Thygeson’s Superficial Punctate Keratitis (TSPK) is a chronic, recurrent epithelial keratopathy primarily affecting the central cornea. It presents with gray-white, discrete, round-to-oval intraepithelial lesions and minimal to no conjunctival involvement. The disease may be unilateral or bilateral, with exacerbations and remissions over years to decades. Its etiology is unknown, though an immune association (HLA-DR3) has been suggested. Risk factors include viral infections (adenovirus, HSV, VZV). Recurrence after refractive surgery has also been reported.
TSPK lesions, predominantly central, sparing the stroma and peripheral cornea, appear as fine, fuzzy flecks that persist with blinking and evolve into slightly raised, irregular oval shape. Once the center of the lesions falls off, their gradual resolution begins, taking hours to weeks. During flare-ups, multiple central lesions can cause blurred vision, photophobia, tearing, and foreign body sensation. Corneal sensation is normal or mildly reduced, but never absent. Inactive phases show flattened, grayish, stellate subepithelial opacities that stain negatively, and some may persist.
Diagnosis is often by exclusion, with differential including viral keratitis (HSV, HZV, adenovirus), dry eye disease, recurrent corneal erosion, epithelial and sub-epithelial punctate keratitis, map-dot-fingerprint dystrophy, vernal keratoconjunctivitis, neurotrophic keratitis, and exposure keratitis.
TSPK management consists of eye lubricants, topical corticosteroids, topical cyclosporine or tacrolimus, and soft contact lenses. Surgical options (PTK or PRK) are rarely recommended.
Case Report
In August 2021, a 55 year-old, Caucasian female with a history of Thygeson’s SPK diagnosed in adolescence presented after a longlasting remission. She reported chronic eye irritation, fluctuating vision, and marked photophobia, requiring near-constant sunglass use, including indoors, with symptoms worse in her left eye. At presentation, she was using Xiidra BID OU, a preservative-free eye lubricant twice or three times daily, and had already completed a 2-week course of Tobradex.
Final Thoughts
Thygeson’s superficial punctate keratitis (TSPK) is a chronic, recurrent corneal epithelial disorder likely driven by immunemediated mechanisms. In this case, coexisting meibomian gland dysfunction contributed to symptom severity. Management combined anti-inflammatory therapy, lubricants for tear film support, and IPL and hot compressed for MGD, with gradual tapering of medications.
After three years of topical immunomodulator and anti-inflammatory therapy, patient has remained stable for over 10 months off-treatment, maintained exclusively with PF LabTRIACTIV eye drops, highlighting its role in ocular surface stability and patient comfort.
This case illustrates the importance of individualized, stepwise therapy and addressing underlying ocular surface issues in chronic TSPK.
About the author:
Dr. Jon Akle was born and raised in Edmonton, where he completed his undergraduate studies at the University of Alberta before earning his Doctor of Optometry degree from Nova Southeastern University in Florida in 2016. While at Nova, he completed clinical rotations at Bascom Palmer Eye Institute in Miami, gaining valuable hands-on experience in areas such as retina, cornea, neuro-ophthalmology, and glaucoma, which helped spark his interest in ocular disease and research.
After returning to the Edmonton area, Dr. Akle worked in a variety of practice settings before founding Emerald Hills Eye Care in 2018. In 2019, he began focusing more on ocular surface disease management as part of his commitment to providing comprehensive care. He currently serves as President-Elect of the Alberta College of Optometrists and is also involved in lectures and educational seminars, where he enjoys sharing insights on both practice management
and ocular surface disease to support fellow optometrists.
References
1. Priyadarshini SR, Roy A, Das S. Thygeson’s superficial punctate keratopathy: A review and case series. Indian J Ophthalmol. 2021 Apr;69(4):806-811. doi: 10.4103/ijo.IJO_1624_20.
PMID: 33727439; PMCID: PMC8012948.
2. https://eyewiki.org/Thygeson_Superficial_Punctate_Keratitis
3. Chung A, Lenci, LT, Wagoner MD. Thygeson’s Superficial Punctate Keratitis.
EyeRounds.org. posted Oct 21, 2015; Available from: https://eyerounds.org/cases/223-Thygesons-SPK.htm
