Early diagnosis ideal for NK
Leonardo Mastropasqua MD
Prompt, early diagnosis, tailored treatment and careful monitoring are the cornerstones of optimal management of neurotrophic keratopathy (NK), according to Leonardo Mastropasqua MD, Italy.
Speaking during a dedicated session on non-healing corneal-ulcers during the 37th Congress of the ESCRS in Paris, France, he outlined the hierarchy of medical treatment for NK, from lubricant to matrix therapy, and nerve growth factor (NGF) and stressed the importance of accurate diagnosis and staging.
Dr Mastropasqua noted that the key goals in the treatment of NK are to promote healing, avoid worsening, reduce recurrences and preserve vision.
“Thus the early diagnosis, severity-based treatment and monitoring of the eye is mandatory to achieve epithelial healing and prevent stromal lysis and perforation,” he commented.
It is also “very important to treat the environment contributing to dry eye, specifically inflammation”, he added.
Dr Mastropasqua advocated taking a step-ladder management approach according to NK stage/severity to stop progression and reverse NK changes (as per the Dua et al 2018 consensus paper), which comprises three steps involving medical management, followed by non-surgical intervention, followed by surgical management.
In mild stage 1 cases of NK where there are epithelial changes without epithelial defects the aim is to improve epithelial quality and transparency; stabilise epithelium and avoid epithelial breakdown; and prevent progression to moderate stage (persistent epithelial defect), he said.
Therapeutic options at this stage include non-preserved topical medications, tear substitution, treating concurrent ocular surface disorders, anti-inflammatory therapy, therapeutic contact lenses and, if needed, punctal occlusion and debridment of sick epithelium.
“But if we have concurrent inflammation it is very important to find out if it is infection and identify pathogens and treat them,” Dr Mastropasqua said, adding that if there is a negative culture finding he would give oral azithromycin or other broad spectrum topical antibiotics, but advised against using toxic aminoglycosides like gentamicin. “The aim is to minimise ocular irritants and reduce inflammation,” he reminded delegates, adding that “eyelid hygiene is of course important”.
Dr Mastropasqua urged caution if using steroids and said topical non-steroidal inflammatory drugs (NSAIDs) should be totally avoided, but topical ciclosporin is also an option.
Successful tear substitution should reduce mechanical epithelial damage and dilute pro-inflammatory mediators with good options available, he added.
Moving on to moderate stage 2 NK where there is a persistent epithelial defect, intervention should aim to promote epithelial healing, prevent the recurrence of epithelial breakdown and prevent progression to severe stage (stromal lysis), Dr Mastropasqua explained.
For these patients, therapeutic options include topical preservative-free antibiotics, tetracycline/macrolides to prevent stromal melting, biological medical products, serum eye drops and platelet-rich plasma, therapeutic contact lenses, non-surgical eyelid closure and, if these options fail, a surgical approach of tarsorrhaphy-amniotic membrane transplantation-conjunctival flap can be performed, he outlined.
Dr Mastropasqua also discussed topical regenerating agents explaining that they are biopolymers engineered to mimic the structural and functional properties of heparan sulfates, which work by the creation of a cellular microenvironment favourable to corneal healing. They offer protection against extensive proteolysis induced by inflammatory, necrotic or fibrotic processes.
Finally, looking at interventions for severe stage 3 NK, Dr Mastropasqua said the aim here again is to promote corneal healing and prevent further corneal stromal lysis and perforation.
He discussed the rise of topical treatment with NGF agents for corneal neurotropic ulcers, quoting early research from 1998 and more recent trial data on the use of recombinant human NGF (rhNGF) for NK. He said the latest multi-centre findings show that rhNGF was well tolerated in patients with stage 2 or 3 NK. “So favourable trends in corneal healing suggest that rhNGF may be effective for treating moderate to severe NK”.
Summarising his presentation, Dr Mastropasqua said his take-home message was that severity-based treatment based on accurate staging of NK is key: “Prompt treatment improves success rates, prognosis and vision.”
Concluding he said that the use of rhNGF “is an aetiological treatment that may change of the prognosis of NK evolution”.