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Superior Limbic Keratoconjunctivitis

ROUTINE — Conjunctiva

Symptoms

  • red eye and burning: localized primarily to the top of the eye
  • foreign body sensation: constant grit or "sand" feeling, worse with blinking
  • tearing and photophobia: light sensitivity that fluctuates with the ocular surface state
  • frequent blinking: a compensatory move to manage the mechanical friction
  • relapsing course: patients often have a history of "flare-ups" lasting months

Clinical Findings

Theodore’s sign (diagnostic key)

  • superior bulbar injection: localized redness and thickening of the top conjunctiva
  • visibility: the lesion is often HIDDEN by the upper lid; must lift the lid in downgaze to see it

Surface changes

  • superior limbal staining: intense staining with lissamine green or rose bengal
  • corneal filaments: small "tails" of mucus and epithelium that pull on the cornea
  • superior micropannus: fine blood vessels growing into the top of the cornea
  • tarsal papillae: small bumps on the underside of the upper eyelid

Systemic link

  • thyroid association: 30–50% of patients have current or history of thyroid dysfunction

Etiology

Mechanical friction

  • pathophysiology: chronic rubbing between a "tight" upper lid and redundant superior conjunctiva
  • result: cellular damage, inflammation, and abnormal keratinization of the surface cells

Risk factors

  • thyroid eye disease: the most significant systemic association (Graves, Hashimoto)
  • demographics: most common in middle-aged women
  • contact lenses: CL-induced SLK can occur (often a reaction to preservatives or fit)

Red Flags

  • unexplained redness under upper lid: always check TSH/fT4 for subclinical thyroid disease
  • severe filaments: indicates advanced surface breakdown and requires aggressive mucolytics
  • persistent pain: if not responding to lubrication, consider secondary neurotrophic changes
  • unilateral presentation: rare for SLK; rule out a localized conjunctival tumor or foreign body

Investigations

Ocular exam

  • staining: use lissamine green; it is superior to fluorescein for showing conjunctival damage
  • "lid-lift" maneuver: essential to visualize the sectoral superior redness
  • lid eversion: to check for tarsal papillae or a hidden foreign body

Systemic workup

  • mandatory labs: TSH, free T4, and TSI (Thyroid Stimulating Immunoglobulin)
  • endocrinology referral: if any thyroid labs are abnormal

Treatment

First-line (medical)

  • lubrication: preservative-free artificial tears q1-2h and ointment at bedtime
  • cyclosporine / lifitegrast: to manage the underlying surface inflammation
  • bandage contact lens: can provide a mechanical shield to reduce friction

Procedural (moderate/severe)

  • silver nitrate (0.5%): chemically cauterizes the redundant, inflamed conjunctiva
  • acetylcysteine: 10% drops to dissolve painful mucus filaments

Surgical (refractory)

  • conjunctival resection: surgically removing the redundant "loose" conjunctiva

Clinical Pearl

Bilateral superior bulbar redness with filaments and tarsal papillae in a middle-aged woman points straight to thyroid disease — check TSH, fT4, and treat the mechanical friction with silver nitrate or conjunctival resection.

Differential Diagnosis

  • • vernal keratoconjunctivitis (look for giant papillae and history of allergies)
  • • floppy eyelid syndrome (lax lids, diffuse punctate staining, associated with sleep apnea)
  • • contact lens-induced keratopathy (resolves with lens cessation)
  • • tracheoma (conjunctival scarring and different geographic prevalence)

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