Medical Care
Many therapies for Thygeson superficial punctate keratitis (TSPK) have been tried and proven unsuccessful over the years.
Antibiotics have been shown to be an ineffective treatment method. [2]
Antivirals have had mixed results; mild improvements have been reported with trifluridine, but it has also been reported to cause the disease to disappear more slowly than when treated with corticosteroids alone. [19] In addition, there have been multiple observations that idoxuridine causes persistent subepithelial ghost opacities and scarring in individuals with TSPK; therefore, it is contraindicated. [2, 11, 20]
A few successful therapies for TSPK do exist.
Topical lubricants have been shown to be an effective treatment method for relieving clinical symptoms. [21]
Topical corticosteroids now are considered to be the mainstream treatment of TSPK, as they have been shown to be very successful in managing both clinical signs and symptoms; however, there is speculation that the natural course of the disease may be prolonged secondary to the introduction of these medications. [2, 3] In addition, topical cyclosporine has been reported to be effective when used as a first-line treatment of patients with TSPK, with the advantage of fewer adverse effects compared with corticosteroids. [13, 22, 23]
Therapeutic soft contact lenses used on an extended-wear basis also offer an alternative or an additive treatment, especially for severe cases, although potential complications (eg, microbial keratitis) may exist. [22, 24] The use of anti-inflammatory topical medications while wearing contact lenses, especially extended-wear lenses, increase the known risks of contact lenses. Contact lenses improve symptoms by covering the elevated corneal lesions and nerves, which are constantly in friction with the conjunctiva during blinking. [2, 25]
Nagra et al have had overwhelming success with topical corticosteroids, and they suggest an initial management of TSPK with fluorometholone 0.1% (FML 0.1%) or a similar low-dose steroid, followed by the use of stronger steroids, and then extended-wear contact lenses or topical cyclosporine in a stepwise approach. [3] They reinforce an important point that steroids must be tapered gradually over the course of months in many patients, with some patients requiring longer term, infrequent, but regular use (ie, weekly, biweekly). Since therapy is aimed at providing patients with comfort, clinicians should be aware that the minimum strength and dosage of topical anti-inflammatory medications necessary to control symptoms should be prescribed. [18]
Surgical Care
There are a few reports of remission and recurrence following laser refractive surgery. [26, 27, 28, 29]
Fite and Chodosh reported that the use of photorefractive keratectomy (PRK) prevented the recurrence of TSPK in the area of the excimer laser treatment. [29]
Seo et al suggested that the recurrence rate of TSPK following refractive laser procedures is lower with PRK than with laser in situ keratomileusis (LASIK). [27]
Other reports have suggested that both PRK and laser subepithelial keratomileusis (LASEK) do not prevent the recurrence of TSPK, and even similar attempts of debridement of the corneal epithelium are insufficient at alleviating the course of inflammation in these patients. [2, 27]
Consultations
A consultation with a cornea specialist or an anterior segment specialist may be warranted if the diagnosis and the management of a patient with TSPK are confounding or if a patient is not responding to treatment.
Long-Term Monitoring
Patients with Thygeson superficial punctate keratitis (TSPK) should be followed regularly during flare-ups; otherwise, they should be followed periodically for routine eye examinations.
Patients using topical steroids need to be seen routinely to monitor for steroid adverse effects, such as glaucoma and cataracts.
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The cornea of a 33-year-old African American man with active Thygeson superficial punctate keratitis (TSPK).
