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Lee DH, Margolis MS, Iovieno A, Ling J, Ng T, Djalilian AR, Yeung SN. Superior limbic keratoconjunctivitis: Update on pathophysiology and management. Ocul Surf 2023; 28:144-152. [PMID: 37011726 DOI: 10.1016/j.jtos.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 03/17/2023] [Accepted: 03/31/2023] [Indexed: 04/03/2023]
Abstract
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.
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Affiliation(s)
- Dong-Ho Lee
- Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, BC, CanadaA.
| | - Mathew S Margolis
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois Chicago, Chicago, IL, USA
| | - Alfonso Iovieno
- Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, BC, CanadaA
| | - Jennifer Ling
- Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, BC, CanadaA
| | - Tony Ng
- Department Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Ali R Djalilian
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois Chicago, Chicago, IL, USA
| | - Sonia N Yeung
- Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, BC, CanadaA
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Sun YC, Inamoto Y, Wang RK, Lee SJ, Hung KF, Shen TT. The disposable bandage soft contact lenses therapy and anterior segment optical coherence tomography for management of ocular graft-versus-host disease. BMC Ophthalmol 2021; 21:271. [PMID: 34217260 PMCID: PMC8254955 DOI: 10.1186/s12886-021-02031-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 06/04/2021] [Indexed: 11/10/2022] Open
Abstract
PURPOSE To identify the ocular surface changes of ocular graft-versus-host disease (GVHD) using anterior segment optical coherence tomography (AS-OCT) and examine the efficacy of disposable bandage soft contact lens (BSCL) treatment in ocular GVHD patients. METHODS This study is a prospective, Phase II clinical trial. Nineteen patients diagnosed with chronic GVHD based on the NIH criteria and ocular symptoms of NIH eye score 2 or greater were enrolled. Disposable BSCL was applied to the GVHD-affected eyes with topical antibiotic coverage. Ocular exams, eye symptom surveys, and AS-OCT were performed with signed informed consent. Patients were followed for one to three months. RESULTS Thirty-eight eyes of 19 patients with ocular GVHD underwent BSCL treatment in this study. AS-OCT scans were done in 14 out of 19 patients. The mean best-corrected visual acuity at enrollment, 2-week, and 4-week visits was 0.180, 0.128, and 0.163 logMAR, respectively. Twenty-four out of 25 eyes (96 %) that initially presented with conjunctival inflammation, twenty-three out of 30 eyes (76.7 %) that initially presented with punctate epithelial erosion, and 8 out of 15 (53.3 %) eyes that initially presented with filamentous keratopathy showed improvement after wearing BSCL for 2 to 4 weeks. AS-OCT revealed corneal epithelial irregularity, abnormal meibomian gland orifice, and conjunctival hyperemia, in patients with ocular GVHD. CONCLUSIONS BSCL treatment provided significant subjective and objective improvements in ocular GVHD patients. Meanwhile, we found that AS-OCT can be a promising diagnostic tool to characterize the ocular surface changes associated with ocular GVHD.
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Affiliation(s)
- Yi-Chen Sun
- Department of Ophthalmology, Taipei Tzu Chi Hospital, The Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan.,Department of Ophthalmology, University of Washington, 1959 NE Pacific St, Washington, Seattle, USA
| | - Yoshihiro Inamoto
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Division of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Ruikang K Wang
- Department of Bioengineering, University of Washington, Seattle, Washington, USA
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Kai-Feng Hung
- Department of Medical Research, Division of Translational Research, Taipei Veterans General Hospital, No.201, Sec 2, Shipai Rd., Beitou District, Taipei, Taiwan. .,Department of Dentistry, School of Dentistry, National Yang-Ming Chiao Tung University, Taipei, Taiwan.
| | - Tueng T Shen
- Department of Ophthalmology, University of Washington, 1959 NE Pacific St, Washington, Seattle, USA.
