VEW 2022: Management of Neurogenic Keratitis

Mark Blumenstein, OD, FAAO, with Schwartz Eye Center, sat with Optometry Times® Editor Cassie Jackson to share highlights from his presentation, “Treating the Corneal Relationship: Managing Neurotrophic Keratitis,” which he presented during this year’s Vision Expo West in Las Vegas.

This text has been slightly edited for clarity:

Jackson:

Hello everyone, I am joined today by Dr. Mark Blumenstein of Schwartz Eye Center. He’s here to share the highlights from his discussion titled, Treating the Corneal Relationship: Managing Neurotrophic Keratitis, which he is presenting during this year’s Vision Expo West in Las Vegas. Thank you for being here, Dr. Blumenstein.

Blumenstein:

Thanks for having me, Cassie.

Jackson:

Would you please tell us the main points from your presentation?

Blumenstein:

I think one of the things we have to realize is that there’s this evolution in the way we diagnose and the way we treat it, but the cornea — this 500-micron optical center of our patient’s eyes — really needs more TLC.

So one of the things that I think we need to start doing is to start looking for some of the more root causes that might be leading to changes in the cornea, and one of those causes is neurogenic keratitis (NK).

You know, we never really talked about NK, and part of the reason was that we didn’t get good treatments. More importantly, I don’t think we actively searched for it.

And so when you start thinking about neurotrophic keratitis, one of the things I’ve tried to highlight is that this is much more common — although rare — it’s more common than we realize, because it goes through stages.

Early stages of NK can just be signs of superficial punctate keratopathy. The mild signs are obviously when we start to see some wear and some damage; Hence, severe cases are those ulcers that do not heal.

You know, for a lot of our patients, they can be people who have had or have had diabetes; It may be people who have had excessive surgeries, for example, people who have had refractive surgery; Younger patients you don’t think about, but the number one cause of NK is still based on herpetic lesions or herpetic infections … So we have to be more aggressive towards these patients, but I think the bigger thing is, look.

We have certain types of anesthesia measuring devices, and I’m not saying that right, and it’s a device with a little wire on the end, and you touch it, and it tells you how bad the intervention is to the nerve, or it’s a way of giving you an assessment of it.

For me, I’m old school. A dear friend of mine, he’s going to take a piece of dental floss, twist it like something like tweezers, and hold it. But for me, I use the cottontip applicator, and I just pull a small piece of the cottontip applicator, and you know, NK is one of those things where it comes in like you’re touching a patient, because there’s a lot of nerves at the end of the cornea, they’re going to go back out, they’ll feel it . But for patients who have reduced sensation, they just sit there, and you can feel it.

I think one of the things we need to do as primary care clinicians is add this to our system, and start looking at the drop so we can start treating these patients a little bit sooner because we have great therapies. I mean, obviously, for us, you know, keep the eye lubricated, or maybe put it on some form of serum, the amniotic membranes; But there is also a new biological factor that has emerged – which is very exciting – because it is a replication of growth factor, which tends to be limited in our NK patients.

So what you missed by not coming to the Expo was just, you know, I’m holding my Starbucks coffee, and I’m thinking, how can we be more aggressive in treating these patients and finding these patients and helping them before it gets to that severe.

If I were to sum this up, Cassie, I’d basically say, you know, neurotrophic keratitis in its severe stages is a little rare, but in the early to moderate stages, it’s a little more common than we realize. So we need to start looking at it so we can manage it beforehand.