Herman Kwong, Ralph Gundel, SUNY College of Optometry, New York, NY, Mark Speaker, Laser and Corneal Surgery Associates, New York, NY. A poster session held at the  1999 Annual Meeting of the American Academy of Optometry in Seattle, Washington, Saturday, 11 December 1999.



Thygesonís superficial punctate keratitis is a recurrent bilateral disease of the cornea characterized by focal epithelial keratitis. All age groups are affected with the greatest incidence seen in the second and third decades of life.  Patients often report episodes of tearing, foreign body, irritation, photophobia and a mild decrease in vision.  Stellate, round, granular, slightly raised dots without associated conjuctival or stromal inflammation are seen on examination.1,2  Fluorescein staining and mild subepithelial opacification may also be present.  



A 39 year old woman presented in our office complaining of a constant foreign body sensation and irritation greater in the right eye lasting for approximately 2 weeks.  The patient also complained of a slight distance and near blur along with photosensitivity while outdoors.  The patientís ocular history revealed a history of bilateral Thygesonís SPK which was initially diagnosed in her late 20s, with additional episodes of reoccurrence.  Examination revealed habitual distance visual acuities of 20/25 in OD and 20/20 in OS.  Biomicroscopy showed no abnormalities on lids and conjuctiva OU.  The cornea of the right eye revealed scattered, slightly raised, multiple white intra- and subepithelial dot-like infiltrates of various granular densities. (Fig 1,2)  The left eye also revealed similar multiple corneal lesions but with less invasion of the central visual axis. Both eyes showed positive staining opacities surrounded by negative staining.(Fig 3)  Prior to our office visit, previous topical treatments given to the patient included FML and Ocuflox  drops in conjunction with artificial tears. Pred Forte was also attempted by another physician. None of these treatments proved effective in reducing the patientís overall symptoms.  However the placement of therapeutic soft contact lenses bilaterally in our office significantly improved the patientís comfort.



Thygesonís superficial punctate keratitis was first described in 1950.  The cause of the disease is unknown but has been postulated to be viral in nature due to the resemblance of epithelial lesions found in other viral infections.  Patients are often symptomatic due to the epithelial erosion from these lesions.  The condition can last from weeks to years and may leave ghostlike intraepithelial opacities during periods of inactivity.3 Various treatments have been used depending on the severity of appearance and symptoms.  Mild presentations and symptoms have been treated by close observation and ocular lubricants. Topical antivirals such as trifluridine 1% and steroids including FML have been beneficial in providing relief and resolution of Thygesonís. However steroid use may prolong or exacerbate the course of the disease further, which may have occurred with our patient due to the lack of response with steroids.2,4 Upon further questioning, our patient reported previous success with soft contact lenses during her first bout with the disease but was not given lenses during subsequent attacks by other doctors.  Although steroids may have been effective in resolving the disease, the patient still remained symptomatic. This case  indicates why bandage soft contact lenses should be considered as the first line of therapy in resolving patientís symptoms with or without topical therapy.

JVF Note: You cannot combine Lotemax and soft contact lenses (As with all ophthalmic preparations containing benzalkonium chloride, patients should be advised not to wear soft contact lenses when using LOTEMAX."



1.    Thygeson P. Further observations on superficial puncatate keratitis. Arch Ophthalmol 1962; 66:158,

2.    Tabbara KF, Ostler HB, Dawson C et al. Thygesonís superficial punctate keratitis. Ophthalmol 1981;88:75-77

3.    Thygeson P. Superficial punctate keratitis. JAMA 1950;144:1544-1549

4.    Neburn AB, Lowe GH, Lepoff NJ, et al. Effect of topical trifluridine on Thygesonís superficial punctate keratitis. Ophthalmology 1984;91:1188-1192


Figures (Not available for posting to this web site)

1.    Wills Eye Hospital Resident Slide Collection, 1989

2,3. Krachmer JH, Palay DA. Cornea Color Atlas 1996;12-11,12-13

e-mail to Herman Kwong, one of the paper's authors.

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