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Uemura K, Hiroki I, Saika S, Suzuki T, Asamura S. Conjunctival Chalasis Should Not be Overlooked: Investigation Into Postoperative Ocular Surface Changes in Involutional Blepharoptosis. J Craniofac Surg 2024:00001665-990000000-01461. [PMID: 38682938 DOI: 10.1097/scs.0000000000010168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 02/20/2024] [Indexed: 05/01/2024] Open
Abstract
BACKGROUND Involutional blepharoptosis is common among elderly people. The tightening of eyelids postptosis surgery could potentially increase friction between the eyelid and the ocular surface, but this hypothesis has not yet been substantiated by research. The authors explored the relationship between involutional blepharoptosis surgery and friction-related diseases, namely conjunctivochalasis, lid wiper epitheliopathy, and superior limbic keratoconjunctivitis. METHODS We conducted a prospective study involving 31 patients who underwent levator advancement for involutional blepharoptosis. Both preoperatively and 6 weeks postoperatively, the authors assessed a range of outcome measures, including margin reflex distance-1, 2, tear film break-up time, superficial punctate keratopathy, inferior conjunctivochalasis, upper lid wiper epitheliopathy, and superior limbic keratoconjunctivitis. RESULTS Conjunctivochalasis was detected in 18 eyes preoperatively and 20 eyes postoperatively. Lid wiper epitheliopathy was detected in 2 eyes preoperatively and in no eyes postoperatively. Superior limbic keratoconjunctivitis was detected in 2 eyes preoperatively and 1 eye postoperatively. From preoperative to postoperative assessments, conjunctivochalasis worsened in 11 eyes (17.2%), and there were no eyes with worsening lid wiper epitheliopathy or superior limbic keratoconjunctivitis. There was a significant worsening of superficial punctate keratopathy in the group with exacerbated conjunctivochalasis compared with the unchanged group (0.72 vs. 0.12, P=0.0222). The superficial petechial keratopathy in the 6 cases in which there was worsening of both conjunctivochalasis and superficial petechial keratopathy were all located inferiorly in the cornea. CONCLUSIONS Conjunctivochalasis can worsen following ptosis surgery, potentially leading to an increase in inferior superficial punctate keratopathy. When performing involutional blepharoptosis surgery, surgeons should be mindful of the potential implications of friction-related diseases, particularly conjunctivochalasis.
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Affiliation(s)
- Kazuhisa Uemura
- Department of Plastic and Reconstructive Surgery, Wakayama Medical University, Wakayama, Japan
| | - Iwanishi Hiroki
- Department of Ophthalmology, Wakayama Medical University, Wakayama, Japan
| | - Shizuya Saika
- Department of Ophthalmology, Wakayama Medical University, Wakayama, Japan
| | - Takuya Suzuki
- Department of Plastic and Reconstructive Surgery, Wakayama Medical University, Wakayama, Japan
| | - Shinichi Asamura
- Department of Plastic and Reconstructive Surgery, Wakayama Medical University, Wakayama, Japan
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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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Superior limbic keratoconjunctivitis following ptosis repair. Can J Ophthalmol 2022; 57:e173-e175. [DOI: 10.1016/j.jcjo.2022.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 01/01/2022] [Accepted: 01/06/2022] [Indexed: 11/22/2022]
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Vu CHV, Kawashima M, Yamada M, Suwaki K, Uchino M, Shigeyasu C, Hiratsuka Y, Yokoi N, Tsubota K. Influence of Meibomian Gland Dysfunction and Friction-Related Disease on the Severity of Dry Eye. Ophthalmology 2018; 125:1181-1188. [PMID: 29459039 DOI: 10.1016/j.ophtha.2018.01.025] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 01/18/2018] [Accepted: 01/19/2018] [Indexed: 10/18/2022] Open
Abstract
PURPOSE To evaluate the effect of meibomian gland dysfunction (MGD) and friction-related disease (FRD) on the severity of dry eye disease (DED). DESIGN Cross-sectional observational study. PARTICIPANTS This study enrolled 449 patients with DED (63 men and 386 women; mean age, 62.6±15.7 years [range, 21-90 years]) for analysis. METHODS Subjective symptoms, the ocular surface, tear function, and the presence of MGD and FRD (superior limbic keratoconjunctivitis, conjunctivochalasis, and lid wiper epitheliopathy) were investigated. MAIN OUTCOME MEASURES Schirmer value, tear film breakup time (TBUT), and keratoconjunctival score. RESULTS We classified the participants into aqueous-deficient dry eye (ADDE; n = 231 [51.4%]) and short TBUT dry eye subtype (TBUT-DE; n = 109 [24.3%]) subgroups. The TBUT was shorter in patients with MGD than in those without MGD, whereas other ocular signs showed no difference (TBUT: MGD present, 1.97±1.02 seconds; MGD absent, 2.94±1.63 seconds [P < 0.001]; ADDE/MGD present, 1.94±1.08 seconds; ADDE/MGD absent, 2.77±1.61 seconds [P < 0.001]; short TBUT-DE/MGD present, 2.07±0.97 seconds; short TBUT-DE/MGD absent, 2.94±1.23 seconds [P = 0.01]). The ADDE patients with FRD showed a worse TBUT than ADDE patients without FRD (TBUT: ADDE/FRD present, 2.08±1.39 seconds; ADDE/FRD absent, 2.92±1.54 seconds; P < 0.001). CONCLUSIONS This study showed associations between MGD, FRD, or both and ocular signs in DED. In the presence of MGD, FRD, or both, TBUT was significantly shortened regardless of the dry eye status or subtype.
