Approach Considerations

Superior limbic keratoconjunctivitis (SLK) has been associated with thyroid dysfunction; therefore, investigations into thyroid function, including thyroid-stimulating hormone (TSH), free thyroxine (T4), thyroid-stimulating immunoglobulin, or TSH–binding inhibitory immunoglobulin, may be appropriate. An endocrinologist consultation should be obtained to aid in this workup.

To evaluate for and/or rule out dry eye syndrome, which often is present with superior limbic keratoconjunctivitis (SLK), the Schirmer test, measurement of tear lake, and tear breakup time are used.

The diagnosis of superior limbic keratoconjunctivitis (SLK) is based on clinical findings. The following laboratory studies and tests should be considered:

Slit-lamp examination
Fluorescein and lissamine green staining or rose Bengal staining
Schirmer test
Examination for thyroid orbitopathy
Thyroid function test
Autoimmune markers (anti-Ro [SS-A] and anti-La [SS-B] antibodies and cyclic citrullinated-peptide antibodies)

Histologic Findings

Surgical specimens taken from patients with superior limbic keratoconjunctivitis (SLK) who had not received treatment with silver nitrate demonstrate abnormal limbic epithelium with keratinized epithelial cells with dyskeratosis and acanthosis and balloon degeneration of some nuclei. The intracellular accumulation of glycogen in the epithelial cells of tissue sections of the bulbar conjunctiva has been documented. The conjunctival stroma demonstrates edema without significant inflammatory cellular infiltrate. In specimens obtained after silver nitrate treatment, significant inflammatory cells, including plasma cells, neutrophils, and lymphocytes, are also found in the epithelium and stroma.

Immunohistochemical pathologic examination of the abnormal conjunctiva in superior limbic keratoconjunctivitis demonstrates a lack of the typical mosaic pattern of the epithelium in the resulting keratinized cells before the patient undergoes treatment and upregulation of transforming growth factor-beta 2 and tenascin.^[14]In separate studies, increased expression of proliferating cell nuclear antigens and altered expression of cytokines,^[15]as well as the presence of involucrin,^[16]was shown. More recently, heightened levels of matrix metalloproteinases 1 and 3 have been detected in specimens with the clinical manifestations of SLK.^[17]

In vivo laser scanning confocal microscopy has been used to aid in diagnosing and grading the severity of the unique manifestations of SLK.^[18] Significant infiltration of inflammatory cells and dendritic cells may be seen in the upper bulbar conjunctiva by in vivo confocal microscopy ^[18].

Treatment & Management

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Author

Jean Deschênes, MD, FRCSC Professor, Research Associate, Director, Uveitis Program, Department of Ophthalmology, McGill University Faculty of Medicine; Senior Ophthalmologist, Clinical Director, Department of Ophthalmology, Royal Victoria Hospital, Canada

Jean Deschênes, MD, FRCSC is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, Canadian Medical Association, Canadian Ophthalmological Society, International Ocular Inflammation Society, Quebec Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Jia Yue You, MDCM Resident Physician, Department of Ophthalmology, McGill University Faculty of Medicine, Canada

Disclosure: Nothing to disclose.

Kubra Ozdemir Yalcinsoy, MD Cornea, External Disease and Uveitis Observer, Department of Ophthalmology, McGill University Health Center, McGill University Faculty of Medicine, Canada

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Christopher J Rapuano, MD Professor, Department of Ophthalmology, Sidney Kimmel Medical College of Thomas Jefferson University; Director of the Cornea Service, Wills Eye Hospital

Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Ophthalmological Society, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Cornea Society, Eye Bank Association of America, International Society of Refractive Surgery

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: AAO; OMIC; American Society of Ophthalmic Trauma (ASOT); Avellino, Baxis; Bio-Tissue; Celularity; Dompe; Emmecell; Glaukos; Kala; Oyster Point; Sun Ophthalmics; Tarsus; TearLab<br/>Serve(d) as a speaker or a member of a speakers bureau for: Glaukos; Dompe; Bio-Tissue<br/>Received research grant from: Glaukos<br/>Received income in an amount equal to or greater than $250 from: AAO; OMIC; Baxis; Bio-Tissue; Cellularity; Dompe; Glaukos; Kala; Sun Ophthalmics; TearLab<br/>stock options for: RPS, Fount Bio.

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, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

James H Oakman, Jr, MD Partner, Southern Eye Center, Augusta, Georgia

James H Oakman, Jr, MD is a member of the following medical societies: Association of American Physicians and Surgeons, Georgia Medical Society, Georgia Society of Ophthalmology, Georgia Society of the American College of Surgeons, American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery

Disclosure: Nothing to disclose.

Susan Ruyu Qi University of Montreal Faculty of Medicine, Canada

Disclosure: Nothing to disclose.

Sections Superior Limbic Keratoconjunctivitis (SLK)
Overview
Presentation
DDx
Workup
Treatment
Medication
References

Superior Limbic Keratoconjunctivitis (SLK) Workup

Approach Considerations

Histologic Findings

References

Tables

Contributor Information and Disclosures

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