BASICS
DESCRIPTION
• Multiple, transient, whitish-grey, slightly elevated corneal epithelial opacities
• No stromal involvement, corneal edema, or conjunctival hyperemia
• Typically bilateral, may be asymmetric (1)
EPIDEMIOLOGY
• Affects patients of all ages
• No sex predilection
Incidence/Prevalence
Rare
RISK FACTORS
None identified
Genetics
Associated with HLA DR3
PATHOPHYSIOLOGY
Unknown
DIAGNOSIS
HISTORY
• Patients often present with ocular irritation/foreign body sensation; may have photophobia.
• Vision may be slightly blurred or normal.
• Usually bilateral but may be asymmetric
• May be asymptomatic
PHYSICAL EXAM
• Slit-lamp examination
– Conjunctival quiet or with minimal inflammation
– Small, usually multiple, whitish, coarse corneal epithelial lesions with clear intervening epithelium and stroma
– Lesions may have overlying punctate staining
– Absence of anterior chamber inflammation
DIAGNOSTIC TESTS & INTERPRETATION
Lab
Clinical diagnosis, no additional testing required
Imaging
Imaging not required but could consider slit-lamp photographs and/or confocal microscopy (2)
DIFFERENTIAL DIAGNOSIS
• Punctate epithelial keratitis
• Subepithelial infiltrates
• Infectious (bacterial) corneal infiltrate
TREATMENT
MEDICATION
First Line
• Mild topical steroid (e.g., fluorometholone 0.1%, loteprednol 0.2%) with very slow taper over months (1)
• Topical cyclosporine
• Asymptomatic patients with few lesions may be observed.
• Topical lubrication (artificial tears/gel), usually in conjunction with steroids or alone in asymptomatic patients with few lesions
Second Line
• Soft contact lenses reported to provide symptomatic relief
• Treatment with idoxuridine contraindicated, (associated with subepithelial infiltrates)
ADDITIONAL TREATMENT
General Measures
• Topical steroids should be tapered very slowly, with some patients requiring long-term, infrequent use (i.e., weekly).
• Chronic condition marked by exacerbations and flare-ups over years
Issues for Referral
Consider referral to cornea specialist if diagnosis is unclear or patient is not responding to treatment
Additional Therapies
Antibiotics ineffective; trifluridine has been shown to be effective in some patients in early reports; idoxuridine is contraindicated
SURGERY/OTHER PROCEDURES
Has been noted to recur following LASIK, case reports suggest lower incidence of recurrence with PRK (3)
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Regular follow-up with goal of slowly tapering steroids over months
PROGNOSIS
Excellent long-term prognosis
COMPLICATIONS
• Mild steroid use (and/or cyclosporine) is the mainstay of treatment but may be associated with side effects including elevated intraocular pressure and cataract formation.
• Anecdotal evidence suggests that steroid use may prolong the course of the disease.
REFERENCES
1. Nagra PK, Rapuano CJ, Cohen EJ, et al. Thygeson’s superficial puncate keratitis: Ten years’ experience. Ophthalmology 2004;111:34–37.
2. Cheng LL, Young AL, Wong AKK, et al. In vivo confocal microscopy of Thygeson’s superficial punctate keratitis. Clin Experiment Ophthalmol 2004;32:325–340.
3. Netto MV, Chalita MR, Krueger RR. Thygeson’s superficial punctate keratitis after laser in situ keratomileusis. Am J Ophthalmol 2004;138:507–508.
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