Eyeworld

49 EW FEATURE Jacobs said. To that end, amniotic membrane transplantation offers only limited assistance. "AMT may downregulate intrinsic inflamma- tion, but it is not as good as a BSCL or scleral lenses for improving the environment." Dr. Pflugfelder is more optimis- tic about AMTs. "There are reports of AMT healing NK," he said. "I tend to use double-layer AMT fixated with fibrin tissue glue and covered with bandage contact lens and temporary tarsorrhaphy to enhance retention." Tarsorrhaphy "Tarsorrhaphy is an excellent option for patients who cannot or will not manage the regimens of frequent application of topical agents or ap- plication and removal of therapeutic lenses," Dr. Jacobs said. "I bring it up immediately if there is already significant ulceration putting integ- rity of the globe at risk or if it is clear that adherence to regimens is going to be a problem because of medical, cognitive, or logistical challenges." While not in disagreement, Dr. Pflugfelder spoke more circumspect- ly regarding the procedure. "Perma- nent tarsorrhaphy is considered the last resort for this condition because it reduces vision/visual field and patients don't like the appearance of the eye." However, Dr. Jacobs noted that "a 40% tarsorrhaphy is much less disfiguring than expected and can be very helpful in support of the surface." Down the pipeline In terms of future options, "[b]io- logics for support of the surface and regeneration of nerves hold prom- ise," Dr. Jacobs said. "I doubt any one of them will be a panacea for all NK. Some target nerve regeneration direction, others work by support- ing the epithelium. What works for damage from multiple surgeries may not work for damage from VZV. Congenital or genetic problems may respond very specifically or not at all and may depend on the age of the patient at the time treatment is initiated." Dr. Pflugfelder has had experi- ence with one of the drugs coming down the pipeline: cenegermin, a recombinant form of human nerve growth factor that was approved in the European Union for the treat- ment of NK in adults in July 2017. "I was an investigator in the FDA Phase 3 clinical trial used for orphan drug approval," he said. "Consequently, I don't know whether patients received placebo or active. The clinical trial results are impressive with a significant difference in healing vs. vehicle (up to 75% healing in some studies) and lack of recurrence for an extended period after stopping the drug." Dr. Pflugfelder is not sure there is evidence that other therapies such as thymosin beta-4 factor and synthetic neurotrophin mimetics will be effective; however, regarding cenegermin, "I plan to use it when it becomes commercially available at the end of this year or early next year," he said. EW References 1. Sacchetti M, Lambiase A. Diagnosis and management of neurotrophic keratitis. Clin Ophthalmol. 2014;8:571–9. Editors' note: Dr. Jacobs was a full-time employee of BostonSight in the past 12 months, but has no financial interests in any contact lens or prosthetic device. Dr. Pflugfelder has no financial inter- ests related to his comments. Contact information Jacobs: deborah_jacobs@meei.harvard.edu Pflugfelder: stevenp@bcm.edu November 2018 • Improving the ocular surface for cataract and refractive surgeons

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