A new surgical technique for management of conjunctivochalasis

PURPOSE: To present a new surgical technique for severe, symptomatic conjunctivochalasis and our hypothesis of the pathogenesis of this condition. METHODS: Six eyes of three patients with conjunctivochalasis (average age +/-SD, 70.0 +/- 9.6 years; range, 56-78 years) were treated with a conjunctival fixation to sclera with three 6-0 Vicryl (Johnson & Johnson, New Brunswick, New Jersey) stitches. RESULTS: With a mean follow-up period of 209.5 days (range, 181-219 days), we achieved successful treatment in all eyes, with no recurrence of conjunctival folds. CONCLUSION: We successfully treated conjunctivochalasis with conjunctival fixation to sclera, which strongly suggests that conjuctival folds are caused by the folding and the elevating of loosely adherent bulbar conjunctiva of the lower eyelid.     

结膜松弛症的发病机理研究

结膜松弛症的发病机理是出现了球结膜、泪液和睑缘三者平衡失调,眼表自动反馈调节系统失灵。球结膜组织发生以弹力纤维减少为主要的组织病理改变,泪液中出现蛋白质及酶的异常表达,在瞬目或闭眼时下睑缘张力增高向上推压已经过度变薄、弹性下降、张力降低、与其下方组织结合疏松的球结膜,松弛结膜就会明显堆积在下睑缘上、内、外眦部之间,形成皱褶,突出于眼表曲面,影响泪液的流动、分布、排泄,在松弛结膜上不能形成正常泪膜,而发生干燥、充血、水肿、上皮角化、泪河变窄或残缺不全,泪液不能正常流动到泪湖区,泪湖不能聚泪,泪液不能进入泪点,使泪液排泄出现障碍,泪液清除延缓又可导致大量降解酶的堆积,可能使胶原纤维溶解,弹力纤维变性,引起眼表泪液学异常的病理循环,而发生结膜松弛症。     

Hughes technique, amniotic membrane allograft, and topical chemotherapy in conjunctival melanoma with eyelid involvement

A 59-year-old woman presented with a pigmented mass in the inferior tarsal conjunctiva of the left eye with an associated diffuse, multifocal pigmentation involving largely the inferior half of the bulbar conjunctiva, fornix, and eyelid skin. Histopathologic examination of map biopsies disclosed conjunctival melanoma from primary acquired melanosis. Surgical excision of the inferior bulbar conjunctiva, fornix, and lower eyelid with histopathologic free margins was performed. Adjuvant cryotherapy was applied. The bulbar conjunctiva and lower fornix were reconstructed with an amniotic membrane allograft. Lower eyelid reconstruction was accomplished by use of the Hughes technique. Topical mitomycin C (0.04%) was applied after surgery. After 2 years of follow-up, no tumor recurrence has been detected and the eyelid and conjunctival defect have been satisfactorily corrected. This combined surgical procedure using amniotic membrane allograft and a composite tarsoconjunctival flap is shown to be useful in the treatment of an advanced conjunctival neoplasia with extensive eyelid involvement.     

离休干部结膜松弛症患病调查

目的:结膜松弛症是老年人常见眼病,为此对离休干部进行结膜松弛症患病调查,探讨结膜松弛症发病机制,寻求有效治疗方法。方法:对上海市普陀区离休干部278例(556眼)年龄69～96(平均81.05)岁,对照结膜松弛症的诊断及分级标准将下睑缘位置分为三型:角膜缘下型、角膜缘型、角膜缘上型;下眼睑张力分为五型:下睑缘内翻型、下睑缘内倾型、下睑缘正常型、下睑缘外倾型、下睑缘外翻型。由专人专职进行松弛结膜、下睑缘位置、下睑缘张力的检查并进行统计分析。结果:有254例(496眼)患有结膜松弛症,占89.2%,其中I级133例(262眼)占47.1%,II级110例(215眼)占38.7%,III、IV级共17例(19眼)占3.4%。结膜松弛症患者中下睑缘位置为角膜缘型最多(143例283眼,占57.1%);其次为角膜缘上型(74例142眼,占28.6%);角膜缘下型最少(41例71眼,占14.3%)。结膜松弛症患者中下睑缘张力为下睑缘正常型114例(224眼),占45.2%;下睑缘内倾型多于(84例147眼,占29.6%)下睑缘外倾型(41例80眼,占16.1%);下睑缘内翻型较少(2例45眼,占9.1%)。本组病例未发现下睑缘外翻型。下睑缘内翻型、内倾型发生结膜松弛症的概率比正常型要高,有显著性差异(P=0.0001)。结论:老年人结膜松弛症发病率较高,下睑缘张力高是结膜松弛症发生因素之一。     

