Conjunctivochalasis: a loose fold of conjunctiva behind a watery, irritated eye

Some watery, irritated eyes have nothing wrong with the tear glands or the tear duct. The trouble is a loose, spare fold of the thin membrane that covers the white of the eye, lying on the edge of the lower lid. The medical name is conjunctivochalasis. It is common with age, easy to miss, and often labelled dry eye. This article explains what it is, how it is told apart from the conditions it imitates, and what the published evidence says about treatment, including the point at which surgery is considered.

What is conjunctivochalasis?

It is loose, redundant conjunctiva, the clear membrane over the white of the eye, that bunches into folds along the lower lid. The American Academy of Ophthalmology's EyeWiki describes it as loose, redundant, non-swollen conjunctiva that is considered to occur secondary to normal ageing. It is usually in both eyes and most often involves the inferotemporal part, which is below the eye towards the outer corner.

The conjunctiva is made loose on purpose, so that it can slide as the eye turns. The spare tissue rides down over the lid margin, the edge of the lid that touches the eye. A 2018 systematic review in Survey of Ophthalmology names ageing as the most important risk factor. It states that the cause is still largely unknown, and lists conjunctival ageing, tear film instability, friction and surface inflammation as proposed mechanisms.

A fold is not the same as a symptom. In a 2014 review of the charts of 30 patients with conjunctivochalasis (50 eyes, mean age 65 years), a third had no symptoms at all. The reviews agree that people without symptoms need no treatment.

Why does a loose fold of conjunctiva make the eye water?

Because it sits in the exact place where tears are collected and carried away. Tears pool along the lower lid margin in a thin ribbon called the tear meniscus, and from there they travel towards the punctum, the tiny opening at the inner corner of the lid that starts the drainage channel. A fold lying across that ribbon disturbs both steps.

EyeWiki says that mechanical forces between the lower lid and the conjunctiva gradually impair lymphatic flow, and that the result is impaired formation of a normal tear meniscus and limits to normal tear movement from the fornix, the deep pocket under the lid. In the 2014 chart review, an altered tear meniscus was recorded in every eye. Tears that cannot ride the lid margin spill over it, even when the tear ducts are open. In some eyes the fold also lies over the punctum and shuts off the entry, which adds to the problem.

Watering is only one of the ways it shows. In those same 30 patients epiphora, the medical word for watering, was reported by 16.7%. Dryness was reported more often, by 50%. That mix is one reason the condition is easy to misread.

The wider causes of a watery eye are in my guide to watery eyes in adults.

Why does the eye feel irritated, as if something is in it?

Because the fold rubs against the lid and the surface of the eye with every blink, and the tear film over it is unstable. EyeWiki lists a foreign body sensation, burning, dryness and discomfort as the symptoms, and notes that more severe cases can bring blurred vision, mucous discharge and a subconjunctival haemorrhage, a flat red blood patch on the white of the eye.

The tear film is the thin layer of water, oil and mucus that coats the eye. In the 2014 chart review the mean tear break-up time, the number of seconds the film holds before it breaks, was 7.6 seconds, which tells you the film was not stable. Other symptoms in that group were redness (26.7%), eye pain (23.3%), blurred vision (16.7%) and a tired-eye feeling (13.3%).

The bleeding is usually the part that frightens people. A red patch from a small burst vessel is almost always harmless, and the article on a bright red patch on the white of the eye explains when it is not.

How is it told apart from dry eye, a blocked tear duct and a lid that has slipped?

By examination under magnification, because the symptoms overlap and no single complaint separates them. EyeWiki says the diagnosis is clinical, made with a slit lamp, the microscope used to examine the eye, and that scans of the tear meniscus can help. It lists dry eye, Sjögren syndrome, meibomian gland dysfunction, blepharitis and allergic conjunctivitis as the conditions it is confused with, and notes that people are often misdiagnosed with dry eye.

