Conjunctivochalasis: The Missed Cause of Watering and Dry Eye Symptoms in Older Patients
Last updated: November 2026
Conjunctivochalasis is loose, redundant bulbar conjunctiva, usually folded between the lower lid and the globe. It is common in older adults and is often dismissed as normal ageing, yet it can cause watering, irritation and blur, and makes dry eye treatment fail. Learn to look for it in every older patient with a watering or gritty eye.
How it causes symptoms
- Folds sit in the lower tear meniscus and interrupt tear flow to the punctum (watering).
- Folds can occlude the lower punctum.
- Unstable, uneven tear film spread (dry eye symptoms, blurred vision especially on downgaze).
- Friction with blinking causes irritation, and the loose tissue can bleed (recurrent subconjunctival haemorrhage).
Examination and grading
Examine the lower lid margin on the slit lamp before instilling drops, with the patient looking straight ahead, then down and up; push the lower lid up gently to see folds appear. Fluorescein shows the meniscus and folds clearly.
| Grade (Meller and Tseng) | Folds |
|---|---|
| 1 | No persistent fold |
| 2 | Single small fold |
| 3 | More than two folds, not higher than the tear meniscus |
| 4 | Multiple folds, higher than the tear meniscus |
Note the location (temporal, middle, nasal; nasal folds affect the punctum most) and whether folds change with gaze or digital pressure.
Differential diagnosis
Chemosis (oedema from allergy, infection, thyroid eye disease or venous congestion), conjunctivitis, entropion or ectropion, and meibomian gland disease. Several often coexist.
Treatment
| Step | Options |
|---|---|
| Medical (first) | Preservative-free lubricants, treat blepharitis and meibomian gland dysfunction, short course of topical steroid or antihistamine if inflamed or allergic |
| Minor procedures | Thermal or radiofrequency cautery to shrink the folds |
| Surgery | Crescent excision of redundant conjunctiva with sutures; excision with amniotic membrane graft fixed with fibrin glue or sutures; suture fixation of conjunctiva to the globe |
Outcomes are similar across surgical methods, with most patients reporting symptom improvement. Fibrin glue makes surgery faster and more comfortable (see fibrin glue).
Pearls
- Look at the lower lid margin before drops in every older patient with watering.
- Nasal folds over the punctum cause watering; temporal folds cause irritation.
- Treat lid disease first; many folds settle when inflammation is controlled.
Common mistakes
- Syringing and planning DCR when folds are blocking the meniscus.
- Mistaking chemosis for conjunctivochalasis.
- Calling it "normal ageing" in a symptomatic patient.
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Related: Watering Eye in Adults: Approach to Epiphora, Syringing, Dye Tests and Treatment, TFOS DEWS III: What Changed in Dry Eye Diagnosis and Treatment, Amniotic Membrane in Eye Surgery: Which Side Is Up, Dry vs Wet Membrane, Inlay, Onlay and Fixation, Fibrin Glue for Pterygium Autograft: Reliseal, Fibroseal and Tisseel Compared, Preparation and Technique, Cornea.
Key sources
- Meller D, Tseng SCG. Conjunctivochalasis: literature review and possible pathophysiology. Surv Ophthalmol. 1998;43:225-232
- University of Iowa EyeRounds. Conjunctivochalasis (case 162)
- Marmalidou A, Kheirkhah A, Dana R. Conjunctivochalasis: a systematic review. Surv Ophthalmol. 2018;63:554-564
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