Punctate keratopathy on the cornea and
conjunctiva indicates severe keatoconjunctivitis sicca

Case Report ID: 17


Keratoconjunctivitis Sicca


Ocular Surface Disease  (3)


This case presents amniotic membrane therapy to treat the corneal and conjunctival sequelae of severe keratoconjunctivitis sicca.

Keratoconjunctivitis sicca is diagnosed based on patient history, dry eye symptoms, and definite clinical signs of keratoconjunctivits sicca.

  • Conjunctival epitheliopathy
  • Corneal epitheliopathy
  • Conjunctival hyperemia

Keratoconjunctivitis sicca is characterized by the following clinical features:

  • The loss of water from the tear film increases its osmolarity above the normal limit of 311 mOsm/L
  • The increase in tear film osmolarity is the link between changes in the lacrimal glands, changes in the eyelids, and disease of the ocular surface

Keratoconjunctivitis sicca evolves through a sequence of four milestones:

1.  Loss of water from the tear film with an increase in tear film osmolarity
2.  Decreased conjunctival goblet cell density and decreased corneal glycogen
3.  Increased corneal epithelial desquamation
4.  Destabilization of the cornea-tear interface

Case Report

  • 82-year-old White female presented with a chief complaint of severe discomfort with dry eyes and blurred vision
  • Case history described cataract surgery on both eyes five months prior
  • Has had dry eyes for nearly 20 years



History of Present Illness

  • Associated signs and symptoms:  severe discomfort
  • Location:  vision is worse in the right eye
  • Duration:  several years
  • Quality:  n/a
  • Context:  decreased vision is interfering with daily activities
  • Severity:  no increase in visual acuity after cataract surgery
  • Timing:  vision seems to be getting worse over time
  • Modifiers:  none

Review of Systems

The patient reported that she was in poor health and taking medications for hypertension, thyroid disease, high cholesterol, and acid reflux.

Past, Family and Social History


Uncorrected Distance Visual Acuity

  • 20/200 in the right eye
  • 20/60 in the left eye

Normal Examination Findings

  • Mental status
  • General medical observation
  • Pupils
  • Gross visual fields
  • Basic sensorimotor examination
  • External examination
  • Adnexal examination
  • External ocular examination with biomicroscopy

Intraocular Pressure Measurements

  • 15 mm Hg in the right eye
  • 16 mm Hg in the left eye

External Ocular Examination With Biomicroscopy

  • Normal fundus appearance in the right eye
  • Focal geographic atrophy in the left macula
Clinical Appearance of the Cornea

  • Damaged epithelial cells stain
  • Dry spots form over damaged areas of the corneal epithelium
  • Geographic areas of abnormal epithelial sloughing stain
  • When large areas of the corneal epithelium are damaged or missing, the lack of microvilli to create a cornea-tear interface leads to areas of poor corneal wetting
  • Areas of poor corneal wetting are indicated by dark spots or streaks (dry spots) visible in the tear film after the blink
Clinical Appearance of the Conjunctiva

  • Abnormal increase in epithelial sloughing results in immature conjunctival epithelial cells moving onto the surface of the eye
  • Immature cells do not have the surface cell coating of glycoprotein (mucin) needed for tear film bonding
  • Uncoated cells are subject to an increase in dessication and injury due to poor tear film bonding
  • Lissamine green dye stains the areas of the conjunctival surface that are not protected by mucin
  • As the conjunctival desquamation accelerates, the damaged cells release inflammatory mediators onto the surface of the eye and the inflammatory process begins

Clinical Diagnosis

The clinical diagnosis is a determination based on the knowledge obtained from the patient’s medical history and from the results of the eye examination alone, without the benefit of diagnostic tests or procedures.

The patient’s clinical diagnosis is keratoconjunctivitis sicca based on the following clinical findings:

  • Severe symptoms
  • Severe conjunctival staining
  • Severe corneal staining
  • Corneal erosions

Treatment Plan

To gather the information required to treat keratoconjunctivitis sicca, a diagnostic and treatment program is initiated.

  • Determination of different types of diagnoses
  • Selection of one or more treatment options

Ordering Diagnostic Tests

When additional clinical information is needed to complete the differential diagnostic process or to assist in the treatment program, diagnostic tests or services are ordered.  The performance of these tests and/or services leads to the completion of the differential diagnostic process while simultaneously initiating the treatment program. 

Based on the clinical diagnosis of keratoconjunctivitis sicca, the following diagnostic tests were ordered at the conclusion of the eye examination: 

  • External ocular photography
  • Corneal topography

External Ocular Photography

Any case of compromised tissue that could pose a threat to function could justify the medical necessity of photodocumentation.  In this case, the compromised cornea tissue posed risks of infection, scarring and neovascularization.  Photodocumentation of the tissue provides a baseline to monitor disease regression and efficacy of treatment.