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Lahoti S, Weiss M, Johnson DA, Kheirkhah A. Superior limbic keratoconjunctivitis: a comprehensive review. Surv Ophthalmol 2021; 67:331-341. [PMID: 34077767 DOI: 10.1016/j.survophthal.2021.05.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 05/19/2021] [Accepted: 05/24/2021] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Sejal Lahoti
- Department of Ophthalmology, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Menachem Weiss
- Department of Ophthalmology, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Daniel A Johnson
- Department of Ophthalmology, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Ahmad Kheirkhah
- Department of Ophthalmology, University of Texas Health San Antonio, San Antonio, TX, USA.
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Jacobs DS, Carrasquillo KG, Cottrell PD, Fernández-Velázquez FJ, Gil-Cazorla R, Jalbert I, Pucker AD, Riccobono K, Robertson DM, Szczotka-Flynn L, Speedwell L, Stapleton F. CLEAR - Medical use of contact lenses. Cont Lens Anterior Eye 2021; 44:289-329. [PMID: 33775381 DOI: 10.1016/j.clae.2021.02.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 02/01/2021] [Indexed: 12/11/2022]
Abstract
The medical use of contact lenses is a solution for many complex ocular conditions, including high refractive error, irregular astigmatism, primary and secondary corneal ectasia, disfiguring disease, and ocular surface disease. The development of highly oxygen permeable soft and rigid materials has extended the suitability of contact lenses for such applications. There is consistent evidence that bandage soft contact lenses, particularly silicone hydrogel lenses, improve epithelial healing and reduce pain in persistent epithelial defects, after trauma or surgery, and in corneal dystrophies. Drug delivery applications of contact lens hold promise for improving topical therapy. Modern scleral lens practice has achieved great success for both visual rehabilitation and therapeutic applications, including those requiring retention of a tear reservoir or protection from an adverse environment. This report offers a practical and relevant summary of the current evidence for the medical use of contact lenses for all eye care professionals including optometrists, ophthalmologists, opticians, and orthoptists. Topics covered include indications for use in both acute and chronic conditions, lens selection, patient selection, wear and care regimens, and recommended aftercare schedules. Prevention, presentation, and management of complications of medical use are reviewed.
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Affiliation(s)
- Deborah S Jacobs
- Massachusetts Eye & Ear, Cornea and Refractive Surgery Service, Harvard Medical School, Boston, MA, USA.
| | | | | | | | | | | | | | | | | | - Loretta Szczotka-Flynn
- Department of Ophthalmology & Visual Science, Case Western Reserve University, Cleveland, OH, USA
| | - Lynne Speedwell
- Great Ormond Street Hospital for Children NHS Trust, Moorfields Eye Hospital, London, UK
| | - Fiona Stapleton
- School of Optometry and Vision Science, UNSW Sydney, Australia
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Sivaraman KR, Jivrajka RV, Soin K, Bouchard CS, Movahedan A, Shorter E, Jain S, Jacobs DS, Djalilian AR. Superior Limbic Keratoconjunctivitis-like Inflammation in Patients with Chronic Graft-Versus-Host Disease. Ocul Surf 2016; 14:393-400. [PMID: 27179980 DOI: 10.1016/j.jtos.2016.04.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 04/26/2016] [Accepted: 04/01/2016] [Indexed: 12/15/2022]
Abstract
PURPOSE Describe the presentation and management of superior limbic keratoconjunctivitis (SLK)-like inflammation and secondary limbal stem cell dysfunction in the setting of ocular chronic graft-versus-host disease (cGVHD). METHODS Retrospective observational case series in a multicenter clinical practice. Participants were 13 patients (26 eyes) with ocular cGVHD and SLK-like inflammation presenting to the University of Illinois at Chicago and BostonSight® between January 1, 2009 and July 1, 2013. MAIN OUTCOME MEASURES 1) Reversal or worsening of SLK, and 2) development of limbal stem cell dysfunction. RESULTS All eyes showed evidence of SLK-like inflammation and superior limbal stem cell dysfunction manifested by conjunctival injection and superior conjunctival and corneal staining. In addition to aggressive lubrication, management strategies for SLK included topical steroids (20/26), punctal occlusion (18/26), topical cyclosporine (24/26), autologous serum tears (12/26), therapeutic soft contact lens (13/26 eyes) and scleral lenses (4/26 eyes). SLK and limbal stem cell dysfunction were reversed in 23/26 eyes. Three eyes of two patients with long-standing disease demonstrated frank limbal stem cell deficiency (LSCD) and corneal pannus, with one patient requiring multiple reconstructive surgical procedures. CONCLUSIONS SLK-like inflammation is an under-recognized condition in patients with severe dry eyes secondary to ocular cGVHD. Untreated SLK can potentially lead to permanent LSCD over time. Early recognition and management of SLK in ocular cGVHD can improve vision, reverse signs, and may prevent these long-term consequences.
