Eyeworld

Supported by an unrestricted education grant from Avedro, Avellino Labs, Dompé, and Johnson & Johnson Vision JANUARY/FEBRUARY 2020 | SUPPLEMENT TO EYEWORLD | 3 The patient had trace injection, peripheral neo-cor- neal vascularization nasally, and a small anterior stromal scar. The defect measured 1.5 mm x 2.5 mm with 80% thinning and minimal white cell recruitment without formed infiltrate. The anterior chamber was quiet. Neurotrophic keratitis was diagnosed. Typical presentation Patients usually are older than 80 years with blurred vision and a 5-mm or larger epithelial defect or history of HSV with light sensitivity. There may be significant asymmetry, so we need to perform a thorough ocular surface examination, including vital dye staining, lid function, and blink rate. It is important to check bilaterally, especially for corneal sensitivity. I perform a corneal cotton wisp contact test, checking for sensa- tion and a reflex blink. Absence of the reflex blink, along with asymmetry, indicates a neuro- trophic condition. Treating neurotrophic keratitis Treatments focus on healing the defect and closing the eyelids. We initially eliminate topical preservatives and ocular irritants, optimize the ocular surface and increase humidity, improve lid hygiene, and lubri- cate the eye. Bandage contact lenses are controversial and should be used with caution. 1,2 Patients with bandage contact lenses require frequent follow-up, particularly early. They may not feel symptoms of infection and there is the risk of hypopyon formation and reactive iritis. Amniotic membrane therapy triggers growth factors to help stimulate stem cells and can promote healing of the acute defect and restore stromal thickness. It is also useful to reestablish epithelial integrity. A one-time bandage with an amniotic membrane may not be enough, and we may consider off-label uses with amniotic membrane extract. The eyelid maybe closed in numerous ways, providing protective ptosis to help the epithelium regenerate and heal. Temporary options include tape or pressure patching, cyano- acrylate glue, and botulinum toxin to the levator palpebrae. 3,4 Alternatively, a permanent tarsorrhaphy can be performed in the operating room. Cenegermin, a novel recombinant human nerve growth factor approved to treat neurotrophic keratitis in adults and children older than 2, is identical to the nerve growth factor protein produced in ocular tissues. This is the first application of human nerve growth factor and the first topical biologic medication in ophthalmology. It plays a crucial role in trophic support, epithelial cell proliferation, and stromal healing. In two clinical trials, almost 130 patients with stage II or III neurotrophic keratitis were treated with the drug for 8 weeks, 6 times a day, with 24 or 48 weeks of follow-up. 5,6 More than half achieved complete corneal healing by week 4. Seventy-two percent were com- pletely healed at 8 weeks in the REPARO study and 65% at 8 weeks in the second study. Of patients who healed af- ter 8 weeks of treatment, 80% remained healed for 12 months in the REPARO study, demon- strating that treating the root cause helps heal the disease process. Additional therapies are in the pipeline. Our 60-year-old patient, who has many years ahead, with good vision potential, is a good candidate for this medication. He has a severe, chronic disease with recurrent breakdown. A self-retaining amniotic mem- brane and other conservative measures were used, but cenegermin was applied to help regenerate corneal sensation and treat the root cause. Conclusion Neurotrophic keratitis remains challenging to manage. Exist- ing treatments help close the epithelial defect or eyelid, but newer therapies offer promise in healing the cornea and regen- erating the nerves. n Patient with neurotrophic keratitis Source: Elizabeth Yeu, MD continued on page 4

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