Severe Foreign-Body Sensation After Surgery

A 68-year-old woman presented with a 9-month history of progressively increasing pain and discomfort in both eyes, greater in the left than the right, which she described as a severe, foreign-body sensation. She experienced intermittent but temporary relief with aggressive lubrication and topical corticosteroids, but these remedies became completely ineffective at relieving discomfort 1 month later.

At the office visit, she described an inability to keep either eye open and found relief only by keeping her eyes closed. Her past medical history was significant only for hypertension, hypercholesterolemia and osteoarthritis for which she was using atorvastatin (Lipitor) and valsartan (Diovan). Her past ocular history included visually significant ptosis bilaterally, which was corrected by blepharoplasty and levator surgery 10 months earlier. She said she’d had none of her current discomfort symptoms before surgery, but after surgery she had developed occasional epithelial defects of her left cornea and corneal filaments.

On examination, her visual acuity was 20/25 in each eye with correction. Corneal thickness and IOP were normal in each eye. An exuberant tear lake was noted, and functional tear testing was well within normal limits. Confluent punctate fluorescein and Rose Bengal dye staining were restricted in both eyes to a base-up trapezoidal area of the superior conjunctiva in both eyes, extending onto the superior 0.5 mm of each cornea. The superior conjunctiva was visibly redundant in the same area. No active filaments were present. Both upper eyelids were tightly applied to the globe and were everted with some difficulty without evidence of retained foreign bodies. The remainder of her examination was normal.

Figure 1

Table 1. Dry Eye Syndrome Diagnosis and Treatment

Intraoperative photo prior to excision with amniotic membrane grafting demonstrating engorged straight conjunctival vessels terminating in a superior corneal pannus characteristic of SLK. Note the stippled light reflex as a result of irregular conjunctival epithelium over this area.
Source: Richard L. Lindstrom, MD

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Diagnosis

This patient was diagnosed with superior limbic keratoconjunctivitis of Theodore (SLK), an inflammatory disorder restricted to the central superior conjunctiva and corneal limbus. Although it has been primarily associated with systemic thyroid disease in as many as 30% of patients, the disorder has also been associated with keratoconjunctivitis sicca and graft vs. host disease, among other conditions, and a similar appearance has also been described with contact lens wear. While the etiology remains unclear, the signs and symptoms are thought to be a result of repeated abrasions caused by the upper eyelid blinking over the “washboard” of a redundant and corrugated superior conjunctiva. Proposed mechanisms include increased friction between the upper lid and superior conjunctiva secondary to either increased eyelid pressure on the globe, as in Graves disease, or tear-deficiency states.

Treatment

In our patient, the lack of symptoms prior to her ptosis surgery (although pseudoptosis may occur in SLK) and a normal thyroid state suggested that her SLK might be primarily mechanical in nature. Regardless of the underlying cause, once the physical finding of SLK is confirmed, treatment of intractable discomfort usually requires elimination of the redundancy or replacing the irregular conjunctival epithelium, which can be achieved by careful chemical (silver nitrate) or heat cautery. Simple excision or, as this patient underwent, excision of the affected area with amniotic membrane grafting will also provide relief. This is clinically important because milder forms of SLK may mimic the symptoms of simple dry eye, but are poorly responsive to traditional dry eye therapy. A simple examination of the superior conjunctiva prior to slit lamp biomicroscopy and vital dye staining of this area should easily reveal the diagnosis for these often frustrated patients.