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Treatment of Thygeson's Superficial Punctate Keratopathy with Soft Contact Lenses
TREATMENT O F THYGESON'S SUPERFICIAL PUNCTATE KERATOPATHY WITH SOFT CONTACT LENSES S. L A N C E F O R S T O T ,
M.D.
Denver, Colorado AND P E R R Y S. B I N D E R , M.D. San Diego,
California
1
Thygeson's superficial punctate keratitis is characterized by multiple, discrete, coarse epithelial corneal opacities, occur ring bilaterally. The disease has a chronic course usually lasting six months to four years with intermittent symptomatic peri ods of photophobia, tearing, and foreign body sensation. The cause of this disease is unknown and topical corticosteroids usually induce remission of symptoms. 2 The discrete corneal opacities are coarse, punctate, strictly epithelial lesions (Fig. 1). Under high magnification they appear to be conglomerates of numerous granular dots in oval or stellate patterns. The overlying epithelial surface is often raised and stains with rose bengal show ing the abnormal epithelial cells and with fluorescein when microerosions occur. These changes distort the normally smooth optical surface and cause the de creased vision and tearing, and the symp toms of photophobia and foreign body sensation. The rationale for using thera peutic soft contact lenses was to relieve the symptoms and improve the optical characteristics of the cornea as described by Gasset and Kaufman 3 in keratitis of other causes. We describe herein the use of soft con tact lenses for symptomatic relief in three patients with Thygeson's superficial punctate keratopathy. From the Department of Ophthalmology, Univer sity of Colorado Medical Center, Denver, Colorado (Dr. Forstot); and the Division of Ophthalmology, University of California, San Diego, and the Section of Ophthalmology, Veterans Administration Hospi tal, San Diego, California (Dr. Binder). Reprint requests to S. Lance Forstot, M.D., 4200 E. Ninth Ave., Box B204, Denver, CO 80262. 186
Fig. 1 (Forstot and Binder). Case 1. Typical dis crete punctate epithelial lesions.
CASE REPORTS Case 1—A 34-year-old woman was referred here with the diagnosis of Thygeson's superficial punc tate keratopathy. She had been treated previously with 0.1% fluorometholone twice daily, which kept her asymptomatic with good vision. A weaker corticosteroid or less frequent dose of fluorometholone would not relieve her symptoms. She appeared to be
AMERICAN JOURNAL O F OPHTHALMOLOGY 88:186-189, 1979
VOL. 88, NO. 2
THYGESON'S SUPERFICIAL PUNCTATE KERATOPATHY
developing posterior subcapsular lens opacities in each eye. The fluorometholone was discontinued three days before referral. On examination her best corrected visual acuity was 6/9 (20/30) in the right eye and counting ringers at six feet in the left eye. Her left eye had been amblyopic since childhood because of an anisometropia. Slit-lamp biomicroscopy revealed multi ple discrete punctate epithelial opacities bilaterally centrally. The epithelium stained with both rose bengal and fluorescein. The epithelial lesions were slightly raised and caused some distortion of the keratometry mires. The lenses were clear except for a slight haze of the posterior capsule bilaterally. Re sults of the remainder of her ocular examination were normal. She was fitted with a piano bandage soft contact lens for daily wear and corticosteroids were discon tinued in the right eye. Two weeks later when re-examined the visual acuity in the right eye with the soft contact lens improved to 6/4.5 (20/15). Her visual acuity in the left eye remained at counting fingers at six feet. The corneal lesions were still present bilaterally. She continued daily wear of the lens in the right eye for one month and remained asymptomatic with good vision. At that time she requested and was fitted with a bandage lens (Softcon) in the left eye. Topical corticosteroid therapy was discontinued. The patient was followed u p for seven months and continued to remain asymptomatic. It was noted that after several months of wearing the lenses the granular lesions became less discrete and faint under the lenses (Fig. 2). Eight months after the lenses were instituted the patient lost the right lens and did not require a new one for comfort or vision for four months. At that time the irritation and mild decrease in vision were severe enough to warrant contact lens wear for relief. No further topical corti costeroid therapy has been needed in this patient. Case 2—A 14-year-old girl was referred here with the diagnosis of Thygeson's superficial punctate keratopathy because of possible corticosteroid de pendence. She had a history of intermittent irritation and photophobia for IV2 years. Five months previ ously she was first treated with topical corticosteroid therapy. Fluorometholone 0.1% and prednisolone acetate 1/8% were ineffective and she required 0.1% dexamethasone (Maxidex) drops for relief. On examination her best corrected visual acuity was 6/6 (20/20) in each eye. Slit-lamp biomicroscopy revealed classic, multiple discrete epithelial opaci ties bilaterally that stained with fluorescein and rose bengal. Results of the remainder of her ocular exam ination were normal, including her lenses. Because she refused a contact lens for daily use, she was treated with a full-time wear therapeutic lens (Plano-T, Bausch and Lomb) in the left eye and was instructed to use topical corticosteroids in the right eye as necessary. She returned three days later unable to tolerate full-time contact lens wear. The lens was removed and treatment with topical corti costeroids was started again in each eye. At her next visit she was advised to try a bandage lens (Softcon)
187
Fig. 2 (Forstot and Binder). Case 1. Patient wear ing soft contact lens with absence of discrete epithe lial lesions in direct or retroillumination.
