ARTICLE
Correlation Between Recurrent Subconjunctival Hemorrhages
and Conjunctivochalasis by Clinical Profile and Successful
Surgical Outcome
Yasuaki Yamamoto, M.D., Ph.D., Norihiko Yokoi, M.D., Ph.D., Miki Ogata, M.D., Ph.D., Atsushi Shiraishi, M.D., Ph.D.,
Masahiko Yamaguchi, M.D., Ph.D., Toshihiko Uno, M.D., Ph.D., Kayoko Inagaki, M.D., Kozaburo Hayashi, M.D., Ph.D.,
Shigeru Kinoshita, M.D., Ph.D., and Yuichi Ohashi, M.D., Ph.D.
Objective: To characterize the clinical profile of patients with recurrent
subconjunctival hemorrhages (SCHs) and evaluate the effect of conjuncti-
vochalasis (CCh) surgery on disease recurrences.
Methods: Three hundred and sixty-two patients with SCHs (mean age,
56.4616.0 years) were enrolled in this multicenter epidemiologic study.
The severity of CCh, lifestyle at the time of SCH onset, and the frequency
of previous SCHs were compared. Thirty-eight patients with 2 or more
episodes of SCHs (mean age, 68.268.9 years) underwent surgery for
CCh. The effectiveness of surgery was evaluated by comparing the fre-
quency of SCH preoperatively and postoperatively.
Results: Patients with three or more recurrent SCHs showed a significantly
(P¼0.003) higher grade of CCh and tended to be engaged in activities that
require visual concentration, such as watching a visual display terminal,
knitting, reading, and driving. More than 80% of eyes that underwent
surgery to CCh showed no recurrence of the hemorrhages, and the fre-
quency of SCH significantly (P,0.0001) decreased postoperatively.
Conclusions: Moderate or severe CCh and activities that may cause dry eye
can be considered to be risk factors for recurrent SCHs. Surgery to treat
CCh is a useful option for patients with frequent recurrences of SCHs.
Key Words: Recurrent subconjunctival hemorrhages—Conjunctivochalasis
surgery—Correlation.
(Eye & Contact Lens 2015;41: 367–372)
S ubconjunctival hemorrhage (SCH), an extremely common
conjunctival disorder, generally occurs in middle-aged or
elderly individuals and usually resolves within 1 to 2 weeks without
visual impairment.1–5 Fukuyama et al.3 reported that the etiology of
SCHs was unknown in half of the patients despite extensive phys-
ical examinations and laboratory testing. The results of a number of
studies designed to identify a relationship with systemic disorders,
From the Department of Ophthalmology (Y.Y., M.O., A.S., M.Y., T.U.,
K.H., Y.O.), Ehime University Graduate School of Medicine, Ehime, Japan;
and Department of Ophthalmology (N.Y., K.I., S.K.), Kyoto Prefectural
University of Medicine, Kyoto, Japan.
The authors have no funding or conflicts of interest to disclose.
Y. Yamamoto and N. Yokoi contributed equally to this study.
Address correspondence to Yasuaki Yamamoto, M.D., Ph.D., Depart-
ment of Ophthalmology, Ehime University Graduate School of Medicine,
Shitsukawa, Toon, Ehime 791-0295, Japan; e-mail: yyasuaki@m.ehime-u.
ac.jp
Accepted January 6, 2015.
DOI: 10.1097/ICL.0000000000000139
Eye & Contact Lens  Volume 41, Number 6, November 2015
Copyright @ Contact Lens Association of Opthalmologists, Inc. Unauthorized reproduction of this article is prohibited.
including essential hypertension, diabetes mellitus, and hemato-
logic abnormalities have differed.1–7
In 1942, Hughes8 reported that SCHs occurred frequently in
patients with conjunctivochalasis (CCh). Di Pascuale et al.9 sug-
gested that the frequency of SCHs increased with CCh. Mimura
et al.10 expanded on this by reporting that patients with SCH
showed more severe CCh compared with controls. Thus, CCh
has been considered a principal cause of SCH.
Although recurrent bleeding is a feature of SCHs, the clinical
profile of the affected patients has not been well described. In this
study, we investigated the prevalence and the clinical manifes-
tations of recurrent SCHs in a prospective, multicenter epidemio-
logic survey and determined the effect of surgery for treating CCh.
MATERIALS AND METHODS
This study adhered to the tenets of the Declaration of Helsinki.
Each patient provided oral informed consent. The Institutional
Review Board of each hospital approved this study.
Prospective Epidemiologic Study of SCH
The study group included 362 patients (171 men, 191 women;
mean age6standard deviation [SD], 56.4616.0 years). The partic-
ipants were outpatients at 23 university-affiliated hospitals and had
been examined over a 6-month period. Patients who experienced
acute conjunctivitis or ocular trauma with signs of conjunctival
infection or inflammation of the anterior segment were excluded
based on slitlamp examination by an ophthalmologist. Patients
with a history of ocular surgery or trauma, the Valsalva maneuver,
or systemic diseases, including essential hypertension, diabetes
mellitus, and hematologic disorders, were excluded based on pre-
liminary interview or medical records.
Before the examination, the patients completed a questionnaire
that recorded the location of the hemorrhage and the frequency of
SCHs during the previous year. The patients were divided into
three groups according to the frequency of the previous SCHs:
group 1, the current SCH was the first episode; group 2, the current
