Q&A: Early diagnosis, treatment key in management of patients with neurotrophic keratitis
Healio spoke with Clark Chang, OD, MSA, MSc, FAAO, FSLS, director of specialty contact lenses at the Cornea Service of Wills Eye Hospital in Philadelphia, about the importance of early diagnosis of neurotrophic keratitis and considerations for treatment.
Healio: Why is early diagnosis so critical?
Chang: Neurotrophic keratitis is a degenerative corneal disease, which means that the disease will worsen or at least has high likelihood of worsening, without clinical intervention. But the clinical recognition for neurotropic keratitis-targeted treatment(s) does not occur without a confirmed diagnosis. Since neurotrophic keratitis can lead to significantly detrimental visual and structural sequalae along with impaired quality of life, it is imperative to diagnose early on in the course of the disease when the therapeutic efficacies and patients outcomes are much improved.
Healio: Are there any barriers or challenges to diagnosis?
Chang: Neurotrophic keratitis can manifest with various clinical presentations, especially at the early phases when patients may be asymptomatic or only present with mild epithelial alternations, ie, Mackie classification stage 1. Hence, the diagnosis of neurotrophic keratitis is often masqueraded as other ocular conditions, such as dry eye or other ocular surface disorders. As the condition fails to respond to initial treatment(s) and advances in severity until epithelial defects manifest, it is then often treated as microbial keratitis.
By the time these nontargeted treatments failed to produce desired therapeutic responses, the stakes of disease management have also been elevated in that neurotrophic keratitis has become more severe and more challenging and/or time-consuming to control and treat.
Healio: Are there ways to improve diagnosis?
Chang: The key to early detection of neurotrophic keratitis lies in the early recognition of the different clinical scenarios associated with potential reduction or complete loss of corneal sensitivity. Cornea sensitivity testing can be done quantitively with the Cochet-Bonnet aesthesiometer (Western Ophthalmics Corp.) or qualitatively with a sterile cotton wisp or dental floss. These are simple tests to perform clinically, but what is not always simple is identifying the clinical red flags for when to perform corneal sensitivity testing on patients.
In a recent study by Reza Dana, MD, MSc, MPH, and colleagues, the authors strongly recommended testing for corneal sensitivity when patients present with newly noted epithelial defect of unknown etiology, persistent epithelial defects that do not heal within 14 days, history of potential trigeminal nerve damages from surgical procedures or prior herpetic eye disease episodes or multiple concurrent risk factors, such as reduced blink or chronic, poorly controlled diabetes.
Personally, I would also add that ocular surface disorder patients with epitheliopathy who do not respond to prescribed therapies should be considered for corneal sensitivity testing, even if the patient reports some sensations of ocular pain.
Healio: How does diagnosis affect treatment and management?
Chang: Early diagnosis with corneal sensitivity testing can lead to earlier provision of neurotrophic keratitis-focused treatment. Additionally, some treatments like Oxervate (cenegermin-bkbj ophthalmic solution 0.002%, Dompe), a topical recombinant human nerve growth factor that treats the underlying degenerative aspect of the condition, will not get approved by insurance carriers without the documentation of impaired corneal sensitivity.
Being able to get a clear clinical diagnosis at an earlier timepoint could help clinicians reach the desired treatment outcome sooner, as well as better preserve patients’ quality of life.
Healio: What should future research focus on?
Chang: Given its degenerative nature, the conventional treatment challenge has primarily been that neurotrophic keratitis patients are likely to relapse with recurring episodes. It is quite impressive to see the treatment results with topical cenegermin, both in clinical trials and from our experiences at Wills Eye Hospital, that many neurotrophic keratitis patients do well after achieving corneal healing. However, we still monitor our patients closely and many of them are managed with ongoing palliative treatments to optimize their ocular surface.
Nonetheless, cenegermin currently requires an intense topical administration regimen (every 2 hours, six times per day for 8 weeks). It would be welcomed to see a form of treatment or a different route of therapy in the future that can be easier to administer which improves both patients’ compliance and their overall experiences.
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