Ophthaproblem

Answer to Ophthaproblem continued from page 667 membrane detachment. With time and mechanical shear-
ing of the eyelids, these areas become elevated and act as
2. Filamentary keratitis receptor sites for mucous and degenerated epithelial cells.
Filamentary keratitis (FK) is a relatively uncommon disor- Once established, corneal filaments are firmly attached
der1-3 characterized by the presence of corneal filaments to the underlying epithelium and the friction between
(Figure 1),3 which are fine strands of degenerated epithe- them and the upper lid results in epithelial tears, pain, and
lial cells and mucous attached to the cornea.1,2,4 It can be inflammation, leading to further filament formation.2,4,5
chronic and debilitating, with recurrent exacerbations.1,5
Management
Figure 1. Corneal filament viewed with normal and For some, FK can be managed with preservative-free arti-
cobalt blue light after fluorescein staining ficial tears.2,5 In other cases, several treatments might be
required. Debridement of filaments might cause swift relief
of symptoms, but it is important to treat the underlying
disease when possible.1,2,5 Other options include muco-
lytic agents, hypertonic saline, topical nonsteroidal anti-
inflammatory drugs, topical steroids, punctual plugs, and
bandage contact lenses.1,2,5 Judicious use of topical medi-
Patients often present with discomfort, photophobia,3 cations is important, as the cornea is more susceptible
foreign body sensation, blurred vision,1 grittiness, blephar- to the intrinsic and preservative toxicities of the medica-
ospasm, and increased blinking.2,5 Signs include decreased tions.1 Topical steroids should be reserved for acute exac-
corneal sensation, corneal filaments, mucous debris, red- erbations, as overuse can lead to cataract formation and
ness,1 superficial punctate keratopathy, and punctate epi- increased intraocular pressure.1,5 Short-term treatment
thelial erosions, as well as abnormal tear break-up time with soft contact lenses is beneficial to allow the basal epi-
and Schirmer test results.5 Impression cytology of the con- thelial cells to re-attach to the basement membrane.2,4,5 It
junctiva might reveal squamous metaplasia and reduced is important to treat concomitant ocular surface problems
goblet cell density with inflammatory cell infiltrates.1 The such as meibomitis1 with warm compresses, eyelid margin
size and shape of corneal filaments might vary and, with hygiene, and in severe cases oral tetracyclines.
time, become fatter, longer, and more twisted owing to Patient education and counseling are crucial for long-
mechanical forces of the eyelids.1,2,5 They stain best with term management.1,5 Many of the underlying etiologies
rose bengal dye and less well with fluorescein.2,5 have no cures, and patients should be prepared to incor-
Filamentary keratitis can be a functionally debilitat- porate a maintenance regimen into their daily routines.5
ing and sight-threatening complication of a number Acute exacerbations are common, and regular follow-up
of systemic and ocular conditions,1 most commonly the visits might be necessary to ensure vision is preserved.5
aqueous-deficient dry eye conditions, also known as kera- Our patient was treated with acetylcysteine eye drops 4
toconjunctivitis sicca (KCS).1 Both the autoimmune (Sjögren times daily for 2 weeks, combined with 5 minutes of warm
syndrome) and nonautoimmune forms of aqueous-defi- compresses twice daily to promote proper eyelid margin
cient dry eye can feature corneal filaments.1 Kowalik and meibomian gland function. Symptoms and corneal fila-
Rakes reported that 95% of corneal filaments were second- ments resolved without debridement. She uses an ocular
ary to KCS and that evidence of rheumatologic disease was lubricant and warm compresses to prevent recurrence.
present in 75% of patients with KCS.2 Superior limbic kera-
Conclusion
toconjunctivitis is the second most common disease asso-
Filamentary keratitis is relatively uncommon but has poten-
ciated with corneal filaments; as many as 50% of patients
tially sight-threatening consequences.1 Thorough systemic
develop FK during the course of their disease.2 Other con-
examination and hematologic workup are important in
ditions associated with FK include exposure keratitis; cor-
chronic cases to investigate for conditions such as Sjögren
neal edema; postcataract, corneal, or refractive surgery; and
syndrome, rheumatoid arthritis, and thyroid disease.5 
contact lens use.1-5 Less often, FK is associated with acne Mr Ehmann is a fourth-year medical student at the University of Saskatchewan in
rosacea and adenoviral, herpetic, and bacterial keratitis.2 Saskatoon. Dr Schweitzer is a resident and Dr Baxter is an Assistant Professor, both
in the Department of Ophthalmology at Queen’s University in Kingston, Ont.
Systemic medications such as diuretics and antihistamines Acknowledgement
are capable of altering aqueous tear and mucous produc- We thank Patricia Pauls for taking the photographs used in this article.
Competing interests
tion, and have been associated with FK.5 Filaments might None declared
also result from extended eyelid closure secondary to medi- References
1. Albietz J, Sanfilippo P, Troutbeck R, Lenton LM. Management of filamentary keratitis
cations, extended patching, or psychiatric conditions. associated with aqueous-deficient dry eye. Optom Vis Sci 2003;80(6):420-30.
2. Kowalik B, Rakes J. Filamentary keratitis—the clinical challenges. J Am Optom Assoc
The exact pathogenesis of FK is unclear.1,4 Zaidman 1991;62(3):200-4.
3. Tabery HM. Filamentary keratopathy: a non-contact photomicrographic in vivo
et al4 hypothesized that an underlying process dam- study in the human cornea. Eur J Ophthalmol 2003;13(7):599-605.
4. Zaidman GW, Geeraets R, Paylor RR, Ferry AP. The histopathology of filamentary
ages the basal corneal epithelium, basement membrane, keratitis. Arch Ophthalmol 1985;103(8):1178-81.
5. Diller R, Sant S. A case report and review of filamentary keratitis. Optometry
or Bowman layer, leading to focal areas of basement 2005;76(1):30-6.

Vol 56:  july • juillet 2010  Canadian Family Physician • Le Médecin de famille canadien  673