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Symptoms ⬇

Moderate-to-severe pain, red eye, foreign body sensation, tearing, and photophobia.

Signs ⬆ ⬇

Critical

Short fluorescein-staining strands of degenerated epithelial cells surrounding a mucus core adherent to the anterior surface of cornea.

Other

Conjunctival injection, poor tear film, and punctate epithelial defects.

Etiology ⬆ ⬇

  • Severe ocular dryness: Most common cause. See 4.3, DRY EYE SYNDROME.
  • SLK: Filaments are located in the superior cornea, in association with superior conjunctival injection, superior punctate fluorescein staining, and superior corneal pannus. See 5.4, SUPERIOR LIMBIC KERATOCONJUNCTIVITIS.
  • Recurrent corneal erosions: Recurrent spontaneous corneal abrasions often occurring upon waking. See 4.2, RECURRENT CORNEAL EROSION.
  • Adjacent to irregular corneal surface (e.g., postoperative, near a surgical wound).
  • Patching (e.g., postoperative, after corneal abrasions) or ptosis.
  • Neurotrophic keratopathy: See 4.6, NEUROTROPHIC KERATOPATHY.

Work Up ⬆ ⬇

Workup
  1. History, especially for the previously mentioned conditions.
  2. Slit lamp examination with fluorescein staining.

Treatment ⬆ ⬇

  1. Treat the underlying condition.
  2. Consider debridement of the filaments. After applying topical anesthetic (e.g., proparacaine), gently remove filaments at their base with fine forceps or a cotton-tipped applicator. This gives temporary relief, but the filaments will recur if the underlying etiology is not treated.
  3. Treatment with one or more of the following regimens:
    • Preservative-free artificial tears six to eight times per day and lubricating gel or ointment q.h.s.
    • Punctal occlusion.
    • Acetylcysteine 10% q.i.d.
  4. If the symptoms are severe or treatment fails, then consider a bandage soft contact lens (unless the patient has severe dry eyes as underlying etiology). Extended-wear bandage soft contact lenses may need to be worn for weeks to months. Concomitant prophylactic or therapeutic topical antibiotics such as fluoroquinolone drops are typically given, especially if associated with a corneal abrasion/epithelial defect. A scleral lens may be helpful in recalcitrant cases.
NOTE:

Acetylcysteine is not commercially available as a drop but can be made by a compounding pharmacy.

Follow Up ⬆

In 1 to 4 weeks. If the condition is not improved, consider repeating the filament removal or applying a bandage soft contact lens. Long-term lubrication must be maintained if the underlying condition cannot be eliminated.