Eyeworld

70 | EYEWORLD | SEPTEMBER 2021 C ORNEA by Ellen Stodola Editorial Co-Director About the physicians Asim Ali, MD Professor of Ophthalmology & Vision Sciences University of Toronto The Hospital for Sick Children Toronto, Canada Kenneth Beckman, MD Clinical Assistant Professor of Ophthalmology Ohio State University Columbus, Ohio Edward Holland, MD Professor of Ophthalmology University of Cincinnati Cincinnati, Ohio • Stage 5: Persistent or recurrent epithelial defects with corneal ulceration • Stage 6: Corneal perforation "We have patients who have epitheliopa- thy without stromal involvement, and we have patients with epitheliopathy with stromal haze but who don't have persistent epithelial defect," Dr. Holland said. "Our Stage 2 is where a lot of patients get diagnosed with dry eye when we want physicians thinking about NK." Dr. Holland said the hope is that this will provide more understanding that there are many stages. "Unfortunately, people don't think about NK until it's a round corneal ulcer and scarring, and that's when the light bulb goes off," he said. Clinical diagnosis of NK When doing a workup for the clinical diagnosis of NK, Asim Ali, MD, said he's trying to figure out the etiology. For example, if you know there's a clear history of herpes, that makes it more straightforward, he said. If it's completely out of the blue, you might have to do an MRI to rule out structural problems in the brain or tumors. The workup will depend on how the patient presents and if you can distinguish between a cause that's in the eye itself. In making a clinical diagnosis, Dr. Holland said the number one thing is to have a differen- tial diagnosis. Dr. Holland also stressed that it's not neces- sary to have a quantified professional aesthesi- ometer. "A lot of people used to use the tip of a cotton swab but even easier is the edge of tissue paper or piece of dental floss," he said, adding that corneal sensation should be in the workup. Dr. Beckman said that when making a clinical diagnosis it's important to do staining to establish that the patient has keratitis in general. Then he will check sensation if they have staining or a defect and if he is suspicious of NK. "If they have decreased sensation, I typi- cally treat as NK," Dr. Beckman said. "I under- stand that many patients may have decreased sensation and coexisting epithelial disease, but the neurotrophic cornea may not have caused the keratitis." He added that it may be dry eye, Breaking down neurotrophic keratitis W ith neurotrophic keratitis (NK), there is a lot to consider in terms of staging, making a diagnosis, and treatment. Three experts discussed how they work up NK patients and some of the options for handling these cases. Stages of NK When staging NK, Kenneth Beckman, MD, said that he separates corneal sensation into normal, decreased, and absent. "Once I establish that they have decreased sensation, and if they have signs of keratitis, I usually separate into the three traditional categories: Stage 1 is punctate epithelial changes but no true defect. Stage 2 is a defect but no thinning. Stage 3 is a defect with thinning," he said. "I don't use the stage number per se, but I describe the cornea based on those criteria." Edward Holland, MD, was involved in a neurotrophic keratitis study group that worked on an updated staging criteria for NK. "We put together a white paper that's been submitted for publication," he said. Dr. Beckman was part of this group as well, along with Albert Cheung, MD, Marjan Farid, MD, Nicole Fram, MD, Preeya Gupta, MD, W. Barry Lee, MD, Francis Mah, MD, Mark Mannis, MD, Jay Pepose, MD, and Elmer Tu, MD. The Mackie classification has been used for staging NK. It starts with Stage 1, which is staining of the inferior conjunctiva and de- creased TBUT and punctate staining of the cornea. Stage 2 is epithelial defect with stromal folds and swelling, and Stage 3 is corneal ulcer and melting, Dr. Holland said. "We thought this didn't represent all the various stages," he said. The study group proposed the following classi- fications: • Stage 0: Altered sensation without any kera- topathy • Stage 1: Corneal epitheliopathy without any stromal involvement • Stage 2: Punctate epithelial keratopathy with anterior stromal haze • Stage 3: Persistent or recurrent epithelial defects • Stage 4: Persistent or recurrent epithelial de- fects with stromal scarring but no ulceration

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