Eyeworld Daily News

28 | EYEWORLD DAILY NEWS | APRIL 23, 2022 ASCRS ANNUAL MEETING DAILY NEWS D uring a Cornea Day session focusing on the ocular surface, Francis Mah, MD, presented on clinical pearls in the manage- ment of neurotrophic keratitis (NK). He first noted that a persistent corneal epithelial defect is an ocular surface wound persisting for 10 days or longer and refractory to conventional non-surgical treatments. This can lead to corneal scarring and vision loss. The estimated U.S. incidence of these per- sistent defects is less than 200,000 per year. But they can also be secondary to a number of conditions including neu- rotrophic keratitis, surgical epithelial debridement, microbial/viral keratitis, corneal transplant, limbal stem cell deficiency, mechanical trauma, and exposure keratopathy. Dr. Mah then went into detail on NK, which is a degenerative corne- al disease that can cause damage to the trigeminal nerve, loss of corneal sensation, breakdown of the corne- al epithelium, and impaired corneal healing. Those with NK may have per- sistent epithelial defect, which could progress to corneal ulceration and even stromal melting and perforation. He said that the hallmark of NK is decreased sensation. It has multiple etiologies and is often overlooked. Clinical presentation of NK may in- clude decreased sensation, decreased or no pain. You could also see corneal epithelium irregularities with or with- out epithelial defect, he said. Stromal involvement is usually oval in shape with smooth and rolled edges, and there could be corneal ulcer, melting, or perforation. Dr. Mah also mentioned medical and surgical treatments available for NK, and he later added that a combina- tion of approaches is often needed. Medical treatments include preservative-free artificial tears/gels, ointments, cyclosporine, lifitegrast, amniotic extract, serum tears, antivi- rals, hypochlorous acid, omega-3 fatty acid supplementation, corticosteroids, preservative-free topical antibiotics, and cenegermin. Surgical options include tarsorrhaphy, conjunctival flap, amniotic membrane, punctal cautery occlusion, keratoplasty, tissue adhe- sives, and direct neurotization. He detailed some of these treat- ments, including autologous serum drops, corneal neurotization, and amniotic membrane. Dr. Mah also men- tioned bandage contact lenses, which he said are "one of the first things we reach for." Scleral lenses are more of a long-term solution because they gen- erally take a little longer to do fittings and follow-ups. He also mentioned cenegermin, a recombinant human nerve growth factor, which is the first approved agent for NK and was launched in 2018. This is able to treat persistent corneal epithelial defects as well as ulcers. The active ingredient is structural- ly identical to human nerve growth factor produced in ocular tissues. He discussed results from those using ce- negermin, specifically noting data that saw complete corneal healing in up to 65.2% of patients receiving cenegermin at week 8; there was data that 80% of patients who achieved complete corne- al healing were still healed 48 weeks after completing one 8-week ceneg- ermin treatment cycle. Dr. Mah mentioned a number of future treatments, including a long list of agents and assets being studied in various phases and trials for persistent corneal epithelial defects as well as NK. He concluded by stressing that NK is the most common cause of per- sistent corneal epithelial defects, and it's critical to test corneal sensitivity to determine if the persistent corneal epithelial defect is from NK. Treatment is based on severity and cause. The ocular surface session also fea- tured a variety of case presentations. Melissa Daluvoy, MD, shared a case of unilateral non-inflammatory limbal stem cell deficiency. The case was that of a 35-year-old female who had a fire- cracker injury to the right eye. She had conjunctivalization of the right eye and symblepharon superiorly. Preoperative vision was hand motion in the eye. The unaffected eye was 20/30 uncorrected with no evidence of damage. Dr. Daluvoy detailed the option of a conjunctival limbal autograft. It takes limbal stem cells from the fellow (unaf- fected) eye transplanted to the affected eye. This option is indicated for unilat- eral disease, so Dr. Daluvoy noted that there are not many good candidates for this because a lot of cases are bilateral. This can be used alone for superficial scarring or a staged procedure with a cornea transplant. There is no risk for rejection and no need for systemic immunomodulators because it uses the patient's own tissue. Dr. Daluvoy chose this option for her patient, and she shared a pho- to from 3 weeks postop where the patient's epithelial cells had started to heal, though she still had corneal neovascularization in the center of the cornea. At 4 months postop, the patient was pinhole 20/50 in the damaged eye, and the donor eye remained 20/30, with little evidence of where it had been harvested. Editors' note: Dr. Daluvoy has no relevant financial interests. Dr. Mah has financial interests with a variety of ophthalmic companies. Ocular surface covered at Cornea Day Dr. Daluvoy shares a case where she used conjunctival limbal autograft to help a patient who had a firecracker injury to the eye.

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