VEW 2022: Managing neurotrophic keratitis

Marc Bloomenstein, OD, FAAO, with the Schwartz Laser Eye Center, sat down with Optometry Times® editor Kassi Jackson to share hightlights from his presentation, "Corneal relationship therapy: managing the neurotrophic keratitis," which he presented during this year's Vision Expo West in Las Vegas.

This transcript has been lightly edited for clarity:

Jackson:

Hi everyone, I'm joined today by Dr. Marc Bloomenstein from the Schwartz Laser Eye Center. He's here to share highlights from his discussion titled, Corneal relationship therapy: managing the neurotrophic keratitis, which he's presenting during this year's Vision Expo West in Las Vegas. Thank you for being here, Dr. Bloomenstein.

Bloomenstein:

Thanks for having me, Kassi.

Jackson:

Would you please share with us the key takeaways from your presentation?

Bloomenstein:

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

So one of the things that I think we need to start doing is start looking for some more inherent root causes that may be inducing changes to the cornea, and one of those is neurotrophic keratitis (NK).

You know, we've never really talked about NK, and part of the reason why is because we just hadn't had good treatments. And more importantly, I don't think we actively looked for it.

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

The early stages of NK can just be signs of superficial punctate keratopathy; the moderate signs, obviously, are when we start to see some erosion, some damage; and then the severe cases are the ones that are those nonhealing ulcers.

You know, for a lot of our patients, it could be people that have had injuries or diabetes; it could be people that have had excessive surgeries, like for example, people that have refractive surgery; younger patients you don't think about, but the number one reason for NK still relies around herpetic lesions or herpetic infections... So those patients we have to be a little more aggressive about, but I think the bigger thing is, is just looking forward.

We have specific types of, and I never say this right, aesthesiometers, which is a device that has a little wire at the end of it, and you touch it, and it tells you how much the intervention to the nerve has been damaged, or it's almost a way of just kind of giving you an assessment of it.

For me, I'm old school. A good friend of mine, he'll take a piece of dental floss, and he'll wrap it around like something like a forceps, and he'll hold it. But for me, I use a cottontip applicator, pull out just a wisp of cottontip applicator, and you know, NK is one of those things where it's like you come and you touch a patient, because there's so many nerves at the end of the cornea, they're gonna flinch, they're gonna feel it. But for patients that have a reduction in the sensation, they just sit there, and you can just feel it.

I think one of the things we have to do as primary care physicians is add this to our regimen, start looking for decrease so that we can start treating these patients a little bit sooner because we have great treatments. I mean, obviously, for us, you know, keeping the eye lubricated, or maybe putting them on some form of like serum, amniotic membranes; but there's also a new biologic which came out—which is pretty exciting—because it's a replication of a growth factor, which tends to be limited in our NK patients.

So what you missed by not coming to Expo was just, you know, me holding up my Starbucks coffee cup, pondering, how we can be more aggressive about treating these patients and finding these patients and helping them before it gets to that severity.

If I was going to summarize this, Kassi, I would basically say, you know, neurotrophic keratitis in its severe stages is a little bit more rare, but in the early to mild stages, it's a little bit more common than we realize. So we need to start looking at it so we can manage it earlier.