Reservoir restoration can re establish the normal anatomy and function of the conjunctiva.
Characterized by loose, redundant conjunctival folds, conjunctivochalasis (CCH), also known as mechanical dry eye (MDE), is a chronic condition that typically affects both eyes and is a common cause of ocular irritation and discomfort.1,2
CCH is associated with various ocular and non-ocular conditions, but it is often overlooked and underdiagnosed in clinical practice as the condition can be asymptomatic. CCH is thought to have a multifactorial etiology that is commonly associated with age and local trauma, such as eye rubbing. Severe CCH can lead to blurred vision, mucous discharge, and subconjunctival hemorrhage.1,2
In patients with CCH/MDE, cryopreserved amniotic membrane (CAM) is a promising therapy for accelerated recovery of ocular surface health and corneal nerve regeneration. CAM helps to improve a number of problems, such as pain, corneal staining, overall dry eye signs and symptoms (e.g., discomfort, visual disturbances), corneal nerve density, and corneal sensitivity.3 CAM is a biologic bandage designed to treat corneal damage by creating an environment for regenerative healing.4
Amniograft is the only ocular transplantation graft offering CryoTek CAM tissue to help speed post-operative recovery, prevent disease recurrence, and optimize long-term patient outcomes. Amniograft's cryopreservation method maintains the tissue's full biologic components, such as heavy-chain hyaluronic acid (HCHA) and pentraxin 3 (PTX3), which help rapidly restore the ocular surface’s own healing capabilities.4
There are some interesting current approaches to diagnosis and management, including the role of CAM.
Mechanical Dry Eye Overview
MDE is age-related, typically presenting in patients over 60 years of age. The etiology of MDE is not completely understood but is thought to be multifactorial, including local trauma, UV radiation, and an increase in conjunctival matrix metalloproteinases. Delayed tear clearance may contribute to accumulation of degrading enzymes in the tears. This results in redundant and loose folds of abnormal conjunctiva that prevent normal blinking and spreading of the tear film. Other risk factors include female sex, decreased ocular sensitivity, and dermatochalasis.1,2
Patient Presentation, Diagnosis, and Treatment
Patients who present with MDE have excess tearing, redness, irritation, and eye pain. The pain tends to be sudden, sharp, intermittent, and aggravated by downgaze. Blinking will not relieve this. Unfortunately, many symptoms are parallel or similar to dry eye disease. These patients, however, may not experience relief from dry eye treatments such as artificial tears. Nasally-located redundant folds of conjunctiva can disrupt tear flow by blocking the inferior nasal punctum and cause epiphora.
Diagnosis is made by clinical findings and patient history, and the extent and location of the redundant conjunctiva is noted. Fluorescein or rose bengal staining of the cornea tends to be negative. However, there can be discrete punctate or linear staining on the mucosal aspect of the lid margin adjacent to the redundant conjunctiva.
No immediate intervention is required for asymptomatic patients. Patients with ocular irritation, pain, or subconjunctival hemorrhage may be given tear substitutes, lubricants, and corticosteroid or antihistamine drops. I will also start lid hygiene and omega-3s to improve their tear film composition. If they have significant improvement and are happy with their level of comfort, I will have them continue the treatment. However, if they are still experiencing a lot of inflammation, burning, and stinging, I may add a mild topical steroid. Cyclosporine ophthalmic emulsion (Restasis) 0.05% or lifitegrast ophthalmic solution (Xiidra) 5% can also be added to help increase tear production.5,6 If these measures are unsuccessful, surgical intervention becomes necessary. I recommend that my patients consider a quick outpatient procedure known as reservoir restoration using AmnioGraft for long term relief.
Reservoir Reconstructive Procedure
The main objective of the procedure is to restore the normal anatomy of the inferior fornix, restoring a deep and well-defined inferior fornix, which serves as the tear reservoir. Abnormal Tenon's and conjunctiva and the prolapsed orbital fat are removed. Then, I glue the CAM over the sclera and down into the inferior fornix, providing a foundation for conjunctival re-epithelialization. The active biological growth factors in CAM prevent inflammation, conjunctival scarring, muscle restriction, and orbital fat prolapse. With normalization of the tear reservoir, routine therapy works better, and the discomfort resolves.
Challenges to Treating MDE
The primary challenge to treating MDE is that patients don't typically think of surgery as a solution. Most patients think the solution is drops, which is why I also don't immediately suggest surgery, usually. I let them know that we are going to try some simple approaches first, and then we can reconsider whether the reservoir restoration procedure is necessary or not.
Another challenge is to help the patient understand the multidimensional and multifactorial basis for their symptoms. Patient education and counseling is important so that they see MDE as a chronic problem that cannot be solved with a simple procedure or a few weeks of treatment. Furthermore, these patients often have other concomitant forms of ocular surface disease (OSD).
MDE and OSD can both have a significant impact on the quality of patients' lives. We use our eyes at every moment, so having chronic symptoms such as foreign body sensations is distracting and disruptive for patients. But when patients experience improvement, particularly after the reservoir restoration procedure, they are motivated to maintain their results. They often become more engaged in their therapy.
Arla Genstler, MD
Genstler is an ophthalmologist in practice in Topeka, Kansas, specializing in cataract and refractive surgery. She is the founder of Genstler Eye Center.
CAM preserves the biological properties of amniotic membrane and umbilical cord tissue, which have been shown to play a major role in controlling inflammation and preventing scarring. The biologics in CAM—such as Pentraxin 3 (PTX3) and heavy-chain hyaluronic acid (HC-HA)—have anti-inflammatory and anti-scarring properties, which are maintained when cryopreserved. Other amniotic membrane preparations do not have these clinical properties, as the dehydration involved in those preparations notably change the structural and biological integrity of the tissue.3,7
CAM is also much easier to work with than other amniotic membranes. It's more robust and works beautifully, particularly in conjunctival reservoir restoration procedures. CAM has multiple applications, and in my experience, its utility is validated when a patient asks for the same treatment on their other eye.
In order to counsel patients about MDE and their treatment, slit-lamp photographs are helpful educational tools that enable patients to visualize the folds of tissue hanging over the lower lid. A picture is worth a thousand words and helps a great deal in explaining the reasons for surgery.
Ophthalmologists are great at treating OSD, but many don't understand the mechanical aspect, and the common prevalence of MDE. More awareness of this condition is needed, and people need to know that there is a specific treatment for it—in contrast to other forms of dry eye. Reservoir restoration can re‑establish the normal anatomy and function of the conjunctiva for patients with MDE. All the drops in the world won't do that.