Thygeson's superficial punctate keratitis: ten years' experience

PURPOSE: To evaluate the presentation, treatment, and disease course of Thygeson's superficial punctate keratitis. DESIGN: Observational case series. PARTICIPANTS: Forty patients, diagnosed and managed with Thygeson's superficial punctate keratitis between January 1, 1992, and December 31, 2001, on the Cornea Service at Wills Eye Hospital. METHODS: Retrospective chart review. MAIN OUTCOME MEASURES: Patient demographics, symptoms, visual acuity, ophthalmic examination, management, duration of disease, and length of follow-up. RESULTS: At the time of presentation, the mean patient age was 28.7 years. The most common presenting symptoms included photophobia, blurred vision, and irritation. Thirty of 38 patients without a history of decreased vision (78.9%) initially were seen with visual acuities in both eyes of 20/30 or better. The 8 (21.1%) remaining patients all had visual acuities between 20/40 and 20/50; improvement in vision with treatment was noted in all 3 observed at our institution. Six patients (16%) had unilateral disease, whereas another 2 patients had bilateral involvement develop after unilateral presentation. Thirty-nine patients (97.5%) were treated with topical steroids at some point in their disease course. The patient not managed with steroids was only seen once and was managed with artificial tears for mild symptoms. In addition to steroids, a patient was treated for recurrent episodes with extended-wear contact lens, and another patient was started on topical cyclosporine because of an inability to be tapered off topical steroids. The average duration of disease in the 15 patients who were observed for more than a single year was 11.1 years. CONCLUSIONS: Thygeson's superficial punctate keratitis is a potentially chronic condition, which might affect people of all ages for years to decades. Corticosteroids are the mainstay of treatment, with extended-wear contact lens and topical cyclosporine reserved as secondary agents.     

Herpes simplex virus keratitis in children

PURPOSE: To describe the spectrum and recurrence of herpes simplex virus (HSV) keratitis in children and adolescents. DESIGN: Retrospective cohort study. METHODS: Twenty-three patients younger than age 16 years were diagnosed with HSV keratitis at one institution. RESULTS: All children presented with dendritic or punctate epithelial keratitis, and stromal keratitis occurred concurrently with epithelial keratitis in 14 patients (61%). Six patients (26%) had bilateral HSV keratitis. Eleven patients (48%) developed recurrent HSV keratitis at a median of 15 months after the first documented episode. Amblyopia occurred in three children. CONCLUSION: Children with herpetic keratitis may have bilateral ocular involvement and are at risk for recurrent keratitis and amblyopia.     

Neuroparalytic keratitis

Unilateral trigeminal denervation can render the cornea hypoesthestic and lead to neuroparalytic keratitis. A patient presented to the clinic with a unilateral hypoesthestic compromised cornea which was subsequently diagnosed as neuroparalytic keratitis. The evaluation and management of this case will be presented with a discussion of neuroparalytic keratitis. Other synonyms include trigeminal neurotrophic keratopathy and neurotrophic keratitis.     

Clinical forms of acanthamoeba keratitis as viewed from the standpoint of biomicroscopy and confocal microscopy

Clinical cases of 60 patients with acanthamebic keratitis examined by biomicroscopy and of 22 patients largely examined by confocal microscopy are generalized. Acanthamebic keratitis is a slowly progressing infectious lesion of the cornea, which is caused by acanthamebas freely residing in soil and water. Contaminated contact lenses are the key risk factor. The main clinical features of acanthamebic keratitis are defined; they are presence of risk factors; a unilateral lesion in young, healthy and immune-competent persons; a typical clinical pattern of surface keratitis mainly of the ring shape; corneal neuritis without corneal neovascularization but with a severe pain in the eye; and a slow chronic clinical course, i.e. lasting for several weeks and months. Confocal microscopy is the most effective and fast diagnostic tool because it ensures the detection of acanthamebic cysts and trophozoids in all strata of the corneal stroma. The authors isolate, within the clinical course of acanthamebic keratitis, 5 stages; they are surface epithelial keratitis; surface epithelial punctate keratitis; stromal ring-shaped keratitis; ulcerous keratitis; and keratoscleritis.     

