Spark ImageWise 8 – Cornea

Amniotic membrane graft for the treatment of Superior Limbic Keratoconjunctivitis

Dr Rashmi Nagar, Dr Prabhat Nangia, Dr Sarang Lambat, Dr Vinay Nangia
Suraj Eye Institute, 559 New colony, Nagpur, India

Case Description
A feA female, 64 years of age who was over-weight and hypertensive presented to us with repeated complaints of irritation, foreign body sensation, pain and redness of both eyes for a period of 2 months. Her best corrected visual acuity was 6/6, N6 in the right eye and 6/9, N6 in the left eye.

Figure (1) – Slit lamp photograph of left eye showing superior conjunctival chalasis (black arrows).
Figure (2) – Slit lamp photograph of left eye showing superior bulbar conjunctiva staining positively with Rose Bengal (demarcated with yellow dashed line).

A provisional diagnosis of Superior Limbal Keratoconjunctivitis was made.
Her thyroid function tests were deranged, treatment for which was started by her physician. Initially we treated her with topical steroids in tapering doses along with lubricants but her symptoms recurred when the steroids were tapered and she was keen on a permanent solution. Hence, she underwent surgery in which the redundant conjunctiva was excised along with underlying Tenon’s capsule and the bare sclera was covered with amniotic membrane graft with the stromal side down for better conjunctival re-epithelization. Fibrin glue was used over the scleral bed to facilitate adhesion of the amniotic membrane.
Post-operative follow up examination was done using fluorescein stain with cobalt blue filter for illumination and Wratten No. 12 (yellow) filter for observation. The amniotic membrane epithelized gradually [healing edges shown with white arrows in Fig.3 and Fig.4]. Complete epithelization of the amniotic membrane was seen at 1 month follow up. [Fig.5].

Figure (3)  Post-op examination using fluorescein stain with cobalt blue filter for illumination and Wratten No. 12 (yellow) filter for observation showing concave healing edges (white arrows) at one week post op follow up.
Figure (4) 
Post-op examination using fluorescein stain with cobalt blue filter for illumination and Wratten No. 12 (yellow) filter for observation showing concave healing edges (white arrows) at two weeks post op follow up.
Figure (5) One-month post-op examination shows complete epitheliazition of the AMG.

At 2 months post–op follow up the patient reported 80 percent improvement in symptoms [Fig. 6 and Fig.7].

Figure (6) Two months post-op slit lamp photograph of left eye showing no redundant fold in the conjunctiva.
Figure (7) 
Two months post-op slit lamp photograph of left eye showing a small area of residual conjunctival fold that is staining positively with Rose Bengal (demarcated with yellow dashed line).

Discussion

Superior limbic keratoconjunctivitis (SLK) is a rare chronic inflammatory disease of the superior bulbar conjunctiva, limbus and upper cornea of unknown etiology. This disease has been associated with thyroid dysfunction1, keratoconjunctivitis sicca and rheumatoid arthritis. It usually affects the tarsal and bulbar conjunctiva. Some theories for the pathogenesis of SLK have been suggested with Wright’s theory of friction between the superior bulbar and tarsal conjunctiva caused by excessive laxity being widely accepted. Histologically conjunctiva in SLK shows keratinization of epithelial cells with dyskeratosis, acanthosis and nuclear balloon degeneration.
Multiple treatment modalities have been described ranging from conservative management to surgical methods like simple resection, thermocautery, conjunctival resection with or without amniotic membrane transplantation, conjunctival resection combined with Tenon layer excision and conjunctival recession. Amniotic membrane facilitates the proliferation and differentiation of epithelial cells, reduces scarring, minimizes vascularization, and decreases inflammation.
Amniotic membrane has important growth factors like epidermal growth factor (EGF), transforming growth factor alpha and beta which help in fast epithelization of wounds and also suppress inflammation and scarring.
In the case of our patient the use of amniotic membrane graft proved helpful in terms of minimal scarring and less post-operative discomfort. Despite surgical management, some degree of positive staining with Rose Bengal was still present indicating the presence of a few residual conjunctival folds. But the redundancy of conjunctiva is much less than it was before surgery. Although there is significant symptomatic improvement, the area is not completely healthy and the treatment of this condition depends on multiple factors including management of the thyroid dysfunction.

Readwise

1.Bartley GB. The epidemiologic characteristics and clinical course of ophthalmopathy associated with autoimmune thyroid disease in Olmsted County, Minnesota. Transactions of the American Ophthalmological Society. 1994;92:477. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1298522/
2.Sheu MC, Schoenfield L, Jeng BH. Development of superior limbic keratoconjunctivitis after upper eyelid blepharoplasty surgery: support for the mechanical theory of its pathogenesis. Cornea. 2007 May 1;26(4):490-2. DOI: 10.1097/ico.0b013e3180303b02
3.Theodore FH, Ferry AP. Superior limbic keratoconjunctivitis: Clinical and pathological correlations. Archives of Ophthalmology. 1970 Oct 1;84(4):481-4. doi:10.1001/archopht.1970.00990040483016
4.Meller D, Maskin SL, Pires RT, Tseng SC. Amniotic membrane transplantation for symptomatic conjunctivochalasis refractory to medical treatments. Cornea. 2000 Nov 1;19(6):796-803. https://journals.lww.com/corneajrnl/Abstract/2000/11000/ Amniotic_Membrane_Transplantation_for_Symptomatic.8.aspx
5.Tseng SC, Li DQ, Ma X. Suppression of transforming growth factor-beta isoforms, TGF-β receptor type II, and myofibroblast differentiation in cultured human corneal and limbal fibroblasts by amniotic membrane matrix. Journal of cellular physiology. 1999 Jun;179(3):325-35. https://doi.org/10.1002/(SICI)1097-4652(199906)179:3<325::AID-JCP10>3.0.CO;2-X

Correspondence 

Dr Prabhat Nangia
DNB, FICO, FMRF, FAICO Consultant
Department of Cornea and Ocular surface
Suraj Eye Institute
Nagpur
Email –education@surajeye.org

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