Corneal Topography



Physical Diagnosis

Completion of the differential diagnosis process either returns you to the original clinical diagnosis or it produces a more substantiated physical diagnosis.  This component of the diagnostic and treatment program, the determination of a physical diagnosis, is accomplished by studying the physical manifestations of health and illness revealed in the eye examination, the patient’s complete medical history, and supported by various diagnostic tests and procedures.

The diagnostic tests results help substantiate the physical diagnosis of keratoconjunctivitis sicca and provide a framework for monitoring changes in the disease and response to therapeutic intervention.

According to Current Procedural Terminology, when eye doctors perform ophthalmological examinations, the complexity of medical decision-making is not separated from the examining techniques used.  However, as a tool to assist eye doctors in enhancing their medical decision-making skills, consider that the complexity of medical decision-making in this case report involves three components.

Diagnosis Guidelines

The first component concerns the number of possible diagnoses and treatment options that must be considered.  The diagnosis and treatment of a dry eye syndrome is predicated on making the proper diagnosis and on understanding the natural history of the effects of chronic dessication on the corneal tissue.

The second component concerns the amount and complexity of medical records and diagnostic tests that have to be obtained, reviewed and analyzed.  In addition to an eye examination, this visit required the review and analysis of external photodocumentation.

Third, the complexity of medical decision-making is affected by the risk of significant complications and/or morbidity associated with neurotrophic keratopathy and the risks involved in any treatment options.  

Treatment Options

To begin the treatment of keratoconjunctivitis sicca, the eye doctor must firmly establish the underlying etiology.  In most cases, primary treatment of the resultant corneal condition is either supportive (moisturize) or prophylactic (antibiosis).  But in most cases, unless the underlying causative factor is addressed, the condition tends to become chronic and more severe.

Surgical Treatment

Amniotic Membrane Inserts

ProKera Amniotic Membrane Insert

  • Cryopreserved amniotic membrane graft fastened to a thermoplastic symblepharon ring
  • The device acts as a self-retaining biological bandage
  • Promotes reepithelialization
BioDOptix Amniotic Membrane Insert

The device acts as a self-retaining biological bandage.

  • Dehydrated amniotic membrane graft
  • Treats ocular surface disease
  • Anti-inflammatory
  • Anti-angiogenic
  • Anti-scarring
BioDOptix Amniotic Membrane Insert

  • This device can be considered in cases of extreme epithelial compromise
  • Although the amniotic membrane provides no curative effect on this corneal disease, it can bring the epithelial structure into a more stable state where other treatment options can be more effective

Protection of the irritated cornea can be accomplished with a standard bandage contact lens or application of a BioDOptix amnionic membrane insert.

Insertion of the Amniotic Membrane Graft

Step 1 Goes Here

  • xxx
  • xxx
Step 2 Goes Here

  • xxx
  • xxx
Step 3 Goes Here

  • xxx
  • xxx
IMG_1460a Step 4 Goes Here

  • xxx
  • xxx
IMG_1463a Step 5 Goes Here

  • xxx
  • xxx
IMG_1466 Step 6 Goes Here

  • xxx
  • xxx
IMG_1467a Step 7 Goes Here

  • xxx
  • xxx
IMG_1469a Step 8 Goes Here

  • xxx
  • xxx
IMG_1470a Step 9 Goes Here

  • xxx
  • xxx

An evaluation of the complete visual system was performed.

  • Perform the eye examination that is medically necessary
  • Provide the diagnostic tests or services that are medically necessary
  • Properly document the services provided
  • Code from the documentation
  • Report the services to the payor


Diagnosis CodeProcedure CodeModifierQuantityPayorAmount Allowed
H16.223 - Keratoconjunctivitis sicca, not specified as Sjogren’s, bilateral65778 - Amniotic membrane placement1Medicare1464.30
H16.223 - Keratoconjunctivitis sicca, not specified as Sjogren’s, bilateral92285 - External ocular photography511Medicare15.36
H52.213 - Irregular astigmatism, bilateral92025 - Corneal topography1Medicare39.45


Diagnosis CodeProcedure CodeModifierQuantityPayorAmount Allowed
H16.223 - Keratoconjunctivitis sicca, not specified as Sjogren’s, bilateral99212 - Level 2 Evaluation & Management1Medicare42.12


Diagnosis CodeProcedure CodeModifierQuantityPayorAmount Allowed
H16.223 - Keratoconjunctivitis sicca, not specified as Sjogren’s, bilateral99212 - Level 2 Evaluation & Management1Medicare42.12

Keratoconjunctivitis sicca,
not specified as Sjogren’s,
right eye

Keratoconjunctivitis sicca,
not specified as Sjogren’s,
left eye

Keratoconjunctivitis sicca,
not specified as Sjogren’s,

Keratoconjunctivitis sicca, not specified as Sjogren’s

External ocular photography

Anterior segment imaging

Bandage contact lens

Punctal occlusion

Corneal topography

Amniotic membrane placement