Pain, photophobia, red eye, foreign body sensation, and mildly decreased or fluctuating vision.

(See Figure 4.1.1.)

Figure 4.1.1: Superficial punctate keratopathy stained with fluorescein.

Critical

Pinpoint locations of corneal epithelial cell damage or breakdown that stain with fluorescein. May be confluent if severe. Staining pattern may allude to etiology. Pain is relieved by the instillation of anesthetic drops. Also referred to as punctate epithelial erosions.

NOTE Relief of pain with the instillation of anesthetic drops (e.g., proparacaine) strongly suggests corneal epithelial disease as the etiology of pain. Although anesthetic drop instillation is an essential part of the ocular examination, patients should NEVER be prescribed topical anesthetic drops, and the clinician should ensure the patient does not take anesthetic drops from the office. When used chronically, these drops inhibit epithelial healing and may cause corneal ulceration.

Other

Conjunctival injection and watery discharge.

Superficial punctate keratopathy (SPK) is nonspecific but is commonly associated with the following disorders, which may be associated with a specific staining pattern:

• Superior staining

  • Contact lens–related disorder (e.g., chemical toxicity, tight lens syndrome, contact lens overwear syndrome, giant papillary conjunctivitis). See 4.21, Contact Lens–Related Problems.

  • Foreign body under the upper eyelid: Typically, linear SPK or fine epithelial defects arranged vertically.

  • Floppy eyelid syndrome: Extremely loose upper eyelids that evert easily. See 6.5, Floppy Eyelid Syndrome.

  • Superior limbic keratoconjunctivitis (SLK): Superior bulbar conjunctival inflammation. See 5.4, Superior Limbic Keratoconjunctivitis.

  • Vernal conjunctivitis: Atopy, large conjunctival papillae under the upper eyelid and/or limbus. See 5.1, Acute Conjunctivitis.

• Interpalpebral staining

  • Dry eye syndrome: Poor tear lake, decreased tear break-up time, decreased Schirmer test. See 4.3, Dry Eye Syndrome.

  • Neurotrophic keratopathy: Decreased corneal sensation. May progress to corneal ulceration. See 4.6, Neurotrophic Keratopathy.

  • Ultraviolet burn/photokeratopathy: Often in welders or from sunlamps. See 4.7, Ultraviolet Keratopathy. 

• Inferior staining

  • Blepharitis: Erythema, telangiectasia, or crusting of the eyelid margins, meibomian gland dysfunction. See 5.8, Blepharitis/Meibomitis.

  • Exposure keratopathy: Poor eyelid closure with failure of eyelids to cover the entire globe. See 4.5, Exposure Keratopathy.

  • Topical drug toxicity (e.g., neomycin, gentamicin, trifluridine, atropine, as well as any drop with preservatives, including artificial tears, or any frequently used drop).

  • Conjunctivitis: Discharge, conjunctival injection, and eyelids stuck together on awakening. See 5.1, Acute Conjunctivitis and 5.2, Chronic Conjunctivitis.

  • Trichiasis/distichiasis: One or more eyelashes rubbing against the cornea (superior SPK if misdirected lashes are from upper eyelid). See 6.4, Trichiasis.

  • Entropion or ectropion: Eyelid margin turned in or out (superior SPK if there is an upper eyelid abnormality). See 6.2, Ectropion and 6.3, Entropion.

• Other

  • Trauma: SPK can occur from relatively mild trauma, such as chronic eye rubbing.

  • Mild chemical injury: See 3.1, Chemical Burn.

  • Thygeson superficial punctate keratitis: Bilateral, recurrent epithelial keratitis (raised epithelial staining lesions, not micro erosions) without conjunctival injection. See 4.8, Thygeson Superficial Punctate Keratitis.

1. History: Trauma? Contact lens wear? Eye drops? Discharge or eyelid matting? Chemical or ultraviolet light exposure? Snoring or sleep apnea? Time of day when worse?

2. Evaluate the cornea, eyelid margin, and tear film with fluorescein. Evert the upper and lower eyelids. Check eyelid closure, position, and laxity. Look for inward-growing or misdirected lashes.

3. Inspect contact lenses for fit (if still in the eye) and for the presence of deposits, sharp edges, and cracks.

NOTE A soft contact lens should be removed before instillation of fluorescein.

See the appropriate section to treat the underlying disorder. SPK is often treated nonspecifically as follows:

1. Noncontact lens wearer with a small amount of SPK

   • Artificial tears q.i.d., preferably preservative-free.

   • Can add a lubricating gel or ointment q.h.s.

2. Noncontact lens wearer with a large amount of SPK

   • Preservative-free artificial tears q2h.

   • Ophthalmic antibiotic ointment (e.g., erythromycin q.i.d. for 3 to 5 days).

   • Consider a cycloplegic drop (e.g., cyclopentolate 1% b.i.d.) for relief of pain and photophobia.

3. Contact lens wearer with a small amount of SPK

   • Discontinue contact lens wear.

   • Artificial tears q.i.d., preferably preservative-free.

   • Can add a lubricating gel or ointment q.h.s.

4. Contact lens wearer with a large amount of SPK

   • Discontinue contact lens wear.

   • Antibiotic: Fluoroquinolone drops (e.g., ofloxacin, ciprofloxacin, gatifloxacin, moxifloxacin, or besifloxacin) or aminoglycoside (e.g., tobramycin) drops q.i.d. as well as ophthalmic ointment q.h.s. (e.g., ciprofloxacin or bacitracin/polymyxin B). If confluent SPK, consider ophthalmic antibiotic ointment three to four times per day.

   • Consider a cycloplegic drop (e.g., cyclopentolate 1% b.i.d.) for relief of pain and photophobia.

NOTE DO NOT patch contact lens–related SPK or epithelial defects because they can quickly develop into severely infected ulcers.

1. Noncontact lens wearers with SPK are not seen again solely for the SPK unless the patient is a child or is unreliable. Reliable patients are told to return if their symptoms worsen or do not improve within 2 to 3 days. When underlying ocular disease is responsible  for the SPK, follow-up is in accordance with the guidelines for the underlying problem.

2. Contact lens wearers with a large amount of SPK are seen every several days until significant improvement is demonstrated. Contact lenses are not to be worn until the condition clears. Antibiotics may be discontinued when the SPK resolves. The patient’s contact lens regimen (e.g., wearing time, cleaning routine) or the contact lenses must be adjusted if either is thought to be responsible (see 4.21, Contact Lens–Related Problems). Contact lens wearers with a small amount of SPK are rechecked in several days to 1 week, depending on symptoms and degree of SPK.

NOTE Contact lens wearers should be advised not to wear contacts when their eyes feel irritated.