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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 19  |  Issue : 1  |  Page : 14-18

Argon laser treatment for symptomatic inferior conjunctivochalasis refractory to medical therapy


Department of Ophthalmology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt

Date of Submission16-Aug-2017
Date of Acceptance26-Oct-2017
Date of Web Publication1-Feb-2018

Correspondence Address:
Mona M Aly
Department of Ophthalmology, Faculty of Medicine, Al-Azhar University, Nasr City 11754, Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/DJO.DJO_54_17

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  Abstract 

Purpose
The aim of this study was to present argon laser procedure as a treatment option for symptomatic inferior conjunctivochalasis (CCh) refractory to medical therapy and to evaluate its efficacy.
Patients and methods
A prospective interventional study was conducted to evaluate the clinical results after argon laser photocoagulation for symptomatic inferior CCh using a slit-lamp-mounted argon laser under topical anesthesia. Twenty eyes with CCh refractory to medical treatment were enrolled in the study.
Results
The symptoms significantly improved in all patients, and the conjunctival laxity disappeared in eight (40%) of 20 eyes and improved in the remaining 12 (60%) eyes after the treatment of CCh with argon laser.
Conclusion
Argon laser photocoagulation of the conjunctiva can successfully treat CCh with symptomatic attenuation.

Keywords: argon laser, conjunctivochalasis, dry eye, lid-parallel conjunctival folds, questionnaire


How to cite this article:
Aly MM. Argon laser treatment for symptomatic inferior conjunctivochalasis refractory to medical therapy. Delta J Ophthalmol 2018;19:14-8

How to cite this URL:
Aly MM. Argon laser treatment for symptomatic inferior conjunctivochalasis refractory to medical therapy. Delta J Ophthalmol [serial online] 2018 [cited 2018 Apr 23];19:14-8. Available from: http://www.djo.eg.net/text.asp?2018/19/1/14/224571


  Introduction Top


Conjunctivochalasis (CCh) is defined as redundant, loose, nonedematous conjunctiva between the globe and eyelid, which tends to be bilateral [1] and leads to ocular surface and tear abnormalities [2]. CCh has been shown to cause dry eye symptoms by inducing tear film instability, delayed tear clearance, and ocular surface inflammation [3]. Patients with CCh are generally asymptomatic. In cases where the patient is symptomatic, symptoms include tearing, foreign body sensation, redness, subconjunctival hemorrhage, eye pain, and blurriness, especially in down gaze [4]. Symptomatic CCh can be treated with topical lubricants with or without topical corticosteroids. Nonresponding cases can be managed with surgical excision of the conjunctiva with or without amniotic membrane transplantation [5]. Other less invasive procedures such as bipolar coagulation, thermocautery coagulation, and argon laser coagulation have also been used [6].

The purpose of the current study was to present argon laser procedure as a treatment option for symptomatic inferior CCh and to evaluate its efficacy.


  Patients and methods Top


This prospective interventional study was conducted on 10 (20 eyes) patients of both sexes with bilateral symptomatic inferior CCh. Patients with history of eyelid abnormalities (such as entropion, ectropion, trichiasis, and floppy eyelid), Stevens–Johnson syndrome, pemphigoid, symblepharon, pterygium, ocular surgery, thyroid eye diseases, autoimmune diseases, and inflammatory eye diseases were excluded from the study.

The chief complaints of all patients were dry eye disease symptoms nonresponsive to the conventional lines of treatment. Their symptoms were obtained by Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire [7].

Standard patient evaluation of eye dryness

SPEED is a symptom questionnaire available for dry eye. The symptoms inquired by the SPEED questionnaire include dryness or grittiness or scratchiness, soreness or irritation, burning or watering, and eye fatigue reported and scored as sometimes (1), often (2), and constant (3), and whether these symptoms pose no problems (0), were tolerable (1), uncomfortable (2), bothersome (3), or intolerable (4) [7].

The SPEED questionnaire is scored on a scale of 0–28, with higher scores representing more severe symptoms. Dry eye symptoms were assessed with SPEED questionnaire before and after argon laser treatment.

All included patients were initially treated with topical artificial tears, NSAIDs, and if needed, topical corticosteroid eye drops, with no satisfactory improvement of symptoms. The duration of this conservative treatment ranged from 3 to 18 months, with a mean of 10.3±4.2 months.