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Affiliation(s)
- Kavitha R Sivaraman
- Illinois Eye and Ear Infirmary, Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL
| | - Renu V Jivrajka
- Illinois Eye and Ear Infirmary, Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL
| | - Ketki Soin
- Illinois Eye and Ear Infirmary, Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL
| | | | - Asadolah Movahedan
- Illinois Eye and Ear Infirmary, Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL
| | - Ellen Shorter
- Illinois Eye and Ear Infirmary, Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL
| | - Sandeep Jain
- Illinois Eye and Ear Infirmary, Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL
| | - Deborah S Jacobs
- BostonSight®, Needham Heights, MA; Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Ali R Djalilian
- Illinois Eye and Ear Infirmary, Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL.
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Superior limbic keratoconjunctivitis causing chronic ocular irritation in a child. J AAPOS 2012; 16:579-81. [PMID: 23158547 DOI: 10.1016/j.jaapos.2012.08.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2011] [Revised: 07/29/2012] [Accepted: 08/05/2012] [Indexed: 11/20/2022]
Abstract
Superior limbic keratoconjunctivitis (SLK) is an uncommon, painful inflammation of the ocular surface localized to the superior sectors of the cornea, limbus, and conjunctiva. The clinical course tends to be chronic, with alternating periods of remission and exacerbation. Many patients experience severe ocular discomfort for long periods. Corneal involvement may induce scarring, astigmatism, and ultimately decreased vision. SLK typically occurs in woman between 20 and 60 years of age. Little is known about the features of SLK in young children because the earliest age described in the literature is adolescence. We report the clinical presentation and management of SLK in a 7-year-old boy who responded well to topical steroids and lubricants.
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Conjunctival Resection With and Without Amniotic Membrane Graft for the Treatment of Superior Limbic Keratoconjunctivitis. Cornea 2010; 29:1025-30. [DOI: 10.1097/ico.0b013e3181d1d1cc] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Treatment of Superior Limbic Keratoconjunctivitis With a Large-Diameter Contact Lens and Botulium Toxin A Treatment of superior limbic keratoconjunctivitis with a large-diameter contact lens and botulium toxin a. Cornea 2009; 28:752-8. [DOI: 10.1097/ico.0b013e3181967006] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Fraunfelder FW. Liquid nitrogen cryotherapy of superior limbic keratoconjunctivitis. Am J Ophthalmol 2009; 147:234-238.e1. [PMID: 18835475 DOI: 10.1016/j.ajo.2008.07.047] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2008] [Revised: 07/30/2008] [Accepted: 07/31/2008] [Indexed: 11/29/2022]
Abstract
PURPOSE To evaluate the effects of liquid nitrogen cryotherapy on superior limbic keratoconjunctivitis (SLK). DESIGN Interventional case series. METHODS In this clinical practice case series, the effects of liquid nitrogen cryotherapy on SLK were observed. Liquid nitrogen cryotherapy was performed using a Brymill E tip spray (0.013-inch aperture) with a double freeze-thaw technique. All subjects were outpatients who had local anesthesia with a single drop of topical proparacaine. The main outcome measure was the resolution of the disease process after treatment. RESULTS Four female patients (average age, 64 +/- 13 years) and seven eyes with SLK were treated with liquid nitrogen cryotherapy. Resolution of signs and symptoms occurred within two weeks. Disease recurred in two patients and three of seven eyes, although repeat cryotherapy eradicated SLK in all cases. The repeat cryotherapy was performed at three months postoperatively. There were no adverse ocular events. CONCLUSIONS Liquid nitrogen cryotherapy appears to be an effective alternative treatment for SLK as all subjects studied achieved long-term cures. Repeat cryotherapy may be necessary in some instances and may be performed three months after the first treatment.
