New conjunctival forceps combined with high-frequency electrocautery-assisted correction of conjunctivochalasis

doi:10.21203/rs.3.rs-4821102/v1

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New conjunctival forceps combined with high-frequency electrocautery-assisted correction of conjunctivochalasis

https://doi.org/10.21203/rs.3.rs-4821102/v1

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Purpose: To investigate the efficiency, efficacy, and safety of new conjunctival forceps combined with high-frequency electrocautery-assisted correction of conjunctivochalasis (CCh).

Methods: 19 patients with CCh, totaling 22 eyes, were included in the study. The forceps have a serrated tapered head and a latch for firm tissue grip. The conjunctiva was secured for resection using the forceps latch, grasped 3-5 mm from the limbus, and treated clockwise. Direct electrocautery was utilized for lifts ≤3 mm; for heights >3 mm, forceps were used to clamp, scissors were used for excision, and the electrode tip was used to close the wound following anesthesia. Surgical duration was recorded, and CCh severity, assessed with lip-parallel conjunctival folds (LIPCOF), along with discomfort scored by Ocular Surface Disease Index (OSDI), were compared pre- and post-operatively. Healing and complications were checked at one week and one month.

Results: Surgery averaged 6.95 minutes. Initially, 18.2% of the patients were LIPCOF Grade I, 22.3% were Grade II, and 59.1% were Grade III. Postoperatively, 59.1% reached grade 0 at one week, and 95.5% by one month. The OSDI scores significantly improved from week one to month one (P<0.05), falling from 40.06 to 17.43 in a single month. Healing was complete within one week for cauterized areas, one month for excision. Minor congestion and edema at one week were cleared by one month with no major issues.

Conclusion: The new conjunctival forceps with high-frequency electrocautery for CCh correction proved to be efficient, effective, and safe.

conjunctivochalasis

new conjunctival forceps

high-frequency electrocautery

lip-parallel conjunctival folds

Conjunctivochalasis (CCh) is a chronic conjunctival disorder characterized by non-edematous and lax conjunctival folds ¹. It is more commonly observed in the bulbar conjunctiva of the lower eyelid and often leads to tear film dysfunction. Although the exact cause of CCh is unknown, aging is linked to the condition. Additionally, studies indicate that aberrant elastic fiber formation and progression are pathogenic traits ². In contemporary life, a high incidence of dry eye syndrome have led to gradual youthfulness in the population affected by CCh and can even exacerbate the condition of dry eye syndrome related to meibomian gland dysfunction ^3. Different levels of CCh can cause different symptoms; lesser cases may provide a sense of a foreign body, while more severe cases may cause burning, redness in the eyes, tears, and keratoconjunctivitis, among other symptoms¹. In the early stages of CCh, treatment often involves symptomatic relief, such as the use of artificial tears ⁴, and treatments include topical medication and laser therapy ^5,6. If conservative treatment is ineffective, then surgical intervention is necessary ^3,5. Traditional surgical methods for the treatment of CCh involve conjunctival resection and,when necessary, amniotic membrane transplantation (AMT) ⁷; however, these methods require suturing and/or suture removal., which are time-consuming and cumbersome. In recent years, some scholars have performed conjunctival correction assisted by high-frequency electrocautery ³, which is simple and time-saving, but the correction for CCh above grade II is limited. In order to accomplish a quick and easy CCh correction, this study presents a novel technique that combines high-frequency electrocautery with conjunctival forceps.

1.New conjunctival forceps

The new conjunctival forceps are made of titanium alloy and consist of two parts: head and body. The head is 9.2 cm long and 0.5 cm wide, with a serrated matching that tapers from thick to thin. This provides for a solid hold on the desired bulbar conjunctiva tissue for excision without leaving an excessive amount of leftover tissue. The body is equipped with a spring-loaded latch mechanism. Once the head clamps the bulbar conjunctiva, pressing the spring-loaded latch on the body will secure it in place, allowing the surgeon to independently complete the operation without the need for an assistant to help fix the tissue (Figure 1).

