Eyeworld

WINTER 2026 | EYEWORLD | 69 C Reference 1. Ayres BD, et al. Retrospective evaluation of successive Bio- vance decellularized basement membrane tissue grafts for the management of chronic sub- clinical and Stage 1 neurotrophic keratitis. Clin Ophthalmol. 2026;20:599498. permanent tarsorrhaphy, and scleral lenses as other treatment options. In terms of medications, Oxervate (ceneg- ermin-bkbj, Dompé) is the only FDA-approved option for NK currently. Dr. Rapuano said it can take several weeks for this treatment to be approved by insurance. The newest treatment that some physicians are beginning to incorporate into practice for these patients is the use of insulin drops, Dr. Rapuano said, though he added that these are not commercially available and not FDA approved for this specific purpose. But there's reasonably good evidence in the literature that they are useful for severe ocular surface disease and especially neurotrophic keratitis, so some compounding pharmacies will make this up. Dif- ferent concentrations have been used, but it is usually not outrageously expensive and typically well tolerated. He added that there is limited data on this so far, but it may be an interesting avenue to explore for the future. Dr. Gupta also mentioned Oxervate as the gold standard FDA-approved therapy for neuro- trophic keratitis. But she agreed that it can take some time to start the paperwork and approval process, so for someone with Stage 1 NK, Dr. Gupta will try a variety of therapies first. Taking the patient off anything that's preserved is a good place to start. Switching to preservative-free and trying to rehabilitate the punctate epithelial erosion may be helpful. Dr. Gupta added that amniotic membrane and serum tears are good biological products that bring an anti-inflammatory but also a reparative effect to the surface. Dr. Gupta noted recent developments in serum tears from Ocubio. The process of making serum tears can be a labori- ous one, and patients have to keep them frozen, then take them out of the refrigerator and use them right away. Ocubio offers serum tears that can be kept at room temperature. "In all of these patients, I try to address any comorbid conditions. … If they do have some dry eye, I might use cyclosporine, lifitegrast, or acoltremon drops … to help with ocular surface inflammation and tear production," she said. Sometimes, Dr. Gupta will even try topical ste- roids to decrease inflammation on the surface. Additionally, punctal occlusion can help. "The therapies that we have easy access to we try in all the patients, but for someone with a progressing ulcer, we have a lot less time because we don't want them to get to perfora- tion," she said. Oxervate is a sight-saving drug for some patients, Dr. Gupta said, so having access to it is amazing, but it still comes with challenges. "I think the biggest pain point for me is the sub- group of patients who respond to Oxervate but regress over time once they have completed the therapy," she said. "As you might imagine, the insurance companies aren't crazy about approv- ing a very expensive drug over and over again. To me, the unmet need is having a therapy that addresses neurotrophic keratitis in a more chronic way." There are a number of drugs that are being studied for persistent epithelial defect, which is a variant of neurotrophic keratitis. For those tri- als, the hardest part is finding the patients, but it's also a difficult patient population to study. Dr. Ayres noted that there is a real push now to not let patients get to Stage 2 or Stage 3 NK, and there are a number of options. In addition to on-label use of cenegermin nerve growth factor, there's also amniotic membrane. Dr. Ayres went into detail about a recent study 1 he was part of that used Biovance amniotic decellularized basement membrane grafts in patients with subclinical or Stage 1 NK. These were used serially, and over time, patients got better. Included in the study were eyes with reduced corneal sensitivity (measured with a Corneal Esthesiometer Brill), epithelial staining, and positive MMP-9. continued on page 70 " When many people think about a neurotrophic ulcer, they might think about a patient who absolutely can't feel anything, but neurotrophic keratitis implies that there is reduced or abnormal sensation." —Brandon Ayres, MD

• Cover