Neurotrophic Keratopathy - Planning for a Painless Problem #Cornea #Sclerals | OOLS | Dr. Avani Dave
Online Optom Learning Series (OOLS)・72 minutes read
Dr. Dave will discuss neurotrophic keratopathy, its management, and treatment options in her lecture. Neurotrophic keratopathy is characterized by impaired corneal healing due to decreased corneal sensory innervation, leading to reduced reflex tearing and increased injury susceptibility.
Insights
- Neurotrophic keratopathy is characterized by impaired corneal healing due to decreased sensory innervation, making the cornea vulnerable to injury.
- Screening for neurotrophic keratopathy involves various assessments like patient history, corneal sensitivity measurements, and corneal nerve imaging.
- Treatment options for neurotrophic keratopathy include topical and systemic management, protective measures like bandage contact lenses, and therapeutic interventions like nerve growth factor stimulation.
- Scleral lenses play a crucial role in promoting ocular surface healing in neurotrophic keratopathy, aiding in the closure of epithelial defects and overall improvement in corneal health.
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Recent questions
What is neurotrophic keratopathy?
Neurotrophic keratopathy is a condition characterized by impaired corneal healing due to decreased or loss of corneal sensory innervation. This leads to reduced reflex tearing, blinking rate, lubrication, and epithelial healing, making the cornea vulnerable to injury. Risk factors include central nervous system conditions, systemic diseases like diabetes, genetic conditions, ocular factors, and trauma. Screening involves patient history, slit lamp evaluation, tear production assessment, corneal sensitivity measurements, and corneal nerve imaging.
How is neurotrophic keratopathy diagnosed?
Neurotrophic keratopathy is diagnosed through various methods such as patient history, slit lamp evaluation, tear production assessment, corneal sensitivity measurements, and corneal nerve imaging. The slit lamp is crucial for assessing lid anatomy, conjunctiva, and cornea for signs of neurotrophic keratopathy. Dyes like fluorescein, rose bengal, and lissamine green help differentiate dry eye disease from neurotrophic keratopathy based on staining patterns. Corneal sensitivity testing, using methods like cotton thread, crochet monofilament, and non-contact aesthesiometers, is essential for diagnosing neurotrophic keratopathy. Corneal imaging, particularly confocal imaging, aids in assessing corneal nerve density and orientation, crucial in diagnosing the condition.
What are the treatment options for neurotrophic keratopathy?
Treatment for neurotrophic keratopathy varies based on the stage of the condition and focuses on preventing epithelial breakdown, promoting healing, and preventing corneal perforation. Topical management includes preservative-free artificial tears, lubrication, immunomodulators, and cytokine tears. Systemic management involves nutrition, tetracyclines, macrolides, and antiviral therapy. Protective measures like bandage contact lenses or scleral contacts are essential to safeguard the ocular surface. Therapeutic interventions include amniotic membranes, tarsorraphy, botox injections, lid weights, and punctal plugs. Nerve growth factor treatments like Oxervate and non-surgical options such as oral systemic treatments, punctal plugs, tarsorraphy, lid weights, amniotic membranes, and bandage contact lenses are also utilized.
What are the challenges in treating neurotrophic keratopathy?
Treating neurotrophic keratopathy poses challenges due to the complexity of the condition and the varying responses of patients to different treatments. Challenges include access to serum tears, which are composed of blood components and used for corneal healing but face issues with availability and composition variability. Additionally, the use of nerve growth factor treatments like Oxervate, which stimulate nerve production and aid in epithelial healing, requires a strict dosing regimen of six times a day for eight weeks. Non-surgical treatments involve oral systemic treatments, punctal plugs, tarsorraphy, lid weights, amniotic membranes, and bandage contact lenses, each with its own set of challenges and considerations.
How can scleral lenses help in treating neurotrophic keratopathy?
Scleral lenses play a crucial role in treating neurotrophic keratopathy by providing a protective barrier and promoting corneal healing through hydration and protection. They are used to safeguard the ocular surface, especially in cases where other treatments have been ineffective or when there is a risk of corneal perforation. Scleral lenses can aid in closing epithelial defects, improving corneal clarity, and reducing corneal scars over time. The lenses come in various sizes to cater to individual patient needs, and their fitting techniques focus on therapeutic use and enhancing vision for patients with different eye conditions.
