Approach Considerations
Superior limbic keratoconjunctivitis (SLK) is managed by various treatment options, none of which has been completely effective. Therapeutic approaches have been aimed primarily toward speeding the patient's recovery and providing symptomatic relief.
See the following for more information:
Pharmacologic Treatment
Pressure patching, placement of a bandage contact lens (primarily or as an adjunct), silver nitrate 0.5% solution application (10-20 seconds to superior tarsal and bulbar conjunctiva after topical anesthesia), mast cell stabilizers, [11, 19] vitamin A preparations, [20] topical cyclosporine (0.05% BID), [7] autologous serum–derived drops, [21, 22] and botulinum injection to the overlying muscle of Riolan [23] have been used with moderate success for managing superior limbic keratoconjunctivitis (SLK). Because these approaches usually offer only temporary mitigation of symptoms, more definitive treatments (eg, surgical resection of the bulbar conjunctiva) are often required.
A 2017 study of 67 eyes showed that continuous lodoxamide 0.1% BID can be an efficacious and well-tolerated therapeutic alternative for the treatment of active and chronic SLK. [24] A 4-week course of 0.03% tacrolimus ointment has been shown anecdotally in two patients to alleviate symptoms. [25] Again, most do not consider these definitive treatments.
Supratarsal triamcinolone injection has had reported success in mitigating signs and symptoms and may be helpful as adjunctive therapy. [26]
Acetylcysteine 10% 3-6 times per day can be added if significant corneal filaments are present.
Topical rebamipide is suggested as a first-line treatment for SLK in patients with thyroid eye disease. The study included 33 eyes from 20 patients with thyroid eye disease, all of whom experienced significant improvement of SLK signs after treatment; 84.8% of eyes achieved complete remission. [27]
It is important to keep in mind that inappropriate use of silver nitrate sticks (75%-95%)—which should never be used in the eyes, as opposed to preparations of topical silver nitrate solution (0.5%)—results in a severe caustic injury to the affected part of the eye where applied.
Cryotherapy
Liquid nitrogen cryotherapy as a single application or repeated for recalcitrant SLK appears to be a safe and effective therapy using a double freeze-thaw technique with the patient under topical anesthesia. [20]
Surgical Resection
When noninvasive or less invasive treatment modalities fail in the treatment of superior limbic keratoconjunctivitis (SLK), surgical intervention is an alternative. [28]
Surgical resection of the involved conjunctiva—as delineated intraoperatively by the use of rose Bengal staining—removes the affected tissue. Folds of superfluous conjunctiva are eliminated, adhesions with underlying Tenon capsule and episclera develop, which may be augmented by transplantation of cryopreserved amniotic membrane with fibrin glue, [29] and keratinized epithelium is replaced by normal ingrowth. [30, 11] Thermocautery accomplishes 2 of these treatment objectives. [19] Autologous serum application has been shown to be beneficial as an alternative therapy in a small case series. [31] Adjunctive superior lacrimal punctal occlusion, [32] bandage contact lens application, [33, 34] and amniotic membrane grafting [35] have been advocated but are not widely used.
Surgical resection of the conjunctiva has the usual complication profile of any surgical procedure, and special care should be taken to avoid involvement of the superior rectus muscle in the dissection.
Application of high-frequency radiowave electrosurgery after techniques for conjunctival chalasis treatment also shortens excess conjunctiva and has been used effectively as an alternative therapy. [36]
Patient Education and Follow-up
Discussing the disease process with patients is important, because it will improve compliance with treatment modalities. This discussion will help to allay their fear of the unknown and will also help them to cope with the often prolonged symptoms of this entity.
Patients should receive follow-up care for recurrences of symptoms after treatment of superior limbic keratoconjunctivitis (SLK), and they require careful examinations for the development of thyroid ophthalmopathy.
