Fluorescein staining comes in many different patterns and presentations. Although corneal filaments tend to stand out when stained with fluorescein, they can be missed and mistaken for excessive tear debris, which is common in ocular surface disease.
Adherence of these mucus strands to the corneal basal epithelium or basement membrane can be a differentiating feature of filamentary keratitis that can help lead the clinician down the right path in the treatment and management of this condition.
A 56-year-old female patient presented to our clinic for consultation. She was referred from an outside optometrist for severe dry eye disease. The patient presented with complaints of a sandy, gritty feeling in both eyes, especially at night and before bed. She also complained of fluctuating vision, worse in the morning and evening.
Her only medications were omega-3 supplements. The referring provider prescribed fluorometholone 0.1% (FML, Allergan) three times per day into her right eye; however, she reported no improvement in symptoms after using this medication for 10 days. Her medical history was unremarkable.
Entering visual acuity was 20/40 OD and 20/20 OS with a recent spectacle correction. Entrance tests and intraocular pressure (IOP) were normal, as was her dilated fundus exam.
Anterior segment exam revealed mild meibomian gland disease (MGD) in both eyes, a minimal tear meniscus in both eyes, and 2+ injection in both eyes. A significant amount of superficial punctate keratitis in both eyes (3+ and 2+, OD and OS, respectively) was also noted. In addition, several small filaments were seen attached to the inferior cornea in the right eye.
After suspicion of an underlying systemic etiology, a rheumatology consult and a Sjögren’s lab panel was ordered in coordination with the patient’s primary-care physician. This patient’s tentative diagnosis of Sjögren’s syndrome and secondary dry eye was confirmed by rheumatology. The patient began systemic therapies, including oral pilocarpine (Salagen, Eisai) and hydroxychloroquine (Plaquenil, Sanofi-Aventis).
The patient was diagnosed with severe dry eye disease and filamentary keratitis. Initial treatment included removal of the filaments, aggressive lubrication, and prednisolone acetate 1% (Pred Forte, Allergan) steroid drops six times daily in both eyes.
Once the anti-inflammatory medications were on board and there was noted stabilization of matrix metalloproteinase-9 (MMP9) levels with InflammaDry (Quidel) testing, we opted to perform complete punctal occlusion to maximize tear volume on the ocular surface.
As our patient’s condition improved with the initial therapy, the patient was changed to Lotemax (loteprednol etabonate, Bausch + Lomb) to minimize the side effect profile and Xiidra (lifitegrast, Shire) for long-term anti-inflammatory therapy.