Histopathologic Characteristics of Conjunctivochalasis

Jeong Bum Bae; Woo Chan Park

doi:10.3341/jkos.2013.54.8.1165

Journal List > J Korean Ophthalmol Soc > v.54(8) > 1009440

Go to TopGo to Top Go to BottomGo to Bottom

TOOLS

Bae and Park: Histopathologic Characteristics of Conjunctivochalasis

Original Article

J Korean Ophthalmol Soc 2013;54(8):1165-1174.

Published online: 7 September 2013

DOI: https://doi.org/10.3341/jkos.2013.54.8.1165

Histopathologic Characteristics of Conjunctivochalasis

Jeong Bum Bae, MD, Woo Chan Park, MD, PhD

Department of Ophthalmology, Dong-A University College of Medicine, Busan, Korea

Address reprint requests to Woo Chan Park, MD, PhD Department of Ophthalmology, Dong-A University Medical Center #26 Daesingongwon-ro, Seo-gu, Busan 602-715, Korea Tel: 82-51-240-5220, Fax: 82-51-254-1987, E-mail: wcpark@dau.ac.kr

This study was presented as a narration at the 108th Annual Meeting of the Korean Ophthalmology Society 2012.

Received 11 January 20135 March 2013 Accepted 1 June 2013

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

In this study we investigated the histopathologic characteristics of conjunctivochalasis and its association with lymphangiectasis using impression cytology and conjunctival excisional biopsy in patients with conjunctivochalasis.

Methods

This prospective study included 14 outpatients diagnosed with conjunctivochalasis, and who had excisional bi-opsies performed between March 1, 2012 and November 30, 2012. Preoperative slit-lamp examination, dry eye diagnostic test and impression cytology were also performed. For histological analysis, conjunctival sections were stained with hema-toxylin and eosin (H&E), Verhoeff-van Gieson (VVG) elastic staining, and monoclonal antibody D2-40, a lymphatic endo-thelial marker.

Results

Tear break-up time and Schirmer’s value were decreased in patients with conjunctivochalasis. Impression cytol-ogy showed a decrease in goblet cell density and an increase in nucleoplasmic/cytoplasmic ratio. The patients’ con-junctival tissues exhibited an infiltration increase of chronic inflammatory cells on H&E stain, and a decrease in collagen density with degeneration of elastic fibers on VVG stain compared to tissues from the control subjects. D2-40 im-munohistochemistry revealed the dilated subconjunctival lymphatics in patients with conjunctivochalasis.

Conclusions

This study suggests that the characteristic histopathological features of conjunctivochalasis include dilated lymphatic vessels as well as decreased goblet cell and collagen densities with degeneration of elastic fibers.

Keywords: Conjunctivochalasis, Impression cytology, Lymphangiectasis

References

1. Meller D, Tseng SC. Conjunctivochalasis: literature review and possible pathophysiology. Surv Ophthalmol. 1998; 43:225–32.

2. Wang Y, Dogru M, Matsumoto Y. . The impact of nasal con-junctivochalasis on tear functions and ocular surface findings. Am J Ophthalmol. 2007; 144:930–7.

3. Watanabe A, Yokoi N, Kinoshita S. . Clinicopathologic study of conjunctivochalasis. Cornea. 2004; 23:294–8.

4. Jordan DR, Pelletier CR. Conjunctivochalasis. Can J Ophthalmol. 1996; 31:192–3.

5. Krachmer JH, Mannis MJ, Holland EJ. Cornea. 3rd ed.St. Louis: Mosby;2011; v. 1:635–9.

6. Hughes WL. Conjunctivochalasis. Am J Ophthalmol. 1942; 25:48–51.

7. Meller D, Maskin SL, Pires RT, Tseng SC. Amniotic membrane transplantation for symptomatic conjunctivochalasis refractory to medical treatments. Cornea. 2000; 19:796–803.

8. Kheirkhah A, Casas V, Blanco G. . Amniotic membrane trans-plantation with fibrin glue for conjunctivochalasis. Am J Ophthalmol. 2007; 144:311–3.

9. Lim HJ, Lee JK, Park DJ. Conjunctivochalasis surgery: amniotic membrane transplantation with fibrin glue. J Korean Ophthalmol Soc. 2008; 49:195–204.