Case-controlled clinical and histopathological study of conjunctivochalasis

BACKGROUND/AIMS: Conjunctivochalasis, a secondary cause of the watery eye, is frequently seen in the older age group as an elevation of the bulbar conjunctiva lying along the lateral or central lower lid margin. A prospective, interventional, case-controlled clinical and histopathological study was conducted. The relevant features of 18 patients (29 eyes) who had their conjunctivochalasis resected as part of the surgical management of their watery eye syndrome were examined. In the control group, tissue was obtained from an age matched series of 24 normal subjects undergoing routine cataract surgery. METHODS: 24 controls (24 specimens) and 18 patients (29 specimens) had conjunctival strip biopsies, taken from the usual lid margin level bulbar conjunctiva in line with the inferior limbus (controls), and the clinically apparent conjunctivochalasis (patients). These were submitted for histological study. RESULTS: 23 of 24 control sections demonstrated normal conjunctival variation. Four of 29 patient specimens demonstrated a chronic non-granulomatous conjunctivitis, while three eyes of the patient group (two patients) demonstrated features of elastosis. Of the four patients who had the inflammatory infiltrates, three had functional nasolacrimal duct obstructions (FNLDOs) and one had a primary acquired nasolacrimal duct obstruction (PANDO). Of the two patients who had elastosis, one had an FNLDO and the other had normal lacrimal drainage and was Jones 1 positive. CONCLUSION: Six of 18 patients--that is, seven of 29 specimens of conjunctivochalasis demonstrated signs of elastosis or of chronic non-granulomatous inflammation. Clinically, patients had a spectrum of aetiologies of their watery eye syndrome.     

结膜松弛症下睑缘位置及张力观察

目的:探讨结膜松弛症发病机制,寻求有效防治方法。方法:对241例(479眼)结膜松弛症(conjunctivochalasis,CCh)下眼睑位置及下睑缘张力检查。将下睑缘位置分为3型:角膜缘下型、角膜缘上型及角膜缘型。将下睑缘张力分为5型:下睑缘内翻型、下睑缘内倾型、下睑缘正常型、下睑缘外倾型及下睑缘外翻型。结果:下睑缘位置以角膜缘型伴有下睑缘内倾型发生结膜松弛症最多(20.2%);其次为角膜缘下型伴下睑缘内倾型(17.3%)。角膜缘上型伴下睑缘外倾型最少(1.5%)。结论:下睑缘张力高是结膜松弛症发生因素之一。     

A quantitative assessment of the location and width of Marx's line along the marginal zone of the human eyelid.

PURPOSE: To quantitatively assess the staining of Marx's line with lissamine green dye.METHODS Forty white (European) subjects, aged 18 to 78 years, were assessed. The subjects had no major eye disease, although some had mild to moderate blepharitis. Lissamine green dye strips were used to stain the marginal zone of the palpebral conjunctiva, and high-magnification photo slit lamp images were taken of the everted upper eyelid along with a scale rule. From prints at 1600x, the distances between the main tarsal (Meibomian) gland orifices, the width of the lissamine green-stained Marx's line, and the location of its anterior border were measured. RESULTS: The group-mean distance between the main tarsal gland orifices was 0.81 +/- 0 16 mm, whereas the width of the lissamine green-stained line was 0.10 +/- 0.09 mm. In most subjects, the lissamine green-stained line was posterior to the tarsal gland orifices, and the location of the proximal (anterior) edge of this line averaged +0.13 mm from a reference line drawn through the orifices. CONCLUSION: Lissamine green dye highlights a very distinct line of cells along the marginal zone. This line of cells is narrow and is thought to be the natural site of frictional contact between the eyelid margin and the surfaces of the bulbar conjunctiva and cornea, rather than the edge of the tear meniscus or location of the edge of the lacrimal river.     

