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Neurotrophic Keratopathy Treatment & Management

  • Author: Robert H Graham, MD; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Jun 14, 2016
 

Approach Considerations

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

Inpatient care

Patients with stage 3 neurotrophic keratopathy should be hospitalized for daily follow-up care until significant improvement is seen.

Consultations

Consult a neurologist if the cause of corneal hypesthesia is not apparent or if any associated neurologic deficits are present.[12]

Monitoring

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.

Deterrence

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
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Pharmacologic Therapy

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[13]
  • 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.[14]
  • Gaudilla et al note 20% autologous topical serum is an effective treatment for stages 1 and 2 neurotrophic keratopathy.[15]
  • 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.[16]

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
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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[17] :

  • Conjunctival flap - Effective, but poor cosmetic and visual result[18]
  • Amniotic membrane transplantation[19]

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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Contributor Information and Disclosures
Author

Robert H Graham, MD Consultant, Department of Ophthalmology, Mayo Clinic, Scottsdale, Arizona

Robert H Graham, MD is a member of the following medical societies: American Academy of Ophthalmology, Arizona Ophthalmological Society, American Medical Association

Disclosure: Partner received salary from Medscape/WebMD for employment.

Coauthor(s)

Mark A Hendrix, MD Consulting Staff, Department of Ophthalmology, Suburban Hospital, Shady Grove Hospital

Mark A Hendrix, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy, Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Acknowledgements

Stephen D Plager, MD, FACS Chief, Department of Ophthalmology, Dominican Hospital; Assistant Clinical Professor, Department of Ophthalmology, Stanford University Hospital

Stephen D Plager, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, American Society of Cataract and Refractive Surgery, and California Medical Association

Disclosure: Nothing to disclose.

Christopher J Rapuano, MD Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Director of the Cornea Service, Co-Director of Refractive Surgery Department, Wills Eye Institute

Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Cornea Society, Eye Bank Association of America, International Society of Refractive Surgery, and Pan-American Association of Ophthalmology

Disclosure: Allergan Honoraria Speaking and teaching; Allergan Consulting fee Consulting; Alcon Honoraria Speaking and teaching; RPS Ownership interest Other; EyeGate Pharma Consulting fee Consulting; Bausch & Lomb Honoraria Speaking and teaching; Bausch & Lomb Consulting; Merck Honoraria Speaking and teaching

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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