BASICS

DESCRIPTION

• Ocular surface disorder is characterized by foreign body sensation, pain out of proportion to exam, and photophobia. The presentation is typically bilateral and frequently asymmetrical.

• Classic signs include superior bulbar conjunctival staining and injection, redundant superior bulbar conjunctiva, velvety fine papillary reaction of the superior palpebral/tarsal conjunctiva, superior corneal epithelial keratitis, and/or mucous filaments.

EPIDEMIOLOGY

Incidence

About 50–65% of patients with superior limbic keratoconjunctivitis (SLK) have underlying thyroid disease (1,2)

RISK FACTORS

• Keratoconjunctivitis sicca (KCS)

• Thyroid disease

• Cosmetic contact lenses induced (CL-SLK)

• Thimerosal

Genetics

No familial association

PATHOPHYSIOLOGY

Chronic and recurrent clinical course

ETIOLOGY

• Unknown: Mechanical versus autoimmune

• Possibly related to dry eye, autoimmune disease, or superior conjunctivochalasis

• Female:male 3:1

• Mean age 50 years

• Increased incidence in thyroid disease, hyperparathyroidism, and KCS (3)

COMMONLY ASSOCIATED CONDITIONS

• Thyroid disorder

• KCS

• Filamentary keratitis

DIAGNOSIS

HISTORY

Targeted history onset, duration, location, quality of symptoms, and associated conditions. History of thyroid disease, KCS, and contact lens wear

PHYSICAL EXAM

• External exam: look for symptoms of thyroid eye disease and inflammatory ptosis

• Decreased Schirmer’s test, decreased tear lake, increased mucus production in advanced cases

• Eyelids: tight upper lids, eversion of upper lid velvety fine papillary reaction of palpebral/tarsal conjunctiva

• Conjunctiva/sclera: sectoral superior bulbar and limbal conjunctival injection, redundant superior conjunctiva, lissamine green/rose bengal staining of superior bulbar conjunctiva (keratinization)

• Cornea: superior punctate epithelial keratitis, mucus filaments superiorly

• Remainder of anterior and posterior segment exams is typically unremarkable.

DIAGNOSTIC TESTS & INTERPRETATION

Lab

• Thyroid function tests

• Consider parathyroid function tests

Diagnostic Procedures/Other

• Lissamine green/rose bengal will stain keratinized or denuded epithelium.

• Demonstrate redundant superior conjunctiva by topically anesthetizing the eye, having the patient look down and slide the superior conjunctiva with a cotton tip applicator onto the superior cornea. This should not be feasible in a normal eye.

Pathological Findings

• Keratinized conjunctival epithelium with polymorphonuclear leukocytes (PMNs)

• Palpebral/tarsal conjunctival cells with lymphocytes and plasma cells on Giemsa scrapings

DIFFERENTIAL DIAGNOSIS

• Allergic

– Seasonal allergic conjunctivitis

– Vernal keratoconjunctivitis

– Atopic keratoconjunctivitis

– Giant papillary keratoconjunctivitis (GPC)

• Contact lens–related keratoconjunctivitis

• KCS

• Filamentary keratitis

• Mucus fishing syndrome

• Topical medication toxicity

TREATMENT

MEDICATION

First Line

• Silver nitrate 0.5–1% solution to anesthetized superior palpebral and bulbar conjunctiva. Irrigate ocular surface thoroughly after 1 minute to neutralize the silver nitrate exposure.

• Can repeat in 4–6 weeks if necessary

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