Letter to Editor Does Clear Corneal Cataract Surgery Influence Conjunctivochalasis? Tatsuya Mimura1,2,3, MD, PhD; Michiko Iida2, MD; Hidetaka Noma4, MD, PhD; Yuko Kamei2, MD Aki Kondo2,3, MD, PhD; Maiko Yoshida2,3, MD; Manami Oguri2, MD; Yuka Tanaka2, MD Atsushi Mizota1, MD, PhD 1Department of Ophthalmology, Teikyo University School of Medicine, Tokyo, Japan 2Department of Ophthalmology, Tokyo Women’s Medical University Medical Center East, Tokyo, Japan 3Department of Ophthalmology, University of Tokyo Graduate School of Medicine, Tokyo, Japan 4Department of Ophthalmology, Hachioji Medical Center, Tokyo Medical University, Tokyo, Japan ORCID: Tatsuya Mimura: https://orcid.org/0000-0001-5593-5338 J Ophthalmic Vis Res 2020; 15 (2): 270–272 Dear Editor, Conjunctivochalasis is a common ocular condition characterized by excess conjunctival folds and is associated with aging.[1–4] We previously demon- strated that the progression of conjunctivochalasis after sclerocorneal tunnel incisions was associated with the axial length of the eyeball and placement of conjunctival sutures.[4] Conjunctival chemosis occurs more frequently in cases of sclerocorneal tunnel incisions than in cases of corneal incisions.[5] This suggests that a clear corneal incision may induce less postoperative conjunctival inflamma- tion compared to a transconjunctival sclerocorneal incision. Therefore, we evaluated the influence of clear corneal incision in cataract surgery on the severity of conjunctivochalasis based on a previously reported grading scale.[1] This study was conducted in accordance with the tenets of the Declaration of Helsinki and Correspondence to: Tatsuya Mimura, MD, PhD. Department of Ophthalmol- ogy, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo 173-8605, Japan. E-mail: mimurat-tky@umin.ac.jp Received: 07-06-2019 Accepted: 04-09-2019 Access this article online Website: https://knepublishing.com/index.php/JOVR DOI: 10.18502/jovr.v15i2.6749 was approved by the Institutional Review Board. The inclusion criteria were: age > 40 years; nuclear cataract grades II–IV based on the Emery–Little classification; and uncomplicated phacoemulsifica- tion surgery. A total of 83 patients (83 eyes) who underwent mini-incision (2.4 mm) phacoemulsifica- tion for corneal wound were enrolled, including 43 men and 40 women aged 72.3 ± 9.8 years (mean ± standard deviation), with an age range of 42–88 years. The severity of conjunctivochalasis was assessed using a modified grading system as previously described.[1, 2] Cataract surgery was performed via a clear corneal incision created with a 2.4 mm knife at the superior or temporal position. We evaluated the severity of conjunctivochalasis after one week and one, three, and six months postoperatively. The total conjunctivochalasis score significantly increased after postoperative month 3 (P = 0.0017) but decreased after postoperative month 6 (P = 0.5806) [Figure 1]. Progression of conjunctivochalasis was defined as ≥ 2-point increase in the total conjunctivochalasis score. Table 1 shows the results of the multivariate analysis using a stepwise This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. How to cite this article: Mimura T, Iida M, Noma H, Kamei Y, Kondo A, Yoshida M, Oguri M, Tanaka Y, Mizota A. . J Ophthalmic Vis Res 2020;15:270–272. 