All patients underwent complete ophthalmic examination including measurement of visual acuity, external eye examination, intraocular pressure measurement, and slit-lamp anterior segment examination for evaluation of the ocular surface and grade of CCh. Indirect ophthalmoscopy and slit-lamp biomicroscopy with +90 D noncontact lens were performed for posterior segment evaluation.

Grading of conjunctivochalasis

The diagnosis of CCh was made based on a slit-lamp examination. Evaluation of lid-parallel conjunctival folds (LIPCOF), the lower temporal LIPCOF, had been used as a guide for evaluation. The patients were instructed to look straight forward, and after some blinking, the LIPCOFs were evaluated with slit lamp at the lower temporal quadrant of the palpebral fissure.

Grading was scored using a grading system (Schirra et al. [8], modified from Höh et al. [9]); the LIPCOF stages were as follows:

Stage 0: no LIPCOF.
Stage 1: small LIPCOF.
Stage 2: medium-sized LIPCOF.
Stage 3: large LIPCOF.

CCh was graded before and after argon laser treatment according to this proposed grading system.

Laser procedure

After explaining the treatment procedures and the possible outcomes, an informed consent was obtained from all patients and the study was approved by the Local Ethics Committee. After application of topical anesthetic, benoxinate hydrochloride 0.4% (Benox; EIPICO, Cairo, Egypt), exposure of the bulbar conjunctiva at the lower temporal quadrant of the palpebral fissure was done by pulling the lower eyelid down with the patient being instructed to look upward and in. The applied argon laser shots (VISULAS 532; Carl Zeiss, Jena, Germany) were directed away from the limbus by more than 2 mm.

A slit-lamp-mounted argon laser was used with a spot size of 500 µm and pulse duration of 0.5 s, with the energy output varied from 650 to 800 mW based on the tissue response. The average number of laser shots was 120. Coagulation was considered to be adequate when the conjunctiva became blanched and shrunken, with small cavitations. After the treatment, topical combined antibiotic and corticosteroid eye drops were used three times/day for 1 week with topical artificial tears.

Slit-lamp examinations and anterior segment photography were used to document the grading of CCh and the occurrence of any complications. The follow-up examinations were performed on days 1 and 7 after the laser treatment and monthly thereafter for 3 months. The SPEED score and the LIPCOF stage were reported before the laser procedure and 1 and 3 months after treatment. In addition, the presence of postlaser treatment complications was recorded, if any.

Statistical analysis

Statistical analyses were performed by SPSS software for Windows, version 15 (SPSS Inc., Chicago, Illinois, USA). Parametric data were tested by paired-sample t-test and expressed as mean±SD. Nonparametric data were tested by χ2-test and expressed as number and percentage. P values less than 0.05 were accepted as significant.


  Results Top


Ten patients with bilateral symptomatic inferior CCh that was refractory to conventional therapies were included in the study. The mean age was 50.5±3.7 years (range: 45–55 years), with five of the 10 patients being females. The patients were diagnosed with moderate to severe CCh which were classified as grade 2 (10/20 eyes) to grade 3 (10/20 eyes) on slit-lamp anterior segment examination.

All patients were treated with a slit-lamp-mounted argon laser, and the laser parameters were summarized in [Table 1]. The treatment of the second eye followed the first one by 1 week. All patients experienced mild discomfort during the procedure. Conjunctival hyperemia was noted in the treated area immediately after the argon laser therapy.
Table 1: Argon laser parameters

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The grade of CCh decreased after the argon laser procedure in all patients ([Figure 1]). At the third month after laser treatment, eight eyes improved from grade 2 and 3 CCh to grade 0 (40%), 10 eyes improved from grade 2 and 3 CCh to grade 1 (50%), and two eyes improved from grade 3 to 2 (10%) ([Table 2]). The decrease in the grades of CCh after laser treatment was statistically significant (P<0.05).
Figure 1: Anterior segment photographs obtained before and after argon laser photocoagulation for conjunctivochalasis; (a) before argon laser, (b) immediately after argon laser with laser marks and conjunctival hyperemia around the laser-treated area, and (c) 1 month after argon laser with disappearance of the conjunctival hyperemia and decrease in lid-parallel conjunctival folds.

