You are on page 1of 3

Thygeson's Superficial Punctate Keratitis

(Thygeson's SPK or TSPK)

First described: Phillips Thygeson. "Superficial Punctate Keratitis". Journal of the American
Medical Association, 1950; 144:1544-1549.

Signs and Symptoms:


Symptoms are minimal, typically these include discomfort such as burning or irritation,
foreign body sensation, mild degrees of tearing, and photophobia (light sensitivity). There
will occasionally be minor decreases in visual acuity.

The typical appearance of the


cornea shows numerous superficial lesions that will stain with fluorescein or rose bengal
dye. The epithelium may be eroded. Lesions may be round, oval or star shaped, they consist
of a conglomerate of tiny grey-white dots that are slightly raised. Individual lesions are
transient and usually are randomly scattered over the central part of the cornea.

During inactive stages of TSPK, lesions can disappear; can be flat, grey dots that do not
stain; or can appear stellate (star shaped). The conjunctiva may be mildly red and swollen;
tiny hair-like filaments may be present; and corneal sensation is generally normal to slightly
decreased. (Arffa, p. 323)

Etiology
The cause of TSPK is unknown but viral or immune mechanisms have been suggested. "A
viral cause has been proposed based on the absence of bacteria and other infectious agents,
the resistance of the disease to antibiotics, and features that are said to resemble the lesions of
measles and adenoviral infections." (Leibowitz, p.461) However, it should also be noted that
the disease is unresponsive to antiviral agents as well. One author also notes that the role of
the immune mechanism is suggested by the presence of white blood cells in the conjunctiva
and corneal epithelium, "by the extended course of the disease, by the therapeutic efficacy of
topical corticosteroids," and by the presence in some individuals of an antigen called HLA-
DR3. (Leibowitz, p.461)

Natural History
TSPK tends to have a chronic recurrent course with asymptomatic periods during which both
corneas are clear interrupted by episodes of blurred vision and minor eye irritation. One
remarkable feature is the absence of any accompanying conjunctivitis. Keratitis is variable
with remissions and exacerbations for several years until it resolves spontaneously, usually
without serious sequellae. (Gock, 1995) "Individual attacks generally last 1 to 2 months, go
into remission for 4 to 6 weeks, and the recur; the time course is variable. Usually after 2 to 4
years, the disease resolves without sequelae." (Arffa, p.323) However, rare cases have been
reported to persist for as long as 20 years. It is thought that steroid use is involved in causing
persistence of the disease (see treatment, below).

Treatment
Treatment is only indicated if the patient suffers with significant decreased vision and/or light
sensitivity or pain to be worth the risks of treatment: development of glaucoma (especially if
there is a family history of glaucoma) or cataract (higher doses of steroids for long periods) or
the possibility of prolonging the TSPK itself..

Lubricant eye drops alone may occasionally relieve symptoms.

The keratitis usually improves with low-dose topical corticosteroids (0.12% prednisone or
equivalent 2 to 3 times per day for a few days up to 2 weeks as recommended by Arffa, p.
323. Leibowitz et al., recommend that acute episodes be treated aggressively with topical
steroids and then tapered and discontinued over a 3 to 4 week interval.) It should be noted
that "steroids may prolong the condition and have the risk of complications in an essentially
benign disease." (Gock, p.76). Complications such as ocular hypertension and cataracts are
associated with extended use of topical corticosteroids. However, the use of steroids may be
warranted in patients who are significantly disabled by the condition

Therapeutic soft contact lenses have been used successfully to treat the condition but the
treatment must be for an extended period of time. One of the first reports was by Goldberg, et
al. who noticed that patients whose eyes had been bandaged or patched for 24 hours showed
considerable symptomatic relief. This prompted a trial period of therapeutic soft contact
lenses in the patients resulting in "almost complete resolution of the lesions and dramatic
almost immediate relief of discomfort." (Goldberg, p.23) It has been postulated that soft
contact lenses "improve symptoms by improving the optical quality of the cornea, and cover
the elevated corneal lesions and nerves that are constantly in friction with the conjunctiva
during blinking. The effect would break a vicious cycle by decreasing lacrimation (tearing)
that is associated with hypotonic (low salt content) tears that may contribute to local
epithelial edema (swelling)." (Tabbara, p. 77) Soft contact lenses may simply protect the
cornea and thus the lesions from exposure and friction.

Outcome/Prognosis
The visual outcome of TSPK is generally good, although some individuals have experienced
slightly reduced visual acuity.

Bibliography
Gock G, Ong K, McClellan K. A classical case of Thygeson's superficial punctate keratitis.
Australian and New Zealand Journal of Ophthalmology. 23(1):76-77, 1995.

Goldberg DB. Schanzlin DJ. Brown SI. Management of Thygeson's superficial punctate
keratitis. American Journal of Ophthalmology. 89(1):22-24, 1980.

Tabbara KF, Ostler HB. Dawson C, Oh J. Thygeson's superficial punctate keratitis.


Ophthalmology. 88(1):75-77, 1981.

Thygeson's Superficial Punctate Keratitis. In Arffa RC. Grayson's Diseases of the Cornea, 4th
ed. Mosby, 1997, pp. 323-329.

Thygeson's Superficial Punctate Keratitis. In Leibowitz HM, Waring GO. Corneal disorders:
clinical diagnosis and management, 2nd ed. Saunders, 1998, pp. 460-461.

Van Bijsterveld OP. Mansour KH. Dubois FJ. Thygeson's superficial punctate keratitis.
Annals of Ophthalmology. 17(2):150-153, 1985.

reviewed January, 1999, by John E. Sutphin, Jr., MD, Cornea and External Diseases, Department of
Ophthalmology and Visual Science, University of Iowa.

last updated: 12-15-03

You might also like