Conjunctival Resection With and Without Amniotic Membrane Graft for the Treatment of Superior Limbic Keratoconjunctivitis

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.

Outcomes of Ipsilateral Simple Limbal Epithelial Transplantation, Tenonectomy, Mitomycin and Amniotic Membrane Transplantation for Treatment of Recurrent Pterygium

PURPOSE

To report on the outcomes of recurrent pterygium treated by ipsilateral simple limbal epithelial transplantation (SLET), mitomycin, tenonectomy, and amniotic membrane transplantation.

METHODS

A retrospective, interventional study was conducted including all patients with recurrent pterygium who underwent SLET surgery under a single surgeon using ipsilateral donor tissue with a minimum 6-month follow-up at Toronto Western Hospital, Canada. Outcome measures included the following: recurrence rates, best spectacle-corrected visual acuity, and postoperative complications.

RESULTS

Ten eyes of 10 patients, aged 60.7 ± 18.5 years (range 23-79) with a mean follow-up time of 15.2 ± 10.0 months of which 50% (n = 5) were men, were included. Eight eyes (80%) had a history of 2 or less pterygium operations. Two patients had 3 and 5 previous pterygium operations, respectively. Concurrent limbal stem cell disease was noted in 6 eyes (60%). Average number of pterygium recurrences per eye was 1.9 ± 1.3 (range 1-5). Mean pre-op best-corrected visual acuity was 0.5 LogMAR (Snellen equivalent 20/60, range 20/20 to counting fingers). Best-corrected visual acuity remained the same or improved in 6 eyes (60%). Recurrence was noted in 1 eye (10%) with a history of 5 previous pterygium excisions and remained stable at the last follow-up. No patients required a second operation.

CONCLUSIONS

Ipsilateral SLET with mitomycin, tenonectomy, and amniotic membrane transplantation is a novel technique to address recurrent pterygium. Concurrent limbal stem cell diseases are often present. Initial results demonstrate low recurrence. Visual improvement is modest. Stabilization of the ocular surface to improve vision is possible.

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.

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.

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.