Persistent superficial punctate keratitis after resolution of chlamydial follicular conjunctivitis.

Two cases of follicular conjunctivitis due to Chlamydia trachomatis followed by punctate epithelial keratitis are described. Both cases were initially treated with either oral tetracycline or doxycycline with resolution of the follicles. These two patients subsequently had recurrent, bilateral grayish lesions at various levels in the corneal epithelium that stained in a punctate fashion with fluorescein. There was anterior stromal edema associated with some of these lesions in one case. The lesions were confined mostly to the central cornea. These recurrent lesions were unassociated with a conjunctival reaction, were unresponsive to oral tetracycline, but were exquisitely responsive to low doses of topical steroids. Chlamydial conjunctivitis and the associated keratitis typically shows no response or actual exacerbation of symptoms with topical steroids, and the keratitis shows a predilection for the upper half of the cornea. These patients demonstrate that chlamydial keratoconjunctivitis might result in a clinical appearance consistent with Thygeson's superficial punctate keratitis.     

In vivo confocal microscopy after herpes keratitis

PURPOSE: To describe the confocal microscopic findings, with special reference to corneal subbasal nerves, after herpes simplex virus (HSV) keratitis. METHODS: In this study, 16 HSV eyes and 14 contralateral eyes of 16 patients, diagnosed with unilateral HSV keratitis 1-12 months earlier by the presence of dendritic corneal ulceration or microbiologic confirmation, were examined by in vivo confocal microscopy for evaluation of corneal morphology. RESULTS: Herpes simplex virus eyes: In 2 eyes the surface epithelial cells appeared large, and no abnormalities were observed in the basal epithelial cells. In 2 eyes subbasal nerve fiber bundles were completely absent, in 3 eyes there was a reduced number of long nerve fiber bundles, and in 11 eyes the subbasal nerve plexus appeared normal. In 10 corneas, highly reflective dendritic structures were found at the level of the basal epithelial cells. Frequently these structures were found in the vicinity of stromal fibrosis. Areas with increased abnormal extracellular matrix were found in 11 eyes. Stromal nerves were not visualized in all corneas, but appeared normal when observed. Contralateral eyes: No abnormalities were observed in the epithelium. All corneas presented with a normal subbasal nerve plexus, but in 2 eyes dendritic particles were observed. Three corneas presented with activated keratocytes and increased amounts of abnormal extracellular matrix. CONCLUSIONS: When visualized by confocal microscopy, the subbasal nerve plexus appears relatively unaffected in cases with resolved HSV keratitis. Unidentified dendritic structures, presumably Langerhans cells, are frequently seen at the level of the basal epithelium in corneas with a history of herpetic disease.     

Corneal complications from herpes zoster ophthalmicus

Of 94 patients with acute herpes zoster ophthalmicus who were seen during a six-year period, 61 had corneal involvement. The corneal complications in the order of chronological clinical occurrence were punctate epithelial keratitis in 51%, early pseudodendrites in 51%, anterior stromal infiltrates in 41%, sclerokeratitis in 1%, kerato-uveitis/endothelitis in 34%, serpiginous ulceration in 7%, delayed corneal mucous plaques in 13%, disciform keratitis in 10%, neurotrophic keratitis in 25%, and exposure keratitis in 11%. Some of the earlier lesions seemed to result from viral infection, whereas later lesions resulted from limbal vasculitis, an immunologic mechanism to soluble viral antigen, a delayed hypersensitivity reaction, or damage to nerves and tissues. An elucidation of the lesions awaits better viral and immunologic detection techniques and further histopathologic study. Modern topical and systemic antiviral therapy, corticosteroids, and surgery have a role in treatment.     

