Dr. Omar Gamal
38 years old female patient.
Presented with LT eye foreign body sensation, burning,
photophobia, redness and sometimes with mucoid
Upgaze may elicit these symptoms and moisturizing
medications only provides minimal relief.
History of the same manifestations in the RT eye which
relieved by surgery from 6 months (conjunctival resection).
No systemic diseases, on alphagan ED.
RT eye: normal anterior segment and posterior fundus
Marked papillary hypertrophy of upper lid tarsal
conjunctiva, with adjacent inflammation of the upper
The conjunctiva extending from the upper limbus to
the insertion of the superior rectus muscle also
demonstrates thickening, hyperemia (with downward
pressure on the upperlid, folds of redundant conjunctiva
crossing the upper limbus).
Cornea: Punctate epithelial erosions on the
upper third of cornea ( no coneal filaments, no
Fundus: Normal, C/D ratio: 0.4.
Tension (OU): 14 mm Hg (controlled on alphagan
• Allergic conjunctivitis (not seasonal).
• Bacterial keratoconjunctivitis.
• Sicaa conjunctivitis.
•Giant papillary keratoconjunctivitis (no CL wear).
• Viral keratoconjunctivitis.
• Thyroid Ophthalmopathy.
• Other causes of chronic cnjunctival inflammation.
Thyroid evaluation - Thyroid-stimulating hormone,
free thyroxine (T4), thyroid-stimulating
immunoglobulin, or thyroid-stimulating hormone–
binding inhibitory immunoglobulin : -ve
specimens taken from the patient and it
was diagnosed as SLK.
• Superior limbic keratoconjunctivitis has been
described as having keratinization of the epithelium,
acanthosis and cellular infiltration with lymphocytes,
plasma cells and ballooning degeneration with
degeneration of epithelial cells and exocytosis of
• SLK appears to be the result of blink-related
mechanical trauma from abnormal forces
between the upper lid and superior bulbar
conjunctiva , probably percipitated by tear film
• This results in loss of the ability of the lid to
move freely over the conjunctiva and excess of
conjunctival tissue. With increased movement of
the conjunctiva there is mechanical damage to
both the tarsal and conjunctival surfaces.
The frequency of SLK has been found to be 3% in
Graves ophthalmopathy patients, but it is much lower in
the general population.
Women are predominantly affected.
Typically, middle-aged people are affected; however, this
entity has been reported to occur in patients aged 4-81
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
Morphological or functional changes in superior
conjunctival apposition to the globe following upper
eyelid procedures may induce SLK.
• Pressure patching, placement of a bandage
• silver nitrate solution application,
• mast cell stabilizers and steriods,
• vitamin A preparations , and cyclosporine
have been used with moderate success.
• Supratarsal triamcinolone injection has
had reported success in mitigating signs
and symptoms and may be helpful as an
• As these approaches usually offer only
temporary relief of symptoms, more
definitive treatments often are required.
• Surgical resection of the involved conjunctiva as delineated
intraoperatively by the use of rose bengal staining removes
the affected tissue.
• Folds of redundant conjunctiva are eliminated, adhesions
with underlying Tenon capsule and episclera develop, which
may be augmented by transplantation of cryopreserved
• Autologous serum application has been shown to be
beneficial as an alternative therapy in a small case series.
inflammation is a very
manifestation, but it needs
time to evaluate and treat its