Medical management of multifocal immune-mediated punctate keratitis in 3 dogs: A case series

Multifocal immune-mediated punctate keratitis (MIPK) is an uncommon corneal disease in dogs characterized by multifocal anterior stromal opacities with fluorescein retention that may not respond to conventional therapy for superficial corneal ulcers. Clinical decision-making is challenging because concurrent corneal epithelial defects are considered a relative contraindication to topical immunosuppressive therapy. Three dogs were presented with multifocal punctate corneal opacities and positive fluorescein staining; MIPK was diagnosed based on characteristic clinical findings and exclusion of infectious causes. All 3 dogs received topical cyclosporine as the primary immunomodulatory agent; 2 dogs were subsequently treated with topical corticosteroids after infectious and non-immune-mediated causes were excluded, and 1 dog initially received a topical nonsteroidal anti-inflammatory drug that was subsequently replaced with a topical corticosteroid. Adjunctive therapies included temporary tarsorrhaphy in 1 dog and bandage contact lens in another. Corneal epithelial defects and stromal opacities improved within 1 to 5 wk and no clinical recurrence was observed during follow-up periods of 4 to 14 wk, despite tapering of anti-inflammatory therapy. These cases support early initiation of topical cyclosporine combined with carefully selected anti-inflammatory agents for canine MIPK, despite the presence of superficial corneal ulceration, provided infectious or non-immune-mediated causes have been thoroughly excluded. Key clinical message: Early initiation of topical cyclosporine combined with carefully selected anti-inflammatory agents effectively managed canine MIPK, even in the presence of superficial corneal ulceration.