Superficial Punctate Keratitis (SPK) and Thygeson's Disease

Superficial punctate keratitis (SPK), also called punctate keratitis, is a scatter of tiny spots of damage on the surface of the cornea, the clear front of the eye. It is a form of keratitis, or inflammation and swelling of the cornea, with many possible causes, among them dry eye, viral pink eye, a reaction to eye drops and eyelids that don't close fully. It can leave the eye red, watery, sore, blurry or sensitive to light, and treatment depends on the cause. Thygeson's superficial punctate keratitis (Thygeson's disease) is a separate condition of unknown cause that flares and settles in both eyes, sometimes for years. Contact lens wearers with pain, redness, blurred vision, light sensitivity or a white spot on the cornea should take the lenses out and call us at 310-828-2010 right away, or go to an emergency room when we're closed.

Key takeaways

Superficial punctate keratitis is a scatter of tiny spots of damage on the cornea's surface, caused by problems such as dry eye, viral pink eye and eye drop reactions.
Treatment follows the cause, from artificial tears for dry eye to resting contact lenses, UV protection or, with your eye doctor, switching to preservative-free drops.
Thygeson's disease is a separate condition of unknown cause that flares and settles in both eyes, and steroid eye drops are its main treatment.
Contact lens wearers with pain, redness, blur, light sensitivity or a white spot need the lenses out and a same-day exam, or an emergency room when the office is closed.

What is superficial punctate keratitis?

Superficial punctate keratitis is a pattern of many pinpoint spots in the outer layer of the cornea. Each word in the name describes the finding: superficial because the spots stay on the surface, punctate because they look like dots, and keratitis because the cornea is inflamed.

Under the magnification of an eye exam, the spots can look different. Some are fine, slightly sunken spots that pick up fluorescein dye, a special eye drop that makes damage to the cornea easier to see, and others are small gray-white dots that show up even without dye.

You may see it written as SPK, or as superficial punctate keratopathy. When an eye doctor finds SPK on the cornea, the next job is finding its cause, since the same pattern comes from many different problems.

What does SPK in the eye feel like?

SPK can make the eye feel gritty or irritated. The American Optometric Association lists redness, pain, excessive tearing, blurred vision and light sensitivity as symptoms of keratitis, and SPK can bring any of them.

The details can hint at the cause: dry eye brings a scratchy feeling, like there's something in your eye, with stinging or burning, while a cornea burned by ultraviolet light causes tearing, pain, swollen eyelids, a feeling of sand in the eye and hazy or decreased vision.

What causes superficial punctate keratitis?

SPK has many causes, from dry eye and contact lens overwear to ultraviolet light, viruses and eye drop preservatives:

Dry eye. If severe dry eye isn't treated, it can sometimes damage the cornea.
Contact lenses. Wearing contact lenses too long can cause keratitis without an infection, and lenses raise the risk of infection too, especially if you sleep in them.
Ultraviolet light. Photokeratitis, which the FDA describes as a sunburn of the cornea, comes from intense UV exposure, such as snow at high altitude or certain tanning lamps.
Viral pink eye, an inflammation of the conjunctiva, the thin membrane over the white of the eye. One adenovirus infection, epidemic keratoconjunctivitis, causes severe inflammation of the conjunctiva and cornea.
Eye drops. Benzalkonium chloride (BAK), a preservative used in approximately 70% of eye drop formulations, is well known to damage the surface cells of the cornea, and glaucoma patients using BAK-preserved drops have a higher rate of punctate keratitis.
Eyelids and lashes. Spots low on the cornea point to inflamed eyelids, lashes that rub the eye, or lids that don't close fully, a problem called lagophthalmos. Bell's palsy, a disorder that causes paralysis or weakness on one side of the face, can make one eyelid hard to close, which dries the eye.
Injuries and chemicals. A scratch, or fumes or liquids splashed in the eye, can cause keratitis.

How is SPK on the cornea diagnosed?

SPK is diagnosed at an eye exam. The doctor looks at the cornea through a microscope and may apply a stain to the surface of your eye to determine the extent of the keratitis.