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Fraunfelder FW. Liquid nitrogen cryotherapy for surface eye disease (an AOS thesis). TRANSACTIONS OF THE AMERICAN OPHTHALMOLOGICAL SOCIETY 2008; 106:301-24. [PMID: 19277243 PMCID: PMC2646430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
PURPOSE To evaluate the effects of new treatments with liquid nitrogen cryotherapy on some external eye conditions. METHODS In this retrospective case study, 6 separate series from a single tertiary care referral center practice are described. Liquid nitrogen cryotherapy was used to treat conjunctival amyloidosis, primary pterygia, recurrent pterygia, advancing wavelike epitheliopathy (AWLE), superior limbic keratoconjunctivitis (SLK), and palpebral vernal keratoconjunctivitis (VKC). The main outcome measure was the resolution of the disease process after treatment. RESULTS Four patients with primary localized conjunctival amyloidosis were treated with liquid nitrogen cryotherapy. Two of them had recurrence of the amyloidosis, which cleared with subsequent treatment. Eighteen patients with primary pterygia had excision and cryotherapy with 1 recurrence. Of 6 subjects who presented with recurrent pterygia, 4 had a second recurrence after excision and cryotherapy. In 5 patients with AWLE, the condition resolved within 2 weeks without recurrence or the need for subsequent cryotherapy. Four patients with SLK were treated with liquid nitrogen cryotherapy. Disease recurred in 2 patients and 3 of 7 eyes, although subsequent cryotherapy eradicated SLK in all cases. Two patients and 3 eyelids with palpebral VKC were treated with liquid nitrogen cryotherapy. VKC recurred in all cases. CONCLUSIONS Liquid nitrogen cryotherapy to the surface of the eye is effective in treating AWLE, and SLK. Excision followed by cryotherapy is successful in treating conjunctival amyloidosis and primary pterygia Liquid nitrogen cryotherapy is unsuccessful in the treatment of recurrent pterygia and VKC.
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Affiliation(s)
- Frederick Web Fraunfelder
- Department of Ophthalmology (Casey Eye Institute), Oregon Health & Science University, Portland, Oregon, USA
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Shen YC, Wang CY, Tsai HY, Lee YF. Supratarsal Triamcinolone Injection in the Treatment of Superior Limbic Keratoconjunctivitis. Cornea 2007; 26:423-6. [PMID: 17457190 DOI: 10.1097/ico.0b013e318030d230] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate the efficacy of supratarsal triamcinolone injection in the treatment of superior limbic keratoconjunctivitis (SLK). METHODS Forty eyes of 20 patients were diagnosed with SLK. All eyes with long-standing severe ocular irritation unresponsive to topical steroid and artificial tears were treated with supratarsal triamcinolone injection in addition to ongoing treatment of dry eye. Objective tarsal conjunctiva inflammation, bulbar conjunctiva, cornea staining, and subjective symptom gradings were performed before and after 2 weeks of therapy. All patients underwent laboratory evaluations of underlying systemic abnormalities. RESULTS All 40 eyes responded well to treatment and had long-term (average, 7.8 months) improvement of irritation and dry sensation and improvement of inflammation and staining of conjunctiva and cornea. Fourteen patients (70%) had associated autoimmune diseases. There were no irreversible complications related to this therapy. CONCLUSIONS Supratarsal triamcinolone injection effectively and rapidly resolved symptoms and signs associated with SLK. It is helpful as primary or adjunctive therapy for SLK.
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Affiliation(s)
- Ying-Cheng Shen
- Department of Ophthalmology, Taichung Veterans General Hospital, Taiwan, China.
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