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    • Basic and Clinical Science Course - Excerpt
  • 2020–2021 BCSC Basic and Clinical Science Course™

    Go to Academy Store Learn more and Purchase.

    8 External Disease and Cornea

    Chapter 4: Structural and Exogenous Conditions Associated With Ocular Surface Disorders

    Superior Limbic Keratoconjunctivitis

    Superior limbic keratoconjunctivitis (SLK) is a chronic, recurrent inflammatory condition involving the superior tarsal and bulbar conjunctiva, as well as the superior limbus and superior cornea.

    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.)

    Kim SK, Couriel DR, Ghosh S, Pflugfelder SC. Superior limbic keratoconjunctivitis in ocular graft vs. host disease. Invest Ophthalmol Vis Sci. 2005;46:2661.

    Sahin A, Bozkurt B, Irkec M. Topical cyclosporine A in the treatment of superior limbic keratoconjunctivitis: a long-term follow-up. Cornea. 2008;27(2):193–195.

    Sheu MC, Schoenfield L, Jeng BH. Development of superior limbic keratoconjunctivitis after upper eyelid blepharoplasty surgery: support for the mechanical theory of its pathogenesis. Cornea. 2007;26(4):490–492.

    Stern GA. Chronic conjunctivitis, Parts 1–2. Focal Points: Clinical Modules for Ophthalmologists. San Francisco: American Academy of Ophthalmology; 2012, modules 11–12.

    Theodore FH, Ferry AP. Superior limbic keratoconjunctivitis. Clinical and pathological correlations. Arch Ophthalmol. 1970;84(4):481–484.

    Udell IJ, Kenyon KR, Sawa M, Dohlman CH. Treatment of superior limbic keratoconjunctivitis by thermocauterization of the superior bulbar conjunctiva. Ophthalmology. 1986; 93(2):162–166.

    Yamada M, Hatou S, Mochizuki H. Conjunctival fixation sutures for refractory superior limbic keratoconjunctivitis. Br J Ophthalmol. 2009;93(12):1570–1571.

    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.

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