The Histopathology of
Filamentary Keratitis
Gerald W. Zaidman, MD; Ragnit Geeraets, PhD; Ralph R. Paylor, MD; Andrew
\s=b\ Filamentary keratitis is character-
ized by the presence of fine filaments of
epithelium and mucus that are attached to
the cornea. The exact pathogenesis of
this entity has remained unclear. One
reason has been the lack of pathologic
specimens of corneas from patients with
filamentary keratitis. We examined the
corneas of a patient who had died while
suffering from filamentary keratitis. Scat-
tered groups of inflammatory cells and
fibroblasts were present just below the
basal epithelium. It seemed that these
cells had disrupted the epithelial base-
ment membrane and Bowman's layer. To
our knowledge, this is the first postmor-
tem analysis of a cornea in a patient with
acute filamentary keratitis. These find-
ings support the theory that filamentary
keratitis results from damage to the basal
epithelial cells, epithelial basement mem-
brane, or both.
(Arch Ophthalmol 1985;103:1178-
1181)
Accepted for publication Feb 15, 1985.
From the Department of Ophthalmology, Med-
ical College of Virginia, Virginia Commonwealth
University (Drs Zaidman, Geeraets, Paylor, and
Ferry) and the Department of Ophthalmology,
McGuire Veterans Administration Hospital (Dr
Zaidman), Richmond, Va.
Presented in part before the annual meeting of
the Association for Research in Vision and Oph-
thalmology Inc, Sarasota, Fla, May 4, 1984.
Reprint requests to the Department of Oph-
thalmology, Medical College of Virginia, Virginia
Commonwealth University, Box 262, MCV Sta-
tion, Richmond, VA 23298 (Dr Zaidman).
Downloaded From: http://archopht.jamanetwork.com/ by a UQ Library User on 06/19/2015
P. Ferry, MD
"CMlamentary keratitis is a relatively
* uncommon disorder characterized
by the presence of strands of epitheli¬
um and mucus attached to the cornea.
Although it is associated with a num¬
ber of corneal conditions, the cause is
unknown. There has been much specu¬
lation on the origin of the filaments.
It has been theorized that filaments
are due to (1) focal abnormalities of
the superficial corneal epithelium1; (2)
scattered areas of damage to the basal
epithelium, epithelial basement mem¬
brane, or Bowman's layer2; or (3)
excess mucus.3 The lack of pathologic
specimens from patients with fila¬
mentary keratitis, however, has ham¬
pered research into this entity.
In this article we present observa¬
tions from what we believe is the first
postmortem analysis of a patient with
filamentary keratitis. These observa¬
tions indicate that filamentary kera¬
titis may be caused by damage to the
basal epithelial cells, the epithelial
basement membrane, or both.
REPORT OF A CASE
In January 1983, we examined a 25-
year-old man who had been comatose since
March 1982, secondary to a drug-induced
brain-stem injury. He had been treated
with topical antibiotics, bland ointments,
and short courses of patching of both eyes
because of chronic conjunctivitis and expo¬
keratitis.
sure
Ocular examination revealed severe
blepharospasm and bilateral filamentary
keratitis (Fig 1). Corneal sensation was
present and seventh cranial nerve function
seemed normal. A soft contact bandage
lens was placed in both eyes. Within a few
days, the filaments disappeared and the
patient could easily open his eyes. We had
difficulty, however, in maintaining the
contact lenses in his eyes. They would
frequently come out, leading to a recur¬
rence of filaments. The contact lenses had
come out of the
patient's eyes about seven
days before his death. As a result, when
the patient died in May 1983, he was again
suffering from filamentary keratitis. Sev¬
eral hours after death both eyes were
enucleated and immediately immersed in a
solution of 4% glutaraldehyde.
HISTOPATHOLOGIC FINDINGS
Several filaments were noted to be
attached to the corneal epithelial sur¬
face of both eyes. Findings from the
remainder of the gross examination of
both eyes were normal. To leave the
filaments undisturbed the corneas
were carefully excised. The corneas
were then sectioned so that a piece of
cornea from each eye with an
attached filament was available for
processing for both light and electron
microscopy. Standard histopathologic
and electron microscopic techniques
were then used.
Unfortunately, the filaments came
off of the corneas during processing.
Light and electron microscopic exami¬
nation of the corneas of both eyes,
however, revealed similar histopatho¬
logic changes. Scattered groups of
inflammatory cells and fibroblasts
were present just below the basal
epithelium (Pigs 2 and 3). These cells
had infiltrated through Bowman's
layer and disrupted the epithelial
basement membrane (Fig 4). In some
areas, the basement membrane was
replaced by vacuoles and bundles of
 Fig 1.—Clinical appearance of filamentary keratitis. Fig 2.—Photomicrograph of superficial cornea shows corneal epitheli¬
um (E), Bowman's layer (BL), and corneal stroma (S). Group of
inflammatory cells and fibroblasts (arrowheads) are just below basal
epithelium (hematoxylin-eosin, X160).

