Neurotrophic Keratopathy: Novel Medical and Surgical Therapies

Nicholas Colatrella, OD, FAAO and Jeffrey Varanelli, OD, FAAO discuss advancements in management of Nuerotrophic Keratopathy.

Cara Moore: Hi everybody. Thanks for joining us here on Optometry TV. I’m Cara Moore, joined now by Dr. Nicholas Colatrella. Thanks for being here. And Dr. Jeffrey Varanelli.

Dr. Jeffrey Varanelli: Thank you.

Cara Moore: Good morning to both of you. Okay, so let’s talk about the advances in the management of Neurotrophic Keratopathy. And I know that you said this was sort of something that was near and dear to you.

Dr. Nicholas Colatrella: Yes, yeah, well thank you for the opportunity to be here today and this is something that’s near and dear to our hearts. You know, ocular surface disease, specifically Neurotrophic Keratopathy is one of the most refractory corneal disorders that we can deal with as clinicians. And it’s been a known disease entity since the early 1800’s when they noticed some type of disruption in the trigeminal nerve created a loss of corneal sensation and that led to superficial Punctate Keratopathy, persistent epithelial defects, even corneal melts, and corneal perforation. So it can be quite challenging to diagnose and manage these patients. And oftentimes we find that it goes underdiagnosed, and even misdiagnosed as dry eye or herpetic disease.

Cara Moore: And is that a little bit about your lecture? Is that sort of a preview?

Dr. Nicholas Colatrella: And the benefit of the lecture is there is new novel medical and surgical therapies that we go through. We talked about the biologic therapies that use allergenic and autologous serum, amniotic membrane therapy, and the first in class recombinant human nerve growth factor, with cenegermin BK BG that, you know, allows us to treat these patients with ways we never had the opportunity to before.

Cara Moore: So how is this diagnosed?

Dr. Nicholas Colatrella: You know, the cornea is arguably the most sensitive structure in the human body, it’s 40 times more sensitive than dental pulp, a hundred times more sensitive than the conjunctiva; 400 times more sensitive than the skin. So, you know, we have to assess corneal sensation in one way, shape, or form. And that’s really where we’re noticing it’s being underdiagnosed cause we’re not testing corneal sensation as often as we should. So whether it’s a qualitative measure such as a cotton wisp or dental floss, or a more quantitative measure, usually the Cochet-Bonnet esthesiometer, we have to have some type of corneal nociception and test corneal sensitivity.

Cara Moore: And now that we’ve talked a little bit about how it’s diagnosed, Dr. Varanelli, talk about symptoms that patients may come in with for practitioners to look out for.

Dr. Jeffrey Varanelli: Sure. And you know, it’s interesting because early on in the disease, these patients might actually come in with some symptoms of dry eye. So it might be foreign body sensation, it might be sensitivity to light, it might be, you know, these symptoms can actually be maybe exacerbated by staring at a computer or by force moving air from the ceiling fan or vents in a car. So things that we can initially think about for a dry eye patient, we always have to keep it in the back of our mind, especially if there’s other signs that we see clinically or through their history. But Neurotrophic Keratopathy can actually be an issue as well. But, you know, paradoxically later on in the disease, so as we get to the more advanced and severe stages, these patients actually don’t come in with a symptom of pain. They actually come in with a symptom of blurred vision. So those are things we have to keep in mind as we kind of go through the history and go through the clinical examination. And as Nick said, you know, these patients are probably underdiagnosed or misdiagnosed. So we have all these different steps in place to really make that correct diagnosis.

Cara Moore: And once you make that correct diagnosis, what about the treatment?

Dr. Jeffrey Varanelli: You know, treatment can be challenging. And I think first and foremost, we have to look at some of the things that can contribute. We do know that certain topical and systemic medications, some neuroleptics, anti-psychotics, antihistamines, long term chronic use of those can actually lead to some symptoms of Neurotrophic Keratopathy. But then we also look, does inflammation play a role? If it does, we need to worry about treating inflammation, but being careful on certain topical medications that can create some issues on the cornea as well. But ultimately, you know, treating early on in the phases, treating the dry eye symptoms, the surface issue. So preservative free artificial tears, punctal occlusion, looking at different lid abnormalities. Maybe a tarsorrhaphy. And then as Nick mentioned before, you know, some of the biological tear substitutes or some of the biologics in general. So autologous serum has been shown to be very, very beneficial for these patients, allogeneic serum, amniotic membranes, and then specifically some newer options Oxervate Cenegermin. The first really human nerve growth factor that’s used in the ophthalmic space. And there’s actually a new novel procedure called corneal neurotization where they’re actually taking a donor nerve graft and trying to reestablish or co-apt the sensation back to the, to the cornea. And it’s been shown in some early phases to be pretty beneficial.

Cara Moore: There’s a lot of options, right, but you go to get that diagnosis though.

Dr. Jeffrey Varanelli: Absolutely. I think that’s really where the key is.

Cara Moore: Okay. Thank you both for being here. I appreciate it.

Dr. Nicholas Colatrella: Thank you for the opportunity. Appreciate it.

Cara Moore: Thanks for watching Optometry TV.

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