Progression of eye disease in "cured" leprosy patients: implications for understanding the pathophysiology of ocular disease and for addressing eyecare needs

BACKGROUND: Ocular damage in leprosy is due either to nerve damage or infiltration by mycobacteria. There is currently little information about the magnitude and nature of incident ocular pathology in cured leprosy patients. This information would increase our understanding of the pathophysiology of ocular involvement in leprosy and help in developing programmes to address the eyecare needs of leprosy patients who have been released from treatment. The cumulative incidence of leprosy related ocular pathology and cataract was measured during an 11 year follow up period in cured leprosy patients released from treatment in Korea. METHODS: In 1988 standardised eye examinations were performed on 501 patients in eight resettlement villages in central South Korea. In May 1999 standardised eye examinations were repeated in this population. RESULTS: Among the patients in whom there was no sight threatening leprosy related ocular disease (lagophthalmos, posterior synechia, or keratitis) in 1988, 14.7% developed one or more of these conditions. Overall, among those with no vision reducing cataract in 1988, 26.4% had developed a vision reducing lens opacity in at least one eye. Among patients examined in both 1988 and 1999, 14.3% developed visual impairment and 5.7% developed blindness. CONCLUSION: This study demonstrates that leprosy related ocular pathology progresses in some patients even after they are cured mycobiologically. The progressive leprosy related lesions are the result of chronic nerve damage; ocular lesions due to infiltration by Mycobacterium leprae did not develop. Based on the factors found to be associated with development of the most visually significant findings (posterior synechia, keratitis, and cataract) certain patients should be targeted at discharge for active follow up eye care. We suggest that patients with lagophthalmos (even in gentle closure), trichiasis, small pupils, and posterior synechiae should be screened regularly for the development of lagophthalmos in forced closure, keratitis, and cataract.     

Insulina tópica en queratopatía neurotrófica tras resección de neurinoma del acústico

Case report

A patient with a history of surgical resection of an acoustic neuroma presented with involvement of both the left facial nerve and the left trigeminal nerve. She initially consulted for exposure keratitis, but two weeks later presented with an infectious keratitis. After taking the corneal sample, she presented with persistent epithelial defect, which did not respond to medical management. Topical insulin was indicated, and a decrease in the area of the lesion was seen in the following 5 days. A therapeutic contact lens was also placed at that time and finally, two weeks after the initiation of insulin, the epithelial defect completely closed.

Classification of herpes simplex virus keratitis

PURPOSE: We propose a nomenclature for classification of herpes simplex virus (HSV) keratitis. We hope that a more consistent classification system will lead to a better understanding of the disease processes, thus resulting in improved diagnosis, treatment, and patient outcomes. METHODS: A review of the literature was performed to evaluate current HSV classification systems. These systems were evaluated in the context of both current clinical and basic science studies and our own clinical observations. RESULTS: The proposed classification system is based on the anatomy and pathophysiology of the specific presentations of HSV keratitis. Anatomically, the primary level of corneal involvement, whether epithelium, stroma, or endothelium, must be elucidated. Pathophysiologically, the cause of the inflammation. whether immunologic, infectious, or neurotrophic, must be determined. There are four major categories of HSV keratitis. (1) Infectious epithelial keratitis, which is made up of cornea vesicles, dendritic ulcer, geographic ulcer, and marginal ulcer. (2) Neurotrophic keratopathy, which includes punctate epithelial erosions and neurotrophic ulcer. (3) Stromal keratitis, which is subdivided into necrotizing stromal keratitis and immune stromal keratitis. (4) Endotheliitis, which has three clinical presentations: disciform, diffuse, and linear. CONCLUSION: We believe that by categorizing cases of HSV keratitis by their primary anatomic and pathophysiologic etiologic characteristics, clinicians can better understand and therefore treat all types of HSV keratitis. The four main categories of HSV keratitis are infectious epithelial keratitis, neurotrophic keratopathy, stromal keratitis, and endotheliitis. Each of these is subdivided to more specific clinical presentations.     

