Supratarsal Triamcinolone Injection in the Treatment of Superior Limbic Keratoconjunctivitis

Chalazion Treatment: A Concise Review of Clinical Trials

A chalazion is one of the most common eye conditions presenting as a mass lesion of the eyelids. It is seen in all age groups. Chalazion is a non-inflammatory process and develops due to retained secretion of the meibomian or Zeis glands. Treatment of choice differs among clinicians and may include application of warm compress onto eyelids, lid hygiene, using local antibiotic ointment with or without steroids, injecting steroid solution (triamcinolone acetonide) into the lesion and surgical removal of the lesion by incision and curettage. In addition, there are some other experimented methods such as injection of botulinum toxin A, tarsal trephination, removal of chalazion by application of CO2 laser or cryogenic action. However, there is currently no commonly agreed treatment of choice. In this review, we aimed to summarize findings from clinical trials and hopefully, identify a treatment of choice in chalazion.

Superior limbic keratoconjunctivitis: Update on pathophysiology and management

Superior limbic keratoconjunctivitis (SLK) is an under-recognized condition characterized by a final common pathologic presentation of superior conjunctival and limbal inflammation and staining. Existing literature attributes both microtrauma and local inflammation, frequently in the setting of tear film insufficiency, as the underlying mechanisms that lead to a self-perpetuating pathologic process dependent in on inflammatory cells and signaling. Effective treatments act by targeting inflammation and by mitigating mechanical stressors. This critical review discusses the latest in our understanding of the pathophysiology of SLK and how it guides our treatment strategies.

Superior limbic keratoconjunctivitis: a comprehensive review

Superior limbic keratoconjunctivitis (SLK) is characterized by chronic inflammation of the superior limbus and superior bulbar and tarsal conjunctivae. Patients also often have fine punctate staining of the limbus and adjacent area, superior limbic proliferation seen as thickening of the limbal epithelium and surrounding conjunctiva, and occasionally filaments at the superior limbus and upper cornea. SLK frequently presents with ocular irritation, foreign body sensation, and photophobia. SLK can be associated with other ocular and non-ocular conditions, such as thyroid disease. Although the pathogenesis of SLK is still unknown, it is thought to be related to mechanical injury, tear film instability, or an autoimmune/inflammatory etiology. Many patients with SLK can be asymptomatic or have symptoms that resolve or remit spontaneously. For symptomatic SLK, patients are managed medically with treatments such as lubricants, topical anti-inflammatory or immunomodulatory medications, punctal occlusion, and bandage contact lenses. Patients with symptoms refractory to medical management may need surgical interventions. We detail the current literature on the epidemiology, clinical manifestations, associated conditions, histopathology, pathogenesis, and treatment of SLK.

Safety and Efficacy of Supratarsal Triamcinolone for Treatment of Vernal Keratoconjunctivitis in Ireland

PURPOSE

To describe the clinical features, risk factors, and treatment outcomes after supratarsal injection of triamcinolone for vernal keratoconjunctivitis (VKC).

METHODS

A retrospective review of all patients treated with supratarsal triamcinolone for VKC between February 2002 and May 2017 at the Royal Victoria Eye and Ear Hospital and Our Lady's Children Hospital Crumlin, Dublin, Ireland, was performed.

RESULTS

Twenty-five patients, 46 eyes, and 145 injections were included for analysis. The mean age at first injection was 9.1 ± 5.7 years. Ninety-six percent of the patients were male. A seasonal variation was noted, with 59 injections (41%) of triamcinolone administered for acute and refractive cases of VKC in the summer compared with 35 (24%), 35 (24%), and 16 (11%) in the spring, autumn, and winter months, respectively. The most common presenting complaint was red eye, which was seen in all cases. Hay fever (64%) was the most common associated systemic disease. Each eye required, on average, 3.2 injections (range 1-9 injections), and the mean duration from the onset of symptoms to final treatment was 3.03 years (range 0-7.9 years). The mean presenting and final visual acuities were 0.33 and 0.11 logarithm of the minimum angle of resolution, respectively (P < 0.0001). During our study period, no patient experienced intraocular pressure rise requiring treatment, development of lenticular opacity, or ptosis after supratarsal injection of triamcinolone.

CONCLUSIONS

In this case series, supratarsal triamcinolone was used in cases of VKC in which topical medications had failed to control the disease process. All patients reported improvement after treatment. There were no cases of intraocular pressure rise, lenticular opacity, or ptosis development after treatment.

Efficacy and safety of 0.1% lodoxamide for the long-term treatment of superior limbic keratoconjunctivitis

PURPOSE

To report the therapeutic efficacy and safety of topical 0.1% lodoxamide in the long-term treatment of superior limbic keratoconjunctivitis.

METHODS

Sixty-seven eyes of 34 patients with active SLK were studied. Therapeutic response was analyzed according to modified-Ohashi parameters. All eyes were treated with 0.1% lodoxamide twice daily, and those with moderate or severe inflammation received a short course (7-14 days) of 0.1% fluorometholone acetate at presentation and during a relapse. Patients were evaluated at regular intervals and followed up for ≥3 months on continuous therapy. Primary endpoints included inflammatory response; rates of inflammatory control and remission; relapses while on therapy or on remission; and therapeutic failure rate.

RESULTS

The mean follow-up time on lodoxamide therapy was 15.3 months. The majority of eyes (82.0%) achieved control of inflammation in a mean time of 2.2 months. Of these, 42 (76.3%) eyes remained under control while on therapy for 13.8 months. There was a significant improvement of SLK-related signs by the third month on therapy (p < 0.05). A total of 24 (35.8%) eyes achieved remission. Relapses presented in 12 (18.0%) treated eyes and in 4 (16.6%) eyes on remission. Only 5 (7.4%) eyes failed to respond to therapy. In the majority of cases (95.3%), lodoxamide 0.1% was well tolerated and minor adverse effects not requiring stopping the medication were reported in only 4.7% of patients.

