eMedicine Specialties > Ophthalmology > Cornea

Keratoconjunctivitis, Superior Limbic

Author: James H Oakman Jr, MD, Partner, Southern Eye Center, Augusta, Georgia
Contributor Information and Disclosures

Updated: Nov 6, 2008

Introduction

Background

This disorder is characterized as an inflammation of the superior bulbar conjunctiva with predominant involvement of the superior limbus, an adjacent epithelial keratitis, and a papillary hypertrophy of the upper tarsal conjunctiva.

In 1963, Thygeson and Kimura described it as a chronic, localized, filamentary conjunctivitis.1 It was given its name, superior limbic keratoconjunctivitis (SLK), by Theodore, contemporaneously. Five years later, Tenzel and Corwin reported an association with thyroid abnormalities and SLK.2,3 A mimicking disorder has been encountered in soft contact lens wearers, typically with exposure to thimerosal-preserved solutions.

Pathophysiology

SLK is believed to be present secondary to superior bulbar conjunctiva laxity, which induces inflammatory changes from mechanical soft tissue microtrauma.4 In settings where the physiological tolerance of mechanical forces on the delicate ocular surface is exceeded, chronic inflammation results in thickening of the conjunctiva and keratinization, which is then cyclical in perpetuating the inflammation. Eventually, a filamentary response may be induced on the affected cornea. Factors inducing conjunctiva laxity include thyroid eye disease, tight upper eyelids, and prominent globes. Immunochemical histopathologic examination of the abnormal conjunctiva in SLK lends credence to microtrauma being of most significance to the development of SLK.

Frequency

United States

The frequency of SLK has been found to be 3% in a cohort of Graves ophthalmopathy patients, but it is much lower in the general population.

International

The international frequency is unknown.

Mortality/Morbidity

The natural history of the disorder is remission and eventual total resolution but only after a prolonged clinical course.

Race

No racial predilection exists.

Sex

Women are predominantly affected.

Age

Typically, middle-aged people are affected; however, this entity has been reported to occur in patients aged 4-81 years.

Clinical

History

  • Patients present with complaints of burning and irritation of the affected eye.
    • Some patients may present with redness. Upgaze may elicit these symptoms.
    • Typically, usage of moisturizing medications only provides minimal relief.
    • Symptoms remit and exacerbate and are variable in degree, but no diurnal pattern to the worsening of symptoms exists.
  • In most cases, the condition is present bilaterally, although one eye may be more symptomatic.
  • Patients with filaments are usually extremely symptomatic.
  • Commonly, a history of thyroid dysfunction is elicited upon questioning. The natural history of SLK is prolonged, with gradual clearing.
  • Patients often have numerous eye specialists for their symptoms. Unless the doctors have specifically examined the upper bulbar conjunctivae or everted the upper eyelids, they may have missed the diagnosis.

Physical

  • Marked inflammation of the upper lid tarsal conjunctiva, adjacent inflammation of the upper bulbar conjunctiva, and punctate rose bengal staining of the cornea at the upper limbus are signs of SLK.
  • The conjunctiva extending from the upper limbus to the insertion of the superior rectus muscle also demonstrates thickening, hyperemia, and typical rose bengal staining. It stands out in stark contrast to the normal appearance of the inferior conjunctiva and cornea.
  • Approximately one third of patients present with filaments on the upper cornea or along the superior limbus.

Causes

  • The cause of SLK is unknown, but inflammatory changes from mechanical soft tissue microtrauma are the final common pathway.
  • SLK is associated with thyroid dysfunction.
  • SLK has also developed in association with scarring of the palpebral conjunctiva in euthyroid patients.
  • Prolonged eyelid closure with associated hypoxia or reduced tear volume may be a risk factor for SLK development.
  • Morphological or functional changes in superior conjunctival apposition to the globe following upper eyelid procedures may induce SLK.5

More on Keratoconjunctivitis, Superior Limbic

Overview: Keratoconjunctivitis, Superior Limbic
Differential Diagnoses & Workup: Keratoconjunctivitis, Superior Limbic
Treatment & Medication: Keratoconjunctivitis, Superior Limbic
Follow-up: Keratoconjunctivitis, Superior Limbic
References
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References

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Further Reading

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Keywords

superior limbic keratoconjunctivitis, SLK, superior limbic filamentary keratoconjunctivitis

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Contributor Information and Disclosures

Author

James H Oakman Jr, MD, Partner, Southern Eye Center, Augusta, Georgia
James H Oakman Jr, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Georgia Medical Society, Georgia Society of General Surgeons, and Georgia Society of Ophthalmology
Disclosure: Nothing to disclose.

Medical Editor

Stephen D Plager, MD, FACS, Chief, Department of Ophthalmology, Dominican Hospital; Assistant Clinical Professor, Department of Ophthalmology, Stanford University Hospital
Stephen D Plager, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, American Society of Cataract and Refractive Surgery, and California Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Christopher J Rapuano, MD, Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Co-Chairman of the Cornea Service, Co-Chairman of Refractive Surgery Department, Wills Eye Institute
Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Cornea Society, Eye Bank Association of America, International Society of Refractive Surgery, and Pan-American Association of Ophthalmology
Disclosure: Allergan Honoraria Speaking and teaching; Allergan Consulting fee Consulting; Alcon Honoraria Speaking and teaching; Inspire Honoraria Speaking and teaching; RPS Ownership interest Other; Vistakon Honoraria Speaking and teaching

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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