Case 4: A 20-Year History of TSPK

Case Report

A 38-year-old woman with a few days’ history of photophobia, tearing, and foreign body sensation in both eyes. The eyes were white but the corneae showed many epithelial lesions reminiscent of adenovirus infection. The symptoms subsided rapidly with topical steroid but returned shortly after the treatment was stopped. During the following 10 years, she was more or less continuously treated with variously potent topical steroids prescribed by various practitioners before being diagnosed with Thygeson’s keratitis. During a further 10 years, she was treated with a weak steroid solution (prednisolone sodium phosphate 0.05%) and kept symptomfree with one drop every other day or twice a week. At each visit, both corneae showed a few epithelial lesions and occasionally fine subepithelial opacities, which were coming and going in various locations. The epithelial lesions were still present when last seen, 20 years after onset.

Fig. 6.11 Low-magnification photograph of TSPK lesions stained red with rose bengal (arrows). There is no rose bengal staining in the in-between areas

With the slit lamp, the hallmark of TSPK are coarse granular epithelial lesions spread over the surface. The “atypical” cases are occasional patients in whom this description does not fit; yet, seen at higher magnification, the basic feature – the presence of rounded/abnormal cells within the epithelium – is the same, and so is the accompanying (unspecific) phenomenon of cysts containing one or a few rounded cells. The same history, symptoms, and the extreme cortisone sensitivity added, these patients seem to represent a variant of the same disease in which, for some reasons, the distribution pattern of the rounded/abnormal cells is more diffuse instead of the well-known distinct lesions, and the

cyst are more abundant. Because of the at random confluence resulting in patterns reminding of branching (dendritic) figures, these rare cases tend to be confused with HSV rather than with adenovirus infections.

In Case 1, the pattern of epithelial changes was perhaps reminiscent of an HSV infection, but the diagnostic error could have been avoided by a more careful observation of the substructure which had no resemblance to an active HSV infection whatsoever. In Case 2, a confusion with HSV resulted in postponements of a well-needed cataract operation. Case 3 shows another variant, followed for almost 20 years. In this patient, it was notable that her granddaughter had a typical TSPK.