Fig 3.—Electron micrograph of basal corneal

epithelium (E), epithelial basement membrane
(brackets), and Bowman's layer (BL). Epitheli¬
al basement membrane is discontinuous.
Fibroblasts are present between basal epithe¬
lium and Bowman's layer (X6.800).

Fig 4. Disruption of epithelial basement

membrane (arrowheads) by cells that had
—

infiltrated through Bowman's layer (BL).

Superficial corneal epithelium (E) and corneal
stroma (S) appear intact (hematoxylin-eosin,
X160).

Downloaded From: http://archopht.jamanetwork.com/ by a UQ Library User on 06/19/2015

 Fig 6.—Complete loss of Bowman's layer (BL)
from one area of cornea. Corneal epithelium
(E) and corneal stroma (S) appear normal
(hematoxylin-eosin, X160).

Fig 7.—Light microscopy of cornea shows

that some corneal epithelial cells (E) have lost
their usual polarity and are oriented toward
cells that have migrated through and disrupted
Bowman's layer (BL). In this area epithelial
basement membrane (arrowheads) is absent.
Corneal stroma (S) appears intact. In addition
basal epithelial cells are less periodic acid-
Schiff-positive than superficial cells (periodic
acid-Schiff, X160).

Fig 5.—Transmission electron microscopy of basal corneal epithelium (E), epithelial basement
membrane (brackets), and Bowman's layer (BL). Discontinuous basement membrane has been
replaced by vacuoles and fibrillarlike material (arrowheads) (X 16,320). ment membrane and Bowman's layer.
Maudgal et al' hypothesized that
there were areas of focal degeneration
fibrillarlike material (Fig 5). There erosions, ocular surgery, viral kerati¬ of the superficial epithelium. Wright,3
were areas in which Bowman's layer tis and, as in this patient, brain-stem however, concluded that filaments are
was absent (Fig 6). Some of the over¬ injuries.4 This variety of disorders has primarily composed of mucus with
lying epithelial cells had lost their led to several theories regarding the epithelial cells attached secondarily
normal polarity and appeared ori¬ origin of filamentary keratitis. Be¬ and that filaments form when excess
ented toward the "invading" cells (Fig cause filaments have generally been mucus and receptor sites (composed of
7). In general, the basal epithelial found to be composed of a combina¬ localized patches of slightly elevated
cells were considerably less periodic tion of mucus and degenerated epithe¬ epithelial cells) are present.
acid-Schiff-positive than the superfi¬ lial cells,5 most of the theories have Our findings support the hypothesis
cial epithelial cells (Fig 7). centered on these two factors. The that filaments are of epithelial origin.
oldest theory is that elevation of the We found an abnormality beneath the
COMMENT basal epithelial cells consisting of seg¬
corneal epithelium predisposes to fila¬
Corneal filaments can occur in dry ment formation. Thiel et aP postu¬ mentai damage to the epithelial base¬
eye syndromes, superior limbic kera¬ lated this was due to a lesion at the ment membrane, with groups of
toconjunctivitis, corneal edema, pro¬ level of the basal epithelial cells, pos¬ inflammatory cells and fibroblasts
longed occlusion, recurrent corneal sibly involving the epithelial base- disrupting the interface between Bow-

Downloaded From: http://archopht.jamanetwork.com/ by a UQ Library User on 06/19/2015


