VIDEO: Expert highlights two treatment advancements in neurotrophic keratitis

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There are a couple for me, and the first one is corneal neurotization in terms of advancement. Corneal neurotization, for those of you who may not be as familiar, refers to a surgical procedure that aims to restore sensory innervation to the cornea. Think of it as a nerve graft directly onto the ocular surface. And that can be done either via direct nerve transfer or nerve graft from a distant site.

As an example, if the fellow eye is not affected in our NK patient, then we can redirect fibers from the supratrochlear or supraorbital nerve of the unaffected eye. Or if both eyes are affected, then you could take a stump from your sural nerve, that’s the distal side methodology. And it used to be a much bigger procedure because of the instrumentation and the large incision that you had to make through the scalp.

Over the last decade or so, I would modify the procedure and with the introduction of a less invasive endoscope, now it can be done endoscopically through the adnexa of the eye. And therefore, in my mind, it’s turning out to be a much more attractive procedure for those patients that really just fail all the current management options. However, another problem with that is that it’s not universally available obviously, because many of you may be thinking, “Hey, that’s relatively new, never seen that before.” And that’s because it requires a very high level of specialization and multidisciplinary team approach, both inside of the OR and outside of the OR, and we’ll talk about that I think a little bit later as well.

However, through small case reviews, this corneal neurotization surgery has really shown promising results with improved corneal sensation and epithelial stability leading to visual improvement. So that’s one, and we’re lucky that one of our surgeons at Wills Eye Hospital in our cornea service, actually in the last couple years, has been providing this procedure to patients. For those of you who may have heard of this procedure, he’s actually also trying to shape the size of the corneal nerve so that once it’s implanted, you see it as protrusion on the conjunctival surface. If we could lessen the height of that graft, then potentially may have less impact to say, content lens fitting afterwards. I’m pretty excited about that.

The second one that I was alluding to from the outset of this question is that we’ve talked a lot about growth factors. We know that there’s a recumbent human nerve growth factor available called cenegermin (Oxervate, Dompé), but what’s new is that clinical-thinking-wise is can we use other type of growth factors to treat patients with NK? A topical insulin, which is a peptide that is very close in structure to a growth factor called insulin growth factor, has been sort of thought, these growth factors can promote wound repair. Some of the thinking or some clinicians are wondering, “Hey, can we maybe just use compound topical insulin?”

We still don’t know what dosage is best, but it has actually been used and been shown to have effect in promoting wound healing in NK patients. If this works, I think more studies needs to be done. I have not incorporated that into my practice in all disclosure and transparency. But if it can work and we know what dosage would be optimum, most studies that I’ve seen kind of shown 1/2 a unit per milliliter to 1 unit per milliliter compounded into a drop form. So, you can imagine that if this works, then it could be a very low-cost and widely available medication that we could offer to our NK patients in the future. So, more to come in that space.