Cornea specialists compare management approaches for neurotrophic keratitis
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Welcome to another edition of CEDARS/ASPENS Debates. CEDARS/ASPENS is a society of cornea, cataract and refractive surgery specialists, here to discuss some of the latest hot topics in ophthalmology.
This month, Kourtney H. Houser, MD, discusses the use of interventional management in patients with neurotrophic keratitis, while Priyanka Sood, MD, discusses some available medical treatments. This disease can be quite difficult to manage, but now, we have more treatment options than ever before.
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Kenneth A. Beckman, MD, FACS
OSN CEDARS/ASPENS Debates Editor
Interventional management
I see a lot of patients with neurotrophic keratitis, and usually the first determination of how to treat them is how severe the disease is. Patients with stage 2 or 3 neurotrophic keratopathy have epithelial defects or ulceration of the surface and require prompt treatment to prevent severe complications such as corneal perforation. In those patients, we do not always have the luxury of using the newer medical management treatments upon diagnosis due to cost or logistical constraints, and if patients already have severe ulceration or thinning of the cornea, I will jump to surgical management first.
For patients with an epithelial defect, a bandage contact lens can be therapeutic within a matter of weeks. I also start an antibiotic drop to prevent infection and preservative-free artificial tears. I see patients back every several days to a week, and if they are not improving, I move to amniotic membrane.
I typically use AmbioDisk (Katena), a dehydrated amniotic membrane disc placed under a bandage contact lens, or Prokera (BioTissue), which is a cryopreserved, self-retained amniotic membrane fixated upon a plastic ring. The amniotic membrane rests on the corneal surface until it dissolves, which could be in 1 to 3 weeks. These membranes promote healing of the surface through anti-inflammatory properties and provide mechanical protection of the surface.
If the patient has significant thinning of the stroma, I will often take them to the operating room to glue on cryopreserved amniotic membrane in a multilayered fashion. There are several manufacturers of frozen amniotic membranes that allow you to cut them to various sizes to match the size of the epithelial defect. From there, I will use a fibrin glue to put the membrane in place in concentrically larger sizes with a bandage contact lens on top.
In severe cases, I will also use a tarsorrhaphy to close the eyelid. Most of the time it is temporary with just a suture. However, if the patient has persistent issues, I might have to do a permanent tarsorrhaphy in which I excise the lid margin epithelium and place a suture so that the eyelid heals together and remains closed for a longer time.
- For more information:
- Kourtney H. Houser, MD, can be reached at Duke Eye Center Arringdon, 5601 Arringdon Park Drive, Morrisville, NC 27560; email: kourtney.houser@gmail.com.
Medical management
When it comes to neurotrophic keratitis, our ability to diagnose it is key. However, diagnosis is not always clear-cut, especially because not all of us have a Cochet-Bonnet esthesiometer to measure corneal thickness in our offices. My technique is to use a cotton-tipped applicator with a wisp to assess corneal sensation. Testing the “good eye” first and the “concerning eye” second is one way to make that test more accurate.
There are different stages of neurotrophic keratitis (NK). Depending on what stage a patient is in, you will treat it differently. In stage 1, it is typically just epithelial irregularities. You might see a little bit of swelling of the cornea or some punctate keratopathy, but you will not see an epithelial defect. Preservative-free artificial tears are the mainstay of treatment for NK, regardless of what stage the patient is in. In stage 1, punctal plugs help keep a patient’s own natural tears on the ocular surface. A lot of times, these patients have underlying dry eye disease, so a mild steroid can help decrease any chronic inflammation. The same goes for other dry eye treatments. One of the issues with NK is that the nerve growth factors are not being produced. Because of that, serum tears can provide some of those growth factors and help heal the ocular surface.
When you get to stage 2 and stage 3, you start to see the epithelial defects and will want to use antibiotics to prevent infections. We now have an approved drug for NK, as well. Oxervate (cenegermin, Dompé) can be expensive, but when other options fail, it is an excellent opportunity to help treat NK.
NK is hard to treat because we do not have anything available to cure it. Oxervate has been beneficial, particularly in extreme cases. However, it was approved in only 2018. We do not know how long that benefit truly lasts. These patients are a challenge because they do not really feel pain. They are not coming to you in the early stages, and it is an inherently challenging condition because of decreased blink reflex. The whole goal is to get that epithelium to heal.
- For more information:
- Priyanka Sood, MD, can be reached at Emory Eye Center, 1365 Clifton Road, Building C, Atlanta, GA 30322; email: psood1220@gmail.com.
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