PATHOGENESIS

The pathogenesis of SLK has not been established, but the condition is thought to result from mechanical trauma transmitted from the upper eyelid to the superior bulbar and tarsal conjunctiva. An association with autoimmune thyroid disease has been observed. In addition, SLK has been associated with graft-vs-host disease and has been seen following blepharoplasty.

CLINICAL PRESENTATION

SLK is a chronic, recurrent condition characterized by ocular irritation and injection superiorly. It is most frequently seen in women between 20 and 70 years of age and may recur over a period of 1–10 years. Vision is not usually affected. SLK is often bilateral but can be asymmetric. The condition can be associated with aqueous tear deficiency (ATD) or blepharospasm. Ocular findings may include the following:

• a fine papillary reaction on the superior tarsal conjunctiva

• injection and thickening of the superior bulbar conjunctiva (Fig 4-3A)

• hypertrophy of the superior limbus

• fine punctate fluorescein, lissamine green, or rose bengal staining of the superior bulbar conjunctiva above the limbus with involvement of the superior cornea just below the limbus (Fig 4-3B)

• superior filamentary keratitis

This condition must be differentiated from contact lens–induced keratoconjunctivitis (CLK), which is in effect a focal limbal stem cell deficiency. Unlike in SLK, vision in CLK may be impaired by punctate keratopathy, which extends through the visual axis. Also, in CLK, filamentary keratitis does not typically occur, and contact lens wear is a cause, not a treatment.

LABORATORY EVALUATION

Hyperproliferation, acanthosis, loss of goblet cells, and keratinization are seen in histologic sections of the superior bulbar conjunctiva. SLK can often be diagnosed clinically. However, scrapings or impression cytology of the superior bulbar conjunctiva showing characteristic features of nuclear pyknosis with “snake nuclei,” increased epithelial cytoplasm–nucleus ratio, goblet cell loss, or keratinization may be helpful in the diagnosis of mild or confusing cases. Patients with SLK should undergo thyroid function tests, including free thyroxine (T4), thyroid-stimulating hormone (TSH), and thyroid antibodies.

MANAGEMENT

A variety of therapies have been reported to provide temporary or permanent relief of symptoms, but in general, medical treatment of SLK is less effective than surgical treatment. Medical treatment options include lubrication, topical anti-inflammatory agents, topical cyclosporine, autologous serum eyedrops, and large-diameter bandage contact lenses. Surgical options include thermocauterization of the superior bulbar conjunctiva, resection of the superior limbal bulbar conjunctiva, amniotic membrane transplantation, and conjunctival fixation sutures.

Figure 4-3 Superior limbic keratoconjunctivitis. A, Note the conjunctival injection, primarily superiorly. B, Rose bengal staining pattern in superior limbic keratoconjunctivitis.

(Courtesy of Vincent P. deLuise, MD.)

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Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.