eMedicine Specialties > Ophthalmology > Cornea
Keratopathy, Neurotrophic: Treatment & Medication
Updated: Feb 3, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
- Stage 1
- Topical lubrication with preservative-free artificial tears, gels, and ointments
- Discontinue any topical ocular therapies, especially those that can decrease corneal sensitivity (eg, timolol, betaxolol, sulfacetamide, diclofenac, ketorolac) or contain preservatives.
- Reevaluate 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 every other day) can reduce the amount of mucus produced.
- Stage 2
- 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
- More likely to require surgical intervention than stage 1
- Stage 3
- All of stage 1 and stage 2 treatments
- Surgical intervention
- Medications to avoid
- Topical corticosteroids may increase collagenase activity and stromal melting.
- Topical NSAIDs have not shown any benefit in wound healing, and diclofenac and ketorolac use can decrease corneal sensitivity.
- Future treatments
- Nerve growth factor has been shown to induce healing of stage 3 keratopathy in one open, uncontrolled study.
- Aldose reductase inhibitor, CT-112, has been shown to reverse abnormal morphology of corneal epithelial cells and to increase corneal sensitivity.
- Topical pindolol has been reported to speed the healing of epithelial defects in rabbits.
Surgical Care
Surgical care for neurotrophic keratopathy has 3 goals, as follows: (1) to protect the epithelium by lid closure, (2) to close a persistent epithelial defect, and (3) to repair a deep ulceration.
- Closure of the lids - 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
- Conjunctival flap - Effective but poor cosmetic and visual result
- Amniotic membrane transplantation
- Repair of a deep ulceration
- Lamellar keratoplasty
- Penetrating keratoplasty - For large defects
- Multilayer amniotic membrane transplantation - Has been used in defects as deep as 90% of the stroma
- Cyanoacrylate glue with a soft bandage contact lens - For defects smaller than 2.0 mm
Consultations
Consult a neurologist if the cause of corneal hypesthesia is not apparent or if any associated neurologic deficits are present.
Medication
No medications are available that can improve corneal sensitivity. The medications used in the treatment of neurotrophic keratopathy are adjunctive to lubrication and surgical intervention.
Antibiotics
The tetracyclines have shown anti-inflammatory and anticollagenolytic activity.
Tetracycline (Sumycin)
May have anticollagenolytic properties that improve symptoms.
Adult
250 mg PO bid
Pediatric
Not established
Antacids, bismuth, carbamazepine, phenobarbital, and phenytoin can decrease efficacy; methoxyflurane can have synergistic effect and increase risk of nephrotoxicity; warfarin may have increased risk of bleeding secondary to decrease in vitamin K production
Documented hypersensitivity; pregnancy; <8 years; caution if renal or hepatic function impaired
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients with impaired renal or hepatic function
Doxycycline (Doryx, Vibramycin, Bio-Tab)
May have anticollagenolytic properties that improve symptoms.
Adult
100 mg PO qod
Pediatric
Not established
Antacids, bismuth, carbamazepine, phenobarbital, and phenytoin can decrease efficacy of tetracycline; methoxyflurane can have synergistic effect and increase risk of nephrotoxicity; warfarin may have increased risk of bleeding secondary to decrease in vitamin K production
Documented hypersensitivity; pregnancy; <8 years; caution if renal or hepatic function impaired
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients with impaired renal or hepatic function
Cycloplegics
These agents relieve pain associated with iridocyclitis.
Atropine solution 1% (Isopto)
Acts at parasympathetic sites in smooth muscle to block response of sphincter muscle of iris and muscle of ciliary body to acetylcholine, causing mydriasis and cycloplegia.
Adult
1 gtt to affected eye(s) qd
Pediatric
Not established
Coadministration with other anticholinergics have additive effects
Documented hypersensitivity; anatomically narrow anterior chamber angles
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May blur vision; keep drug away from small children
Lubricants
The goal of a lubricant is to keep as much moisture in the eye as possible and to reduce irritation.
Artificial tears (Celluvisc, Akwa Tears, Murine, Refresh, Tears Naturale)
Contains equivalent of 0.9% NaCl and are used to maintain ocular tonicity. Acts to stabilize and thicken precorneal tear film and prolong tear film breakup time, which occurs with dry eye states.
Adult
Solution: 1-2 gtt into eye(s) tid/qid prn
Ointment: Apply 0.5-inch ribbon to subconjunctiva hs
Pediatric
Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Hyperemia, photophobia, stickiness of eyelashes, ocular discomfort or irritation may occur
More on Keratopathy, Neurotrophic |
| Overview: Keratopathy, Neurotrophic |
| Differential Diagnoses & Workup: Keratopathy, Neurotrophic |
 Treatment & Medication: Keratopathy, Neurotrophic |
| Follow-up: Keratopathy, Neurotrophic |
| References |
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References
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Further Reading
Keywords
neurotrophic keratopathy, neurotrophic keratitis, neuroparalytic keratitis