Eye involvement in AIDS

Between 1984 and 1987 (over two-and-a-half years) 30 hospitalized patients with HIV infections of different degrees of severity were ophthalmologically examined. Ocular involvement was found in 17 patients (approx. 57%). In 16 of these 17 patients with pathologic ophthalmologic findings (approx. 94%), AIDS was already fully developed. Ocular involvement is therefore a sign of poor prognosis. Fourteen patients had a microvascular retinal syndrome and four patients had infectious (chorio-)retinitis (causative organisms: cytomegalovirus in three cases, Cryptococcus neoformans in one). Further findings included sicca syndrome with superficial punctate keratitis in two cases, keratitis in one patient with generalized mucocutaneous candidiasis, Kaposi's sarcoma of the eyelids in two cases, Kaposi's sarcoma of the conjunctiva in one case, papilledema with cryptococcal meningitis in one case, and atypical hordeolum in one case. Morphologic and pathogenetic aspects of the ophthalmologic findings, their importance and course in AIDS patients, and therapeutic problems are discussed.     

Neuro-ophthalmic considerations in trigeminal neuralgia and its surgical treatment

PURPOSE OF REVIEW: In this review, we will briefly discuss the clinical manifestations and etiology of trigeminal neuralgia, outline the neuro-ophthalmic features of trigeminal neuralgia, and detail the neuro-ophthalmic side effects and complications of the surgical treatment of trigeminal neuralgia. RECENT FINDINGS: There is a variety of surgical treatment modalities available for patients with trigeminal neuralgia intolerable or resistant to medical therapy. Significant ocular and visual morbidity can result from the surgical treatment of trigeminal neuralgia. SUMMARY: Percutaneous or open surgical procedures for trigeminal neuralgia can result in corneal anesthesia, neurotrophic keratitis, exposure keratitis, herpetic keratitis, ocular motor cranial neuropathies, and optic neuropathy. Ophthalmologists should be aware of these potential problems because they may need to evaluate and provide care to patients with ocular or visual complaints following surgery for trigeminal neuralgia.     

临床表现罕见的流行性角结膜炎1例:腺病毒角结膜上皮炎(英文)

腺病毒角结膜炎,由腺病毒血清型8,19,37引起。腺病毒结膜炎典型的体征包括耳前淋巴结病变,结膜充血水肿,结膜下出血,结膜滤泡。腺病毒角结膜炎角膜受累情况各不相同,多数患者有弥散的轻微的浅层角膜炎,局部隆起的点状上皮损害,随后形成上皮下混浊。我们报道一例罕见的腺病毒角结膜上皮炎,为临床表现特殊的流行性角结膜炎(EKC),并回顾相关特殊病例文献。患者,男,35岁,患腺病毒结膜炎,临床表现罕见,表现为角结膜上皮炎形式,这种病例文献未见报道。经过保守治疗患者痊愈。角结膜上皮炎可以是临床表现特殊的腺病毒角结膜炎。     

Photorefractive keratectomy for myopia in the setting of Thygeson's superficial punctate keratitis

PURPOSE: To describe a patient with Thygeson's superficial punctate keratitis who underwent photorefractive keratectomy for the correction of myopia. METHODS: A 49-year-old woman with unilateral Thygeson's keratitis was examined before and after photorefractive keratectomy. RESULTS: A myopic patient underwent photorefractive keratectomy in the left eye and gained 20/20 uncorrected visual acuity. Seventeen months after surgery, symptomatic Thygeson's keratitis lesions recurred in the peripheral but not the central cornea. CONCLUSION: Photorefractive keratectomy reliably corrected myopia in a patient with previous Thygeson's keratitis. The recurrence of lesions only in the peripheral untreated cornea suggests that the inflammatory signal in Thygeson's keratitis may reside in the superficial corneal stroma.     

