Purpose

Botulinum toxin injections into the eyelid can be administered in cases of superior limbic keratoconjuctivitis that do not respond to conventional treatments. Oculoplastic surgeons can support Cornea colleagues with these challenging cases by administering this treatment adjunct.

The etiology of superior limbic keratoconjunctivitis is not well elucidated, but discussions have focused on a mechanical theory of microtrauma due to the aberrant apposition of the eyelid to the globe. In patients with tight upper eyelids, floppy eyelid syndrome, proptosis, high myopia, and similar conditions, there is increased friction between the superior palpebral conjunctiva and the superior bulbar conjunctiva. The vertical pressure of the upper eyelid often leads to conjunctivochalasis, keratinization and a reduction in goblet cells in the superior conjunctiva.

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Methods

We report 3 cases of eyelid-associated mechanical friction syndrome, an often missed clinical entity in patients presenting with dry eye disease. On slit lamp exam, persistent superior peri-limbal corneal staining is the main clinical sign and a long history of pain with blinking. In these cases, we used an injection protocol published by Periman et al, 2025. We injected 2-4 units of botulinum toxin A into the pretarsal orbicularis, at the point of maximum friction on the cornea, as well as the glabella area.

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Results

Clinically significant and impressive resolution of superior corneal staining is seen at 2 weeks in our case series. Included reference photos demonstrate the guided approach to botulinum injection based on maximal friction points, and the before and after- botulinum toxin corneal staining findings.

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Conclusion

Targeted eyelid botulinum injection shows promise as an effective treatment in superior limbic keratoconjunctivitis by breaking the eyelid-associated friction cycle on the cornea, decreasing ocular surface staining, and improving a patient’s painful blink symptoms.

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Additional Authors

First name	Last name	Base Hospital / Institution
Roshni	Echharam	North Toronto Centre for Dry Eyes and Specialty Contact Lenses
Laura	Periman	Periman Eye Institute

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