Where the spots sit, and how coarse they are, narrows down the cause. A review in the Indian Journal of Ophthalmology groups the patterns like this:

Where the spots are, or how they look	What they can point to
A band across the middle, where the cornea is exposed between open lids	Dry eye, or eyelids that don't close fully
The lower cornea	Inflamed eyelids, eyelids that don't close fully, or lashes rubbing the eye
The upper cornea	A speck caught in the eye, or lashes rubbing the eye
Spread across the whole surface	Viral pink eye, a reaction to eye drops, or an injury
Coarse gray-white dots	Thygeson's superficial punctate keratitis, or a herpes virus infection

Your history fills in the rest: how long you wear your lenses and how you clean them, which drops you use and how often, recent hours in strong sun or snow, and whether a cold or pink eye came first.

Our optometrists in Los Angeles put fluorescein dye in the eye and examine the cornea under blue light with the slit lamp (the exam microscope), as we do for a scratched cornea. When dryness looks like the cause, our dry eye evaluation adds tests of tear film stability and imaging of the eyelid oil glands.

How is superficial punctate keratitis treated?

The right treatment depends on what caused the spots. For keratitis without an infection, the AOA says artificial tears may help mild discomfort, while a bandage contact lens and anti-inflammatory eye medicines may be needed in more severe cases.

Dry eye: artificial tears are the most common treatment for mild dry eye. Your eye doctor may also prescribe cyclosporine (Restasis) or lifitegrast (Xiidra), or suggest punctal plugs, tiny plugs in the tear ducts that keep tears on the eye.
Contact lens overwear: the lenses stay out until the cornea heals. Then follow the wearing schedule and care routine your eye doctor prescribes, replace the lens case at least every 3 months, and have the fit checked at a contact lens exam.
Ultraviolet burns: the cornea usually heals in 24 to 48 hours, and a doctor can prescribe drops to help it heal. Sunglasses with 100% UV protection and a wide-brimmed hat lower the risk of eye damage outdoors; see UV protection and sunglasses.
Viral pink eye: it usually clears up in 7 to 14 days without treatment, though some cases take 2 to 3 weeks or more, and cold compresses and artificial tears ease the inflammation and dryness in the meantime.
Eye drop reactions: in clinical studies, eye surface signs and symptoms are consistently better with preservative-free drops than preserved ones, so switching can help; see preservative-free eye drops. If the drop is a prescription, such as a glaucoma drop, don't stop it on your own: ask the doctor who prescribed it whether a preservative-free version would work for you.
Eyelids that don't close: lubricating eye drops or eye patches can help keep the eye moist, and shielding the eye matters most while you sleep.

When are steroid eye drops used for SPK?

Steroid eye drops calm inflammation, and FDA labeling for prednisolone acetate drops lists superficial punctate keratitis among the steroid-responsive inflammatory conditions it treats. The same label says not to use them in most viral diseases of the cornea and conjunctiva, including herpes simplex infection of the cornea's surface, or in fungal eye infections, and it warns that they may hide or worsen an eye infection that produces pus. They carry other risks too: prolonged use may result in glaucoma with damage to the optic nerve and in cataract, and it can raise the risk of other eye infections. The label calls for routine eye pressure checks when the drops are used for 10 days or longer, and it urges great caution in anyone with a history of herpes simplex.

Use steroid drops only when an eye doctor has examined the eye and prescribed them, and don't reach for a leftover bottle. For dry eye flares, our doctors use short courses of loteprednol, a prescription steroid drop, to calm inflamed eyes so longer-term treatment can work; see prescription dry eye drops.

What is Thygeson's disease?

Thygeson's disease, short for Thygeson's superficial punctate keratitis (TSPK), is one specific condition: a chronic disease with flare-ups and quiet spells that involves both eyes, though one eye can flare on its own.

The spots are coarse, oval, slightly raised gray-white dots, gathered mostly in the center of the cornea and confined to its surface layer. The conjunctiva is barely involved, if at all.

Symptoms include irritation, a feeling that something is in the eye, mild pain, light sensitivity and watering. The exact cause is unknown. It has been reported in people aged 2.5 to 70, with an average age of 29, and can last from 2 months to 41 years.

How is Thygeson superficial punctate keratitis treated?

