Tenon excision with fibrin glue-assisted reattachment of conjunctiva flap (T.E.F.A.R.C) for the treatment of conjunctivochalasis

Abstract

To observe the surgical outcome of “Tenon Excision with Fibrin Glue-Assisted Reattachment of Conjunctiva Flap” (T.E.F.A.R.C.) for the treatment of symptomatic conjunctivochalasis (CCH). This is a retrospective case series of CCH patients undergoing T.E.F.A.R.C. from January 2017 to December 2020 were reviewed. Seven patients (14 eyes) with symptomatic CCH received T.E.F.A.R.C. in both eyes. The symptoms before and after the procedures were compared and surgical complication was evaluated. The mean follow-up time was 13.7 ± 2.14 months. After the operation, resolution of the symptoms was reported in 12 eyes (86%). The grade of CCH decreased from 3 to 0 in all 14 eyes, and the restoration of inferior conjunctival surface and fornix within 1 day was also observed in all eyes. Most patients had localized injection and mild chemosis after the operation, which mostly recovered within 3 weeks. No complication or recurrence of CCH was reported after 1 year of follow-up. In conclusion, T.E.F.A.R.C. is a simple and effective treatment option for CCH with less surgical complication. Future larger studies are needed to confirm its clinical applicability.

Introduction

Conjunctivochalasis (CCH) is a degenerative disease commonly seen in the inferior bulbar conjunctiva of both eyes.[1] While the precise pathology of CCH remains uncertain, one potential pathophysiological mechanism involves the dissolution of the Tenon’s capsule, leading to insufficient adhesion between the bulbar conjunctiva and the sclera. This, in turn, causes conjunctival laxity and subsequently contributes to the development of conjunctival folds.[2] Although CCH is often considered an aging process and most patients are asymptomatic, some patients suffered from dry eye symptoms such as ocular irritation and epiphora due to tear film instability and delayed tear clearance.[1] For patients with CCH in the superior bulbar conjunctiva, the redundant conjunctiva may also cause mechanical traumas during blinking, which can lead to superior limbic keratoconjunctivitis.[3]

Topical lubricants and anti-inflammatory medication have been shown effective in relieving discomforts in mild symptomatic CCH.[4] For patients who failed to respond to medical treatments, several surgical techniques have been proposed.[1,4] Cauterization of the lower conjunctiva flap, excision of the redundant folds, and restoration of fornix tear reservoir with fornix reconstruction were some of the most popular techniques.[4] However, many problems associated with these procedures remain to be solved, including the recurrence of CCH, unnecessary sacrifice of healthy conjunctival tissue, unstable tear film spread on the cornea surface when blinking, harm to limbal tissue, conjunctival scar due to cauterization, and shortage of fornix tear reservoir.[2,4,5]

Here, we propose a new surgical technique for symptomatic CCH named “Tenon Excision and Fibrin Glue Assisted Reattachment of Conjunctiva Flap (T.E.F.A.R.C.),” which consists of the creation of a limbal-based conjunctival flap, the removal of redundant Tenon tissue, and flap reattachment with fibrin glue. In this study, the outcome and complications of T.E.F.A.R.C were reviewed.

Methods

This observational case series adhered to the tenets of the Declaration of Helsinki and was approved by the Research Ethics Committee of National Taiwan University Hospital (NTUH-REC No. 202105035RIN).

Patients with symptomatic CCH that did not respond well to medical treatments were recruited from January 2017 to December 2020. Informed consent was obtained from all patients. The diagnosis of CCH was based on the criteria described by Meller and Tseng,[6] and the grading of CCH was based on the lid-parallel conjunctival folds system (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).[6] Patients were excluded if they had any of the following conditions that may influence the ocular surface and conjunctiva anatomy: (1) conjunctival scars, (2) concurrent ocular infection, (3) ocular trauma, (4) symblepharon, (5) inadequate blinking, (6) ocular surface problem, and (7) previous lower lid surgery. Comprehensive history-taking (including age, gender, past systemic and ocular history, and initial symptoms), clinical photographs, and ocular examination (including slit-lamp evaluations, conjunctival folds, and CCH grading were performed before the surgery.

The surgery was performed by an experienced ophthalmologist (WL Chen). Under peribulbar anesthesia, 2% lidocaine with epinephrine was injected subconjunctivally at several points from the perilimbal area down to around 5 mm way from limbus at the 4 and 8 o’clock hours, aiming to separate the lower redundant bulbar conjunctival from the underneath Tenon located from limbal area down to the fornix [Figure 1a]. After using the Westcott scissors to create a large lower limbal-based conjunctival flap [Figure 1b], the flap was then lifted. The Tenon attached to the inner side of the flap and residual Tenon remained on the sclera were completely excised with Westcott scissors without damaging the conjunctival flaps [Figure 1c]. The conjunctival flap was then gently placed back to cover the lower bare sclera down to the fornix, and the excess conjunctival tissue at the lower edge of the flap was excised. Fibrin glue (Tissucol duo; Baxter, Irvine, CA) was placed on the bare sclera and was used to reattach the conjunctival flap firmly and smoothly to the underneath sclera and extending to the fornix [Figure 1d]. No cauterization or suture is needed. The conjunctival flap was firmly reattached to the underlying bare sclera without the possibility of the movement and the deep lower fornix was successfully created.

