dr. A. Kentar Arimadyo Sulakso, M.Si.Med, Sp.

M (K)

Salmah Alaydrus
 Definition
• Hughes (1942): common condition characterized by the presence of redundant conjunctival folds

Symptoms
• dry eye, pain, epiphora, irritation, foreign body sensation, blurred vision, and discharge

Treatments Depends on the severity of symptoms

• When discomfort persists despite medical treatment, surgery may be needed

Surgical techniques
• conjunctival resection with amniotic membrane autograft, suture conjunctival fixation, and, recently, thermal
cautery conjunctivoplasty, and paste-pinch-cut conjunctivoplasty
To evaluate the intraoperative patient experience of paste-
pinch-cut conjunctivoplasty and cautery conjunctivoplasty

To evaluate the intraoperative outcomes of paste-pinch-cut

conjunctivoplasty and cautery conjunctivoplasty
 Single-centre, contralateral eye, prospective study

Ethics approval was obtained from the Research

Ethics Board at the Ottawa Hospital Research Institute

All patients gave informed consent for study

participation
Sixteen patients with symptomatic bilateral conjunctivochalasis
refractory to medical treatment were recruited from the
University of Ottawa Eye Institute (September 2014-June 2015)

Medical therapy included topical lubrication, anti-inflammatory

drops, antihistamine drops, or all of the above

Diagnosed under slit-lamp biomicroscopy  presence of loose

conjunctival folds at the inferior lid margin
•Comprehensive
Diagnose •Left eye: paste-pinch-
Surgeries
ophtalmologic cut conjunctivoplasty
examination •Slit-lamp •Right eye: thermal •Under local
biomicroscopy cautery anesthesia
•Loose conjunctival conjunctivoplasty
folds at the inferior lid
margin
Surgical
Patients
techniques
Fig. 1A and B, Paste-pinch-cut conjunctivoplasty;
dissection down to bare sclera. C, Gathering the
excess conjunctiva and sealant into a ridge. D,
Resection of ridge.
 Fig. 2 Cautery
conjunctivoplasty
Patient demographics
• Age, gender, ocular history

Snellen visual acuity

• Converted to logMAR for analysis

Grade of conjunctivochalasis (slit lamp examination, LIPCOF system)

• 0 = no persistent fold
• 1 = single, small fold
• 2 = more than 2 folds and not higher than the tear meniscus
• 3 = multiple folds and higher than the tear meniscus
Dryness symptoms (Canadian Dry Eye Assessment Score)
• 0 = asymptomatic
• 10 = severe

Tear osmolarity (TearLab osmolarity test)

Ocular surface staining (Oxford Schema of corneal staining)

• Scale of 0 to 5
• 0 = least staining

Pain rate intraoperatively and postoperatively

• 10-point scale
• 0 = no pain
• Study population  descriptive statistics

• Visual outcomes and pain scores  Wilcoxon, Kruskal Walls, t tests

• Statitical analysis  STATA (version 188 12.0, StataCorp, College Station,

TX

• P < 0.05 were considered statistically significant

 Sixteen patients with
bilateral Mean age, gender Follow up, ocular history
conjunctivochalasis
• Left eye: paste-pinch- • 72.4 ± 8.67 year • All patients attended
out conjunctivochalasis • 15 of 16 patients being follow-up visits at 1
• Right eye: thermal female month
cautery • Ocular history: 10 eyes
conjunctivoplasty (blepharitis), 4 eyes
(previous punctual
cautery), and 1 eye
(punctual plug,
punctoplasty, and
blepharoplasty)
Table 1 Patient experience and visual outcomes following paste-pinch-cut conjunctivoplasty
versus cautery conjunctivoplasty
• Ocular surface irritation (tearing, foreign body sensation, minor pain)
• Mild conjunctival injection and chemosis (most patients)

• Mild conjunctivochalasis bilateral (2 patients, 1 month follow up, grade 1)

• Subconjunctival hemorrhage (2 patients, 4 eyes, 1 week postop)
• Pyogenic granuloma (4 eyes, 3 with paste-pinch-cut conjunctivoplasty)

• No infectious or corneal complications

 Paste-pinch-cut
conjunctivoplasty and
•Too much resection Cautery
conjunctivoplasty
•Scarring, retraction of
fornix, improper wound •Using hemostatic
healing properties
•Suture-related •Simple quick
complications alternatives
•Safley performed in
outpatient settings
Simple crescentic
resection
•Used a modified
technique of paste-
pinch0cut
conjunctivoplasty
•Easier access to the
subconjunctival space
Comparison with
previous studies
Prior studies
• 91.4% patients paste-pinch-cut conjunctivoplasty  improvement in
symptoms (3-month follow-up)
• Symptoms improved in all patients receiving cauterization

Yokoi et al (168 eyes)

• Symptom improvement 78% to 88.2% of eyes after surgery

This study
• majority patients improved grading of conjunctivochalasis, with redundant
conjunctiva absent in 14 patients (28 eyes)
• Bilateral subconjunctival hemorrhage (within a month)
• Pyogenic granuloma (4 eyes, 3 with cauterized eye)