for daily wear but was unable to learn insertion and removal. She returned several months later, at her mother's request, because she had been receiving corticoste roid therapy for about one year. The patient was taught to insert and remove the soft contact lens. A trial of intermittent full-time soft contact lens wear in the right eye was begun with a bandage lens (Softcon, 8.4 base curve, 14.0 diameter). She tolerated the lens well with removal and cleansing once per week. She required no topical corticosteroids in the right eye and was comfortable. She continued to use topical corticosteroids in the left eye. She was reexamined in three weeks and it was noted that the lesions under the lens were more diffuse and less discrete than in the left eye, and this finding contin ued to be present at each follow-up visit. At six weeks she was given a similar lens for full-time wear in the left eye; the topical corticosteroids were
188
AMERICAN JOURNAL OF OPHTHALMOLOGY
discontinued. She remained asymptomatic in each eye with soft contact lens wear. Two months later she was still asymptomatic and did not require corticosteroid medication. On exam ination her visual acuity was 6/6 (20/20) in each eye but there was no soft contact lens in either eye. She was informed of this and asked to continue without the lenses or corticosteroids. At follow-up visits of one month, six months, and one year she was asymp tomatic without any therapy. Case 3—A 26-year-old woman was discovered to have superficial punctate keratitis by Phillips Thygeson, M.D., when she was 8 years old. Initially her episodes of photophobia were treated with sunglass es. She first received topical corticosteroid therapy at the age of 20 years when 0.1% dexamethasone (Decadron) was used four times a day for one week during an acute episode. In 1974 she was fitted with cosmetic soft contact lenses (Bausch and Lomb). From 1974 through April 1975 she noted periods of photophobia and mild ocular discomfort while wearing her soft contact lenses. When she used topical corticosteroids with her contact lenses the symptoms lasted less than one week. However, when corticosteroids were used without the soft contact lens, she experienced symptoms that gradu ally resolved over several weeks. She was first seen here in April 1975 complaining of bilateral ocular pain and photophobia. Best cor rected visual acuity was 6/4.5 (20/15) in both eyes. Both corneas revealed classic superficial punctate epithelial lesions consistent with Thygeson's punc tate epithelial keratitis. Results of the remainder of the ocular examination were normal. Over the next three years she continued to wear the Bausch and Lomb soft contact lenses and devel oped occasional foreign body sensation and photo phobia, but did not require treatment with cortico steroids. In March 1978 she was re-examined when she had another attack, and she was treated with one drop of prednisolone acetate 1% daily while lens wear was discontinued. In August 1978 she returned after a repeat attack while wearing Hydrocurve soft contact lenses. Best corrected visual acuity in the right eye was 6/7.5 (20/25) and in the left eye was 6/6 (20/20). On slit-lamp examination the only positive findings were classic Thygeson's punctate epithelial keratitis lesions in the right eye. She complained of mild discomfort while wearing her lenses, but when the lenses were removed she complained of more photophobia and foreign body sensation. She was fitted with bandage soft contact lenses (Softcon) in both eyes and visual acuity was immediately corrected to 6/6 (20/20) in both eyes. One week later she returned with best corrected visual acuity of 6/4.5 (20/15) in both eyes and an absence of corneal lesions without any corticosteroid treatment. DISCUSSION
Most patients with Thygeson's superfi cial punctate keratopathy are easily man aged on low dose topical corticosteroids
AUGUST, 1979