Herpes simplex of the lid margin (author's transl)]

Isolated herpes simplex affecting the lid margin can be distinguished from herpes simplex involving the entire eyelid by characteristic features. The typical intermarginal form of herpes-simplex-blepharitis presents itself as an erosion of about 3 mm in length which may be well discerned in detail after fluorescein staining. The skin adjecent to the lesion may also exhibit superficial ulceration, possibly being covered by crusts. The affected portion of the lid shows localized and moderate swelling as well as pain upon pressure. Injection of the bulbar conjunctiva will characteristically be noted mainly in the area opposing the lid lesion. The regional lymph nodes are enlarged, and possibly tender upon palpation. Local medication with anti-viral ophthalmic ointment is effective within a few days.     

下睑缩肌后徙与切断手术治疗轻度下睑退缩

目的探讨下睑缩肌后徙或切断手术治疗轻度下睑退缩的临床效果。方法手术多在局麻下进行，采用经典的下睑袋皮肤切口。打开下眶隔，将眶脂肪向下推，暴露下睑缩肌的前表面，沿下睑板下缘处分离下睑缩肌，将下睑缩肌完全分离至下穹隆。于穹隆水平处切断或将其后徙缝合于下穹隆处结膜面。患者取坐位观察下睑位置，以下睑位于下方角膜缘上0．5mm为宜。术后1周、1月及6月测量下睑位置，观察其变化情况。结果11例（14眼），随访6—20月，平均7．3月，获良好效果。12眼在双眼平视时下睑位于角膜下缘，2眼仍残存下睑退缩约0．5mm。全部病例下睑退缩较术前有极大的改善，手术效果良好。结论下睑缩肌后徙或切断手术治疗轻度下睑退缩可获得较好的功能和美容效果。对于轻度下睑退缩的治疗是一种较理想的方法。     

结膜松弛症研究新进展

结膜松弛症是年龄相关性老年性常见眼病,随着人口老龄化加快,患者日趋增多。下睑缘张力高、睑板腺功能障碍及结膜淋巴流动阻塞可能是结膜松弛症诱发因子之一。自身免疫性甲状腺疾病患者结膜松弛症发病率高。结膜松弛症患者球结膜杯状细胞减少,并有形态及超微结构异常表现。结膜松弛症泪液分泌减少,泪膜稳定性下降,泪液中黏蛋白减少,出现调节凋亡相关蛋白质和防御素。细胞凋亡和炎症可能是结膜松弛症发病的原因。结膜松弛症发病机制认为是泪液中IL-1β,IL-6,肿瘤坏死因子-α等炎性因子增加,使结膜成纤维细胞中MMP-1,3,9过度表达,使得MMPs与TIMPs之间失去平衡,可能使胶原纤维融解,弹力纤维变性减少,导致球结膜基质和Tenon囊的过度降解,引起眼表泪液异常的病理循环,而发生结膜松弛症。纤维蛋白胶应用于结膜松弛症手术中,电凝治疗结膜松弛症及开展上方结膜松弛症手术治疗。     

New surgical treatment for superior limbic keratoconjunctivitis and its association with conjunctivochalasis

PURPOSE: To introduce a new surgical procedure for treating superior limbic keratoconjunctivitis (SLK) and to suggest the association of SLK with conjunctivochalasis. DESIGN: Interventional case series. METHODS: Six eyes of five patients with long-standing severe ocular irritation unresponsive to treatment with topical steroid and artificial tears were operated on using our new procedure. This technique consists of four steps as follows: (1) Rose bengal (RB) staining is used to localize the abnormal conjunctival area; (2) an arc-like conjunctival incision is placed from the 2 to the 10 o'clock position adjacent and distal to the RB-stained area; (3) the conjunctiva is resected to form a crescent using the arc-like incision as the base; the size of the resection is determined by conjunctival redundancy after removal of the subconjunctival connective tissue; and (4) the crescent conjunctival opening is closed with interrupted sutures. In two eyes, the new surgical procedure was performed together with surgery for inferior bulbar conjunctivochalasis. RESULTS: In all operated eyes, RB staining had disappeared by the end of the second postoperative week; recovery from symptoms and loss of inflammation were recorded by 1 month after treatment. In the case with the longest follow-up (14 months), there was cytologic evidence of goblet cell recovery at 3 months after the operation. In another, there was normalization of the nucleo/cytoplasmic ratio of conjunctival cells without the appearance of goblet cells. CONCLUSIONS: Our treatment very effectively resolved symptoms associated with SLK, even in eyes unresponsive to conventional therapy with eye drops. Considering that we did not address the diseased part of the conjunctiva but rather the adjacent conjunctival redundancy, we propose that superior bulbar conjunctivochalasis is involved in the pathogenesis of SLK.     