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Summary
00:00
Dr. Dave discusses neurotrophic keratopathy management
- Dr. Dave received her Bachelor's of Science degree with honors from McMaster University and a Doctorate of Optometry degree from the New England College of Optometry.
- She completed a residency in cornea contact lens at the New England College of Optometry and focused on specialty contact lens fitting and managing corneal diseases.
- Dr. Dave practices in the United States in New York and Toronto, Canada, and is the director of optometry and contact lens services at the University of Buffalo's Ross Eye Institute.
- She is a fellow of the American Academy of Optometry and is pursuing her fellowship with the Scleral Lens Education Society.
- Dr. Dave is involved in lecturing residents and is the recipient of the Johnson & Johnson Vision Care Award of Excellence in contact lens patient care.
- Dr. Dave will discuss neurotrophic keratopathy, its management, and treatment options in her lecture.
- Neurotrophic keratopathy is characterized by impaired corneal healing due to decreased or loss of corneal sensory innervation.
- The condition leads to reduced reflex tearing, blinking rate, lubrication, and epithelial healing, making the cornea susceptible to injury.
- The cornea receives innervation through the trigeminal nerve, with the nasociliary nerve playing a crucial role in corneal sensitivity.
- Risk factors for neurotrophic keratopathy include central nervous system conditions, systemic diseases like diabetes, genetic conditions, ocular factors, and trauma.
16:09
Neurotrophic Keratopathy: Diagnosis and Treatment Overview
- Screening for neurotrophic keratopathy involves patient history, slit lamp evaluation, tear production assessment, corneal sensitivity measurements, and corneal nerve imaging.
- The slit lamp is crucial for assessing lid anatomy, conjunctiva, and cornea for signs of neurotrophic keratopathy.
- Dyes like fluorescein, rose bengal, and lissamine green help differentiate dry eye disease from neurotrophic keratopathy based on staining patterns.
- Corneal sensitivity testing, using methods like cotton thread, crochet monofilament, and non-contact aesthesiometers, is essential for diagnosing neurotrophic keratopathy.
- Corneal imaging, particularly confocal imaging, aids in assessing corneal nerve density and orientation, crucial in diagnosing neurotrophic keratopathy.
- The Mackie classification categorizes neurotrophic keratopathy into mild, moderate, and severe stages based on symptoms, epithelial defects, and tear film characteristics.
- Treatment of neurotrophic keratopathy varies based on the stage, focusing on preventing epithelial breakdown, promoting healing, and preventing corneal perforation.
- Topical management includes preservative-free artificial tears, lubrication, immunomodulators, and cytokine tears.
- Systemic management involves nutrition, such as vitamin C and omega-3s, tetracyclines, macrolides, and antiviral therapy.
- Protective measures like bandage contact lenses or scleral contacts are essential to safeguard the ocular surface in neurotrophic keratopathy.
31:46
Innovative Treatments for Neurotrophic Keratopathy
- Therapeutic interventions for neurotrophic keratopathy include amniotic membranes, tarsorraphy, botox injections, lid weights, and punctal plugs.
- Serum tears, composed of blood components, are used for corneal healing but face challenges in access and composition variability.
- Nerve growth factor, such as Oxervate, stimulates nerve production and aids in epithelial healing, dosed six times a day for eight weeks.
- Intranasal stimulation, like TrueTear or TierVia, activates the nasolacrimal reflex to increase tear production.
- Non-surgical treatments for neurotrophic keratopathy involve oral systemic treatments, punctal plugs, tarsorraphy, lid weights, amniotic membranes, and bandage contact lenses.
- Amniotic membranes, derived from the placenta, act as a barrier and promote corneal healing due to their anti-inflammatory properties.
- Bandage contact lenses, including scleral lenses, provide a protective barrier and promote corneal healing through hydration and protection.
- Corneal neurotization surgery involves transferring nerves to promote nerve health and innervation on the ocular surface.
- Indirect neurotization methods, like using nerves from the leg or ear, can also aid in promoting nerve development on the ocular surface.
- Case discussions illustrate the application of various treatments, such as scleral lenses and neurotrophic ulcer management, in healing neurotrophic keratopathy.
47:17
Scleral Lenses Heal Neurotrophic Keratopathy Defects
- Patient had a non-healing central corneal epithelial defect, considered e-nucleating the eye for prevention of globe perforation.
- Epithelial defect had been present for seven months, unresponsive to topical treatments and amniotic membranes.
