eMedicine Specialties > Ophthalmology > Cornea

Thygeson Superficial Punctate Keratitis

Author: Robert S Duszak, OD, FAAO, Co-Director of Residency Program and Consulting Staff, Philadelphia Veterans Affairs Medical Center; Consulting Staff, Nemours Health Clinic & Mayfair Eye Associates; Adjunct Clinical Faculty, Pennsylvania College of Optometry
Contributor Information and Disclosures

Updated: Jun 17, 2008

Introduction

Background

In 1950, Phillips Thygeson published case reports on a superficial punctate keratitis that he described as a transient, bilateral disease, having coarse corneal epithelial opacities and no associated stromal involvement1  Today, this condition, now known as Thygeson superficial punctate keratitis (TSPK), is a chronic one, lasting years to decades. Multiple, whitish gray, intraepithelial corneal lesions, with minimal to no conjunctival involvement, are trademark characteristics of the disease. 

Although TSPK has a genetic association with HLA-DR3, controversy exists regarding its exact etiology. 

Artificial tears, topical corticosteroids, topical cyclosporine, and soft contact lenses are the typical treatment methods for the disease, and the success of these treatments varies according to the severity of the disease.

Although vision may be mildly decreased during the active disease, the long-term visual prognosis is excellent. 

Pathophysiology

A review of the literature suggests the pathophysiology of TSPK remains unclear, although viral and immunogenic components are both likely in the disease's formation. 

Frequency

United States

A review of the literature suggests the frequency of TSPK in the United States is currently unknown.

International

A review of the literature suggests the worldwide frequency of TSPK is unknown.

Mortality/Morbidity

A review of the literature suggests TSPK does not cause mortality and the morbidity of the disease is unknown. 

Race

A review of the literature suggests statistics on race for TSPK are currently unknown.   

Sex

A review of the literature suggests there is no predilection for sex in TSPK.

Age

TSPK can affect individuals of all age groups.  Cases of TSPK in patients ranging in age from 2.5 years to 70 years have been reported, with a mean age of 29 years.2

Clinical

History

Patients with TSPK often report bilateral tearing, burning, photophobia, foreign body sensation, and ocular irritation during exacerbations. 

During the inactive stages of the disease, patients may have no complaints.

Physical

TSPK is characterized by a bilateral, recurrent, focal, epithelial keratitis without associated conjunctival or stromal inflammation.2,3,4,5,6 The classic corneal lesion in active TSPK is a conglomerate of coarse, oval shaped, slightly raised, whitish gray dots that stain minimally with fluorescein. The lesions tend to accumulate centrally in the cornea, and 1-50 lesions may be present (averaging about 20 lesions per flare-up).7  

Corneal sensitivity is typically normal or only slightly decreased, but it is never completely absent as in herpes simplex keratitis.2

Although a conjunctival response is typically not seen, a minimal reaction by way of conjunctival injection may be noted.3,8

Causes

The exact etiology of TSPK is unclear. 

Associations with various viral infections, including the adenovirus, herpes simplex virus, and varicella zoster virus, have been made9,10   In 1953, Braley and Alexander provided questionable results suggesting a virus may be responsible for TSPK, and, in 1974, Lemp et al were able to isolate the varicella zoster virus from a corneal surface, albeit a 10-year-old boy.9,10 In more recent studies using polymerase chain reactions, the varicella zoster virus was not detected in eyes with TSPK, providing doubts this virus is the causative agent11,12

HLA-DR3, an antigen associated with immune response genes and multiple autoimmune disorders, has some association with TSPK as well.  It has been proposed that this antigen may alter the immune response of individuals with TSPK, yielding the prolonged course of the disease and its hallmark of exacerbations and remissions.3

More on Thygeson Superficial Punctate Keratitis

Overview: Thygeson Superficial Punctate Keratitis
Differential Diagnoses & Workup: Thygeson Superficial Punctate Keratitis
Treatment & Medication: Thygeson Superficial Punctate Keratitis
Follow-up: Thygeson Superficial Punctate Keratitis
Multimedia: Thygeson Superficial Punctate Keratitis
References
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References

  1. Thygeson P. Superficial punctate keratitis. J Am Med Assoc. Dec 30 1950;144(18):1544-9. [Medline].

  2. Tabbara KF, Ostler HB, Dawson C, Oh J. Thygeson's superficial punctate keratitis. Ophthalmology. Jan 1981;88(1):75-7. [Medline].

  3. Darrell RW. Thygeson's superficial punctate keratitis: natural history and association with HLA DR3. Trans Am Ophthalmol Soc. 1981;79:486-516. [Medline].

  4. Jones BR. Thygeson's Superficial Punctate Keratitis. Trans Ophthalmol Soc U K. 1963;83:245-53. [Medline].

  5. Nagra PK, Rapuano CJ, Cohen EJ, Laibson PR. Thygeson's superficial punctate keratitis: ten years' experience. Ophthalmology. Jan 2004;111(1):34-7. [Medline].

