A Case Study using a Novel Technique
Plasma Pens are FDA 501k Class II electrocautery devices indicated for the removal and destruction of skin lesions and coagulation of tissue. Non-contact energy delivery of the electrical discharge exits the device tip and induces an immediate. focal tissue contraction and non-spreading, controlled depth thermal disruption.
Plasma induces a denaturation of collagen and other proteins in the skin with a predictable wound healing response and fibroblast activation. With the safety profile and ease of use for aesthetics and dermal lesions (ie. rhytides, skin tags, etc), the NuVissa (Lake Wylie, South Carolina) device was used to perform an in-office conjunctivoplasty (CCh Plasty) in a highly symptomatic conjunctival chalasis (CCH) patient.
CCh is a common condition that is also commonly overlooked and undeserved. Typical symptoms may include localized pain or foreign body sensation, particularly later in the day and with reading as well as contact lens intolerance, epiphora and recurrent subconjunctival hemorrhage.
This is the first reported application of the commonly used plasma pen to address the redundant folds associated with symptomatic CCh. Further case studies and IRB approved studies are planned.
History: A 61 year-old Caucasian male with high myopia, rosacea, demodex, MGD and dry eye disease presented to our clinic with longstanding history of symptomatic, grade 3 conjunctival chalasis that interfered with scleral contact lens wear.
DVA with Sclerais: 20/20 OU. Pupils 3-2, no APD, EOM, CVF full, and NVA sc: J1 OU IOP iCare tonometer pre/post procedure: 12-14 OD 16-20 OS respectively.
Slit lamp exam revealed telangiectasias, grade 2 MGD, 2″ lid parallel conjunctival folds (LIPCOF) effacing the meibornian gland orifices and with anteriorization of the mucucutaneous junction.
Procedure: Patient was prepped with betadine swabs to the lids, lashes, periorbital area, and small amount to ocular surface. Single drop of tetracaine was placed in the inferior fornix by 0.2 cc 2% lidocaine with epinephrine injection into inferior sulcus with insulin syringe.
After sterile preparation and adequate topical anesthesia was confirmed, multiple spot welds were delivered with NuVissa plasma pen to the inferior bulbar conjunctiva OS in 3 curviliner rows, 2-3 mm from the limbus.
Post – Procedure 1 drop of PF moxifloxacin and 1 drop of PF Pred Forte were instilled. Procedure was well tolerated, patient ambulatory.
Complications: moderate subconjunctival hemorrhage temporally, controlled with gentle compression with sterile guaze on closed eyelids.
Follow up plan for OD: given BAK sensitivity, dilute aphagan P for vessel constriction and a 0.2 cc subconjunctival injection of 2: lidocaine with epinephrine for hemotasis and discontinuing omega fatty acid supplementation 7 days prior to CCH plasty OD was recommended.
OD was treated with the same procedure 1 month later. Despite additional vessel constriction pharmacologic preparation, the procedure was assocaited with subconjunctival hemorrhage. Five months post procedure, the fluorescein images and AOS image analysis revealed excellent improvements in the height of the CCH folds. (FIGURE 3). This corresponded to the esxcellent symptom improvements and comfort with scleral lens wear.
Click Image to Enlarge
When maximal medical treatment of CCH with lubricants inflammation control and goblet cell density optimization are insufficient, surgical approaches that shrink redundant tissue, excise redundant tissue or improve adhesion are considered.
Plasma pen treatment is a novel approach in the third category of improving tissue adhesion to tack the excessive folds to the underlying tenons capsule in a minimally invasive, outpatient fashion. Additional plasma pen advantages include sparing excision of goblet cell containing conjunctival tissue and sparing adjacent coagulative necrosis as is common with traditional thermal approaches.
The procedure was complicated with subconjunctival hemorrhage that resolved. Symptoms were significantly improved by day 3 post-op and continue 5 months post-operatively with excellent patient satisfaction. AOS software 3D image analysis demonstrates the improvements in the elevation of the excess CCH folds before and after treatment. (figure 1,2,3)
We plan to try other plasma pen top configurations and continue to adjust / modify the technique to prevent subconjunctival hemorrhage and to enhance the CCh improvements both structurally and symptomatically.
- Yvon, C, Patel BC, Malhotra R. Conjuntivalchalasis. Treasure Island (FL): StatPearls Publision Jan 2022. www.ncbi.nih.gov/books/NBK756410/
- Marmalidou A, KheirkhahA, Dana R. Conjunctivochalasis: A systematic review. Survey of Opthalmology 2018;3:554-564
LP: consultant for ADS NuVissa SM: no relevant disclosures.