Eyeworld

SEPTEMBER 2021 | EYEWORLD | 71 C lenses as an early treatment. "If there's conflu- ent punctate staining and I'm worried about scarring or ulceration, I want to be aggressive with an early bandage contact lens," he said. Dr. Beckman also said he uses a bandage contact lens to treat a persistent defect. "Ini- tially, for NK, I treat these patients the same as non-neurotrophic corneas with persistent de- fect, and bandage contact lenses are used very early," he said. "I may add amniotic membrane to those as well." Dr. Beckman added that the main risk with a contact lens is infection, so antibiotics are typically used. "Of course, the more drops that are used, the greater the risk of toxicity compromising healing, so it must be a balance," he said. A scleral contact lens may be helpful, and Dr. Beckman said these can be particularly use- ful in cases of non-healing defects and dry eye, though they can be expensive. "Some vision insurances will cover scleral lenses for certain diagnoses, but NK may not be covered," he said. "If these are attainable, they can work very well." Dr. Ali agreed that scleral lenses can be helpful, particularly the PROSE treatment. These can work well for someone with stable NK, he said, as they help with the epithelial surface. Autologous serum tears are another poten- tial treatment for NK. "They provide growth factors that aid in epithelial healing," Dr. Beckman said. There may be some challenges in access and obtaining these. Dr. Beckman works medication toxicity, or something else. "I treat with traditional methods first, but if they have these findings and do not respond to conven- tional treatment, I treat as NK," Dr. Beckman said. Systemic diseases associated with NK and NK from herpes Dr. Beckman has found that the two most com- mon systemic diseases associated with NK are diabetes and MS. NK can also be associated with herpes. Dr. Beckman said he hasn't found a big difference between herpes simplex and herpes zoster in severity. "The one curveball is that with herpes simplex, we need to determine if there is active viral keratitis requiring antiviral therapy rather than just treatment for NK," he said. "I prefer oral antivirals, particularly because they don't have the toxicity that topical therapy does." Dr. Holland said there are a number of conditions that can be associated with NK. In addition to herpes simplex and herpes zoster, he said that any severe infection on the cornea or severe injuries, like chemical burns, can lead to NK. Other factors like LSCD and chronic contact lens wear can also be associated. Dr. Holland added that you can see NK from ocular surgeries, such as PK or DALK, refractive corneal surgery, or any procedure that removes epithelium. Medications can also be associated with NK. Dr. Holland said there are some con- genital causes as well, though these are gener- ally rare. Treatments There are a number of treatments for NK that physicians can employ at various stages and depending on the individual patient. According to Dr. Holland, it's a "step ladder approach" based on the severity. In the early steps, it's important to add pre- servative-free lubrication and remove any toxic topical medications, which can cause dryness on the surface, Dr. Holland said. If there is ocular surface disease, it should be treated with preser- vative-free drops, ointments, omega-3s, etc. Different types of contact lenses can also be used. Dr. Holland will use bandage contact continued on page 72 "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." —Edward Holland, MD

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