Neurotrophic Keratopathy: Ophthalmology's Diabetic Foot Problem

This article summarizes key elements of the 2020 Harold A. Stein Lecture presented at the Eye and Contact Lens Special Symposium "Healing the Ocular Surface: What's New for Neurotrophic Keratitis." The major point that I made in this talk is that we need to think about neurotrophic keratopathy as ophthalmology's diabetic foot problem; as a chronic condition that is, often best managed by prevention. Neurotrophic keratopathy is not primarily an inflammatory condition, as suggested by the term ‟neurotrophic keratitis." The epitheliopathy in this condition is a consequence of the dysregulated epithelial cell migration, differentiation, and homeostasis that occurs with denervation of the ocular surface. Although this epitheliopathy may be complicated by poor lid closure, or rarely, aqueous tear deficiency, most of these eyes are not dry and do not require exogenous lubrication for comfort, prophylaxis, or healing. The use of topical agents in these eyes inevitably leads to unrecognized iatrogenic injury, with poor outcomes because of inherently poor wound healing and delays in seeking medical care. Tarsorrhaphy is a time-honored method of protecting the neurotrophic cornea, shielding the eye from iatrogenic injury. Alternative methods for protecting the ‟at risk" surface of the neurotrophic cornea include patient education, minimizing topical agents, and the use of protective eyewear.