Superficial Punctate Keratopathy

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.

Only gold members can continue reading. Log In or Register to continue

Nov 9, 2016 | Posted by in OPHTHALMOLOGY | Comments Off on Superficial Punctate Keratopathy
Premium Wordpress Themes by UFO Themes