• Foreign body sensation, mild pain, subconjunctival cysts, subconjunctival

hemorrhage
• Resolved within the first few weeks

• Excess cicatrization of conjunctiva (cautery technique)  not observed

 Prospective
design

Well-defined
Strength outcome
measures

Both techniques
were performed
in the same
patient
 Poor patient
compliance
with follow
up

A larger
sample size
Limitations may be
needed

Budget
limitations
Thermal cautery and paste-pinch-cut conjunctivoplasty are both safe and
effective techniques for the treatment of symptomatic conjunctivochalasis

The cautery technique may provide more symptom relief after surgery, but
the surgical procedure is more uncomfortable for the patient (more
postoperative complications were found in the cautery)

Further studies with larger sample sizes and long-term follow-ups are required to
confirm this study findings
 STUDY IDENTIFICATION
More than 12 words, can illustrate the journal
Too long/ short?
content generally

Illustrate the observed variables? Yes

Non standard Abbreviation? No

Any corresponding author and email? No

 SECTION 1: INTERNAL VALIDITY
The study addresses an appropriate and clearly focused
Well covered
question
SELECTION OF SUBJECTS
The two groups being studied are selected from source
populations that are comparable in all respects other than Well covered
the factor under investigation
The study indicates how many of the people asked to take Adequately addressed. Sixteen
patients with symptomatic vilateral
part did so, in each of the groups being studied conjunctivochalasis were recruited
Adequately addressed. Sixteen
The likelihood that some eligible subjects might have the patients with symptomatic
outcome at the time of enrolment is assessed and taken bilateral conjunctivochalasis
into account in the analysis refractory to medical treatment
were recruited
 SECTION 1: INTERNAL VALIDITY
What percentage of individuals or clusters recruited into
Not reported. These data could
each arm of the study dropped out before the study was
not be used for statistical analysis
completed
Comparison is made between full participants and those Not reported. These data could
lost to follow up, by exposure status not be used for statistical analysis
ASSESSMENT
The outcomes are clearly defined Well covered
Not addressed. The assessors were
The assessment of outcome is made blind to exposure not blinded to which participants
status received the exposure and which
did not
Where blinding was not possible, there is some recognition
that knowledge of exposure status could have influenced Not reported
the assessment of outcome
 SECTION 1: INTERNAL VALIDITY

The measure of assessment of exposure is reliable Well covered

Evidence from other sources is used to demonstrate that

Well covered
the method of outcome assessment is valid and reliable
Exposure level or prognostic factor is assessed more than
Not reported
once
CONFOUNDING
The main potential confounders are identified and taken
Not reported
into account in the design and analysis
STATISTICAL ANALYSIS

Have confidence intervals been provided? Well covered. P value < 0.05
 SECTION 2: OVERALL ASSESSMENT OF THE STUDY
How well was the study done to minimise the risk of bias or
confounding, and to establish a causal relationship Not reported
between exposure and effect? Code ++, +, or -
I am not certain. Further studies
Taking into account clinical considerations, your with larger sample sizes and long-
evaluation of the methodology used, and the statistical term follow-ups are required to
confirm this study findings and The
power of the study, are you certain that the overall effect is assessors were not blinded to
due to the study intervention? which participants received the
exposure and which did not
Are the results of this study directly applicable to the Yes. It is applicable to the patient
patient group targeted in this guideline? group targeted in this guideline

SECTION 3: DESCRIPTION OF THE STUDY

Do we know who the study was funded by? Not reported
 SECTION 3: DESCRIPTION OF THE STUDY
From which countries are patients selected? Kanada (Ottawa)
What is the social setting (ie type of environment in which
Mixed
they live) of patients in the study?
All of the patients underwent
comprehensive ophthalmologic
What criteria are used to decide who should be INCLUDED examination and were diagnosed
with bilateral conjunctivochalasis
in the study? under slit-lamp biomicroscopy
(loose conjunctival folds at the
inferior lid margin)
What criteria are used to decide who should be EXCLUDED
Not reported
from the study?
Paste-pinch-cut conjunctivoplasty
What intervention or risk factor is investigated in the study? (left eye) and thermal cautery
conjunctivoplasty (right eye)
 SECTION 3: DESCRIPTION OF THE STUDY
Paste-pinch-cut conjunctivoplasty
What comparisons are made in the study? (left eye) and thermal cautery
conjunctivoplasty (right eye)
What methods were used to randomize patients, blind
patients or investigators, and to conceal the randomization Not reported
process from investigators?
Not reported. This study was
How long did the active phase of the study last? performed from September 2014
to June 2015
All patients were seen for
postoperative follow-up visits at
How long were patients followed-up for, during and after day 1, week 1, and month 1. A 3-
month follow-up was intended,
the study? but because of poor patient
compliance, these data could not
be used for statistical analysis