The 2014 chart review gives pointers. Dryness from conjunctivochalasis was worse in the morning and when looking down, while dryness from a shortage of tears was worse as the day went on and when looking up. Fluorescein stain, the dye that shows damage on the surface, picked up the non-exposed zone with conjunctivochalasis and the exposed strip between the lids in dry eye. None of the 30 patients had a true tear shortage despite dry-eye symptoms. That is a small group, so these are pointers, not rules, and the two conditions can sit side by side. The lid-margin causes are in my article on dry eyes after fifty.

The drainage system is the second thing to sort out. A narrowed punctum, punctal stenosis, or a blocked duct (the blocked tear duct and DCR article) also gives a wet eye, and a dye test shows whether tears drain. The third is the lid itself. A lower lid that has turned in (entropion) irritates the surface, and one that has turned out or slackened (ectropion) spills tears over the edge. A fold, a lid and a duct problem can all be present in one eye.

A raised lump on the white of the eye is a different problem, covered in the page on pterygium and pinguecula.

What helps first: drops, anti-inflammatory treatment and time?

Lubrication and calming inflammation come first, and surgery only follows if symptoms continue. The Review of Ophthalmology states that people without symptoms need no treatment and that symptomatic patients should first try conservative management. EyeWiki lists topical lubrication, blinking exercises, antihistamines and corticosteroids as the medical options.

A 2020 Corneal Physician review adds that artificial tears, ointments and autologous serum drops, made from the patient's own blood, remain a mainstay, and that a topical corticosteroid, an anti-inflammatory drop, can help break the cycle of inflammation. The AAO advises preservative-free tears if they are used more than six times a day. Steroid drops are not a casual purchase, and the reasons are in my article on pharmacy eye drops for a red eye.

The reviews present this as the usual first step, and the outcome figures quoted in them come from surgical studies, which are the next section. Drops deserve a proper trial with a review at a set time, and continuing symptoms are a reason to be re-examined, not to add more bottles.

When does surgery help, and what does it involve?

It is considered when symptoms continue despite medical treatment, and it works by removing or tightening the spare conjunctiva so that the lid margin is clear again. The reviews group the operations into shrinking the tissue (cautery, argon laser or radiowave energy), excising it with a stitched, glued or grafted closure, and fixing the conjunctiva to the white of the eye so that it cannot slide.

The numbers are modest in size. The Corneal Physician review quotes success rates of 84.8% to 93.3% for excision, judged by improved tear break-up time, staining scores and tear film stability, without giving study sizes. A comparison of two ways of attaching the conjunctiva after excision, in 23 patients (42 eyes), found that fibrin glue, a tissue glue made from clotting proteins, took 12.0 minutes against 25.0 minutes for stitches. Watering fully cleared in 36.4% of the glue eyes and 30% of the suture eyes, and the difference was not significant. Complete or partial improvement came to about 73% with glue and 75% with stitches.

For stubborn cases a thin membrane from donated placenta, amniotic membrane, can be glued over the bare area. In a series of 25 eyes of 16 patients with refractory disease, followed for a mean of 10.6 months, symptoms were completely relieved in 44% of eyes and substantially improved in the other 56%. This was a non-comparative case series, so there was no control group, and none of the techniques has been shown to outperform the others. Focal conjunctival inflammation occurred in four eyes and a pyogenic granuloma, a small red bump of healing tissue, in one.

Surgery has costs. The excised conjunctiva does not grow back, and removing it can in theory worsen dryness over time. Reported complications include scarring between the lid and the eye, a shortened lower fold, a lid that turns in, and stitch-related abscess or granuloma. Under-treatment is the other risk, and a repeat procedure is sometimes needed. This is why the order is drops first, and why the diagnosis has to be right before anyone operates. For the wider picture of the area, see the section on the white of the eye and the eye surface and my hub article on why eyes look tired.

When should a watery, irritated eye be seen?

Any eye with pain, light sensitivity or reduced vision needs examination promptly, and so does one that is red with discharge. A watery, gritty eye that has lasted more than a few weeks despite drops should be examined too, because the fold, the lid and the drainage all need to be checked together.

Tenderness, redness and swelling at the inner corner below the eye point to an infected tear sac, which needs treating without delay. The reassuring part is that a loose conjunctiva is an age-related change of the eye surface, and for many people the right answer is simple lubrication and a clear explanation.