- Patient was on ofloxacin, preservative-free artificial tears, and bandage contact lenses exchanged every two weeks.
- Corneal epithelial defect measured 2mm by 9mm, with classic rolled edges, classified as stage two of the Machi classification.
- Patient was fitted with a scleral lens, which led to the closure of the defect within two weeks.
- Defect size further decreased at the one-month visit, aiming to promote ocular surface healing.
- At the three-month visit, the defect appeared worse, indicating weak epithelium connection and potential breakdown.
- Concern arose at the four-month visit for neurotrophic keratopathy progression to stage four, with stromal thinning and high risk of perforation.
- Consideration of a tarsorrhaphy was discussed but deferred due to patient's concerns, leading to a trial of tears and lubricants.
- By the five-month visit, the epithelial defect had completely closed, emphasizing the restorative and protective role of scleral lenses and the importance of varied treatment approaches.
- A 50-year-old female presented with blurred vision and redness due to a neurotrophic ulcer from trigeminal nerve damage post-brain tumor resection.
- Patient had a 4.5mm by 2.5mm epithelial defect, classified as stage two neurotrophic keratopathy, treated with preservative-free fluoroquinolone and bandage contact lenses.
- Culturing revealed a gram-positive infection, leading to antibiotic adjustment and bandage contact lens replacements every two weeks.
- At the eight-week follow-up, the epithelial defect had completely closed, prompting consideration of scleral contact lens fitting for long-term protection.
- Importance of maintenance treatment, culturing, and bandage contact lenses in healing and preserving the ocular surface was highlighted.
- A 62-year-old patient with a history of neurotrophic keratopathy underwent multiple surgeries and recurrent epithelial defects.
- Corneal sensitivity testing confirmed neurotrophic keratopathy, with absent response in the left eye.
- Treatment involved bandage contact lenses, functional plugs, and a trial of oxervate nerve growth factor six times a day for eight weeks.
- Epithelial defects significantly reduced in size after three weeks of oxervate treatment, leading to complete closure by six weeks.
- Scleral lens fitting post-oxervate treatment showed further improvement in corneal clarity at three months, emphasizing the importance of healing before protecting the ocular surface.
01:01:51
Enhancing Vision Through Scleral Lens Treatment
- Patient wears scleral lens for 12 hours daily, uses ointment and lubricants throughout the day and night.
- Ocular surface improved significantly with no epithelial defects after using scleral lens.
- Consideration of YAG capsulotomy for dense cataract to improve vision.
- Importance of staining, nerve growth factor in topical treatment, scleral lenses, and monitoring patients.
- Case of a 62-year-old female with redness, blurred vision, light sensitivity, and history of surgeries and herpetic eye condition.
- Initial diagnosis of corneal abrasion, later revealed epithelial defect improving with treatment.
- Use of functional plug, amniotic membrane, and bandage contact lens for treatment.
- Transition from prednisone to fluorometholone for corneal healing.
- Patient's vision improved with nerve growth factor treatment but declined during second course.
- Failed scleral lens treatment due to epithelial defect, leading to neovascularization with bandage contact lenses.
- Patient now stable with daily contact lens, artificial tears, plugs, and ointment, monitored every 3-4 months.
- Importance of corneal sensitivity measurement, consistency in testing methods, and involving staff in objective measurements.
- Differentiation between neurotrophic keratopathy and corneal neuralgia, both possibly related to photophobia.
- No significant differences in fitting scleral lenses for neurotrophic keratopathy compared to vision correction, focusing on therapeutic use and fitting techniques.
01:17:02
Enhancing Vision with Scleral Lenses
- Scleral lenses come in various sizes, with preferences varying based on patient needs and the type of lenses being used.
- 3D imaging and corneal molding are methods used to create accurate scleral lenses, with a focus on improving vision for patients with different eye conditions.
- Scleral lenses can aid in reducing corneal scars over time, potentially enhancing vision and promoting ocular surface healing.
- The prevalence of neurotrophic keratopathy (NK) varies based on risk factors like diabetes, with efforts to improve early diagnosis through corneal sensitivity measures.
- Topical steroids are considered in stage one of NK treatment to reduce inflammation and preserve the ocular surface, with new low-dose options available for flare-up control.
- Bell's palsy can lead to exposure keratopathy and subsequent neurotrophic keratopathy, highlighting the importance of protecting the cornea with scleral lenses.