部分结膜切除术治疗结膜松弛症性溢泪的疗效

目的：评价球结膜部分切除术治疗球结膜松弛症患者溢泪的安全性和有效性。方法：回顾性病例系列研究。对2015年6月到2017年12月在陆军军医大学附属西南医院眼科确诊为结膜松弛症并伴有溢泪症状,接受部分结膜切除手术治疗的患者31例（31眼）,完成随访的27例（27眼）进行统计分析。所有患者的结膜松弛症均为Ⅲ级或以上,接受球结膜部分切除术后,检查患者自觉症状及结膜脱垂体征变化。采用配对t检验比较术前及术后1、6、12个月泪膜破裂时间变化以及术前和术后6个月的下泪河高度变化。结果：术后患者的溢泪症状均消失。拆除结膜缝线后未见切口处的结膜裂开。至术后平均15个月的随访期间,裂隙灯显微镜检查未见结膜松弛症复发。术后随访各时间点泪膜破裂时间均显著提高（P<0.001）,术后12个月下泪河高度较术前提高（t=-14.642,P<0.001）。结论：切除松弛脱垂的球结膜,间断缝合球结膜切口,并固定于浅层巩膜上,可有效避免手术中结膜撕裂和术后结膜切口裂开等手术并发症,能够改善患者的溢泪,一定程度上稳定泪膜,且安全、有效。     

Effect of suction ring application during LASIK on goblet cell density

PURPOSE: To study the effect of LASIK surgery on conjunctival goblet cells as one of the proposed mechanisms for dry eye occurring after LASIK. METHODS: This prospective study included 22 eyes (11 patients) that underwent LASIK for the correction of myopia. Three pairs of samples were taken from the bulbar conjunctiva of each eye. The first pair was taken preoperatively before application of the suction ring. The second and third pairs were taken from the same sites at 1 week and 1 month consecutively. The first site was at 12 o'clock and the second at the inferotemporal quadrant between 7 and 8 o'clock. Time of suction was recorded. RESULTS: Preoperatively, mean goblet cell density was 424 +/- 105 cells/mm2 (range: 284 to 630 cells/mm2). All postoperative samples showed a statistically significant decrease in goblet cell count: 216 +/- 81 cells/mm2 (range: 40 to 325 cells/mm2) at 1 week and 218 +/- 99 cells/mm2 (range: 50 to 396 cells/mm2) at 1 month. Other parameters of conjunctival impression cytology were normal. The difference between the samples in the inferior conjunctiva preoperatively and 1 week postoperatively was greater than that of the superior conjunctiva. Recovery rate in both sites was similar and the damage did not correlate with the duration of suction. CONCLUSIONS: The application of the microkeratome suction ring induced changes in the perilimbic conjunctiva. These changes contribute to the pathology of dry eye. Goblet cell count remains affected at 1 month postoperatively.     

带蒂结膜瓣移植联合MMC治疗翼状胬肉合并结膜松弛症

目的：探讨带蒂结膜瓣移植联合丝裂霉素治疗翼状胬肉合并结膜松弛症的疗效。 方法：对翼状胬肉合并结膜松弛症患者122例156眼进行翼状胬肉切除,下方带蒂结膜瓣移植联合术中使用0.2g/L丝裂霉素C。 结果：患者122例156眼术后2mo眼部症状有不同程度改善。泪河恢复正常者136眼（87.18％）;泪膜破裂时间（BUT）≥10s者117眼（75.00％）;裂隙灯显微镜检查眼球与下睑缘、内外眦部之间无松弛结膜皱褶者147眼（94.23%）;下睑缘位置正常者142眼（91.03%）。手术后观察6mo~4a,胬肉复发5眼（3.21%）,结膜松弛复发15眼（9.62%）。 结论：翼状胬肉切除术中,下方带蒂结膜瓣移植联合术中使用丝裂霉素C治疗翼状胬肉合并结膜松弛症,手术简单易行,取材容易,安全可靠,损伤小,并发症少,复发率低,适合临床开展。     

