Ocular Microbiology and Immunology Group
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2014 OMIG Abstract 20

Topical Tacrolimus in Thygeson's Superficial Punctate Keratitis
MC Marquezan, H Nascimento, L Vieira, M Serapião, R Belfort Jr, D Freitas
Department of Ophthalmology and Visual Sciences, Paulista School of Medicine,
São Paulo Hospital, Federal University of São Paulo, Brazil

Introduction: Thygeson's superficial punctate keratitis (TSPK) was originally described by Phillip Thygeson in 1950. Ocular irritation, epiphora, photophobia and visual impairment, with exacerbations and remissions are characteristics of this chronic disease. The diagnosis is clinical with the slit lamp examination, revealing bilateral aggregates of punctate fluorescein staining in the keratitis. The treatment of choice is topical corticosteroid, that needs to be used with care, because long term use can cause elevation of intraocular pressure and cataract. An alternative treatment is topical Tacrolimus, which inhibits the transcription of interleukin 2 in T lymphocytes. The drug is well tolerated, with less ocular and systemic side effects. The purpose of this study is to report the outcomes of using topical Tacrolimus in Thygeson's superficial punctate keratitis.

Material and Methods: This retrospective case series was carried out at Paulista School of Medicine, in São Paulo, Brazil. Medical records of 12 patients diagnosed with Thygeson's superficial punctate keratitis, in use of Tacrolimus, were collected. The following variables were assessed: age, gender, visual acuity prior and after treatment, and the duration of disease and treatment with Tacrolimus. The diagnosis was based on clinical symptoms and signs. The patients were treated with 0.03% Tacrolimus eye ointment, handled by compounding farmacy, which vehicle consists of vaseline and lanolin with no preservatives, twice a day for 15 days, followed by once a day at night. Mild corticosteroid eye drops were prescribed at the first week of treatment.

Results: The patients’ age ranged from 8 to 65 years old and 7 were female. The average follow-up was 7 years, and 33% had visual acuity between 20/30 and 20/50 in both eyes before treatment with improvement to 20/25 or better in all patients. Similarly, 100% of the patients improved symptoms and signs (photophobia, foreign body sensation, tearing and typical superficial punctate keratitis).

Discussion: Thygeson's superficial punctate keratitis is a curious disease that needs to be better understood, its pathophysiology and treatment. Good outcomes were observed, as Reinhard et al showed in a pilot study of 15 patients with corneal and conjunctival disease treated with topical FK 506 0,06%, just 1 had TSPK, and they noted a decrease of the inflammatory changes in the cornea and they suggest to use lower concentrations of local Tacrolimus and believe to be a promising therapeutic option. Miyazaki et al evaluated 10 patients with inflammatory ocular surface diseases but TSPK, and found that topical 0,02% tacrolimus ointment was effective and should be considered an alternative to topical steroids or surgical intervention, and no side effect was noted for 2 to 26 months of treatment. The present patients used for 3 months and according the literature there were no significant side effects. This series cases showed that topical Tacrolimus 0,03% is safe and capable to control TSPK recurrences for a long period with less side effects in comparison to corticosteroids. Because the disease is so rare it is difficult to do conduct randomized studies.

Conclusion: Topical Tacrolimus seems to be effective to control the symptoms and signs of patients with Thygeson's superficial punctate keratitis. Tacrolimus has the advantage of triggering fewer side effects compared to the use of topical steroids, treatment of choice for patients with acute Thygeson Keratitis. The introduction of Tacrolimus in the arsenal of treatment of external eye diseases revolutionized its course and follow-up. Tacrolimus in our opinion is a breakthrough for the treatment of Thygeson's superficial punctate keratitis.

References:
1. Kobayashi et al. Case reports. Disappearance of Honeycomb Opacity of Thiel-Behnke Corneal Dystrophy After Thygeson Superficial Punctate Keratitis Cornea 2005;24:1029–1030.
2. Fintelmann et al. Thygeson Superficial Punctate Keratitis and Scarring. Cornea 2012;31:1446–1448.
3. Kobayashi et al. In Vivo Laser Confocal Microscopy Findings of Thygeson Superficial Punctate Keratitis. Cornea 2011;30:675–680.
4. Tanzer et al. Superficial punctate keratitis of thygeson: the longest course on record? Cornea 1999 Nov;18(6):729-30. 5. Reinhard et al. Topical Fk506 in inflammatory corneal and conjunctival diseases. A pilot study. Article in German Klin Monbl Augenheilkd. 2002 Mar;219(3):125-31.
6. Miyazaki et al. Therapeutic effects of tacrolimus ointment for refractory ocular surface inflammatory diseases Ophthalmology. 2008 Jun;115(6):988-992.e5.
No financial interests to disclose related to this presentation

Disclosure: N

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