SCH was the second episode; and group 3, the current SCH was
one of three or more episodes.
The patients’ lifestyle or behavior near the time of onset of current
bleeding was asked in the questionnaire and classified by the con-
tents as follows: “keeping late hours or being sleep-deprived,”
“activities that require visual concentration (such as watching a visual
367
 Y. Yamamoto et al.
display terminal, knitting, reading, and driving),” “excessive drink-
ing of alcohol,” and “shoulder stiffness.” The items that applied to
more than 5% (19 patients) were analyzed.
An ophthalmologist at each university-affiliated hospital exam-
ined the location and extent of the SCH by slitlamp biomicroscopy.
Conjunctivochalasis was assessed by fluorescein dye staining at the
lower lid margin according to grading of lid-parallel conjunctival
folds on a scale of 0 to 3 as described by Höh et al.,11 with
0 indicating no persistent fold; 1, one small fold; 2, more than
two folds not higher than the tear meniscus, and 3, multiple folds
higher than the tear meniscus.
Effect of Surgery to Treat Conjunctivochalasis
Forty-two eyes of 38 patients (4 men, 34 women; average age,
68.268.9 years) with 2 or more episodes of SCHs over the pre-
vious year underwent surgery to treat CCh. The patients showed
grade 2 or 3 CCh with no systemic disorders. The surgery was
suitable for treating all types of CCh and included four basic steps.
Briefly, step 1, an arc-like incision was made parallel to and 2.0
mm from the limbus in the bulbar conjunctiva; step 2, Tenon’s
capsule was removed; step 3, four radial cuts were made along
the first incision to remove the excisable redundancy in each area;
and step 4, the incision was sutured.12,13 The patients were fol-
lowed postoperatively for 1 to 4 years and 7 months (average, 2
years and 9 months). The frequency of the hemorrhages was
grouped based on patient recollection from the first awareness of
a SCH to the time of surgery: group T1, 1 to 2 times; group T2, 3 to
4 times; group T3, 5 to 9 times; and group T4, more than 10 times.
The sizes of the hemorrhages before and after surgery were
described as follows: small, a hemorrhage covering only part of
one side of the bulbar conjunctiva; medium, a hemorrhage cover-
ing one side of the bulbar conjunctiva; large, a hemorrhage cover-
ing one side of the bulbar conjunctiva and extending into the other
side; and varied, multiple hemorrhages that varied in size.
FIG. 1. Age distribution of cur-
rent SCH and the frequency of
history of hemorrhagic episodes.
The patients were divided into 3
groups according to the fre-
quency of the previous SCHs:
group 1 (254 cases, 70.2%), the
current SCH was the first episode;
group 2 (66 cases, 18.2%), the
current SCH was the second epi-
sode; and group 3 (42 cases,
11.6%), the current SCH was 1 of
3 or more episodes. The Steel–
Dwass multiple comparison test
was used to compare the mean
patient age of these groups.
*P¼0.031. SCH, subconjunctival
hemorrhages.
368
Copyright @ Contact Lens Association of Opthalmologists, Inc. Unauthorized reproduction of this article is prohibited.
Eye & Contact Lens  Volume 41, Number 6, November 2015
Statistical Analyses
The Steel–Dwass multiple comparison tests were used to com-
pare the average patient age with the CCh grades in the three
groups of SCHs. Chi-square test was used to compare patients’
rates of the answered questionnaire in the three groups. The num-
bers and the sizes of the hemorrhages before and after the surgery
were compared using the Wilcoxon signed-rank test. Ordinal logis-
tic regression analysis was applied to estimate the recurrent risk
factors in the three groups. The results were analyzed using JMP
software (version 10.0; SAS Institute, Inc., Cary, NC). P,0.05 was
considered statistically significant.
RESULTS
Epidemiologic Survey of Recurrent SCH
Most patients were between 40 and 70 years of age, with a peak
in the 60s (Fig. 1). Most patients (n¼254) were in group 1, fol-
lowed by 66 patients in group 2, and 42 patients in group 3. The
patients in group 3 were from 40 to 70 years of age. The average
patient age in group 3 (62.169.2 years) was significantly
(P¼0.031, by the Steel–Dwass multiple comparison tests) older
than that in group 1 (54.8617.3 years) (Fig. 1).
The most common site of bleeding was the temporal interpalpebral
area (39.8%), followed by the nasal interpalpebral area (28.2%), and
the temporal side of the lower lid margin (15.5%) (Fig. 2). Hemor-
rhages in the interpalpebral area (69.3%) were more prevalent than in
the upper and lower lid margins (4.4% and 26.2%, respectively)
(Table 1). The SCHs recurred in 108 cases (29.8% in groups 2 and
3). The sites of the hemorrhages were the same in 40 cases, different
in 17 cases, either the same or different in 7 cases, and unknown in 44
cases (Table 1); thus, approximately 62.5% (40 of 64 cases) or more
cases experienced bleeding that recurred at the same site.
Most of the patients with a SCH showed grade 1 or 2 CCh,
whereas patients in group 3 showed a significantly (P¼0.003, by
Eye & Contact Lens  Volume 41, Number 6, November 2015
 Eye & Contact Lens  Volume 41, Number 6, November 2015 Hemorrhages and Conjunctivochalasis