that may only be needed during periods of exacerbations. Additionally, most cases appear to resolve or remit after several years. However, two types of patients may require an alternative form of thera py. The first are those patients requiring topical corticosteroids for relief of symp toms over a prolonged period of many years. The second type of patients are those who appear to become corticoste roid dependent. Case 1 is an example of a patient who required topical corticosteroid for relief of symptoms and good visual acuity for over two years. Case 2 is an example of a patient who was probably psychological ly dependent on corticosteroids. When corticosteroids were gradually tapered off with temporary soft contact lens wear she did well. There is no evidence that the soft contact lenses cured her disease. The lesions were still present once she discon tinued lens wear. In Case 3 the patient with Thygeson's superficial punctate keratopathy was not corticosteroid dependent for relief of her symptoms. She clearly derived sympto matic relief from the soft contact lenses. Her daily soft contact lens wear may have kept her from seeking more frequent medical therapy for her keratitis. These three patients are not the only ones with Thygeson's superficial punc tate keratitis we have attempted to treat with soft contact lenses. An additional patient required lens removal within 19 hours after fitting because of increased pain and photophobia related to lens in tolerance (overwear). Another patient was treated with a soft contact lens in one eye and topical corticosteroids in the other eye. Although on follow-up both eyes were less symptomatic, the patient thought that the corticosteroid treated eye was more comfortable and she discontin ued lens wear in favor of topical cortico steroids for the acute episode. Soft contact lenses appear to exert a
VOL. 88, NO. 2
THYGESON'S SUPERFICIAL PUNCTATE KERATOPATHY
bandage effect, relieving symptoms and impaired visual acuity as the result of anterior irregular corneal astigmatism. 4 However, the usefulness of soft contact lenses as an adjunct or alternative to topi cal corticosteroid therapy requires that the patient can be fit comfortably for either full-time or daily contact lens wear. The advantage of this alternative therapy is that it avoids the complications of long-term topical corticosteroids, cata racts, glaucoma, and supra-infection. Since institution of soft contact lens therapy in our patients, another report 5 has appeared that mentions the use of soft contact lenses as an adjunct to Thygeson's superficial punctate keratitis. SUMMARY
Three patients had Thygeson's superfi cial punctate keratopathy; two of whom previously had required prolonged top ical corticosteroid therapy for sympto matic relief. The use of therapeutic soft contact lenses provided improved visual acuity as well as symptomatic relief in all three patients. Corneal opacities fa ded while the soft contact lenses were in place. One patient who had been on long-term topical corticosteroids was gradually taken off this medication with
189
the use of soft contact lens. Another pa tient noted only mild symptoms from acute episodes while wearing soft contact lenses; only minimal topical corticoste roids were required to control her symp toms. Two additional patients were treat ed with soft contact lenses. One could not tolerate soft lens wear and the other chose corticosteroid therapy instead of soft lens wear. Soft contact lenses are an acceptable alternative to topical corticosteroid thera py in the treatment of Thygeson's superfi cial punctate keratopathy. ACKNOWLEDGMENTS
Thedore E. Wills, M.D., referred Case 1 and James R. Cerasoli, M.D., referred Case 2.
REFERENCES 1. Thygeson, P.: Superficial punctate keratitis. J.A.M.A. 114:1544, 1950. 2. Thygeson, P.: Further observation on superfi cial punctate keratitis. Am. J. Ophthalmol. 66:34, 1961. 3. Gasset, A. R., and Kaufman, H. E.: Therapeu tic uses of hydrophilic contact lenses. Am. J. Oph thalmol. 69:252, 1970. 4. Gasset, A. R., and Lobo, L.: Corneal disease and soft contact lenses. Ophthalmol. Digest 19, 1974. 5. Sundmacher, R., Press, M., Neumaan-Haefelin, D., and Riede, U.: Thygeson's superficial punctate keratitis. Klin. Monatsbl. Augenheilkd. 170:908, 1977.