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Table 2: Conjunctivochalasis grades preargon and postargon laser treatment

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The mean SPEED score decreased from 19.8±2.9 (range: 16–24/28) before laser to 6.6±2.6 (range: 4–12/28) at the end of the third month after laser ([Table 3]), which was statistically significant (P<0.05).
Table 3: Standard Patient Evaluation of Eye Dryness Score preargon and postargon laser treatment

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In six (30%) eyes, it was noticed that dense conjunctival pigmentations which were present before laser treatment disappeared after the argon laser treatment for CCh.

The early complications of argon laser photocoagulation were foreign body sensation, mild pain, and conjunctival hyperemia. The foreign body sensation and mild pain disappeared after 1–2 days and the conjunctival hyperemia disappeared within 1 week. No corneal or scleral complications were noted during the follow-up period.


  Discussion Top


CCh is a common dry eye disorder, which can cause an unstable tear film and ocular discomfort [10]. It is a common cause of ocular surface irritation, and its clinical significance is often overlooked [11]. No treatment is needed if patients with CCh remain asymptomatic. Medical treatments with artificial tears, lubricants, steroids, and antihistamines have been advised for symptomatic patients [12].

The severe CCh characterized by a high LIPCOF degree usually requires surgical intervention [10]. Because the symptoms in CCh are caused by mechanical problems subsequent to folded conjunctiva, alleviation of the symptoms can be achieved through surgical removal [11]. Conservative conjunctival resection, conjunctival fixations to the sclera, or amniotic membrane grafts are among the methods which have been used [13]. Surgical excision possesses certain limitations, such as removal of normal conjunctival tissues, scar formation, inflammation, infection concerns, and long period of recovery [14].

Argon laser photocoagulation is widely used for retinal diseases, laser iridotomy, removal of conjunctival nevus, and so on [15]. Conjunctivoplasty using an argon laser can be used to induce conjunctival shrinkage in patients with CCh [16]. Shrinkage of the conjunctiva may reduce the redundancy of the conjunctiva, and conjunctival coagulation may induce reinforcement of conjunctival attachments to the globe, reducing conjunctival laxity [17].

In the current study, moderate to severe CCh was treated with argon laser leading to a reduction in the severity of CCh as well as the SPEED scores. Of the 20 eyes included in the study, eight eyes improved from grade 2 and 3 CCh to grade 0 (40%), 10 eyes improved from grade 2 and 3 CCh to grade 1 (50%), and two eyes improved from grade 3 to 2 after laser (10%) by the end of the scheduled 3 months of follow-up. The symptoms significantly improved in all enrolled patients.

In their study, Yang et al. [16] reported a decrease in the grade of CCh in 86% of eyes (25 of 29 eyes) at 6 months after the argon laser conjunctivoplasty with a significant symptomatic improvement in most of the patients. Argon laser photocoagulation was applied for the treatment of CCh, because it is a very simple procedure, shrinkage of the conjunctiva after application of the argon laser was found, and could be easily performed in outpatient clinics. It is also advantageous because it is a noninvasive and quick procedure [18].It was noticed that dense conjunctival pigmentations previously reported in six enrolled eyes, in the present study, had disappeared after argon laser treatment for CCh. Similarly, argon laser had been used as a safe and effective treatment for benign superficial conjunctival pigmentation [19].

In the present study, conjunctival hyperemia occurred in all patients immediately after the argon laser treatment. The conjunctival injection can be explained by the response to the heat delivered by the laser [19].

All recruited patients had improved CCh grading, with redundant conjunctiva being absent in eight eyes. SPEED symptom questionnaire scores improved after the argon laser technique, suggesting that the use of argon laser to treat CCh may provide symptom relief or attenuation.

The limitations of the current study included the small number of patients and the short follow-up period that did not allow for a definitive conclusion regarding the long-term effect of the argon laser therapy. So, further studies on a larger number of patients with long-term follow-up should be performed and could include further investigations of other additional factors such as tear break-up time, Schirmer’s test, and height of the tear meniscus.