FIG. 2. Hemorrhagic sites. The numbers in the circles and ellipses represent the number of SCH cases.
The location was assigned one site based on the center of the extent of the hemorrhage. The sizes of the
ellipses and/or circles show the relative frequency of the SCHs. The center circle corresponds to the
cornea. SCH, subconjunctival hemorrhages.

the Steel–Dwass multiple comparison test) higher grade of CCh Fifty-eight patients (16.0%) experienced pain or a foreign-body
(mean CCh grades, 1.9060.79, compared with patients in group 1 sensation in the eye at the time of bleeding (Table 1). Patients in
[1.5160.75]) (Fig. 3). group 3 experienced significantly (P¼0.042, by the x2 test) more

TABLE 1. Clinical Profile of Patients With Recurrent Subconjunctival Hemorrhages

Total Group 1 Group 2 Group 3 Estimate Standard Error P

Number of subjects 362 254 66 42

Sex
Men 171 127 29 15
Women 191 127 37 27 0.181 0.120 0.131
Age (y) 56.4616.0 54.8617.3 59.2612.8 62.169.2
CCh grade 1.5760.75 1.5160.75 1.6160.68 1.9060.79
Grade (0–1) 20.362 0.495 0.464
Grade (1–2) 0.760 0.272 0.005a
Grade (2–3) 0.120 0.402 0.765
Lifestyle at the time of bleeding, n (% in each groups)
Keeping late hours or sleep-deprived 86 (23.8) 56 (22.0) 20 (30.3) 10 (23.8) 0.078 0.134 0.561
Activities that require visual concentration 78 (21.5) 48 (18.9) 13 (19.7) 17 (40.5) 0.307 0.135 0.023a
Shoulder stiffness 27 (7.5) 18 (7.1) 5 (7.6) 4 (9.5) 0.097 0.217 0.653
Excessive alcohol drinking 19 (5.2) 13 (5.1) 5 (7.6) 1 (2.4) 0.170 0.267 0.525
Symptom at the time of bleeding, n (% in each groups)
Pain or foreign-body sensation in the eye 58 (16.0) 36 (14.2) 10 (15.2) 12 (28.6) 0.223 0.150 0.136
Sites of hemorrhage, n (% in each groups)
Upper lid margin 16 (4.4) 11 (4.3) 3 (4.5) 2 (4.8)
Interpalpebral 251 (69.3) 174 (68.5) 47 (71.2) 30 (71.4)
Lower lid margin 95 (26.2) 69 (27.2) 16 (24.2) 10 (23.8)
Site of recurrent hemorrhage (% in each groups)
Same — — 24 (36.4) 16 (38.1)
Different — — 14 (21.2) 3 (7.1)
Either — — — 7 (16.7)
Unknown — — 28 (42.4) 16 (38.1)
a
Multiple ordinal logistic regression analysis.
CCh, conjunctivochalasis.

