Neurotrophic Keratopathy: Current Concepts, Management, and Emerging Treatments

To provide an updated brief review on neurotrophic keratopathy (NK) including classification, etiology, features, diagnosis, and management.

Literature review.

NK is defined as the dysfunction of corneal innervation that results in dysregulation of corneal and/or cellular function. It is characterized by loss of corneal sensation and neuronal homeostasis, leading to eventual corneal epithelial breakdown and ultimately keratolysis if untreated. Classification, etiology, features, diagnosis, and management of NK are reviewed. Prevalence is likely higher than previously estimated, and decreased sensation can originate from various causes. The Neurotrophic Keratitis Study Group classification emphasizes verifying corneal sensation early and distinguishes different epithelial and stromal aspects of NK. Optimal treatments regardless of NK stage include preservative-free lubricants (tears, gels, and ointments), punctal occlusion, autologous serum tears/umbilical cord serum drops/platelet-rich plasma drops, and removal of toxic or preservative-containing medications. Specific direct treatments, such as cenegermin and neurotization, address the decreased innervation and can improve sensation. A timely tarsorrhaphy may be necessary in refractory or quickly progressing cases. Keratoplasty is high risk in this setting but may be possible with aggressive medical therapy, adjunct procedures (i.e., amniotic membrane, tarsorrhaphy), perioperative direct treatments increasing sensation, and close follow-up postoperatively.

NK is a chronic and potentially progressive disease that requires vigilance to monitor for future progression even after periods of apparent stability. As in other serious chronic conditions without a cure, earlier intervention in this challenging disease may obviate future decompensation and visually significant sequelae.