. The epiphora was relieved in all patients. Similar obser- lasis were also largely resolved.

Cornea, Vol. 19, No. 6, 2000 802 D. MELLER ET AL.

The focal inflammation noted on the host conjunctiva adjacent 12. Tseng SCG, Prabhasawat P, Lee S-H. Amniotic membrane transplan- to the amniotic membrane might be a form of suture knot-induced tation for conjunctival surface reconstruction. Am J Ophthalmol 1997; 124:765–74. granulomatous reaction. This can be reduced by suturing with 10-0 13. Franch A, Rama P, Lambiase A, et al. Human amniotic membrane nylon with the knot buried. It should be noted that such an inflam- transplantation [abstract]. Invest Ophthalmol Vis Sci 1998;39:S90. mation appeared to be prolonged and could be diminished by 14. Azuara-Blanco A, Pillai CT, Dua HS. Amniotic membrane transplan- subconjunctival injections of long-acting steroids (Figs. 4C–J). tation for ocular surface reconstruction. Br J Ophthalmol 1999;83: Our recent laboratory data showed that fibroblasts isolated from 399–402. conjunctivochalasis specimens overexpress collagenase (MMP-1) 15. Lee S-H, Tseng SCG. Amniotic membrane transplantation for persis- 38 tent epithelial defects with ulceration. Am J Ophthalmol 1997;123: and stromelysin (MMP-3) and the production of these two ma- 303–12. trix metalloproteinases and gelatinase B (MMP-9) are further up- 16. Prabhasawat P, Tseng SCG. Impression cytology study of epithelial regulated by proinflammatory cytokines interleukin-1␤ (IL-1␤) phenotype of ocular surface reconstructed by preserved human amni- and tumor necrosis factor ␣ (TNF-␣).39 The finding that conjunc- otic membrane. Arch Ophthalmol 1997;115:1360–7. tivochalasis fibroblasts overexpress MMP-1 and MMP-3 re- 17. Shimazaki J, Yang H-Y, Tsubota K. Amniotic membrane transplan- sembles that of pterygium head fibroblasts.40 This additional evi- tation for ocular surface reconstruction in patients with chemical and thermal burns. Ophthalmology 1997;104:2068–76. dence together with its frequent association with pinguecula sug- 18. Tseng SCG, Prabhasawat P, Barton K, et al. Amniotic membrane gests that conjunctivochalasis fibroblasts may share the same transplantation with or without limbal allografts for corneal surface common pathogenesis with pterygium fibroblasts. Recently, our reconstruction in patients with limbal stem cell deficiency. Arch Oph- laboratory further noted that pterygium body fibroblasts could up- thalmol 1998;116:431–41. regulate their expression of MMP-1 and MMP-3 when exposed to 19. Tseng SCG, Li D-Q, Ma X. Suppression of TGF-␤1, ␤2, ␤3, and ␤ such proinflammatory cytokines IL-1␤ and TNF-␣.41 These data TGF- receptor II expression and myofibroblast differentiation in human corneal and limbal fibroblasts by amniotic membrane matrix. J collectively suggest that fibroblasts with a tendency to overexpress Cell Physiol 1999;179:325–35. MMP-1 and MMP-3 may be linked with fibrovascular prolifera- 20. Meller D, Tseng SCG. In vitro conjunctival epithelial differentiation tion under inflammation. This hypothesis may explain why some on preserved human amniotic membrane [abstract]. Invest Ophthalmol of our patients developed symblepharon and why postoperative Vis Sci 1998;39:S428. steroid injection had helped some of them. We thus believe future 21. Kruse FE, Rohrschneider K, Vo¨lcker HE. Transplantation von Amni- research is need to test this hypothesis and may one day help us onmembran zur Rekonstruktion der Augenoberfla¨che. Ophthalmologe 1998;95:114–9. understand the pathogenesis of conjunctivochalasis and identify 22. Meller D, Tseng SCG. Rekonstruktion der konjunktivalen und korne- adjunctive therapies to augment the success of AMT. alen Oberfla¨che. Transplantation von Amnionmembran. Ophthalmo- loge 1998;95:805–13. 23. Lemp MA. Report of the National Eye Institute/Industry Workshop on Acknowledgment: Supported in part by an unrestricted grant from Re- clinical trials in dry eyes. 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