结膜松弛症的临床及病理研究

目的探讨结膜松弛症的临床特征及组织病理学改变。方法收集结膜松弛症患者26例（39只眼）的相关临床资料,并进行回顾性分析;对患病组26例（39只眼）结膜松弛症患者松弛结膜组织和对照组15例（15只眼）单纯白内障患者球结膜组织进行病理组织学检查,对照观察两组样本组织病理改变。结果结膜松弛症患者多为中老年人,性别比较差异无显著性,均为双眼发病,均有溢泪与干眼症状,不同程度的多余球结膜堆积于下眼睑与眼球之间,泪膜破裂时间（BUT）〈3S,角膜荧光素染色阳性。组织病理学改变：对照组有14只眼为正常的结膜改变,患病组39只眼中有16只眼为慢性非肉芽肿性结膜炎,17只眼为弹性组织变性。结论结膜松弛症患者多为中老年人,主要表现为溢泪与干眼症状,选择合适的手术可以有效的改善患者的病情;其主要病理改变为弹性组织变性,慢性非肉芽肿性结膜炎及炎性细胞浸润等。     

Conjunctivochalasis: associations with pinguecula in a hospital‐based study

Purpose: To assess the relationship between the prevalence and severity of conjunctivochalasis and pinguecula. Methods: Cross‐sectional, consecutive case study conducted at the university hospital of University of Tokyo Graduate School of Medicine. A total of 1061 patients aged from 1 to 94 years were enrolled. The grade and other parameters of conjunctivochalasis (classified into three locations: nasal, middle and temporal) and the grade of pinguecula located on the nasal or temporal conjunctiva were determined in all subjects. Patients were also divided into 5 or 10 age groups. Results: The severity of conjunctivochalasis affecting the nasal and temporal bulbar conjunctiva was significantly correlated with the grade of pinguecula located on the nasal and temporal conjunctiva in each age group (p < 0.05). Pinguecula was independently associated with conjunctivochalasis (nasal: odds ratio [OR] = 1.44; temporal: OR = 1.43) after adjustment for age. Conclusion: This was the first assessment of the relation between the grade of conjunctivochalasis and pinguecula in a large consecutive series of patients. Our results suggest that the prevalence and severity of conjunctivochalasis are related to the presence of pinguecula.     

四种上睑下垂术式临床效果分析

目的:观察4种上睑下垂术式的临床效果。方法:为探讨上睑下垂术的有效治疗方法,不断改进手术方式。结果:每种手术均有其优点及并发症,提上睑肌折叠术为目前较为理想的手术方法。结论:临床实践提上睑肌折叠术与以往专家理论:提上睑肌节制韧带上每缩短3～5mm肌肤,可矫正下垂量1mm不同:在节制韧带上缘折叠提上睑肌腱膜即可提起上睑,且上睑缘正好在角膜缘上2mm,术后恢复在角膜缘处。     

