Cornea 19(6): 796–803, 2000. © 2000 Lippincott Williams & Wilkins, Inc., Philadelphia 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 granu- loma (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 conjunctivochala- sis.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%).