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Affiliation(s)
- Chi Hoang Viet Vu
- Department of Ophthalmology, Keio University School of Medicine, Tokyo, Japan
| | - Motoko Kawashima
- Department of Ophthalmology, Keio University School of Medicine, Tokyo, Japan.
| | - Masakazu Yamada
- Department of Ophthalmology, Kyorin University, Tokyo, Japan
| | - Kazuhisa Suwaki
- Department of Japan Medical Affairs, Santen Pharmaceutical Co., Ltd., Osaka, Japan
| | - Miki Uchino
- Department of Ophthalmology, Keio University School of Medicine, Tokyo, Japan
| | - Chika Shigeyasu
- Department of Ophthalmology, Kyorin University, Tokyo, Japan
| | - Yoshimune Hiratsuka
- Department of Ophthalmology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Norihiko Yokoi
- Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kazuo Tsubota
- Department of Ophthalmology, Keio University School of Medicine, Tokyo, Japan
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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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Son BK, Yang CM, Kim TG, Jin KH. A Case of Conjunctival Lithiasis with Clinical Manifestations of Superior Limbic Keratoconjunctivitis. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2016. [DOI: 10.3341/jkos.2016.57.6.983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Bo Kwon Son
- Department of Ophthalmology, KyungHee University Hospital, KyungHee University School of Medicine, Seoul, Korea
| | - Chan Min Yang
- Department of Ophthalmology, KyungHee University Hospital, KyungHee University School of Medicine, Seoul, Korea
| | - Tae Gi Kim
- Department of Ophthalmology, KyungHee University Hospital, KyungHee University School of Medicine, Seoul, Korea
| | - Kyung Hyun Jin
- Department of Ophthalmology, KyungHee University Hospital, KyungHee University School of Medicine, Seoul, Korea
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Treatment of Superior Limbic Keratoconjunctivitis With Topical Tacrolimus 0.03% Ointment. Cornea 2013; 32:1499-501. [DOI: 10.1097/ico.0b013e318295e6b9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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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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Kim KY, Lee YS, Lee HJ, Park IK, Jin KH. A Case of Conjunctival Lymphangioma With Clinical Manifestations of Superior Limbic Keratoconjunctivitis After Upper Lid Blepharoplasty. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2010. [DOI: 10.3341/jkos.2010.51.9.1276] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Kook Young Kim
- Department of Ophthalmology, KyungHee University School of Medicine, Seoul, Korea
| | - Young Seob Lee
- Department of Ophthalmology, KyungHee University School of Medicine, Seoul, Korea
| | - Hui Jae Lee
- Department of Ophthalmology, Kangwon University School of Medicine, Chuncheon, Korea
| | - In Ki Park
- Department of Ophthalmology, KyungHee University School of Medicine, Seoul, Korea
| | - Kyung Hyun Jin
- Department of Ophthalmology, KyungHee University School of Medicine, Seoul, Korea
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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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Current world literature. Curr Opin Ophthalmol 2008; 19:435-43. [PMID: 18772678 DOI: 10.1097/icu.0b013e32830d5da2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Sun YC, Hsiao CH, Chen WL, Wang IJ, Hou YC, Hu FR. Conjunctival resection combined with tenon layer excision and the involvement of mast cells in superior limbic keratoconjunctivitis. Am J Ophthalmol 2008; 145:445-452. [PMID: 18201682 DOI: 10.1016/j.ajo.2007.10.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2007] [Revised: 10/21/2007] [Accepted: 10/24/2007] [Indexed: 11/27/2022]
Abstract
PURPOSE To evaluate the effectiveness of conjunctival resection combined with Tenon layer excision in treating superior limbic keratoconjunctivitis (SLK) and the involvement of mast cells in SLK. DESIGN Retrospective, interventional case series. METHODS Forty eyes of 30 SLK patients who were unresponsive to medical treatment received superior bulbar conjunctival resection, and another 20 patients who underwent cataract and retinal surgery served as a control group. The conjunctiva specimens from study and control patients were examined by hematoxylin and eosin staining and immunohistochemistry using antibodies against mast cell tryptase. RESULTS In all operated eyes, the clinical symptoms and signs, including irritation and redness and superior bulbar conjunctival hyperemia and superior tarsal conjunctival papillary hypertrophy, subsided significantly three months after the operation. Only three eyes had recurrence from the margin of conjunctival resection, and this was relieved after reoperation. Keratinized conjunctival epithelium, loss of goblet cells, and increased mast cell numbers (P<.05) were found in the SLK group. CONCLUSIONS Our cases demonstrate that superior bulbar conjunctival resection combined with Tenon layer excision is an effective treatment for SLK. The pathologic findings suggest that mast cells may play a role in the pathogenesis of SLK.
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Affiliation(s)
- Yi-Chen Sun
- Department of Ophthalmology, Buddhist Tzu Chi General Hospital, and College of Medicine, National Taiwan University, Taipei, Taiwan
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