  Conclusion Top


Argon laser is a simple and effective technique to treat symptomatic inferior CCh refractory to medical therapy. It can be performed in outpatient clinic. The postoperative discomfort is minimal, and this technique represents a minimal invasion of the ocular surface.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Kheirkhah A, Casas V, Esquenazi S, Blanco G, Li W, Raju VK et al. New surgical approach for superior conjunctivochalasis. Cornea 2007; 26:685–691.  Back to cited text no. 1
    
2.
Zhang XR, Zou HD, Li QS, Zhou HM, Liu B, Han ZM et al. Comparison study of two diagnostic and grading systems for conjunctivochalasis. Chin Med J (Engl) 2013; 126:3118–3123.  Back to cited text no. 2
    
3.
Kocabeyoglu S, Mocan MC, Irkec M, Orhan M, Karakaya J. Conjunctivochalasis as a contributing factor for the development of ocular surface disease in medically treated glaucoma patients. J Glaucoma 2014; 23:333–336.  Back to cited text no. 3
    
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Balci O. Clinical characteristics of patients with conjunctivochalasis. Clin Ophthalmol 2014; 8:1655–1660.  Back to cited text no. 4
    
5.
Chan TC, Ye C, Ng PK, Li EY, Yuen HK, Jhanji V. Change in tear film lipid layer thickness, corneal thickness, volume and topography after superficial cauterization for conjunctivochalasis. Sci Rep 2015; 5:12239.  Back to cited text no. 5
    
6.
Arenas E, Muñoz D. A new surgical approach for the treatment of conjunctivochalasis: reduction of the conjunctival fold with bipolar electrocautery forceps. Scientific World Journal 2016; 2016:6589751.  Back to cited text no. 6
    
7.
Asiedu K, Kyei S, Mensah SN, Ocansey S, Abu LS, Kyere EA. Ocular surface disease index (OSDI) versus the standard patient evaluation of eye dryness (SPEED): a study of a nonclinical sample. Cornea 2016; 35:175–180.  Back to cited text no. 7
    
8.
Schirra F, Höh H, Kienecker C, Ruprecht KW. Using LIPCOF (lid-parallel conjunctival fold) for assessing the degree of dry eye, it is essential to observe the exact position of that specific fold. Adv Exp Med Biol 1998; 438:853–858.  Back to cited text no. 8
    
9.
Höh H, Schirra F, Kienecker C, Ruprecht KW. Lid-parallel conjunctival folds are a sure diagnostic sign of dry eye. Ophthalmologe 1995; 92:802–808.  Back to cited text no. 9
    
10.
Kiss HJ, Németh J. Isotonic glycerol and sodium hyaluronate containing artificial tear decreases conjunctivochalasis after one and three months: a self-controlled, unmasked study. PLoS One 2015; 10:e0132656.  Back to cited text no. 10
    
11.
Zhang XR, Zhang ZY, Hoffman MR. Electro-coagulative surgical procedure for treatment of conjunctivochalasis. Int Surg 2012; 97:90–93.  Back to cited text no. 11
    
12.
Meller D, Maskin SL, Pires RT, Tseng SC. Amniotic membrane transplantation for symptomatic conjunctivochalasis refractory to medical treatments. Cornea 2000; 19:796–803.  Back to cited text no. 12
    
13.
Petris CK, Holds JB. Medial conjunctival resection for tearing associated with conjunctivochalasis. Ophthal Plast Reconstr Surg 2013; 29:304–317.  Back to cited text no. 13
    
14.
Kashima T, Akiyama H, Miura F, Kishi S. Improved subjective symptoms of conjunctivochalasis using bipolar diathermy method for conjunctival shrinkage. Clin Ophthalmol 2011; 5:1391–1396.  Back to cited text no. 14
    
15.
Kwon JW, Jeoung JW, Kim TI, Lee JH, Wee WR. Argon laser photoablation of conjunctival pigmented nevus. Am J Ophthalmol 2006; 141:383–386.  Back to cited text no. 15
    
16.
Yang HS, Choi S. New approach for conjunctivochalasis using an argon green laser. Cornea 2013; 32:574–578.  Back to cited text no. 16
    
17.
Youm DJ, Kim JM, Choi CY. Simple surgical approach with high-frequency radio-wave electrosurgery for conjunctivochalasis. Ophthalmology 2010; 117:2129–2133.  Back to cited text no. 17
    
18.
Shin KH, Hwang JH, Kwon JW. New approach for conjunctivochalasis with argon laser photocoagulation. Can J Ophthalmol 2012; 47:380–382.  Back to cited text no. 18
    
19.
Shin KH, Hwang JH, Kwon JW. Argon laser photoablation of superficial conjunctival nevus: results of a 3-year study. Am J Ophthalmol 2013; 155:823–828.  Back to cited text no. 19
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3]



 

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