AAOpt 2024: Addressing corneal nerve dysfunction in ocular surface disease

Alongside Walt Whitley, OD, MBA, FAAO, Ahmad Fahmy, OD, FAAO, gave a presentation entitled, "Management of Neurotrophic Keratitis and Corneal Neuropathic Pain," at this year's AAOpt meeting. Fahmy is an optometrist at Minnesota Eye Consultants, founder of the Twin Cities Ocular Disease Symposium, and cofounder of Eyes on Dry Eye.

Video transcript:

Editor's note: The below transcript has been lightly edited for clarity.

Ahmad Fahmy, OD, FAAO:

Hello. My name is Ahmad Fahmy. I'm a Doctor of Optometry at Minnesota Eye Consultants. I'm the founder of the Twin Cities Ocular Surface Disease Symposium and the cofounder of Eyes on Dry Eye. I just gave a presentation at the 2024 Academy meeting here in Indianapolis with [Dr] Walt Whitley on corneal nerve dysfunction in ocular surface disease. So the key takeaways, and I think we did a good, compelling case of really the importance of looking for corneal nerve dysfunction in ocular surface disease. The main takeaways is that corneal nerve dysfunction can show up in an underactive way. It can also be overactive, and it's important for us to be testing for these patients, the corneal sensitivity, and doing a proparacaine challenge in patients we suspect might have a central component.

So misconceptions, some of the things that sometimes can be really troubling for these patients that have a more of a neuropathic component, is that sometimes the clinical picture looks pretty good, [but] we don't really address their pain aggressively enough. And so it's important for us to do a proparacaine challenge in these patients and when we identify a central component, it's important to be thinking about comanaging these patients with a pain specialist.

So the severity of the pain can be really understood, better understood by just listening carefully to that patient. In my experience, these are patients that usually come in very sensitive to light and just really struggle to do any computer work. So it's really important to be thinking about the treatment for these patients, is to decrease the inflammation and really try to get normal nerve regeneration in these patients.

Human nerve growth factor is really my go to medication, topical medication for improving the inflammation and getting better corneal nerve health, reestablishing better corneal nerve health. And a lot of these patients, I'll end up using other regenerative types of medications like amniotic membrane and platelet rich plasma, autologous serum, and again, co managing these patients with a pain specialist, I think, is really critical.

So one thing I would really like to touch on, too is that sometimes we don't think of it early enough. But also, scleral contact lenses can be very helpful. Specialty types of contact lenses can really help these patients. In my experience, the patients that end up doing a little bit better with a specialty type of lens or a scleral contact lens are the ones that really don't have as much conjunctival inflammation. And of course, we want to stay away from doing a scleral contact lens in patients that have a trabeculectomy. But scleral contact lenses can be really helpful in patients with any kind of coronial nerve abnormality. Honestly, I don't really do a lot of the contact lens fitting myself, but I know that that contact lens really has to be a really good fit in order for it to really help these patients, because, again, inducing a little bit of inflammation is the main thing we're trying to avoid. So it's really critical to get just a really an excellent fit. And so I'm really fortunate to be working with a lot of my colleagues that do just a phenomenal job in fitting these patients with sclerals.