10. Nam K, Jo YJ, Lee SB. The efficacy of fibrin glue in surgical treat-ment of conjunctivochalasis with epiphora. J Korean Ophthalmol Soc. 2010; 51:498–503.

11. Oh SJ, Byon DS. Treatment of conjunctivochalasis using bipolar cautery. J Korean Ophthalmol Soc. 1999; 40:707–11.

12. Youm DJ, Kim JM, Choi CY. Simple surgical approach with high-frequency radio-wave electrosurgery for conjunctivochalasis. Ophthalmology. 2010; 117:2129–33.

13. Shin KH, Hwang JH, Kwon JW. New approach for conjunctivochalasis with argon laser photocoagulation. Can J Ophthalmol. 2012; 47:380–2.

14. Francis IC, Chan DG, Kim P. . Case-controlled clinical and his-topathological study of conjunctivochalasis. Br J Ophthalmol. 2005; 89:302–5.

15. Meller D, Li DQ, Tseng SC. Regulation of collagenase, stromely-sin, and gelatinase B in human conjunctival and conjunctivochalasis fibroblasts by interleukin-1β and tumor necrosis factor-α. Invest Ophthalmol Vis Sci. 2000; 41:2922–9.

16. Erdogan-Poyraz C, Mocan MC, Bozkurt B. . Elevated tear in-terleukin-6 and interleukin-8 levels in patients with conjuncti- vochalasis. Cornea. 2009; 28:189–93.

17. Ellis S. Structure and function of the lymphatic system: and overview. Br J Community Nurs. 2006; 11:S4–6.

18. Skandalakis JE, Skandalakis LJ, Skandalakis PN. Anatomy of the lymphatics. Sur Oncol Clin N Am. 2007; 16:1–16.

19. Kim JT, Kim JH, Kim JC. Visualization of subconjunctival lym-phatics and its significance. J Korean Ophthalmol Soc. 2008; 49:1215–9.

20. Meisler DM, Eiferman RA, Ratliff NB, Burns CD. Surgical man-agement of conjunctival lymphangiectasis by conjunctival resection. Am J Ophtahlmol. 2003; 136:735–6.

21. Höh H, Schirra F, Kienecker C, Ruprecht KW. [Lid-parallel con-junctival folds are a sure diagnostic sign of dry eye. Ophthalmologe. 1995; 92:802–8.

22. Park JS, Ha SW, Lew H. Histopathologic properties of eyelid skin and conjunctiva in patients with dermatochalasis. J Korean Ophthalmol Soc. 2011; 52:582–8.

23. Ward SK, Wakamatsu TH, Dogru M. . The role of oxidative stress and inflammation in conjunctivochalasis. Invest Ophthalmol Vis Sci. 2010; 51:1994–2002.

24. Jaros PA, DeLuise VP. Pingueculae and pterygia. Surv Ophthalmol. 1988; 33:41–9.

25. Wollenberg A. Pseudopterygium mit faltenbildung der conjunctiva bulbi. Klin Monatsbl Augenbeilkd. 1922; 68:221–4.

26. Li DQ, Meller D, Liu Y, Tseng SC. Overexpression of MMP-1 and MMP-3 by cultured conjunctivochalasis fibroblasts. Invest Ophthalmol Vis Sci. 2000; 41:404–10.

27. Nelson JD, Wright JC. Conjunctival goblet cell densities in ocular surface disease. Arch Ophthalmol. 1984; 102:1049–51.

28. Karalezli A, Borazan M, Altinors DD. . Conjunctival im-pression cytology, ocular surface, and tear-film changes in patients treated with systemic isotretinoin. Cornea. 2009; 28:46–50.

29. Nagi KS, Carlson JA, Wladis EJ. Histologic assessment of derma-tochalasis: elastolysis and lymphostasis are fundamental and inter-related findings. Ophthalmology. 2011; 118:1205–10.

30. Singh D. Conjunctival lymphatic system. J Cataract Refract Surg. 2003; 29:632–3.

31. Jung TC, Kim HB, Yoo HM, Suh SC. Lymphangiectasia of the conjunctiva. J Korean Ophthalmol Soc. 1982; 23:191–3.

32. Teichmann L. Das saugadersystem. Leipzig: Engelmann;1861; 1–121.

Figure 1.

