Case Report: Managing Chronic Thygeson’s SPK with PF LabTRIACTIV as Monotherapy
Case Report
In August 2021, a 55 year-old, Caucasian female with a history of Thygeson’s SPK diagnosed in adolescence presented after a long-lasting 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.
Thygeson’s Superficial Punctate Keratitis (TSPK)
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 sub-epithelial 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.
Presentation – Follow-up duration: 4 years and 5 months
|
Date |
Clinical Findings | Treatment/Intervention | Patient Report/Outcome |
|
Aug 2021 |
OD: 5-6 faint Thygeson’s spots, with scattered 1+ SPK. OS: 7-8 faint Thygeson’s spots, 2 dense spots nasal & inf.; Inflammadry +++ OU: 2+ capped glands, Conj. 1+ injection, TBUT 4-5 sec; mild bulbar staining |
Xiidra BID OU, PF eye lubricant BID-TID, (prior Tobradex for 2 weeks) Recommended: IPL treatment |
Chronic irritation, light sensitivity, fluctuating vision, OS worse than OD. |
|
Nov–Dec 2021 |
Post-IPL for MGD: improvement in irritation and foreign body sensation |
IPL treatment (3 months), continue Xiidra BID, PF eye lubricant BID -TID |
Symptomatic improvement, still some photophobia and occasional “bad days”. |
|
Feb 2022 |
OD: 1 faint spot. OS: 2 faint spots, lids/conjunctiva improved, TBUT 7-8 sec |
Switched Xiidra → Cequa BID, PF eye lubricant BID-TID, hot compress QHS |
Stinging from Xiidra resolved, and symptoms mostly improved. |
|
Jul 2022– Mar 2024 |
Fluctuating symptoms; occasional bad days |
Cequa BID, PF eye lubricant, limited hot compress compliance |
Patient overall stable, no major exacerbations. |
|
Aug 2024 |
OD: 2 dense spots central/inferior + 0.5+ SPK. OS: 2 faint spots, lids/conjunctiva improved, TBUT 7-8 sec OU: 1+ capped glands; trace conj. injection & mild staining |
Cequa BID, PF eye lubricant BID, Lotemax TID x 2 weeks |
Eyes extremely irritated for 3 months; slight relief with Lotemax. |
|
Oct 2024 |
Symptoms slightly improved; Lotemax QD every other day to maintain relief
|
Cequa BID, PF eye lubricant BID, Lotemax QD every other day, patient declined further interventions (IPL, PRP, AM) |
Modest symptomatic relief
|
|
Feb 2025 |
OD: central SPK, no Thygeson spots. OS: 1-2 faint spots, and 1+ nasal SPK OU: 1+ capped glands; trace conj. injection & mild staining
|
Discontinuation of Lotemax; Cequa BID, switched to new lubricant: PF LabTRIACTIV TID, hot compress QHS |
Stable, minimal “bad days”
|
|
Mar 2025 (6-week FUP) |
Eyes calmer; discontinuation of Cequa
|
PF LabTRIACTIV TID only |
Symptoms resolved
|
|
Jul 2025 |
OU: 100% clear cornea, 1+ capped glands, trace conj. Injection.
|
PF LabTRIACTIV TID only |
Symptom-free; stable
|
|
Jan 2026 |
~ 10 months on only PF LabTRIACTIV TID, remains asymptomatic. OS: isolated 1 faint spot, with very mild irritation.
|
Lotemax BID x 1 week |
This represents patient’s longest symptom-free period on eye lubricant alone. While this may be a “winter” flare-up, her condition has clearly improved over the past 10 months and she reports doing well.
|
OD (Aug. 2021)
OD (Jan. 2026)
OS (Aug. 2021)
OS (Jan. 2026)
Final Thoughts
Thygeson’s superficial punctate keratitis (TSPK) is a chronic, recurrent corneal epithelial disorder likely driven by immune-mediated 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. Weiss M, Molina R, Ofoegbuna C, Johnson DA, Kheirkhah A. A review of filamentary keratitis. Surv Ophthalmol. 2022 Jan-Feb;67(1):52-59. doi: 10.1016/j.survophthal.2021.04.002. Epub 2021 Apr 20. PMID: 33862042.
2. Ortiz-Morales, G., Nordmann-Gomes, M. C., Navarrete-Azuara, M., Loya-Garcia, D., Navas, A., Ramirez-Miranda, A., & Graue-Hernandez, E. O. (2025). Filamentary Keratitis: A Persistent Challenge in Ocular Surface Disease. Seminars in Ophthalmology, 1–9. https://doi.org/10.1080/08820538.2025.2507296