CONCLUSIONS

Lodoxamide 0.1% is an efficacious therapeutic alternative for the treatment of active and chronic SLK. This medication has proved to be safe and well tolerated.

Extensive superior limbic keratoconjunctivitis in Graves' disease: case report and mini-review of the literature

Background

Superior limbic keratoconjunctivitis (SLK) is characterized as an inflammation of the superior bulbar conjunctiva with predominant involvement of the superior limbus and adjacent epithelial keratitis.

Methods

A 51-year-old woman, with a history of medically controlled Graves’ disease was seen with an extensive SLK involving 5 mm of the superior cornea.

Results

Total remission was observed with topical steroids (DXM). Recurrence was observed 1 week after steroid discontinuation, and steroidal treatment was reintroduced with tapering over 1 month. Total remission was then observed for 1 year.

Conclusion

Extensive keratitis and vascular pannus in SLK is rarely reported. This form could be treated with topical steroids. Tapering treatment remains essential for long-term success.

Topical rebamipide treatment for superior limbic keratoconjunctivitis in patients with thyroid eye disease

PURPOSE

To evaluate efficacy of topical rebamipide for superior limbic keratoconjunctivitis (SLK) in patients with thyroid eye disease.

DESIGN

Retrospective, observational case series.

METHODS

Thirty-three eyes from 20 thyroid eye disease patients with SLK who received topical rebamipide (Mucosta ophthalmic suspension unit dose 2%; Otsuka Pharmaceutical Co, Ltd; chemical name, (2RS)-2-(4-chlorobenzoylamino)-3-(2-oxo-1, 2-dihydroquinolin-4-yl) propanoic acid) were included. The following items were evaluated before and 4 weeks after the start of treatments: presence or absence of SLK, rose bengal staining score, area and density classification of fluorescein staining, Schirmer test I results (without topical anesthesia), tear film break-up time, Hertel exophthalmometry values, and margin reflex distances 1 and 2.

RESULTS

Twenty-eight eyes showed complete disappearance of SLK after treatment (84.8%; P < .001). The other 5 eyes (15.2%) demonstrated significant improvement, but had residual punctate rose bengal staining and fluorescein staining near the superior corneal limbus. All 5 eyes exhibited at least 1 of the following findings: proptosis of more than 17.7 mm and upper or lower eyelid retractions or both. Incidence of upper eyelid retraction was significantly higher in eyes with SLK than in those without SLK at the 4-week follow-up (P = .021). The severity of rose bengal staining and fluorescein staining improved significantly after treatment (P < .001). Although the Schirmer test results remained constant before and after the treatment (P = .212), tear film break-up time increased significantly in the posttherapeutic state (P = .009). No serious adverse events were reported.

CONCLUSIONS

Topical rebamipide improved SLK in patients with thyroid eye disease, suggesting a first-line treatment in such patients.

Supratarsal injection of triamcinolone acetonide and childhood allergic keratoconjunctivitis

To evaluate the efficacy and safety of supratarsal injection of triamcinolone acetonide in the treatment of refractory allergic keratoconjunctivitis in childhood. Thirty-five patients (70 eyes) with severe allergic keratoconjunctivitis were included in this study. Fifteen patients (42.8%) had atopic keratoconjunctivitis (AKC) and 20 (57.2%) had vernal keratoconjuncivitis (VKC). All patients underwent a bilateral supratarsal injection of 20 mg triamcinolone acetonide. Mean follow-up was 28 months (range 14-38). All patients showed a significant symptomatic improvement and partial resolution of clinical features of keratoconjunctivitis within the first 2 weeks. Corneal complications related to keratoconjunctivitis disappeared in all patients. One patient with VKC experienced ocular hypertension. No patient with AKC showed side-effects. Severe relapse of the disease was noted in 10% of eyes with VKC and in 6.7% of eyes with AKC after a mean follow-up of 9 and 11 months, respectively. Supratarsal injection of triamcinolone acetonide is effective and safe in patients with severe chronic allergic keratoconjunctivits to relieve severe inflammation associated with this disease.

[Using systemic corticotherapy for adult gonococcal keratoconjunctivitis: three case reports]

INTRODUCTION

adult gonococcal keratoconjunctivitis is a rare disease possibly leading to blindness, whose severity is related to the risk of corneal perforation and whose progression is conditioned by the rapidity of diagnosis and therapeutic management.

PURPOSE

discuss the value of general corticotherapy in the treatment of scleritis associated with this disease.

PATIENTS AND METHODS

retrospective analysis of patients with adult gonococcal keratoconjunctivitis managed in an emergency setting in 2007.

OBSERVATION

three patients aged 22-55 years contracted the disease during unprotected sexual activity. Involvement was bilateral in two cases out of three; the intensity of the signs was always asymmetrical. Each patient underwent stromal melting of the superior limbic structures, with severity proportional to the delay in treatment. For each case, systemic and local antibiotics did not control corneal thinning, which seemed correlated with the intensity of the systematically associated signs of scleral inflammation. Treatment of scleritis with general corticotherapy under antibiotic cover stabilized the corneal thickness.

DISCUSSION

whether the physiopathology of perilimbic corneal thinning can lead to ocular perforation in this condition is unknown. In our experience, the stabilization of corneal thickness seems correlated with regression of the scleritis observed after introducing general corticotherapy, potentially indicating aseptic inflammatory involvement.

CONCLUSION

stromal melting of the limbus observed in adult gonococcal keratoconjunctivitis seems to be related to the associated scleritis. Systemic corticotherapy controls progression and reduces the risk of corneal perforation.