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Confirming this diagnosis takes two steps: have the patient look down so that you can examine the superior bulbar conjunctiva, and then stain the globe with lissamine green dye. Allow 30 to 60 seconds for adequate staining. If these bulbar and tarsal conjunctival tissues have become idiopathically keratinized, the mechanical rubbing of these two interfacing tissues is the cause for the distressing symptoms. We initially use 0.5% silver nitrate compounded solution to help diminish these keratinized tissues. After the patient takes your prescription to a known ophthalmic compounding pharmacy and obtains the solution, have him or her bring the drop back to the office where topical proparacaine is instilled twice (about 30 seconds between each drop). We then dip a sterile cotton swab into the compounded solution, flick off the excess, Eyes in primary gaze appear healthy. Upon downgaze, the diagnosis of SLK is obvious, thus emphasizing the necessity of lifting the eyelids to search for the cause of his presenting symptoms. These eroding calcific bodies caused this patient’s foreign body sensation. Clinical Pearls You Can Count On Heed these time-honored insights gleaned through 80+ years of patient visits. SECTION I: STRATEGIES FOR SUCCESS SUPERIOR LIMBIC KERATOCONJUNCTIVITIS • Both sexes affected, women more • Main symptoms: distressingly irritated eyes • Dry eyes common companion finding • Symptoms disproportionate to clinical findings • Spontaneous exacerbations and remissions • 25% to 40% have some thyroid dysfunction • Tx (difficult): 0.5% silver nitrate, optimum lubrication, pressure patching, therapeutic soft lenses, surgical resection, cryotherapy REVIEW OF OPTOMETRY JUNE 15, 2020 9 and have the patient look down, evert the upper eyelid(s) and “paint” the superior tarsal tissues. This is just like painting a wall with a paint roller; do this for about 20 seconds. Then un-evert the eyelid and have the patient look down. Now perform the same procedure to the affected superior bulbar conjunctival tissues. We then instill a moderate amount of generic Maxitrol (neo-poly-dex) ophthalmic ointment, which we keep in our lab coat pockets. We encourage these patients to frequently instill lipid-based artificial tears to the eye(s) over the course of the day and to use a preservative-free artificial tear ointment at bedtime until they return to us in one month, at which time we repeat the “painting” procedure. We keep the patient’s silver nitrate solution in our refrigerator, clearly marked with the patient’s name, date of birth and medical record # until that time. While this process is highly beneficial, there may be occasional recalcitrant-to-treatment patients.
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