By all means, let's talk about conjunctival chalasis and the overlap of symptoms it can have with dry eye...
WAIKOLOA, Hawaii — Recognizing conjunctival chalasis depends on listening to the patient’s symptoms and investigating any report of a specific site of discomfort or foreign body sensation, a speaker said.
“Conjunctival chalasis occurs when there is a degeneration of Tenon’s fascia that ordinarily tethers the bulbar conjunctiva to the globe,” OSN Cataract Surgery Section Editor John A. Hovanesian, MD, FACS, said at Hawaiian Eye 2013. “This allows stretching and redundancy of the conjunctiva, which bunches up at the inferior lid margin, and sometimes elsewhere, and causes a foreign body sensation especially when the patient blinks.”
Conjunctival chalasis, which is a common and frequently misdiagnosed condition that mimics dry eye, is accompanied by signs of conjunctival redundancy.
Hovanesian recommends performing a “thumb test,” wherein the clinician, pressing gently on the lower lid externally over the area of discomfort, puts light pressure against the globe and asks the patient to move the eye back and forth in a direction that would deliberately cause gathering of the bulbar conjunctiva and pinching between the globe and the eyelid margin.
“When the patient complains of a specific site of pain, and there is evidence of conjunctival laxity, and there is a positive ‘thumb test,’ you’ve got your diagnosis of conjunctival chalasis,” Hovanesian said.
Fair enough. Getting a detailed thorough diagnosis is really, really important in any ocular surface disease, especially when there's a lot of chronic pain going on.
Which then leads us to the inevitable dilemma about treatment. Do we slice & dice?
After making an attempt at lubrication with artificial tears, Hovanesian recommends surgical excision with ocular surface reconstruction with amniotic membrane. The technique is highlighted on his website at http://www.bettereyesurgery.com/video-library/.
This is where I start getting worried... having come across far too many people over the years who had high ocular surface pain levels and were highly motivated to pursue any and all treatment. They had ocular surface reconstruction with amniotic membrane, and they felt and looked great... for six months. At some point later, back to square one. Maybe $10k poorer.
Often these people have had a slightly different diagnosis from every doctor they went to. No one was ever really able to help then. Suddenly, an exciting and totally different diagnosis! Better yet, I can fix you! One little surgery and all that will be gone!
How do you not succumb?
Caution, folks, caution. Fine, suppose we've established your conj is a mess BUT have we established, do we have sufficient reason to believe that's what's your pain source or even tipping point is? Really?
Naturally, my views will be biased because I hear far more from unhappy patients than happy patients (nature of the beast). Nevertheless, I think my concern is valid. It's so tempting for a doctor when they see a nail that looks like a great match for their hammer, to hammer away. But whenever we're talking about ocular surface pain, you've got to appreciate how little is really known about corneal pain, and not set patients up to expect miracle cures when at the end of the day we don't really know.