Filamentary Keratitis

Highland Ophthalmology

Mary Davidian, MD, is a cornea specialist and medical director at Highland Ophthalmology Associates in New Windsor, NY. DR. Davidian completed her residency at the New York Eye and Ear Infirmary and a cornea fellowship at UC Irvine. She is an active participant of multiple ophthalmology societies. She is a consultant and speaker for BIO‑TISSUE® and can be reached at (845) 562-0138.



Filamentary keratitis is a chronic corneal condition characterized by multiple filaments attached to areas of compromised corneal epithelium. The filaments can be quite extensive and may enmesh calcareous granules, bacteria, and dust particles. Blinking lids pull on the loose ends of the filaments, stimulating the pain-sensitive corneal nerves and creating multiple epithelial defects. Patients often experience foreign body sensation, discomfort, photophobia, pain, and blurry vision. Filamentary keratitis most often accompanies dry eye syndrome and patients may also have underlying systemic conditions, particularly connective tissue disorders. Cryopreserved amniotic membrane contains anti-inflammatory mediators and complex arrays of growth factors and cytokines, which help regenerate a healthy corneal epithelium and may reduce recurrence.


  • Symptoms: Ocular discomfort, foreign body sensation, pain, photophobia, and blurred vision.
  • Examination:
    Tadpole-shaped mucus filaments adhering to the corneal surface, with the tails floating freely within the tear film
  • Rose bengal dye makes the filaments more readily visible on biomicroscopy
  • Reduced tear break-up time and punctate epithelial keratopathy

Treatment Strategy

  • Treat ocular surface inflammation (nonpreserved steroids)
  • Treat associated dry eye (artificial tears/punctal occlusion)
  • Restore corneal integrity (PROKERA®)
  • Prophylactic antibiotics if necessary

Case Study

  • A 68-year-old female presented with acute ocular pain, photophobia, and blurred vision (20/70) for 3 days. She had a history of similar repeated attacks as well as dry eye (treated with artificial tears and punctal plugs).
  • Diagnosis of filamentary keratitis was confirmed based on the clinical findings of positively stained mucus strands attached to the cornea (Fig. A, C)
  • Numerous treatment regimens were implemented, including non-preserved artificial tears, lubricating ointment, and topical steroids for 2 months without success
  • Without debridement, PROKERA® was placed for 3 days. Her symptoms were completely relieved, filaments disappeared, and the cornea became clear (Fig. B, D). Her vision improved to 20/40.


Filamentary keratitis is a recurrent and incapacitating condition that may prove difficult to manage. PROKERA® effectively treated the above patient and restored a healthy corneal epithelium.

Bonini S, Rama P, Olzi D, Lambiase A. Neurotrophic keratitis. Eye (Lond). 2003;17(8):989-995.
Touhami A, Grueterich M, Tseng SC. The role of NGF signaling in human limbal epithelium expanded by amniotic membrane culture. Invest Ophthalmol Vis Sci. 2002;43(4):987-994.
Pachigolla G, Prasher P, Di Pascuale MA, et al. Evaluation of the role of ProKera in the management of ocular surface and orbital disorders. Eye Contact Lens. 2009;35(4):172-175.
Kent HD, Cohen EJ, Laibson PR, Arentsen JJ. Microbial keratitis and corneal ulceration associated with therapeutic soft contact lenses. CLAO J. 1990;(16):49-52.
Sheha H, Liang L, Li J, Tseng SC. Sutureless amniotic membrane transplantation for severe bacterial keratitis: Cornea. 2009;28(10):1118-1123.
Tseng SC. A practical treatment algorithm for managing ocular surface and tear disorders. Cornea. 2011;30(suppl 1):S8-S14.
Chotikavanich S, de Paiva CS, Li de Q, et al. Production and activity of matrix metalloproteinase-9 on the ocular surface increase in dysfunctional tear syndrome. Invest Ophthalmol Vis Sci. 2009;50(7):3203-3209.
Reidy JJ, Paulus MP, Gona S. Recurrent erosions of the cornea: epidemiology and treatment. Cornea. 2000;19(6):767-771.
Chen YT, Huang CW, Huang FC, et al. The cleavage plane of corneal epithelial adhesion complex in traumatic recurrent corneal erosion. Mol Vis. 2006;12:196-204.
Fini ME, Cook JR, Mohan R. Proteolytic mechanisms in corneal ulceration and repair. Arch Dermatol Res. 1998;290(suppl):S12-23.
Heiligenhaus A, Li HF, Yang Y, et al. Transplantation of amniotic membrane in murine herpes stromal keratitis modulates matrix metalloproteinases in the cornea. Invest Ophthalmol Vis Sci. 2005;46(11):4079-4085.
Narayanan R, Gaster RN, Kenney MC. Pseudophakic corneal edema: a review of mechanisms and treatments. Cornea. 2006;25(9):993-1004.
Lee HK, Kim JK, Kim EK, et al. Phototherapeutic keratectomy with amniotic membrane for severe subepithelial fibrosis following excimer laser refractive surgery. J Cataract Refract Surg. 2003;29(7):1430-1435.