treatment plan

Options for Superior Limbic Keratoconjunctivitis

BY LEO SEMES, OD, FAAO

A 68-year-old female presented with a complaint of dry and uncomfortable eyes. She had experienced this with exacerbations and remissions over several years, according to her history.

The clinical findings included good visual acuity, 20/25 in each eye, which was limited by mild age-related cataract. IOP was 14mmHg in each eye, and there was absence of corneal staining in the intrapalpebral region. The conjunctiva of each eye stained with fluorescein, and bulbar conjunctivochalasis was present. Palpebral conjunctiva evaluation revealed a 2+ papillary response. There was distinct inflammatory involvement of the superior limbus with adjacent keratitis.

Her clinical findings fit the description of superior limbic keratoconjunctivitis (SLK) of both Thygeson and Theodore in 1963. The patient does not suffer from thyroid abnormalities, nor is she a contact lens wearer.

The pathophysiology is thought to arise secondary to superior bulbar conjunctival laxity. This may lead to inflammatory changes from mechanical microtrauma. Eventually, chronic inflammation results in thickening of the superior limbal conjunctiva and adjacent keratitis. Without intervention this evolves into a vicious cycle fueled by chronic inflammation. One reported sequela is filamentary keratitis arising from excess mucus production in response to irritation.

It is rare in the United States (<3 percent prevalence) and perhaps self-limiting, but when SLK is symptomatic, it deserves attention. Females are affected preferentially.

Primary Treatments

At the presenting visit, I prescribed Zylet (loteprednol etabonate 0.5% and tobramycin 0.3%; Bausch & Lomb) for topical application four times per day for two weeks.

At the first follow up, the patient reported some remediation of symptoms but clinical signs were little changed. I continued the same routine for another two weeks, this time with minimal progress. Although she was symptomatically improved, I saw little in the way of tissue response.

At this point, I prescribed Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan). This represents an off-label use of this immunomodulator. Restasis is FDA-approved to improve tear production for dry-eye patients whose condition has underlying inflammation.

Other primary treatment options for SLK include palliative treatment with tear supplements, bandage contact lenses, mast cell stabilizers and topical vitamin-A preparations. Some have suggested surgical approaches to debulk the offending and redundant conjunctiva. I based my choice on a recent clinical trial whose results suggested positive outcomes at six to 18 months of follow up.

Following a discussion with the patient regarding the off-label use of Restasis, she accepted my recommendation.

Off-label use is not uncommon in medicine. Some conditions have nearly as much off-label as on-label prescribing. It's the prescribing physician's decision as to what to prescribe for any patient. Weigh the positive and negative consequences carefully. A complete discussion of this topic is beyond the scope of this case.

A Positive Result

At the two-week follow up, the patient reported using the Restasis as prescribed. In addition, she reported improvement of symptoms. I documented reduced tissue response of both the bulbar and palpebral conjunctiva.

Thinking outside the package insert may have been beneficial in this instance. CLS

For references, please visit www.clspectrum.com/references.asp and click on document #152.

Dr. Semes is an associate professor at the University of Alabama at Birmingham School of Optometry.