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Symptoms:
recurrent episodes of:
- tearing
- foreign-body sensation
- photophobia
- reduced vision
- minimal to no conjunctival injection
- mucous secretion may be present
The course of the disease is variable, one episode can last from 1 to 2 months and the remission can take as long as 6 weeks. It is believed that after 4 years the disease disappear in most cases without complications.
- The etiology is unknown. Although many of the clinical features resemble those of a viral infection of the corneal
epithelium, Adenovirus, herpes simplex virus, and varicella zoster virus, have all been implicated as a possible causes of the disease. however, attempts to confirm viral particles by electron microscopy or culture have been unsuccessful.
- No inflammatory cells are evident. The rapid response of the lesions to corticosteroid therapy suggests that Thygeson keratitis is largely immunopathogenically derived.
On the other hand, an immune based etiology has also been proposed, since the presence of the HLA-DR3, a class-II MHC molecule associated with immune response genes and multiple autoimmune disorders (Gluten enteropathy, Addison's and Sjögren's syndromes, systemic lupus erythematosus, diabetes mellitus) has been positively implicated to patients with TSPK
Described in 1950 by Phillips Thygeson in a case report series, Thygeson's superficial punctate keratitis (TSPK) is an insidious, chronic and recurrent disorder, characterized by corneal lesions show a tendency for the central pupillary area distribution with mild or absent conjunctival inflammation and no association to systemic disease.
References:
- https://eyewiki.aao.org/Thygeson_Superficial_Punctate_Keratitis
- Marquezan MC, Nascimento H, Vieira LA, et al. Effect of topical tacrolimus in the treatment of Thygeson’s superficial punctate keratitis. Am J Ophthalmol. 2015;160(4):663–668.
- Vieira AC, Schwab IR. Superficial punctate keratitis of Thygeson. In: Mannis MJ, Holland EJ, eds. Cornea. Vol 1. 4th ed. Philadelphia: Elsevier; 2017:1030–1034.
-Kobayashi A, Yokogawa H, Kazuhisa S. In Vivo Laser Confocal Microscopy Findings of Thygeson Superficial Punctate Keratitis. Cornea 2011;30:675–680.
-Goldstein MH, Feistmann JA, Bhatti MT. PRK-pTK as a treatment for a patient with Thygeson' superficial punctate keratopathy. CLAO J. 2002; 28(4):172-3.
- Fite SW, Chodosh J. Photorefractive keratectomy for myopia in the setting of Thygeson's superficial punctate keratitis. Cornea. 2001;20(4):425-6.
- Netto MV, Chalita MR, Krueger RR. Thygeson's superficial punctate keratitis recurrence after laser in situ keratomileusis. Am J Ophthalmol. 2004;138(3):507-8.
- It affects children to older adults with a range of 2.5 to 70 years of age (median: 29 years).
- typically bilateral, although it may develop initially in 1 eye or may be markedly asymmetric in some cases.
- TSPK may affect both sexes, but a higher incidence has been reported in females.
Pathology
images of the basal cell layer of the corneal epithelium in three patients with TSPK. All images show the honeycomb-like appearance characteristic of the normal cornea. Highly refractive dots and aggregation of dendritic cells (arrow)
In a more recent study
using confocal microscopy,
Kobayashi found three findings that
were consistently present in all patients with TSPK:
1- aggregates of highly reflective deposits with a starburst-like appearance that might correspond with punctate lesions at the superficial and basal epithelial cell layers.
2- invasion of Langerhans cells at the
basal epithelial layer.
3- subepithelial haze
images of the sub-epithelial nerve plexus of the cornea in three patients with TSPK. Aggregated dendritic cells were apparent in association with the nerve plexus (arrow)
The histopathology is characterized by:
- Intra and intercellular edema at the level of the
corneal epithelium, as well as exudates under the lesions.
- Other abnormalities have been found in the subepithelial nerve plexus, Bowman’s membrane, and the anterior stroma; these changes are most severe in eyes with a longer duration of TSPK.
- Under confocal microscopy, keratocytes show highly reflective nuclei and cell bodies of irregular size, orientation, and shape. These changes were present under the intraepithelial lesions, and in other areas where lesions were not present. They are thought
to be related to the duration of the disease, and
were not seen in normal controls
Follow up:
- Weekly during an exacerbation, then every 3-6 months
- Patient receiving topical steroid require IOP checks every 4 to 12 weeks
- Elevated or flat round-oval shaped, gray-whitish lesion, occupying the central intraepithelial corneal area with no underlying stromal edema or inflammation.
- The acute lesion may stain minimally with fluorescein, and may or may not stain with vital dyes (rose bengal or lissamine green). In occasions, the lesion is described as starry, in the late stages, a sub-epithelial scar can be noticed. Around 20 of them are present in each eye, but up to 50 lesions have been reported. The lesions tend to disappear without leaving a trace in the course of 4 to 6 weeks.
- Corneal sensitivity is usually preserved or slightly diminished.
-The conjunctiva remains quiet but in a few cases, redness and
filament formation may also be found
1-Staphylococcal epithelial keratitis
2-Pneumococcal conjunctivitis
3-Seborrheic blepharitis
4-Keratoconjunctivitis sicca (Sjögren syndrome) >> dec. TBUT and schirmer test
5-Neurotrophic keratitis >> decreased corneal sensation
6-Exposure keratitis >> poor eyelid closure and failure to cover the entire globe
7-Recurrent corneal erosion syndrome
8-Map-dot-fingerprint dystrophy
9-Viral keratitis
10-Vernal keratoconjunctivitis >> large conjunctival paplliae
11-Others: molluscum contagiosum, trauma.
*treatment is based more on patient symptoms than corneal appearance*
Mild:
1- AFT 4X to 8x per day
2- AFT ointment QHS
Moderate to Severe:
1- mild topical steroid e.g. FML 0.1% or loteprednol 0.2% to 0.5% QID X1-4 weeks, followed by slow taper. (may need prolonged low-dose topical steroid therapy)
2- if no improvement with topical steroid >> BCL can be tried
3- cyclosporine 0.05% drops daily to QID may be an alternative or adjunctive treatment especially in patient with side effects from steroid.
There have been a few case reports of TSPK patients treated with excimer laser phototherapeutic keratectomy (PTK) with only partial improvement of signs and symptoms, but with a high rate of recurrence of the corneal lesions, making it no alternative for the management of the disease.