Figure 1.

(a) Preoperatively, redundant lower bulbar conjunctiva, degenerated Tenon, and shortage of fornix tear reservoir were found. (b) 2% lidocaine with epinephrine was injected subconjunctivally at the 4 and 8 o’clock hours and create a limbal-based conjunctival flap. (c) The conjunctival flap was lifted and the Tenon attached to the inner side of the flap and remained on the sclera was completely excised with Westcott scissors. (d) The conjunctival flap was placed back to cover the lower bare sclera down to the fornix. Fibrin glue was used to reattach the conjunctival flap firmly to the sclera and extending to the fornix and fornix tear reservoir was created

After the surgery, topical steroid and antibiotic ointment were prescribed for the first 2 weeks, and then were tapered gradually. All patients were examined on the postoperative day 1 and weekly in the 1^st month, followed by the examination every 3 months. External eye photograph, slit-lamp examination, and subjective reports of the symptoms were recorded at each clinic follow-up.

Results

A total of seven patients (14 eyes) were recruited. The demographics, reported symptoms, and grading of CCH of all patients are summarized in Table 1. The mean follow-up time was 13.7 ± 2.14 months. The mean age was 72.5 ± 10 years (range: 63–81 years). Before surgery, all patients reported persistent foreign-body sensation, dry eye, irritation, and epiphora after topical medication treatments. Among the seven patients, all had bilateral inferior CCH and 3 (6 eyes, 42%) had positive staining over bilateral cornea. In addition, conjunctival injection or intermittent subconjunctival hemorrhage was observed in all patients by slit-lamp examination. Based on the LIPCOF system, all patients had grade 3 CCH [Figure 2a].

Table 1.

Demographic and clinical characteristics of the patients with conjunctivochalasis undergoing Tenon Excision with Fibrin Glue-Assisted Reattachment of Conjunctiva Flap

Case number	Age	Sex	Eye	Symptoms	CCH	Conjunctival folds	LIPCOF system grading
1	69	Female	OU	FBS, dryness	Inferior	>3/>3	3
2	73	Female	OU	FBS, tearing	Inferior	>3/>3	3
3	63	Female	OU	Tearing, SCH	Inferior	>3/>3	3
4	66	Female	OU	Dryness, SCH, FBS	Inferior	>3/>3	3
5	81	Female	OU	SCH	Inferior	>3/>3	3
6	72	Female	OU	Tearing, SCH	Inferior	>3/>3	3
7	77	Female	OU	FBS, dryness	Inferior	>3/>3	3

CCH=Conjunctivochalasis, FBS=Foreign-body sensation, SCH=Subconjunctival hemorrhage, LIPCOF=Lid-parallel conjunctival folds system, OU=Oculus Uterque

Figure 2.

(a) Before operation, slit-lamp biomicroscopy revealed loosen and redundant lower conjunctival folds which caused increased tear film meniscus (white arrows). (b) At 1 week after operation, smooth and firmly attached lower conjunctiva with normal height of tear film meniscus was found

The surgery was performed on both eyes at the same time for all patients. After the surgery, slit-lamp examination showed smooth and firmly attached lower conjunctiva with deep inferior fornix in all eyes [Figure 2b]. None of the cases developed wound dehiscence and overriding of the conjunctiva over the inferior peritomy wounds. No epithelial defect or exposure of bare sclera was noted throughout the entire follow-up period. Localized hyperemia and mild chemosis were noted in the postoperative day 1 but soon resolved within the 1^st week. Prolonged injection (>3 weeks) and subconjunctival hemorrhage were only noted in one eye of one patient. Furthermore, the resuming of a normal tear film height with smooth distribution over the inferior fornix was observed in all cases. The CCH grade was also reduced from 3 to 0 in all patients within 1 month, and no recurrence of CCH or increase in CCH grade was noticed until the end of the follow-up.

As for the postoperative symptoms report, all patients reported significant improvement within 1 month, with 12 eyes (86%) reaching complete symptom resolution and 2 eyes (14%) reaching partial resolution. One year after the operation, all eyes reported complete symptom relief.

Discussion

In dealing with CCH, asymptomatic CCH requires observation only.[6] As for symptomatic CCH, topical lubricants and medication were suggested as the first-line therapy, with surgical intervention preserving for those poorly responsive to topical medication.[1,4] However, so far, there has been no consensus on the best surgical procedure for treating CCH.

