Clinical characteristics of conjunctivochalasis with or without aqueous tear deficiency

Aim: To show characteristic ocular surface findings caused by conjunctivochalasis (CCh) in dry eye patients with or without aqueous tear deficiency (ATD). Design: Comparative non-interventional cases. Patients and methods: Clinical data of five ATD patients without CCh ( group A), eight CCh patients with ATD ( group B), and eight CCh patients without ATD ( group C) were retrospectively reviewed. Presence or absence of CCh was determined by fluorescein staining to outline tear meniscus and conjunctival folds with an enhancing filter. Dry eye symptoms, history of subconjunctival haemorrhage, meibum expression, tear break up time, fluorescein and rose bengal staining, and fluorescein clearance test, and other abnormal ocular surface findings were measured. Results: CCh patients were significantly older ( p = 0.001). In pure ATD, the principal symptom of dryness became worse as the day progressed. In contrast, blurry vision, burning sensation, and dryness became worse during reading in all CCh patients ( p = 0.0008) or worse in the morning upon awakening in the majority patients with CCh only ( p = 0.02). Besides the interpalpebral exposure, which was noted in ATD, positive fluorescein or rose bengal staining was noted in the redundant conjunctival folds and the nonexposure zone in CCh ( p = 0.0008). Redundant conjunctival folds were present in both lower and upper bulbar conjunctiva, obliterating both lower and upper tear meniscuses, and spatially correlated with anterior migration of the mucocutaneous junction in CCh. Delayed tear clearance was significantly more prevalent in CCh than ATD ( p = 0.0008). Vigorous blinking worsened in CCh but not in ATD ( p = 0.0008). Lacrimal puncta were swollen in groups B and C, but not in group A ( p = 0.04). Conclusions: CCh is not restricted to the lower bulbar conjunctiva, and contributes to pathogenesis of dry eye by obliterating both lower and upper tear meniscus, causing unstable tear film and by creating delayed tear clearance. Dry eye symptoms were worsened by downgaze during reading and by vigorous blinking. Other characteristic signs including subconjunctival haemorrhage, swollen puncta, anterior migration of the mucocutaneous junction, and patterns of dye staining also help distinguish dry eye associated with CCh from that caused by ATD alone.