Grading of conjunctivochalasis. (A) Grade 0: No persistent fold in control group. (B) Grade 1: Single, small fold. (C) Grade 2: More than two folds and not higher than the tear meniscus. (D) Grade 3: Multiple folds and higher than the tear meniscus.

Figure 2.

Method of impression cytology and biopsy (A and B). Cellulose acetate paper is applied to the in-ferior and superior bulbar conjunctiva using a pair of smooth and flat-ended forceps. (C) Conjunctival biop-sy samples are excised in redundant conjunctiva lo-cated 1 mm apart from the limbus at 3 to 9 o’clock position.

Figure 3.

Impression cytol-ogy shows a marked decrease in goblet cell density and an increase in nucleoplasmic/ cytoplasmic ratio in conjun- ctivochalasis group (B and C) compared with the control group (A). PAS-positive gob-let cells increased at post-operative 3 months in con-junctivochalasis group (D) (Periodic acid Schiff stain, ×200).

Figure 4.

Histologic findings of the conjunctiva in the control (A) and conjunctivochalasis group (B-D). Infiltrating in-flammatory cells are increased in conjunctivochalasis group compared with the control (H & E stain, ×200).

Figure 5.

Elastic degener-ation and collagen density of the conjunctiva (Verhoeff-van Gieson stain, ×200).(A) No fragmentation of elastic fibers and dense colla-gen fibers in control group. (B-D) Fragmentation of elas-tic fibers and sparsely as-sembled collagen fibers. (B) Mild elastic degeneration (Grade 1) and high collagen density (Grade 3). (C) Moderate elastic degeneration (Grade 2) and moderate collagen den-sity (Grade 2). (D) Severe elastic degeneration (Grade 3) and low collagen density (Grade 1).

Figure 6.

Histologic findings of the conjunctiva in D2-40 stain (×200). Conjunctivo- chalasis group (B-D) reveals increased number of lym-phatics and lymphangiectasis compared with the control group (A).

Table 1.

Classification of conjunctivochalasis using the lid-paral-lel folds method grading of conjunctivochalasis by LIPCOF^1,13

Grade	Number of folds and relationship to the tear meniscus height
0	No persistent fold
1	Single, small fold
2	More than two folds and not higher than the tear meniscus
3	Multiple folds and higher than the tear meniscus

LIPCOF = lid parallel conjunctival folds test.

Table 2.

Clinical characteristics of the patients

Patient no.	Sex	Age	Chalasis grade	BUT (sec)		Schirmer test (mm)
Patient no.	Sex	Age	Chalasis grade	OD	OS	OD	OS
1	F	74	2	4	3	10	5
2	F	77	3	3	4	4	3
3	F	64	3	4	2	7	3
4	M	54	2	2	4	5	6
5	M	73	3	6	5	11	3
6	F	55	2	3	3	9	7
7	F	60	2	1	1	5	5
8	M	69	2	1	1	3	4
9	F	78	3	3	2	7	5
10	F	56	3	1	1	6	5
11	F	80	3	3	1	7	4
12	M	74	2	2	2	4	5
13	M	74	3	2	2	6	4
14	M	73	3	3	3	5	5
Mean + SD		68.6 ± 9.1	2.6 ± 0.5	2.7 ± 1.4	2.4 ± 1.3	6.4 ± 2.3	4.6 ± 1.2

Table 3.

Histologic analysis

Stain	Histologic analysis	Conjunctivochalasis	Control	p-value^*
Impression cytology H & E	Goblet cell density Inflammatory cells	42.1 ± 10.0 117.4 ± 45.6	89.1 ± 22.9 78.0 ± 14.6	0.020 0.042
H & E	Inflammatory cells	117.4 ± 45.6	78.0 ± 14.6	0.042
Verhoeff Van Gieson	Elastic fiber degeneration Collagen density	2.3 ± 0.7 1.7 ± 0.7	1.4 ± 0.6 2.8 ± 0.5	0.029 0.010
D2-40	Collagen density Lymphangiectasis count	1.7 ± 0.7 29.3 ± 11.0	2.8 ± 0.5 8.8 ± 2.2	0.010 0.001
D2-40	Lymphangiectasis count	29.3 ± 11.0	8.8 ± 2.2	0.001
	Largest lymphatic vessel diameter	286.1 ± 125.3	79.4 ± 27.5	0.001

Values are presented as mean ± SD.

^* Mann-Whitney U test.

TOOLS

Similar articles