© 2015 Contact Lens Association of Ophthalmologists 369

Copyright @ Contact Lens Association of Opthalmologists, Inc. Unauthorized reproduction of this article is prohibited.
 Y. Yamamoto et al. Eye & Contact Lens  Volume 41, Number 6, November 2015

FIG. 3. The CCh grades in SCH. Conjunctivochalasis was assessed at the lower lid margin as follows: 0, no persistent fold; 1, one small fold; 2,
more than two folds not higher than the tear meniscus; and 3, multiple folds higher than the tear meniscus. The percentages of the CCh grades in
362 patients (total) and for the 3 groups based on the frequency of the previous episodes of SCHs were shown on the y-axis. The CCh grade was
analyzed by the Steel–Dwass multiple comparison test. *P¼0.003. CCh, conjunctivochalasis; SCH, subconjunctival hemorrhages.

pain or foreign-body sensations than the patients in groups 1
and 2.
About a quarter of patients reported either keeping late hours or
being sleep-deprived or engaged in an extended period of activities that
require visual concentration, such as watching a visual display terminal,
knitting, reading, and driving. Some patients reported shoulder stiffness
or excessive drinking of alcohol (Table 1). Patients in group 3 reported
engaging in more activities that require visual concentration than those
in the other two groups (P¼0.008 by the x2 test).
Multiple ordinal logistic regression analysis showed that a dif-
ference between CCh grade 1 and 2 (P¼0.005) and participation in
the activities that require visual concentration (P¼0.023) was sig-
nificantly related to the order of the 3 groups (Table 1).
Because we considered that a difference between CCh grade 1 and 2
of the eyes can affect the order of the recurrent groups, these eyes were
categorized into 2 new groups: CCh grade“0&1” (155 eyes; mean
age6SD, 49.7617.0 years) and CCh grade“2&3” (207 eyes;
61.4613.1 years), and were analyzed by multiple ordinal logistic

TABLE 2. Clinical Profile of Patients With Eyes of CCh Grade“0&1” or “2&3”

CCh Grade“0&1” Total Group 1 Group 2 Group 3 Estimate Standard Error P

Number of subjects 155 121 25 9

Sex
Men 80 66 10 4
Women 75 55 15 5 0.281 0.218 0.199
Age (y) 49.7617.0 48.7618.5 53.2610.3 54.867.6 20.020 0.014 0.162
Lifestyle at the time of bleeding, n (% in each groups)
Keeping late hours or sleep-deprived 30 (19.4) 24 (19.8) 5 (20.0) 1 (11.1) 20.267 0.273 0.328
Activities that require visual concentration 33 (21.3) 21 (17.4) 7 (28.0) 5 (55.6) 0.660 0.234 0.005a
Shoulder stiffness 14 (9.0) 9 (7.4) 4 (16.0) 1 (11.1) 0.218 0.314 0.487
Excessive alcohol drinking 9 (5.8) 6 (5.0) 3 (12.0) 0 (0.0) 0.765 0.416 0.066
Symptom at the time of bleeding, n (% in each groups)
Pain or foreign-body sensation in the eye 19 (12.3) 12 (9.9) 5 (20.0) 2 (22.2) 0.484 0.272 0.076

CCh Grade“2&3” Total Group 1 Group 2 Group 3 Estimate Standard Error P

Number of subjects 207 133 41 33

Sex
Men 91 61 19 11
Women 116 72 22 22 0.099 0.150 0.510
Age (y) 61.4613.1 60.3614.1 62.8612.9 64.168.6 20.020 0.012 0.090
Lifestyle at the time of bleeding, n (% in each groups)
Keeping late hours or sleep-deprived 56 (27.1) 32 (24.1) 15 (36.6) 9 (27.3) 0.250 0.167 0.133
Activities that require visual concentration 45 (21.7) 27 (20.3) 6 (14.6) 12 (36.4) 0.176 0.170 0.300
Shoulder stiffness 13 (6.3) 9 (6.8) 1 (2.4) 3 (9.1) 20.032 0.304 0.915
Excessive alcohol drinking 10 (4.8) 7 (5.3) 2 (4.9) 1 (3.0) 20.092 0.364 0.800
Symptom at the time of bleeding, n (% in each groups)
Pain or foreign-body sensation in the eye 39 (18.8) 24 (18.1) 5 (12.2) 10 (30.3) 0.116 0.182 0.524
a
Multiple ordinal logistic regression analysis.
CCh, conjunctivochalasis.