M.D.
Denver, Colorado AND P E R R Y S. B I N D E R , M.D. San Diego,
California
1
Thygeson's superficial punctate keratitis is characterized by multiple, discrete, coarse epithelial corneal opacities, occur ring bilaterally. The disease has a chronic course usually lasting six months to four years with intermittent symptomatic peri ods of photophobia, tearing, and foreign body sensation. The cause of this disease is unknown and topical corticosteroids usually induce remission of symptoms. 2 The discrete corneal opacities are coarse, punctate, strictly epithelial lesions (Fig. 1). Under high magnification they appear to be conglomerates of numerous granular dots in oval or stellate patterns. The overlying epithelial surface is often raised and stains with rose bengal show ing the abnormal epithelial cells and with fluorescein when microerosions occur. These changes distort the normally smooth optical surface and cause the de creased vision and tearing, and the symp toms of photophobia and foreign body sensation. The rationale for using thera peutic soft contact lenses was to relieve the symptoms and improve the optical characteristics of the cornea as described by Gasset and Kaufman 3 in keratitis of other causes. We describe herein the use of soft con tact lenses for symptomatic relief in three patients with Thygeson's superficial punctate keratopathy. From the Department of Ophthalmology, Univer sity of Colorado Medical Center, Denver, Colorado (Dr. Forstot); and the Division of Ophthalmology, University of California, San Diego, and the Section of Ophthalmology, Veterans Administration Hospi tal, San Diego, California (Dr. Binder). Reprint requests to S. Lance Forstot, M.D., 4200 E. Ninth Ave., Box B204, Denver, CO 80262. 186
Fig. 1 (Forstot and Binder). Case 1. Typical dis crete punctate epithelial lesions.
CASE REPORTS Case 1—A 34-year-old woman was referred here with the diagnosis of Thygeson's superficial punc tate keratopathy. She had been treated previously with 0.1% fluorometholone twice daily, which kept her asymptomatic with good vision. A weaker corticosteroid or less frequent dose of fluorometholone would not relieve her symptoms. She appeared to be
AMERICAN JOURNAL O F OPHTHALMOLOGY 88:186-189, 1979
VOL. 88, NO. 2
THYGESON'S SUPERFICIAL PUNCTATE KERATOPATHY
developing posterior subcapsular lens opacities in each eye. The fluorometholone was discontinued three days before referral. On examination her best corrected visual acuity was 6/9 (20/30) in the right eye and counting ringers at six feet in the left eye. Her left eye had been amblyopic since childhood because of an anisometropia. Slit-lamp biomicroscopy revealed multi ple discrete punctate epithelial opacities bilaterally centrally. The epithelium stained with both rose bengal and fluorescein. The epithelial lesions were slightly raised and caused some distortion of the keratometry mires. The lenses were clear except for a slight haze of the posterior capsule bilaterally. Re sults of the remainder of her ocular examination were normal. She was fitted with a piano bandage soft contact lens for daily wear and corticosteroids were discon tinued in the right eye. Two weeks later when re-examined the visual acuity in the right eye with the soft contact lens improved to 6/4.5 (20/15). Her visual acuity in the left eye remained at counting fingers at six feet. The corneal lesions were still present bilaterally. She continued daily wear of the lens in the right eye for one month and remained asymptomatic with good vision. At that time she requested and was fitted with a bandage lens (Softcon) in the left eye. Topical corticosteroid therapy was discontinued. The patient was followed u p for seven months and continued to remain asymptomatic. It was noted that after several months of wearing the lenses the granular lesions became less discrete and faint under the lenses (Fig. 2). Eight months after the lenses were instituted the patient lost the right lens and did not require a new one for comfort or vision for four months. At that time the irritation and mild decrease in vision were severe enough to warrant contact lens wear for relief. No further topical corti costeroid therapy has been needed in this patient. Case 2—A 14-year-old girl was referred here with the diagnosis of Thygeson's superficial punctate keratopathy because of possible corticosteroid de pendence. She had a history of intermittent irritation and photophobia for IV2 years. Five months previ ously she was first treated with topical corticosteroid therapy. Fluorometholone 0.1% and prednisolone acetate 1/8% were ineffective and she required 0.1% dexamethasone (Maxidex) drops for relief. On examination her best corrected visual acuity was 6/6 (20/20) in each eye. Slit-lamp biomicroscopy revealed classic, multiple discrete epithelial opaci ties bilaterally that stained with fluorescein and rose bengal. Results of the remainder of her ocular exam ination were normal, including her lenses. Because she refused a contact lens for daily use, she was treated with a full-time wear therapeutic lens (Plano-T, Bausch and Lomb) in the left eye and was instructed to use topical corticosteroids in the right eye as necessary. She returned three days later unable to tolerate full-time contact lens wear. The lens was removed and treatment with topical corti costeroids was started again in each eye. At her next visit she was advised to try a bandage lens (Softcon)
187
Fig. 2 (Forstot and Binder). Case 1. Patient wear ing soft contact lens with absence of discrete epithe lial lesions in direct or retroillumination.