Topical corticosteroids, meaning steroid eye drops, are considered the mainstay of treatment, used during flare-ups when pain, light sensitivity or reduced vision is disabling. Because the disease can last for years, so can treatment, and the Indian Journal of Ophthalmology review advises keeping the eye side effects of long steroid use in mind. It also notes that steroids may prolong the natural course of the disease.

Other options described in the same review include artificial tears for comfort, cyclosporine drops in place of steroids, tacrolimus, and a soft contact lens to relieve symptoms. Cyclosporine and tacrolimus are prescription medicines used off-label here, meaning for a use their FDA labels don't list; cyclosporine eye drops are approved to increase tear production in dry eye.

When is SPK an emergency?

SPK needs same-day care when you wear contact lenses and have pain, redness, blurred vision, light sensitivity or a white spot on the cornea. Take the lenses out first, then call us at 310-828-2010 right away; when we're closed, go to an emergency room.

The CDC's signs of a lens-related infection also include worsening pain and unusually watery eyes or discharge, and it advises calling your eye doctor immediately. The FDA says to keep the lenses in their case and take them with you.

Without contact lenses, call us the same day, or go to an emergency room when we're closed, for eye pain with light sensitivity, a red eye that keeps getting worse, blurred vision with discharge, or a white spot on the cornea. The National Eye Institute lists intense eye pain, a change in vision, blurry vision and very red, watery eyes as reasons to go to the eye doctor or the emergency room right away.

For a chemical splash, rinse with lots of room-temperature water for at least 15 to 20 minutes first, then call Poison Control at 1-800-222-1222 and us or an emergency room.

Call 911 for sudden loss of vision in one or both eyes, even if it comes back, sudden double vision, or any change in vision with face drooping, arm weakness or trouble speaking. Sudden trouble seeing in one or both eyes can be a sign of stroke.

We see eye pain, red eyes and contact lens infections the same day during office hours (Monday 10am to 5pm, Tuesday to Friday 8am to 5pm), and keratitis is one of the red-eye problems we diagnose and treat at urgent eye care visits.

Questions patients ask

Is superficial punctate keratitis an eye infection?

Sometimes, though many of its causes involve no germs. Keratitis may or may not be associated with an infection: SPK from dry eye, ultraviolet light or eye drop preservatives is not an infection and isn't contagious. When a virus is behind it, as in viral pink eye from adenoviruses, it can spread: viral pink eye is very contagious. The cause of Thygeson's disease is unknown. If you wear contacts, treat a painful red eye as a possible infection: take the lenses out and call us at 310-828-2010 for a same-day exam, or go to an emergency room when we're closed.

Is superficial punctate keratitis the same as a corneal ulcer?

No. SPK is a scatter of tiny spots on the surface of the cornea, while corneal ulcers are open sores in the outer layer of the cornea, usually caused by infections. Ulcers can develop very quickly and can be very serious. A white spot on the cornea, especially if you wear contacts, needs a same-day exam, or an emergency room when we're closed; take the lenses out first. Our guide to corneal ulcer symptoms covers the warning signs.

Can superficial punctate keratitis cause corneal scarring?

It can if the cause goes untreated, though damage confined to the surface usually heals. The National Eye Institute notes that small scratches on the cornea usually heal on their own, while deeper injuries can cause corneal scarring, and the AOA warns that keratitis left untreated may permanently damage your vision. If a scar leaves the cornea irregular and blurs your sight, scleral lenses for corneal scarring can give light a smooth new surface to enter through.

Can Sjögren's syndrome cause superficial punctate keratitis?

It can, through dry eye. The National Eye Institute lists autoimmune conditions like lupus or Sjögren syndrome among the risk factors for dry eye, and severe dry eye that isn't treated can sometimes damage the cornea. Our page on Sjögren's and autoimmune dry eye explains how we treat the eye surface alongside your rheumatologist, from prescription drops to scleral lenses.

Sources

Written by

Dr. Kevin Cohenmehr, OD

Medical eye care: glaucoma, diabetic eye exams, macular degeneration and eye infections, plus vision therapy for children. A graduate of UCLA and SUNY College of Optometry.

About Dr. Kevin →

Superficial Punctate Keratitis (SPK): Causes, Treatment and Thygeson's Disease