370 Eye & Contact Lens  Volume 41, Number 6, November 2015

Copyright @ Contact Lens Association of Opthalmologists, Inc. Unauthorized reproduction of this article is prohibited.
 Eye & Contact Lens  Volume 41, Number 6, November 2015
regression analysis. In the eyes with CCh grade“0&1,” participation in
the activities that require visual concentration (P¼0.005) was signifi-
cantly related to the order of the 3 groups, but it was not in the eyes
with CCh grade“2&3” (P¼0.300) (Table 2).
Effect of Surgery for Conjunctivochalasis
Postoperatively, more than 80% of eyes that underwent surgery
showed no recurrences of the hemorrhages during the follow-up
period for 1 to 4 years and 7 months (average, 2 years and 9
months). The frequency and size of the hemorrhages markedly
decreased (P,0.0001, by the Wilcoxon signed-rank test) after sur-
gery (Fig. 4A,B).
DISCUSSION
The current results are consistent with those of Mimura et al.10
who reported the association between the severity of CCh and the
occurrence of SCHs. In the present study, recurrent SCHs devel-
oped in approximately 30% of the patients most prevalently
between the ages of 40 and 70 years. Patients with three or more
recurrent SCHs (in group 3) showed a higher grade of CCh.
Hughes8 first addressed the association of CCh with SCH. Since
then, a possible relationship between SCHs and CCh has been
reported repeatedly.9,10 In our study, the association between
CCh and SCHs was strongly supported by the successful surgical
outcomes in the patients with recurrent SCHs. The frequency and
the degree of the hemorrhages were markedly suppressed by a sim-
ple band-form resection of redundant bulbar conjunctiva in the
lower portion. Therefore, the success of this surgery was not due
to direct excision of the bleeding site, but rather by the decreased
friction during blinking resulting from adhesion of redundant con-
junctiva to the scleral surface.
In CCh, the bulbar conjunctiva adheres poorly to the sclera. The
bulbar conjunctiva and superficial blood vessels are compressed
because of the friction of the upper lid during eye closing. As a result,
superficial conjunctival blood vessels tend to stretch with blinking. In
support of this friction hypothesis, approximately 16% of the current
patients reported in the questionnaire that they experienced a foreign-
body sensation in the eye at the onset of the disease.
© 2015 Contact Lens Association of Ophthalmologists
Copyright @ Contact Lens Association of Opthalmologists, Inc. Unauthorized reproduction of this article is prohibited.
Hemorrhages and Conjunctivochalasis
FIG. 4. Surgery to treat CCh decreases
the frequency and size of hemorrhages
before and after surgery. The frequency
(A) and size (B) of hemorrhages before
surgery were plotted against those after
surgery, with individual patients repre-
sented by single dots. The Wilcoxon
signed-rank test was used to compare
preoperative and postoperative status
(P,0.0001). CCh, conjunctivochalasis.
Furthermore, it was revealed that the activity that requires visual
concentration is a risk factor of recurrent SCHs in the eyes with mild
to moderate CCh, which corresponds to CCh score 0 or 1. These
patients are relatively young in the entire patient group and should
have well-maintained tension of the orbicular and superior levator
muscles; they are therefore expected to have stronger friction against
superficial conjunctival vessels during blinking than the elderly.
However, SCH does not occur every time they blink, and there must
be some other causes of recurrent SCHs in these patients. The
activities that require visual concentration are characterized by
reduced blinking that promotes tear film evaporation.14–18 The pres-
ence of CCh aggravates the extent of the dry eye by occupying the
lower tear meniscus.9,12,13,19 As a result, increased friction at the time
of blinking induces stretching of the conjunctival vessels and may
eventually lead to blood vessel rupture.
The bleeding was most prevalent in the temporal area of the
interpalpebral zone followed by the nasal area of the interpalpebral
zone, the temporal area of the lid margin, and the nasal area of the
lid margin. Most patients with recurrent SCHs experienced
