A CCH Case Study: Addressing the Real Cause of Conjunctivochalasis (CCH)

CCH

 

An optometrist in my office referred a 69-year-old male patient, who for years had been treated for dryeye with RESTASIS, and occasionally Lotemax. At the time, he also wore scleral lenses to try to combat his dry eye. After years of struggling and trying different treatments, he still had no relief.

Upon examination, the patient had some staining on his cornea, his vision was 20/30 OD and 20/40 OS, and his eyes burned, watered and were very dry. Additionally, his conjunctiva was so red and inflamed, that when he looked straight ahead, it would pool over his lower lid and actually form a little mound at the inferior cornea. Due to this, the tear film wasn’t uniformly covering his cornea.

I explained to the patient that he had what is known as Conjunctivochalasis (CCH), a condition that is often mistaken for dry eye, as patients tend to present with similar symptoms. The patient mentioned that a while back, he had seen an oculoplastic specialist and had a cautery procedure on his conjunctiva that for a year or so had brought some relief however, his symptoms returned.

The Reservoir Restoration Procedure for CCH

I told the patient about a surgical procedure I had been doing with much success called the Reservoir Restoration Procedure for CCH. This procedure uses cryopreserved amniotic membrane (AmnioGraft) to heal the ocular surface and restore the function of the tear reservoir (see previous blog Conjunctivochalasis (CCH) Dry Eye: The Reservoir Restoration Procedure for CCH). After hearing more, he decided to move forward with this procedure. We started with his right eye and after only four days he already felt better. I typically wait a few weeks in between eyes to assess how the patient feels and the results, but he was planning to go to Florida, so a week later we did the other eye.

One-week post surgery the patient was healing well, was off steroids, and wasn’t wearing his scleral contact lenses. I saw him again a few weeks later. He was still doing well and felt much better, and at that point, the cryopreserved amniotic membrane had started to absorb the tissue around it. It was nice to actually see his eyes, and not have the conjunctiva over his lower lid and covering the punctum. When he left for his trip to Florida, I set him up with a local ophthalmologist to check on him. I called the patient to check in, and he said it was the first season in a long time that he was able to actually enjoy Florida because he wasn’t always rubbing his eyes and needing to wear glasses to cover his tearing.

He said he is feeling better and continuing to improve, which is very encouraging, and he is happy he had the surgery. Prior to the Reservoir Restoration Procedure for CCH, everything he had been doing was a quick fix, and for the first time in 15 years he felt relief. I look forward to seeing him soon when he returns from Florida.

Prior to learning about the Reservoir Restoration Procedure for CCH, I would typically refer CCH patients to oculoplastic surgeons who tend to do a cautery procedure, but like my patient I described in this case, the relief if any is only temporary. I had also tried over the counter decongestants on some patients, and that would only make the symptoms worse. I ended up taking a course in Florida and what I learned from Neel Desai, MD and others is that CCH is not a disease of an over abundance of conjunctiva, it’s a disease of the Tenon’s and the conjunctiva contracting. So if you cut it, you are making the problem worse because the patient is left with less conjunctiva and surface area, and you are also not addressing that it’s actually not attached to the ocular surface the way it should be. Once I saw this surgery, I was amazed. The clinical and cosmetic results are outstanding.

My Advice to Colleagues

When first starting with this procedure, I recommend selecting patients who have tried many things yet are still suffering, as they will get the biggest benefit. Being patient is also important as it may take a bit of time for your patients to fully heal from the procedure. I always tell my patients not to get frustrated if they don’t feel better right away. Some do, but sometimes patients don’t experience complete relief for six to eight weeks. So setting their expectations is important. Overall, it’s a fun procedure that’s low stress for me and is not terribly uncomfortable for the patient. Most importantly it improves my patient’s quality of life!

Download Clinical Studies: 

"Conjunctivochalasis Interferes with  Tear Flow from Fornix to Tear Meniscus""Restoration of Fornix Tear Reservoir  in Conjunctivochalasis With Fornix Reconstruction"


Ashley Holdsworth, DO, is an ophthalmologist at Traverse City Eye Consultants, Traverse City, MI. She received her medical degree from Michigan State University College of Osteopathic Medicine, and completed her internship and residency through Michigan State University at Metro Health Hospital in Grand Rapids, MI. Dr. Holdsworth performs many of her Reservoir Restoration Procedures for CCH at Kalkaska Memorial Health Center, Kalkaska, MI.