2.Patients

Among the 19 patients who visited Foshan Aier Zhuoyue Eye Hospital between January 2023 and December 2023, 22 eyes were given the diagnosis of "CCh." Inclusion criteria: Individuals with slit-lamp examination-diagnosed CCH who had not responded to conservative treatment for more than three months, including artificial tears and low-concentration corticosteroids. Patients with uncontrolled systemic diseases, implanted cardiac pacemakers or stents, or acute ocular emergencies were excluded. After routine examination, patients underwent CCh correction assisted by new conjunctival forceps combined with high-frequency electrocautery. This study adhered to the Declaration of Helsinki and was approved by the Ethics Committee of the Foshan Aier Zhuoyue Eye Hospital (approval number: 2023IRB2). All the patients provided informed consent to participate in the study.

3. Surgical Procedure

The surgery was performed by the same surgeon. Supine was the posture in which the patients were positioned. Following a standard cleansing of the skin and the edges of the eyelids with 0.5% An'erdian (Type III), the eyelids were retracted using a speculum. Instilling 0.5% Alcaine eye drops (Alcon, USA) for topical anesthesia, medical sodium hyaluronate gel (Bausch & Lomb Incorporated) to protect the cornea, and using high-frequency electrocautery (Ellman Surgitron; Ellman International, Inc., Hewlett, NY), set to coagulation mode with an energy setting of 1, and select a wide tip electrode ^8. At a distance of 3–5 mm behind the limbus, microforces were used to lift the bulbar conjunctiva in a clockwise direction at each clock-hour position. If the height lifted did not exceed 3 mm, the lifted conjunctival tissue was touched several times with the electrode tip until satisfactory shrinkage of the conjunctival tissue was achieved ⁵(Figure 2A). If the height lifted exceeds 3 mm (commonly seen in theconjunctival folds and the temporal side of the bulbar conjunctiva), Then perform infiltration anesthesia by injecting 0.1 ml of 0.2% lidocaine solution subconjunctivally with a 30-gauge needle (Figure 2B). Little anesthesia is administered, and it has little effect on the loose conjunctiva's inherent pathological anatomy. Subsequently, clamp the intended conjunctival tissue for resection with the new conjunctival forceps, excise with microscissors, leaving a residual of 0.1 to 0.2 mm at the base, and then cauterize to seal the incision with the electrode tip. (Figures 2C, 2D). After surgery, the operated eye was treated with an ophthalmic suspension of tobramycin and dexamethasone (Sa. Alcon-Couvreur N.V.) four times a day for 1 week and an ophthalmic solution of polyethylene glycol (Alcon Laboratories, Inc.) four times a day for 1 month. In the second week, the ophthalmic suspension of tobramycin and dexamethasone was switched to an ophthalmic suspension of loteprednol etabonate (Bausch & Lomb Incorporated) four times a day for 3 weeks. All patients were followed-up for 1 week and 1 month after surgery.

4. Surgical evaluation

4.1 Duration of surgery.

The surgical time was reported by the same nurse using a clock, beginning when the speculum was opened and ending when the speculum was removed.

4.2 Degree of CCh.

With slit-lamp examination, the degree of CCh was classified according to the lid-parallel conjunctival folds (LIPCOF) classification system (grade 0: no conjunctival folds; grade I: a single small fold; Grade II: More twice but not exceeding the height of the tear meniscus; Grade III: Multiple folds that exceed the height of the tear meniscus) ⁹.

4.3 The Ocular Surface Disease Index (OSDI; Allergan, Irvine, CA, USA) scoring method was used to evaluate the ocular discomfort of patients before surgery, 1 week after surgery, and 1 month after surgery.

4.4 Postoperative wound healing was observed using fluorescein staining with the same slit lamp; if the incision did not take up the stain, it indicated that the wound had healed, whereas if it took up the stain, it indicated that the wound had not healed.

5. Statistics

Statistical analysis was performed using the SPSS software (version 18.0). Quantitative data are presented as the mean ± standard deviation, and qualitative data are presented as percentages. Paired t-tests were used to compare preoperative and postoperative OSDI scores, with a P-value of less than 0.05 indicating statistical significance.

A total of 19 patients with 22 eyes diagnosed with CCH were included in this study; 7 of the patients were men and 12 were women, with an average age of 68.8±10.3 years.

1. Surgical time

The average surgery time was (6.9±1.5) minutes.