bleeding at the same site, which may indicate that a certain
anatomic characteristic susceptible to bleeding must be present in
these individuals. Around the limbus, the anterior ciliary artery
provides numerous branches, some of which bend as recurrent
branch vessels and communicate with the posterior conjunctival
arteries.20 Because the recurrent branch vessels are fixed firmly at
the limbus, mechanical stress on these vessels presumably can be
exaggerated to the rupturable point.
The frequency of SCH decreased in the patients in the ninth
decade of life. The reason for this is unclear. One explanation may
be related to the tension of the orbicular and superior levator
muscles that is reduced by sagging eyelids in patients over 80 years
of age. The friction is decreased with blinking and may not produce
substantial stress on the conjunctival vessels.
In conclusion, the current study showed that moderate or severe
CCh and activities that may cause dry eye can be considered to be
risk factors for recurrent SCHs by enhanced friction on ocular
surface. Surgery to treat CCh can markedly suppress the recurrent
hemorrhages and is a good and reasonable option for patients with
frequent recurrences of SCHs.
371
 Y. Yamamoto et al.
ACKNOWLEDGMENTS
The authors thank Dr. Shoko Iwaki for editing the article.
REFERENCES
1. Duke-Elder S. Ecchymosis and hemorrhage. In: Duke-Elder S, ed. System of
Ophthalmology. Volume 8. London, United Kingdom, Henry Kimpton,
1965, 33–39.
2. Wilson RJ. Subconjunctival hemorrhage: Overview and management. J Am
Optom Assoc 1986;57:376–380.
3. Fukuyama J, Hayasaka S, Yamada K, et al. Causes of subconjunctival
hemorrhage. Ophthalmologica 1990;200:63–67.
4. Pitts JF, Jardine AG, Murray SB, et al. Spontaneous subconjunctival
haemorrhage-a sign of hypertension? Br J Ophthalmol 1992;76:297–299.
5. Mimura T, Usui T, Yamagami S, et al. Recent causes of subconjunctival
hemorrhage. Ophthalmologica 2009;224:133–137.
6. Sodhi PK, Jose R. Subconjunctival hemorrhage: the first presenting clinical
feature of idiopathic thrombocytopenic purpura. Jpn J Ophthalmol 2003;47:
316–318.
7. Incorvaia C, Costagliola C, Parmeggiani F, et al. Recurrent episodes of
spontaneous subconjunctival hemorrhage in patients with factor XIII Val34-
Leu mutation. Am J Ophthalmol 2002;134:927–929.
8. Hughes WL. Conjunctivochalasis. Am J Ophthalmol 1942;25:48–51.
9. Di Pascuale MA, Espana EM, Kawakita T, et al. Clinical characteristics of
conjunctivochalasis with or without aqueous tear deficiency. Br J Ophthal-
mol 2004;88:388–392.
372
Copyright @ Contact Lens Association of Opthalmologists, Inc. Unauthorized reproduction of this article is prohibited.
Eye & Contact Lens  Volume 41, Number 6, November 2015
10. Mimura T, Usui T, Yamagami S, et al. Subconjunctival hemorrhage and
conjunctivochalasis. Ophthalmology 2009;116:1880–1886.
11. Höh H, Schirra F, Kienecker C, et al. Lidparrallele konjunktivale Falten
(LIPCOF) sind ein sicheres diagnostisches Zeichen des trockenen Auges [in
German]. Ophthalmologe 1995;92:802–808.
12. Yokoi N, Komuro A, Nishii M, et al. Clinical impact of conjunctivochalasis
on the ocular surface. Cornea 2005;24:S24–S31.
13. Yokoi N, Inatomi T, Kinoshita S. Surgery of the conjunctiva. Dev Oph-
thalmol 2008;41:138–158.
14. Tsubota K, Nakamori K. Dry eyes and video display terminals. N Engl J
Med 1993;328:584.
15. Asplund R. Nocturia in the elderly in relation to thirst, dry mouth and dry
eyes. Can J Urol 2004;11:2322–2326.
16. Miljanovic B, Dana R, Sullivan DA, et al. Impact of dry eye syndrome on
vision-related quality of life. Am J Ophthalmol 2007;143:409–415.
17. Uchino M, Schaumberg DA, Dogru M. Prevalence of dry eye disease
among Japanese visual display terminal users. Ophthalmology 2008;115:
1982–1988.
18. Nakamura S, Kinoshita S, Yokoi N, et al. Lacrimal hypofunction as a new
mechanism of dry eye in visual display terminal users. PLoS One 2010;5:
e11119.
19. Meller D, Tseng SC. Conjunctivochalasis: Literature review and possible
pathophysiology. Surv Ophthalmol 1998;43:225–232.
20. Duke-Elder S. The conjunctival vessels. In: Duke-Elder S, ed. System of
Ophthalmology. Volume 2. London, United Kingdom, Henry Kimpton,
1965, 547–551.
Eye & Contact Lens  Volume 41, Number 6, November 2015