Thygeson Superficial Punctate Keratitis: A Clinical and Immunologic Review

Abstract

Thygeson superficial punctate keratitis (TSPK) is clinically characterized by exacerbations and remissions of gray-white opacities within the corneal epithelium, most often bilateral but may be asymmetric. Symptoms typically include photophobia, tearing, blurring, and eye irritation. Although disease progression and prognosis are well described, the exact cause is unknown. Hypotheses exist implicating virus-mediated immunity as the cause of TSPK following cases of viral keratitis; however, several polymerase chain reaction studies refute the infectious process concurrently with symptomatic TSPK. This is further supported by the consistent lack of response to antiviral and antibacterial treatment. A subset of dendritic cells known as Langerhans cells (LC) found within the corneal epithelium has been positively correlated with exacerbations of TSPK. Langerhans cells proliferate to protect and mitigate the cornea's inflammatory response, but the inflammatory triggers and relapses associated with TSPK are not well understood. Several topical drugs exist to treat inflammation related to TSPK; however, drug delivery is a major barrier to treatment because of the tear film and epithelial barrier. Drug-eluting contact lenses that target intermediates of inflammation could serve as a more effective treatment modality because of the increased bioavailability of the drugs. This review is an in-depth survey of the literature regarding the relationship between the origin and pathophysiology of LC and TSPK at the immunologic level. We also discuss potential pharmacotherapeutic interventions for TSPK prevention and treatment.

Rare Case of Thygeson Superficial Punctate Keratitis After COVID-19 Vaccination

“…9 Furthermore, a genetic predisposition has also been postulated with a significantly increased gene frequency of human leukocyte antigen-DR3 found in some patients with TSPK; our patient did not exhibit this genetic marker. 8,9 Together, these findings suggest that TSPK may represent an altered immune response to an unknown inciting agent.…”

“…Historically, the condition has been believed to be infectious in nature, given the isolation of viral particles in early reports. 8 More recent studies have failed to consistently confirm this suspicion. In one study, cells from the cornea of 8 patients diagnosed with TSPK failed to show viral DNA for HSV, varicella zoster virus, and adenovirus.…”

“…TSPK is a chronic and recurring corneal epitheliopathy characterized by small, elevated, gray-white intraepithelial lesions that typically present bilaterally. 8,9 Although recognized over half a decade ago by ophthalmologist Dr. Phillips Thygeson, the etiology and pathophysiology remain poorly understood. 8,9 Although considered a generally benign condition, the recurrent nature of the disease, often characterized by pain and photophobia, makes TSPK a particularly distressful condition with a significant impact on quality of life.…”

“…8,9 Although recognized over half a decade ago by ophthalmologist Dr. Phillips Thygeson, the etiology and pathophysiology remain poorly understood. 8,9 Although considered a generally benign condition, the recurrent nature of the disease, often characterized by pain and photophobia, makes TSPK a particularly distressful condition with a significant impact on quality of life. 10 The etiology of TSPK remains to be fully elucidated and several hypotheses regarding pathogenesis have been proposed over the years.…”

West Indian Punctate Keratopathy and “Puerto Rican (PR) Spots”

“…Examination of Thygeson's superficial punctate keratopathy (TSPK) also reveals dots in the cornea [4,9,11,12]. However, TSPK primarily affects the corneal epithelium and tends to manifest with a range of symptoms, including photophobia, tearing, burning, and a foreign body sensation [13][14][15]. It is also important to consider non-infectious differential diagnoses such as scars in patients with a history of superficial corneal foreign bodies or ocular trauma.…”