Simple conjunctival cauterization or conjunctival excision with primary suture is among the most widely used procedures for managing CCH.[4] The main goal of these procedures is to remove or shorten the redundant conjunctiva, or to fix the conjunctiva on the underneath sclera to reduce friction.[1] In prior prospective studies, the success rate of conjunctival cauterization and conjunctival excision with sutured wound closure ranged from 84.6% to 100%[7-9] and 84.8% to 93.3%,[3,10-13] respectively, with varied recurrence rates reported. Restoration of the inferior tear meniscus was achieved in 92.3%–100% of cases receiving conjunctival cauterization,[7,14] and 65.2%–100% of cases receiving conjunctival excision.[10-12] Nevertheless, complications such as conjunctival scarring, suture-related complications, granuloma formation, and fornix shortening were often reported in these techniques.[4] In addition, inaccurate estimation of the tissue amount for excision remains a challenge. In the present study, T.E.F.A.R.C. was shown effective in all cases, with significant improvement in both subjectively reported symptoms and the objective CCH grading. Furthermore, the restoration of smooth lower conjunctiva and tear film integrity were also noted under slit-lamp examination. These findings were consistent with the study by Cheng et al., in which improvement in basal tear volume was observed after fornix reconstruction.[2] Our results suggested that T.E.F.A.R.C. is helpful for reconstructing the inferior fornix, which may thus improve tear meniscus integrity and basal tear volume.

In a recent study, the pathology of CCH was described as involving not only the conjunctiva, but also the Tenon capsule, which functions as a “carpet pad” to adhere the superficial conjunctiva (“carpet”) to the underlying sclera (“floor”).[2] The lack of a healthy Tenon capsule, which is mostly caused by excessive degradation of the extracellular matrix by the matrix metalloproteinase, can lead to loosen and redundant conjunctiva extending from the lid margin to the fornix.[2,5,6,15,16] Numerous studies have also demonstrated that CCH impairs the spread of preocular tear film by blocking the tear drainage, disrupting the tear meniscus, and interfering with the tear flow from the fornix tear reservoir to the tear meniscus.[1,6] To address this issue, it is important that novel surgical treatments target not only the redundant conjunctiva, but also the degenerated Tenon and other structural anomalies on the tear flow pathway.[2,5] Cheng et al.[2] proposed a technique with reconstruction of the fornix after conjunctival recession from the limbus to the fornix, coupled with the removal of degenerated Tenon and amniotic membrane transplantation for covering the bare sclera. While this technique focuses on more than the conjunctiva, some other complications including the possible limbal damage during peritomy, the inconvenience and high cost of the amniotic membrane, and the longer process of postoperative conjunctival re-epithelialization on the amniotic membrane surface remain unsolved.

Based on previous studies, the utilization of fibrin glue in the surgical treatment of CCH has been identified as a valuable tool in the process of wound closure.[17,18] The fibrin glue (Tissucol duo; Baxter, Irvine, CA) consists of various components such as Factor XIII, fibrinogen, plasma fibronectin and plasminogen, apoprotein solution (bovine), thrombin, and calcium chloride. It facilitates the conversion of fibrinogen into fibrin and promotes cross-linking of the fibrin to form a clot. The glue can create a better smooth conjunctiva surface. Fibrin glue can be a better alternate approach for fixation of the conjunctiva. This technique offers several advantages over traditional sutures. Fibrin glue helps to avoid suture-related complications, providing a more comfortable postoperative experience for patients. In addition, the use of fibrin glue ensures a tight adhesion between the conjunctiva and the sclera, promoting proper healing and reducing the risk of complications associated with inadequate fixation.[4,18]

In our study, T.E.F.A.R.C. provides solution to the redundant conjunctiva without sacrificing the large conjunctival tissue and without the need of amniotic membrane transplantation. Moreover, we preserve the intact limbal tissue and lower bulbar conjunctiva, making a firm attachment between conjunctiva and sclera with fibrin glue. No eyes in this study reported complication such as conjunctiva fibrosis, fornix shortening, or prolonged wound healing, and a recurrence-free outcome was noted during the postoperative follow-up. This indicates that, as compared to prior approaches, our modified CCH technique may help achieve a similar successful rate while having a lower rate of complication and recurrence. In addition, the procedure takes <15 min in one eye and both eyes can be performed simultaneously, making it an efficient treatment option. Of note, the immediate postoperative discomfort was also tolerable under oral analgesics, and the patients can see well without the need of eye patching after the surgery. This may in part be due to the restoration of a stable tear film through T.E.F.A.R.C., which helps improve visual acuity and subjective comfortableness during the recovery.[1,2,15]

This study has some limitations, including the limited follow-up period and a relatively small case number. The long-term efficacy and complications of T.E.F.A.R.C. are a subject for future study when a larger case number of CCH is available. However, this technique provides new approach for the treatment of symptomatic CCH and demonstrated less complication as compared to most existing techniques.

In summary, T.E.F.A.R.C. is the novel surgical technique featuring the use of fibrin glue for reattaching the limbal-based lower conjunctival flap after removing the underlying Tenon. Such technique may serve as a simple and effective alternative for treating patients with symptomatic CCH.

Data availability statement

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Financial support and sponsorship

Nil.

Conflicts of interest

Dr. Wei-Li Chen, an editorial board member at Taiwan Journal of Ophthalmology, had no role in the peer review process of or decision to publish this article. The other authors declared no conflicts of interest in writing this paper.