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Filamentary keratitis improved by blepharoptosis surgery: two cases

2003; Wiley; Volume: 81; Issue: 6 Linguagem: Inglês

10.1046/j.1395-3907.2003.0141.x

1600-0420

Hirohiko Kakizaki, Masahiro Zako, Hidenori Mito, Masayoshi Iwaki,

Ocular Surface and Contact Lens

Sir, Filamentary keratitis presents as long and slender extuberances on the corneal surface where part of the corneal epithelium proliferates excessively (Komuro 2001). The two cases described here showed filamentary keratitis with signs of dry eye and blepharoptosis. After blepharoptosis surgery (levator resection), the filamentary keratitis disappeared in both cases. This is the first report of improvements of filamentary keratitis after blepharoptosis surgery and it suggests that blepharoptosis is a trigger of filamentary keratitis in dry eye patients. Case 1 concerned a 69-year-old female who presented with right filamentary keratitis 2 years after contracting herpes keratitis (Fig. 1). Corneal sensitivity was slightly decreased in the right eye (Cochet-Bonnet: 35 mm). There were dry eye signs in the right eye. Thus, Schirmer's test results (ST, first method) were 2 mm in the right eye and 10 mm in the left eye, while break-up time (BUT) was 3 seconds in the right eye and 7 seconds in the left eye. Conservative treatment, such as topical artificial tears, hyaluronate sodium drops, lacrimal punctum plugs and soft contact lenses were used; but improvements were only transient. As the upper eyelids of the patient showed blepharoptosis, we performed blepharoptosis surgery. After surgery, the filamentary keratitis disappeared completely, while all conservative treatment except for soft contact lenses was continued. Case 1. Top row: pre-operation. (A) Blepharoptosis is observed. (B) On the corneal surface, corneal erosion, filament and diffuse superficial punctuate keratopathy (SPK) are seen. (C) No lesion is observed. Bottom row: post-operation. Blepharoptosis is improved. A smooth corneal surface is seen, and corneal erosion, filament and diffuse SPK have disappeared. (D) Upper eyelids appearance. (E) Right eye. (F) Left eye. Case 2 concerned a 71-year-old female suffering from Sjögren's syndrome, who presented with filamentary keratitis in both eyes (Fig. 2). Bilateral dry eye signs were demonstrated as Schirmer's test results of 2 mm in both eyes and BUT values were 3 seconds in the right eye and 4 seconds in the left. The same treatment as in the first case was undertaken, with a similar course. As the degrees of proptosis were 5 mm in both eyes and the patient's upper eyelids showed blepharoptosis, we performed blepharoptosis surgery on both eyelids. After surgery, filamentary keratitis improved significantly, and the conservative therapies, except for soft contact lenses, were continued. Case 2. Top row: pre-operation. (A) Light blepharoptosis is observed. (B, C) Filament and diffuse SPK are seen on the corneal surface. Bottom row: post-operation. Blepharoptosis is improved. The corneal surface is almost smooth and no filament is observed, but slight SPK is seen. (D) Upper eyelids' appearance. (E) Right eye. (F) Left eye. Dry eye is generally considered to be the cause of filamentary keratitis (Komuro, 2001). In the two cases described here, the causes were thought to include increased mucin viscosity and loss of lacrimal fluid turnover (Maudgal et al. 1979; Zaidman et al. 1985). Additionally, both patients had blepharoptosis. We considered the ptosis to be one of the triggering factors of the filamentary keratitis, and thus performed blepharoptosis surgery with good results. Blepharoptosis induces a deficiency of eye blinks along with filaments caused by longstanding contact between eyelid and cornea, plus inhibition of mucin turnover (Komuro, 2001). Mucin is generally diffused over the cornea by eye blinks (Komuro, 2001), but in blepharoptosis this mechanism is thought to be deficient. Dry eye syndrome can injure the corneal epithelium and increase mucin viscosity, thus inducing filamentary keratitis. Hence, in dry eye patients, blepharoptosis may be considered a trigger of filamentary keratitis. By instituting blepharoptosis surgery in these two cases, both the corneal status and the filamentary keratitis improved.