角膜缘干细胞移植治疗翼状胬肉合并结膜松弛症的观察

目的：观察下方角膜缘干细胞移植治疗翼状胬肉合并结膜松弛症的效果、并发症和眼表泪液动力学变化等。方法：观察2010-12/2012-12在我院确诊为鼻侧翼状胬肉合并结膜松弛症患者30例46眼,年龄49～75（平均61.2±7.2）岁,在鼻侧翼状胬肉切除后,于下方角膜缘取一块与切除区域大小一致,带角膜缘干细胞结膜瓣,移植到翼状胬肉切除后巩膜面暴露区,修整下方球结膜,再将球结膜固定于下方角膜缘及巩膜面。术后随访1a,比较术前和术后1mo的视力变化,以及术前和术后3mo眼表泪液动力学方面的变化,包括泪河线高度及完整性、泪膜破裂时间、荧光素活体染色、氯霉素尝味试验,统计手术并发症及术后1a复发率等。结果：患者术前视力0.04～0.6,中位数0.2; 术后1mo视力0.04～1.0,中位数0.4。术后46眼视力提高21眼（45.7%）,无变化25眼（54.3%）。术后与术前视力比较差异有统计学意义（P〈0.01）。术后3mo泪膜破裂时间、荧光素活体染色、氯霉素尝味试验、泪河线高度及完整性均较术前改善,差异有统计学意义（P〈0.01）。术后随访1a,翼状胬肉痊愈33眼（71.7%）,显效11眼（23.9%）,总有效率95.6%,无效2眼（4.4%）,为胬肉复发,复发率4.4%。结膜松弛症主观疗效评价治愈33眼（71.7%）,改善9眼（19.6%）,4眼（8.7%）自觉无明显改善,总有效率91.3%; 客观疗效评价手术区结膜正常41眼（89.1%）,异常5眼（10.9%）,为结膜松弛症复发,复发率10.9%。未发现肉芽增生、下穹隆缩窄、眼球运动障碍等并发症。结论：下方角膜缘干细胞移植治疗翼状胬肉合并结膜松弛症能有效提高患者术后视力,并消除或缓解患者临床症状,改善眼表泪液动力学,是一种有效的治疗方法。     

Effect of unilateral blepharoptosis repair on contralateral eyelid position

PURPOSE: This study evaluates the effect of unilateral blepharoptosis repair on contralateral eyelid position and assesses the relation between preoperative eyelid height interdependence, consistent with Hering law, and surgical outcome. METHODS: The medical records of 54 patients (21 men, 33 women; mean age, 65 years) who underwent external levator advancement for unilateral aponeurotic blepharoptosis were reviewed for preoperative and postoperative margin reflex distance (MRD) of the nonoperated eye. To assess the relation between preoperative Hering dependence (mechanical elevation of the ptotic eyelid causing a decrease in contralateral eyelid height) and postoperative eyelid position, the change in MRD of the nonoperated eye was compared between subjects who on preoperative evaluation did (n=18) and did not (n=36) demonstrate eyelid height interdependence, using the 2-sample t test. RESULTS: After unilateral blepharoptosis repair, the mean (+/- SD) change in contralateral MRD was -0.2 +/- 0.8 mm. There was no significant difference in contralateral MRD change in subjects with and without preoperative Hering dependence (-0.3 +/- 0.8 mm versus -0.2 +/- 0.9 mm, respectively, p=0.78). Seventeen percent (9 of 54) of patients had a contralateral MRD decrease of more than 1 mm. Three patients (5.6%) required contralateral blepharoptosis repair within 1 year of initial surgery. CONCLUSIONS: After levator advancement for unilateral blepharoptosis, roughly 17% of patients will have a decrease in contralateral eyelid height of more than 1 mm, with 5% of patients requiring surgical repair during the first postoperative year. The degree of change in contralateral eyelid height cannot be reliably predicted by preoperative assessment of Hering dependence.     

A quantitative approach to shortening the levator palpebrae superioris to correct congenital ptosis in children

AIM: To develop a feasible method to correct congenital ptosis in children. METHODS: Sixty-four patients (102 eyelids) were divided into three groups based on the degree of ptosis: mild (<2 mm); moderate (3-4 mm); and severe (>4 mm). All patients underwent the same levator resection surgery in which the suspensory system of the LPS is retained. After capturing a standard photograph of primary position, the height of the superior palpebral margin was measured preoperatively by using Image J software to calculate its ideal height required during surgery. Postoperative outcome measures included upper eyelid margin height, degree of scleral exposure and exposure keratitis. The patients were followed-up at 1wk, 1mo and 6mo postoperatively. RESULTS: In the early postoperative period, except two cases with overcorrection, the positions of the eyelid upper margins were normal in all cases in the mild and moderate groups. Six months postoperatively, the eye with overcorrection in the moderate group showed improvement, while the eye in the mild group did not. Seven eyes in the severe group exhibited residual ptosis to varying degrees. The eyelids exhibited appropriate closing functionality; exposure keratitis was absent. CONCLUSION: Using this preoperative quantification technique to guide surgery not only provide a gauge for LPS shortening under general anesthesia, but also increase the success rate of surgery.