2. Degree of CCh (Table 1, Figure 3)

3.OSDI scores

The OSDI scores of the patients were (40.1±10.4) before surgery, (40.4±11.3) 1 week after surgery, and (17.4±6.4) 1 month after surgery. The difference in the OSDI scores preoperatively and at 1 week postoperatively was not statistically significant (t=-0.13, P=0.90). The difference in the OSDI scores between 1 week and 1 month postoperatively was statistically significant (t=10.23, P<0.05). The difference in the OSDI scores before and after surgery was statistically significant (t=9.71, P<0.05).

4. Wound healing

One week after surgery, examination with fluorescein staining using a slit lamp revealed that the areas of the conjunctiva that were touched and shrunk by the electrode tip did not absorb the stain, indicating complete healing (Figure 3C). Even so, there was still some staining in the incisions where the conjunctiva was clamped with the new conjunctival forceps, resected, cauterized, and sealed with electrocautery, suggesting incomplete healing (Figure 3D). One month after the operation, none of the incisions had the stain removed, indicating complete healing.

5. Complications

Mild to moderate bulbar conjunctival congestion and edema were seen one week following surgery, along with mild to moderate foreign body feeling (Figure 3B). These symptoms disappeared one month later without any more significant complications.

Mechanical loss,buildup, and blockage of the lower punctum due to laxity of the bulbar conjunctiva results in abnormal tear film dynamics and dry eye syndrome in individuals who do not respond to conservative therapy. Therefore, efforts must be taken to reestablish normal tension in the bulbar conjunctiva ⁵. We achieved great success using new conjunctival forceps along with high-frequency electrocautery for correcting CCh.

Conventional techniques for treating CCH entail conjunctival resection, in which the superfluous loose conjunctiva is surgically removed in the form of a crescent under a microscope. The incision is then sutured with absorbable sutures, which are taken out a week following the procedure. This approach involves a large incision, a longer surgical procedure, and slower recovery ¹⁰. The positive aspect of our innovative surgical technique is that it solvesthe issue definitively, thus obviating the need for the application and removal of sutures. Marmalidou et al. ¹¹ and Harley et al. ¹²used conjunctival excision combined with AMT, which could reduce the risk of fornix shortening; however, suture-related complications still occurred. Alayna et al. ¹³ employed conjunctival cauterization with an electrocoagulator, a technique based on the principle of CCh shrinking through cauterization. This approach eliminates the need for sutures, which in turn reduces the duration of the surgical procedure. However, there is a higher chance of residual laxity and the probable need for subsequent treatments for people with moderate to severe problems. Scleral fixation of the conjunctiva can reinforce its attachment to the sclera; however, it presents challenges in terms of surgical skills and carries suture-related complications ¹⁴. In recent years, some scholars have employed high-frequency electrocautery-assisted correction of CCh ⁵, which usesthermal energy to contract conjunctival tissue. This technique is time efficient and facilitates rapid recovery. However, it is only appropriate for patients with grade I CCh or certain patients withgrade II CCh because to the restricted amount of conjunctival shrinking, comparable to conjunctival cauterization ¹⁵. Patients with a CCh grade greater than II still requiredconventional conjunctival resection. Furthermore, by avoiding tissue charring, this technique effectively shrinks redundant conjunctiva, thus avoiding complications typically associated with conjunctival cauterization and surgical excision¹⁶.

This article presents a novel kind of conjunctival forceps made of titanium alloy that may maximally clamp extra lax conjunctival tissue and fix it without the assistance of a helper. After the resection, the incision was coagulated using high-frequency electrocautery. The average surgical time was (6.9±1.5) minutes, which was shorter than that of traditional surgery. Since the incision did not fully heal one week after surgery, there was no change in OSDI scores from preoperative levels. But a month following the procedure, the incision had healed and the OSDI scores had dramatically decreased, compared to the preoperative levels, suggesting that the patients' sensations of ocular pain had improved. Among our patients, 81.4% were preoperatively diagnosed with grades II and III CCh. Despite the presence of bulbar conjunctival edema one week after the operation, the severity of CCh in all patients was reduced to grade 0 or I. AtOne month after the operation, the conjunctival edema resolved, the incision healed, and 95.5% of the patients achieved grade 0. Thus, even those with grade II and III CCh can benefit from quickand convenient correction. One month after surgery, a patient (4.5%) continued to show grade I CCh due to persistent bulbar conjunctival edema, which resulted from non-adherence to the prescribed medication regimen.