Fig 8.—Hypothesized sequence of events in
(lament formation. Top, Damage to basal
epithelial cells, epithelial basement mem¬
brane, and Bowman's layer. Center, Irregular
elevation of corneal epithelium- Bottom, For¬
mation of flament.
man's layer and the epithelial base¬
ment membrane. Therefore, we
believe the initial step in filament
formation is damage to the basal epi¬
thelial cells, epithelial basement
membrane, or Bowman's layer. These
lesions may lead to focal areas of
epithelial basement membrane de¬
tachment. With time, and under the
shearing influence of the blinking eye¬
lids, these affected areas of epitheli¬
um can become elevated (Fig 8). As
the corneal surface becomes irregular,
the eye becomes further inflamed
with resultant production of large
amounts of mucus and debris. The
areas of epithelial elevation then
serve as receptor sites for this materi¬
al with eventual formation of fila¬
ments. The force of the eyelids eventu¬
ally tears the filament off its base
(leaving a bare area of epithelial base¬
ment membrane or Bowman's layer,
which can be further traumatized).
This theory also explains the value of
bandage soft contact lenses in treat¬
ing filamentary keratitis.' The ban¬
dage lens protects the epithelial sur¬
face from the shearing effects of the
eyelids and protects any denuded
areas of epithelial basement mem-
brane and Bowman's layer from fur¬
ther trauma. This may permit the
basal epithelium to smoothly reattach
to the epithelial basement membrane
and prevent the formation of elevated
receptor sites for the filaments.
This investigation was supported in part by
grants from Research to Prevent Blindness Ine,
New York, the A. D. Williams Fund, Medical
College of Virginia, Richmond, and the Veterans
Administration.
Peter Schatzki, HD, and Jane Payne provided
assistance with electron microscopy.
References
1. Maudgal PC, Missotten L, Van Deuren H:
Study of filamentary keratitis by replica H:
nique. Graefes Arch Clin Exp Ophthalmol 1979;
211:11-21.
2. ThielHJ, Bl\l=u_\mckeS, Kessler WD: Zur
pathogenese der keratopathia filamentosa (Ker-
atitis filiformis): Lichtund elektronmikrosko-
pische Untersuchung. Graefes Arch Clin Exp
Ophthalmol 1972;184:330-344.
3. Wright P: Filamentary keratitis. Trans
Ophthalmol Soc UK 1975;95:262-266.
4. Davis WG, Drewry RD, Wood TO: Filamen-
tary keratitis and stromal neovascularization
associated with brain-stem injury. Am J Oph-
thalmol 1980;90:489-491.
5. Theodore FH: Filamentary keratitis. Con-
tact Lens J 1982;8:137-146.
6. Bloomfield SE, Gasset AR, Forstot SL, et al:
Treatment of filamentary keratitis with the soft
contact lens. Am J Ophthalmol 1973;76:978-980.

Currently in Other AMA Journals

ARCHIVES OF NEUROLOGY
Cerebral Latéralisation: Biological Mechanisms, Associations, and Pathology: IH. A
Hypothesis and a Program for Research
Norman Geschwind, MD, Albert M. Galaburda, MD (Arch Neurol 1985;42:634-654)

Spatial Vision in Alzheimer's Disease: General Findings and a Case Report

Mary Jo Nissen, PhD; Suzanne Corkin, PhD; Ferdinando S. Buonanno, MD; John H.
Growdon, MD; Shirley H. Wray, MD; Joseph Bauer, MS (Arch Neurol 1985,42:667-
674)
Ventricular Size and Neuropsychological Impairment
Stephen M. Rao, PhD; Sander Glatt, MD; Thomas A. Hammeke, PhD; Michael P.
McQuillen, MD; B. 0. Khatri, MBBS; Ann Marie Rhodes, MA; Susan Pollard, MA (Arch
Neurol 1985;42:678-682)

Optic Neuritis and Multiple Sclerosis

George C. Ebers, MD, FRCP(C) (Arch Neurol 1985;42:702-703)
Optic Neuritis or Multiple Sclerosis
John F. Kurtzke, MD (Arch Neurol 1985;42:704-709)
Optic Neuritis and Multiple Sclerosis
Vladimir Hachinski, MD FRCP(C) (Arch Neurol 1985;42:710-711)

Pituitary Apoplexy: A Review

Robert L. Reid, MD; Malachi E. Quigley, MD; Samuel S. C. Yen, MD, DS (Arch Neurol
1985;42:712-719)

Downloaded From: http://archopht.jamanetwork.com/ by a UQ Library User on 06/19/2015