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Joanne F Shen, Yael Kusne; Botulinum toxin A use in dry eye patients with superior limbic keratoconjunctivitis (SLK). Invest. Ophthalmol. Vis. Sci. 2017;58(8):2698.
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© ARVO (1962-2015); The Authors (2016-present)
Treatment for severe dry eye with SLK is challenging for ophthalmologists. No accepted protocol exists for SLK treatment. Retrospective observational clinical study was performed to describe the utility of botulium toxin A in dry eye patients with SLK.
IRB approved retrospective review revealed 19 unique patients with botulinum toxin A injections. Thirteen patients treated for symptomatic dry eye with SLK, with blink rate of 1 blink per second, and at least 6 months of follow-up were included. An average of 30 units botulinum toxin A was used in the orbicularis oculi area, and in the procerus and corregators if those muscles were overactive. Of these 13 patients, 2 had Sjogren’s Syndrome and 1 had GVHD. 2 patients had previous AMT and conjunctival resection by outside doctors which were unsuccessful.
The mean age was 67.1 years. 53.8% (7/13) patients were women. 84.6% (11/13) patients showed symptomatic improvement by 14 days after injection and decreased SLK staining. 46.2% (6/13) required only 1 botulinum toxin A treatment; the remainder required injections every 3-4 months to maintain symptom control. One patient’s bilateral ocular hypertension resolved after botulinum toxin A treatment. One patient had improved SLK but was intolerant due to refractive change after injection.
Mechanical friction between the upper eyelid and superior bulbar conjunctiva is a contributor to SLK. Upper lid position is balanced between the forces of the upper lid orbicularis muscle of Riolan and the levator palpebris. During a blink, the upper lid has vertical movement with significant power and velocity. The force exerted is enough to squeeze the globe, and in a years’ time 85 kilometers of lid/globe excursion may be endured. Under dry eye conditions, loss of the protective glycocalyx and diminished maintenance and regeneration of the epithelial surface may cause derangement of normal homeostasis leading to the physical findings of SLK. For refractory dry eye patients, it is important to have a high clinical suspicion and check for SLK with lissamine green. When SLK patients fail to respond to conjunctival cauterization or amniotic membrane transplant, a trial of botulinum toxin A should be considered to change the muscle dynamics. Close follow-up is needed to monitor for complications from exposure keratopathy and lagophthalmos.
This is an abstract that was submitted for the 2017 ARVO Annual Meeting, held in Baltimore, MD, May 7-11, 2017.
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