High-frequency electrocautery, a staple in ophthalmology, is usedfor a variety of procedures, including electrolysis of trichiasis, removal of conjunctival tumors, and achievement ofhemostasis in ocular plastic surgery. It causes less tissue damage because of its lower energy output as compared to an electrocoagulato. When employing high-frequency electrocautery, it is crucial to protect the cornea and maintain the dryness of the bulbar conjunctiva. The efficacy of the electrode can be compromised if the conjunctiva is overly moist, or if an excessive volume of anesthetic is administered subconjunctivally. If high-frequency electrocautery is unavailable, an electrocoagulator serves as a viable alternative, although meticulous control over the duration and intensity of cauterization is required.

We give numerous surgical advice and advocate conventional excision for loose conjunctival folds. Even while lower punctum blockage may prevent some patients from consulting for CCh-induced epiphora, flexibility in the conjunctival folds might nevertheless elicit symptoms of epiphora ^[5,7]. The use of new conjunctival forceps simplifies the clamping of excess lax tissue in the folds, reducing the risk of postoperative incision splitting. Clamping and excision of the lax bulbar conjunctiva with these forceps should be performed in areas that the eyelids can cover, as electrocoagulated incisions are unstable and prone to dehiscence with movement. Covered incisions are less likely to form granulation tissue. In the present study, no conjunctival granulomas were observed.

All things considered, the use of high-frequency electrocautery in conjunction with novel conjunctival forceps to rectify corneal hypochlorhydria is safe, effective, and efficient for patients with varying degrees of CCH severity.

Ethics approval and consent to participate

This study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by theEthics Committee of Foshan Aier Zhuoyue Eye Hospital in China with the approval number (2022) Ethics Review No. (IRB4). Written informed consent was obtained from all individual participants prior to their enrollment of this study.

Consent for publication

Informed consent was obtained from all individual participants for the publication of any potentially identifiable images or data included in this study.

Availability of data and material

The datasets used and analyzed during the current study are available from the corresponding author (Huihui Luo) on reasonable request.

Competing interests

The authors, Tingting Song, Xianjun Liang, Yingjie Lin, and Huihui Luo, declare that they have no affiliation with or involvement in any organization or entity with any financial interest in the subject matter or materials discussed in this manuscript.

Funding

This work was supported by the Foshan Science and Technology Bureau Self-Funded Scientific and Technological Plan Project (Grant No. 2220001003937). The funding agency had no role in the design of the study, data collection, analysis, interpretation, or writing of the manuscript.

Authors' contributions

Tingting Song conceived and designed the experiments and wrote the first draft of the manuscript. Xianjun Liang provided administrative support and helped with data collection. Yingjie Lin contributed to data analysis and helped revise the manuscript. Huihui Luo is the applicant who secured the funding for this project and also performed the surgeries. All authors read and approved the final manuscript.

Acknowledgements

We are deeply grateful for the support provided by the Foshan Science and Technology Bureau through the Self-Funded Scientific and Technological Plan Project, with the grant number 2220001003937. Our thanks go to Tiehong He, a colleague at Foshan Aier Excellence Eye Hospital, for meticulously conducting the preoperative and postoperative examinations of our patients. We also extend our appreciation to Master Liu Chang, who from the Sixth People's Hospital in Shanghai, for his expert guidance on statistical analysis, and to Doctor Xifang Zhang from Beijing Tongren Hospital for her invaluable advice on manuscript writing. Furthermore, we extend our heartfelt thanks to all the participants who willingly took part in the clinical trials.

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Table 1: Proportion of LIPCOF Grades Before and After Surgery

LIPCOF Grades	Grade 0	Grade I	Grade II	Grade III
Preoperative	/	18.2%（4/22）	22.3%（5/22）	59.1%（13/22）
1 Week Postoperative	59.1%（13/22）	40.9%（9/22）	0%（0/22）	0%（0/22）
1 Month Postoperative	95.5%（21/22）	4.5%（1/22）	0%（0/22）	0%（0/22）

No competing interests reported.

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New conjunctival forceps combined with high-frequency electrocautery-assisted correction of conjunctivochalasis

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