for daily wear but was unable to learn insertion and removal. She returned several months later, at her mother's request, because she had been receiving corticoste roid therapy for about one year. The patient was taught to insert and remove the soft contact lens. A trial of intermittent full-time soft contact lens wear in the right eye was begun with a bandage lens (Softcon, 8.4 base curve, 14.0 diameter). She tolerated the lens well with removal and cleansing once per week. She required no topical corticosteroids in the right eye and was comfortable. She continued to use topical corticosteroids in the left eye. She was reexamined in three weeks and it was noted that the lesions under the lens were more diffuse and less discrete than in the left eye, and this finding contin ued to be present at each follow-up visit. At six weeks she was given a similar lens for full-time wear in the left eye; the topical corticosteroids were
188
AMERICAN JOURNAL OF OPHTHALMOLOGY
discontinued. She remained asymptomatic in each eye with soft contact lens wear. Two months later she was still asymptomatic and did not require corticosteroid medication. On exam ination her visual acuity was 6/6 (20/20) in each eye but there was no soft contact lens in either eye. She was informed of this and asked to continue without the lenses or corticosteroids. At follow-up visits of one month, six months, and one year she was asymp tomatic without any therapy. Case 3—A 26-year-old woman was discovered to have superficial punctate keratitis by Phillips Thygeson, M.D., when she was 8 years old. Initially her episodes of photophobia were treated with sunglass es. She first received topical corticosteroid therapy at the age of 20 years when 0.1% dexamethasone (Decadron) was used four times a day for one week during an acute episode. In 1974 she was fitted with cosmetic soft contact lenses (Bausch and Lomb). From 1974 through April 1975 she noted periods of photophobia and mild ocular discomfort while wearing her soft contact lenses. When she used topical corticosteroids with her contact lenses the symptoms lasted less than one week. However, when corticosteroids were used without the soft contact lens, she experienced symptoms that gradu ally resolved over several weeks. She was first seen here in April 1975 complaining of bilateral ocular pain and photophobia. Best cor rected visual acuity was 6/4.5 (20/15) in both eyes. Both corneas revealed classic superficial punctate epithelial lesions consistent with Thygeson's punc tate epithelial keratitis. Results of the remainder of the ocular examination were normal. Over the next three years she continued to wear the Bausch and Lomb soft contact lenses and devel oped occasional foreign body sensation and photo phobia, but did not require treatment with cortico steroids. In March 1978 she was re-examined when she had another attack, and she was treated with one drop of prednisolone acetate 1% daily while lens wear was discontinued. In August 1978 she returned after a repeat attack while wearing Hydrocurve soft contact lenses. Best corrected visual acuity in the right eye was 6/7.5 (20/25) and in the left eye was 6/6 (20/20). On slit-lamp examination the only positive findings were classic Thygeson's punctate epithelial keratitis lesions in the right eye. She complained of mild discomfort while wearing her lenses, but when the lenses were removed she complained of more photophobia and foreign body sensation. She was fitted with bandage soft contact lenses (Softcon) in both eyes and visual acuity was immediately corrected to 6/6 (20/20) in both eyes. One week later she returned with best corrected visual acuity of 6/4.5 (20/15) in both eyes and an absence of corneal lesions without any corticosteroid treatment. DISCUSSION
Most patients with Thygeson's superfi cial punctate keratopathy are easily man aged on low dose topical corticosteroids
AUGUST, 1979