  6. Thygeson P. Clinical and laboratory observations on superficial punctate keratitis. Am J Ophthalmol. May 1966;61(5 Pt 2):1344-9. [Medline].

  7. Arffa RC. Grayson's Diseases of the Cornea. 4th ed. St. Louis: Mosby-Year Book; 1997.

  8. Tantum LA. Superficial punctate keratitis of Thygeson. J Am Optom Assoc. Dec 1982;53(12):985-6. [Medline].

  9. Lemp MA, Chambers RW Jr, Lundy J. Viral isolate in superficial punctate keratitis. Arch Ophthalmol. Jan 1974;91(1):8-10. [Medline].

  10. Braley AE, Alexander RC. Superficial punctate keratitis; isolation of a virus. AMA Arch Ophthalmol. Aug 1953;50(2):147-54. [Medline].

  11. Reinhard T, Roggendorf M, Fengler I, Sundmacher R. PCR for varicella zoster virus genome negative in corneal epithelial cells of patients with Thygeson's superficial punctate keratitis. Eye. Mar 2004;18(3):304-5. [Medline].

  12. Reinhard T, Sundmacher R. Topical cyclosporin A in Thygeson's superficial punctate keratitis. Graefes Arch Clin Exp Ophthalmol. Feb 1999;237(2):109-12. [Medline].

  13. Cheng LL, Young AL, Wong AK, Law RW, Lam DS. In vivo confocal microscopy of Thygeson's superficial punctate keratitis. Clin Experiment Ophthalmol. Jun 2004;32(3):325-7. [Medline].

  14. Watson SL, Hollingsworth J, Tullo AB. Confocal microscopy of Thygeson's superficial punctate keratopathy. Cornea. May 2003;22(4):294-9. [Medline].

  15. Tanzer DJ, Smith RE. Superficial punctate keratitis of thygeson: the longest course on record?. Cornea. Nov 1999;18(6):729-30. [Medline].

  16. Nesburn AB, Lowe GH 3rd, Lepoff NJ, Maguen E. Effect of topical trifluridine on Thygeson's superficial punctate keratitis. Ophthalmology. Oct 1984;91(10):1188-92. [Medline].

  17. Gock G, Ong K, McClellan K. A classical case of Thygeson's superficial punctate keratitis. Aust N Z J Ophthalmol. Feb 1995;23(1):76-7. [Medline].

  18. Del Castillo JM, Del Castillo JB, Garcia-Sanchez J. Effect of topical cyclosporin A on Thygeson's superficial punctate keratitis. Doc Ophthalmol. 1996-1997;93(3):193-8. [Medline].

  19. Forstot SL, Binder PS. Treatment of Thygeson's superficial punctate keratopathy with soft contact lenses. Am J Ophthalmol. Aug 1979;88(2):186-9. [Medline].

  20. Goldberg DB, Schanzlin DJ, Brown SI. Management of Thygeson's superficial punctate keratitis. Am J Ophthalmol. Jan 1980;89(1):22-4. [Medline].

  21. Jabbur NS, O'Brien TP. Recurrence of keratitis after excimer laser keratectomy. J Cataract Refract Surg. Jan 2003;29(1):198-201. [Medline].

  22. Seo KY, Lee JB, Jun RM, Kim EK. Recurrence of Thygeson's superficial punctate keratitis after photorefractive keratectomy. Cornea. Oct 2002;21(7):736-7; author reply 737. [Medline].

  23. Netto MV, Chalita MR, Krueger RR. Thygeson's superficial punctate keratitis recurrence after laser in situ keratomileusis. Am J Ophthalmol. Sep 2004;138(3):507-8. [Medline].

  24. Fite SW, Chodosh J. Photorefractive keratectomy for myopia in the setting of Thygeson's superficial punctate keratitis. Cornea. May 2001;20(4):425-6. [Medline].

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Further Reading

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Keywords

Thygeson’s superficial punctate keratitis, TSPK, cornea, corticosteroid, cyclosporine

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Contributor Information and Disclosures

Author

Robert S Duszak, OD, FAAO, Co-Director of Residency Program and Consulting Staff, Philadelphia Veterans Affairs Medical Center; Consulting Staff, Nemours Health Clinic & Mayfair Eye Associates; Adjunct Clinical Faculty, Pennsylvania College of Optometry
Robert S Duszak, OD, FAAO is a member of the following medical societies: American Academy of Optometry, American Geriatrics Society, and American Optometric Association
Disclosure: Nothing to disclose.

Medical Editor

Richard W Allinson, MD, Associate Professor, Department of Ophthalmology, Texas A&M University Health Science Center, Scott and White Clinic
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

Christopher J Rapuano, MD, Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Co-Chairman of the Cornea Service, Co-Chairman of Refractive Surgery Department, Wills Eye Institute
Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Eye Bank Association of America, Pennsylvania Medical Society, and Philadelphia County Medical Society
Disclosure: Allergan Honoraria Speaking and teaching; Allergan Consulting fee Consulting; Alcon Honoraria Speaking and teaching; Inspire Honoraria Speaking and teaching; RPS Ownership interest Other

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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