Clinical evaluation of cornea pseudoguttata

AIM: To report on cornea pseudoguttata which occurred in 44 eyes from 40 patients. METHODS: In 3521 consecutive patients seen at a local eye clinic, eyes were examined with a slit-lamp biomicroscope in specular illumination. When guttate appearance was found, specular microscopy was performed. RESULTS: Cornea pseudoguttata was found in 44 eyes of 40 patients (1.1%). All patients had some form of anterior-segment ocular diseases, including keratitis (corneal infiltration) with contact lens wear (n = 16), epidemic keratoconjunctivitis (n = 8), corneal epithelial defect (n = 6), superficial punctate keratitis (n = 4), corneal foreign body (n = 3), keratitis of unknown causes (n = 3), corneal ulcer (n = 2), herpetic keratitis (n = 1), and iritis (n = 1). Six eyes were lost to follow-up, but in the remaining 38 eyes, cornea pseudoguttata completely resolved as the primary anterior-segment diseases subsided. Specular microscopy, measured after resolution of cornea pseudoguttata, showed that corneal endothelial cell density was not different between the affected and contralateral healthy eyes. CONCLUSION: Cornea pseudoguttata is commonly found in cases with corneal infiltration and inflammation. These results indicate that cornea pseudoguttata is reversible in its nature and resolves completely without any damage to the corneal endothelial cells.     

Marginal corneal abscess associated with adult chlamydial ophthalmia.

In four patients with an adult chlamydial ophthalmia small, marginal corneal abscesses were detected. These corneal abscesses were associated with unilateral papillary and follicular conjunctivitis and punctate keratitis. In these patients no bacteria was isolated from the abscesses, but Chlamydia trachomatis was isolated from materials collected from the abscesses and from the conjunctival swabbings. In addition all patients had microbiologically proved concomitant chlamydial genital infections. The clinical signs resolved after topical treatment with rifampicin or tetracycline eye ointment for six weeks or systemic treatment with tetracycline for two weeks. Because of concomitant chlamydial genital infection it is advisable to treat patients with adult chlamydial ophthalmia with systemic tetracycline and to refer these patients and their consorts for investigation and treatment of their genital infection.     

Radial keratoneuritis as a presenting sign in Acanthamoeba keratitis

Three myopic patients who wore soft contact lenses developed unilateral Acanthamoeba keratitis that presented with unusual infiltrates that appeared to be located along the corneal nerves. These infiltrates were found in the midstroma, beginning paracentrally, and extending to the limbus in a radial pattern. The epithelium overlying these infiltrates was intact. In two patients, the central epithelium had a stippled, almost dendritiform appearance leading to the misdiagnosis of herpes simplex keratitis. Cultures from corneal scrapings of two patients and cultures of a corneal biopsy from one patient, which included an area of presumed neural involvement, grew Acanthamoebae. All three patients used homemade saline solutions (salt tablets dissolved in distilled water). In one patient, Acanthamoebae were found in the contact lens case solution. In our recent experience, Acanthamoebae have also been found in the distilled water bottle and the saline solution made from distilled water and salt tablets in two additional patients with A. keratitis. Distilled water, which is not sterile, has proven to be one potentially avoidable source of A. keratitis in contact lens wearers.     

Extended wear contact lens related bacterial keratitis

AIMS: To report the clinical findings and visual outcome of patients with extended wear contact lens (EWCL) related bacterial keratitis. METHODS: 11 cases with EWCL related bacterial keratitis were included. Corneal scrapings were obtained for cytology and cultures. RESULTS: Nine patients had unilateral bacterial keratitis and two patients showed bilateral involvement. Corneal scrapings revealed Pseudomonas aeruginosa in seven patients, Staphylococcus aureus coagulase positive in one patient, and Staphylococcus epidermidis in three patients. CONCLUSION: EWCLs may be associated with bacterial keratitis and may result in visual loss. Dispensing contact lenses by optometrists should be performed in consultation with ophthalmologists.     

PCR for varicella zoster virus genome negative in corneal epithelial cells of patients with Thygeson's superficial punctate keratitis

PURPOSE: To find out if varicella zoster virus is the causative agent of Thygeson's superficial punctuate keratitis. METHODS: Epithelial cells were harvested from the punctuate epithelial lesions 9 patients with Thygeson's superficial punctate keratitis. After DNA extraction polymerase chain reaction was carried out with varicella zoster virus primers. RESULTS: All samples were negative with regard to varicella zoster virus genome. CONCLUSIONS: This result suggests that varicella zoster virus is most probably not the causative agent of Thygeson's superficial punctate keratitis.