that may only be needed during periods of exacerbations. Additionally, most cases appear to resolve or remit after several years. However, two types of patients may require an alternative form of thera py. The first are those patients requiring topical corticosteroids for relief of symp toms over a prolonged period of many years. The second type of patients are those who appear to become corticoste roid dependent. Case 1 is an example of a patient who required topical corticosteroid for relief of symptoms and good visual acuity for over two years. Case 2 is an example of a patient who was probably psychological ly dependent on corticosteroids. When corticosteroids were gradually tapered off with temporary soft contact lens wear she did well. There is no evidence that the soft contact lenses cured her disease. The lesions were still present once she discon tinued lens wear. In Case 3 the patient with Thygeson's superficial punctate keratopathy was not corticosteroid dependent for relief of her symptoms. She clearly derived sympto matic relief from the soft contact lenses. Her daily soft contact lens wear may have kept her from seeking more frequent medical therapy for her keratitis. These three patients are not the only ones with Thygeson's superficial punc tate keratitis we have attempted to treat with soft contact lenses. An additional patient required lens removal within 19 hours after fitting because of increased pain and photophobia related to lens in tolerance (overwear). Another patient was treated with a soft contact lens in one eye and topical corticosteroids in the other eye. Although on follow-up both eyes were less symptomatic, the patient thought that the corticosteroid treated eye was more comfortable and she discontin ued lens wear in favor of topical cortico steroids for the acute episode. Soft contact lenses appear to exert a
VOL. 88, NO. 2
THYGESON'S SUPERFICIAL PUNCTATE KERATOPATHY
bandage effect, relieving symptoms and impaired visual acuity as the result of anterior irregular corneal astigmatism. 4 However, the usefulness of soft contact lenses as an adjunct or alternative to topi cal corticosteroid therapy requires that the patient can be fit comfortably for either full-time or daily contact lens wear. The advantage of this alternative therapy is that it avoids the complications of long-term topical corticosteroids, cata racts, glaucoma, and supra-infection. Since institution of soft contact lens therapy in our patients, another report 5 has appeared that mentions the use of soft contact lenses as an adjunct to Thygeson's superficial punctate keratitis. SUMMARY
Three patients had Thygeson's superfi cial punctate keratopathy; two of whom previously had required prolonged top ical corticosteroid therapy for sympto matic relief. The use of therapeutic soft contact lenses provided improved visual acuity as well as symptomatic relief in all three patients. Corneal opacities fa ded while the soft contact lenses were in place. One patient who had been on long-term topical corticosteroids was gradually taken off this medication with
189
the use of soft contact lens. Another pa tient noted only mild symptoms from acute episodes while wearing soft contact lenses; only minimal topical corticoste roids were required to control her symp toms. Two additional patients were treat ed with soft contact lenses. One could not tolerate soft lens wear and the other chose corticosteroid therapy instead of soft lens wear. Soft contact lenses are an acceptable alternative to topical corticosteroid thera py in the treatment of Thygeson's superfi cial punctate keratopathy. ACKNOWLEDGMENTS
Thedore E. Wills, M.D., referred Case 1 and James R. Cerasoli, M.D., referred Case 2.
REFERENCES 1. Thygeson, P.: Superficial punctate keratitis. J.A.M.A. 114:1544, 1950. 2. Thygeson, P.: Further observation on superfi cial punctate keratitis. Am. J. Ophthalmol. 66:34, 1961. 3. Gasset, A. R., and Kaufman, H. E.: Therapeu tic uses of hydrophilic contact lenses. Am. J. Oph thalmol. 69:252, 1970. 4. Gasset, A. R., and Lobo, L.: Corneal disease and soft contact lenses. Ophthalmol. Digest 19, 1974. 5. Sundmacher, R., Press, M., Neumaan-Haefelin, D., and Riede, U.: Thygeson's superficial punctate keratitis. Klin. Monatsbl. Augenheilkd. 170:908, 1977.