Neurotrophic Keratopathy Treatment & Management
- Author: Robert H Graham, MD; Chief Editor: Hampton Roy, Sr, MD more...
Pharmacologic care for neurotrophic keratopathy varies by stage with regard to the number and types of drugs used for treatment.
Surgical care may be necessary in stage 2 or 3 neurotrophic keratopathy. Such treatment has 3 goals, as follows:
- Protect the epithelium by lid closure
- Close a persistent epithelial defect
- Repair a deep ulceration
Patients with stage 3 neurotrophic keratopathy should be hospitalized for daily follow-up care until significant improvement is seen.
Consult a neurologist if the cause of corneal hypesthesia is not apparent or if any associated neurologic deficits are present.
Patients with stage 1 neurotrophic keratopathy can be monitored on an outpatient basis every 3-7 days.
Patients with stage 2 disease should be monitored on an outpatient basis every 1-2 days until improvement is seen, then every 3-5 days until resolution.
Medications to avoid in patients with neurotrophic keratopathy are as follows:
- Topical corticosteroids - These may increase collagenase activity and stromal melting
- Topical NSAIDs - These have not shown any benefit in wound healing, and diclofenac and ketorolac use can decrease corneal sensitivity
Treatment for stage 1 neurotrophic keratopathy is as follows:
- Topical lubrication with preservative-free artificial tears, gels, and ointments
- Discontinuation of any topical ocular therapies, especially those that can decrease corneal sensitivity (eg, timolol, betaxolol, sulfacetamide, diclofenac, ketorolac) or that contain preservatives
- Reevaluation of the need for systemic drugs, such as neuroleptics, antipsychotics, and antihistamines.
- Punctal occlusion may need to be considered.
- Oral tetracycline (250 mg PO bid) or doxycycline (100 mg PO qod) can reduce the amount of mucus produced
- Weyns et al proposed scleral contact lenses as a valid long-term alternative to standard treatment options in patients with neurotrophic keratopathy.
- Gaudilla et al note 20% autologous topical serum is an effective treatment for stages 1 and 2 neurotrophic keratopathy.
- Lee and Kim reported that oral nicergoline helped heal corneal epithelial defects among patients who did not respond to conventional therapy. Additionally, in patients treated with nicergoline, levels of tear nerve growth factors were higher than levels before treatment.
Stage 2 treatment is as follows:
- All of stage 1 treatments
- Topical tetracycline reportedly increases the healing of epithelial defects (not available in an ophthalmic drop preparation)
- Topical cycloplegia with atropine 1% or scopolamine 0.25% once daily in the presence of anterior chamber inflammation
- Patients with stage 2 disease are more likely to require surgical intervention than are those with stage 1 disorder
Treatment for stage 3 neurotrophic keratopathy is as follows:
- All of stage 1 and stage 2 treatments
- Surgical intervention
Surgical Repair of Eyelids, Epithelial Defects, and Ulcerations
Closure of the eyelids
In the presence of severe or total loss of corneal sensation, keratitis sicca, or exposure keratopathy, a lateral tarsorrhaphy, palpebral spring, or botulinum A toxin injection in the levator muscle may prevent progression to stage 2.
Closure of a persistent epithelial defect
Repair options for such lesions include the following :
- Conjunctival flap - Effective, but poor cosmetic and visual result
- Amniotic membrane transplantation
Repair of a deep ulceration
The following can be used in ulceration repair:
- Lamellar keratoplasty
- Penetrating keratoplasty - For large defects
- Multilayer amniotic membrane transplantation - Has been used in defects as deep as 90% of the depth of the stroma[20, 21]
- Cyanoacrylate glue with a soft bandage contact lens - For defects smaller than 2 mm
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