270 © 2020 JOURNAL OF OPHTHALMIC AND VISION RESEARCH | PUBLISHED BY PUBLISHED BY KNOWLEDGE E http://crossmark.crossref.org/dialog/?doi=10.18502/jovr.v15i2.6749&domain=pdf&date_stamp=2019-07-17 https://knepublishing.com/index.php/JOVR Letter; Mimura et al Table 1. Multivariate analysis of factors influencing progression of conjunctivochalasis (n = 83). Variable OR (95% CI) P-value Age (years) 1.01 (1.00 – 1.02) 0.0660 Gender (male) 1.21 (0.97 – 1.51) 0.0895 Hypertension 1.11 (0.90 – 1.37) 0.3341 Diabetes 1.00 (0.79 – 1.27) 0.9964 Hyperlipidemia 0.94 (0.66 – 1.34) 0.7317 Coronary heart disease 1.14 (0.87 – 1.50) 0.3435 Refraction (diopters) 0.99 (0.96 – 1.02) 0.3293 Anterior chamber depth 0.89 (0.68 – 1.17) 0.3972 Lens thickness 1.00 (0.85 – 1.19) 0.9589 Axial Length (mm) 1.01 (0.93 – 1.10) 0.8196 Corneal incision (superior / temporal) 1.06 (0.84 – 1.34) 0.6190 Baseline total conjunctivochalasis score 0.90 (0.85 – 0.95) 0.0001 OR, odds ratio; CI, confidence interval The total conjunctivochalasis score was calculated as the sum of the scores for the temporal, central, and nasal regions (0–9). Figure 1. Mean postoperative total conjunctivochalasis score at each time point. selection of factors associated with progression of conjunctivochalasis. The baseline total conjunc- tivochalasis score was significantly associated with the progression of conjunctivochalasis (odds ratio = 0.90, P = 0.0001). In this study, the postoperative total conjunc- tivochalasis score increased after postoperative week 1 but subsequently returned to the preop- erative level. Additionally, the preoperative sever- ity of conjunctivochalasis was an independent determinant of the postoperative progression of conjunctivochalasis. These results suggest that a clear corneal incision did not change the severity of conjunctivochalasis. The severity of conjunctivochalasis showed a significant increase after the first postoperative week, which was probably due to postoperative conjunctival inflammation, as there was a subsequent return to baseline. We found that the axial length influences the severity of conjunctivochalasis.[3] Our previous study had also demonstrated that the axial length was independently associated with the grade of conjunctivochalasis after adjustment for age.[3] In conclusion, our results showed no significant change in the severity of conjunctivochalasis after 24 postoperative weeks despite a transient early increase. This article complements our previous study on the progression of conjunctivochalasis after sclerocorneal tunnel incisions. Financial Support and Sponsorship The Ministry of Education, Culture, Sports, Sci- ence and Technology of Japan provided financial support in the form of a Grant-in-Aid for Scientific Research (16K11332). The sponsor had no role in the design or conduct of this research. JOURNAL OF OPHTHALMIC AND VISION RESEARCH VOLUME 15, ISSUE 2, APRIL-JUNE 2020 271 Letter; Mimura et al Conflicts of Interest There are no conflicts of interest. REFERENCES 1. Meller D, Tseng SC. Conjunctivochalasis: literature review and possible pathophysiology. Surv Ophthalmol 1998;43:225–232. 2. Mimura T, Yamagami S, Usui T, Funatsu H, Mimura Y, Noma H, et al. Changes of conjunctivochalasis with age in a hospital-based study. Am J Ophthalmol 2009;147:171– 177. 3. Mimura T, Yamagami S, Kamei Y, Goto M, Matsubara M. Influence of axial length on conjunctivochalasis. Cornea 2013;32:1126–1130. 4. Mimura T, Iida M, Oshima R, Noma H, Kamei Y, Goto M, et al. Changes of conjunctivochalasis after cataract surgery via a superior transconjunctival sclerocorneal incision. Int Ophthalmol 2017;37:691–700. 5. Sugai S, Yoshitomi F, Oshika T. Transconjunctival single- plane sclerocorneal incisions versus clear corneal inci- sions in cataract surgery. J Cataract Refract Surg 2010;36:1503–1507. 272 JOURNAL OF OPHTHALMIC AND VISION RESEARCH VOLUME 15, ISSUE 2, APRIL-JUNE 2020