Neurotrophic keratitis (NK) results from trigeminal nerve innervation impairment to the ocular surface that causes varying degrees of corneal anesthesia (Semeraro et al, 2014). Common causes of this condition include infectious herpes zoster, herpes simplex, or injury secondary to chemical burns and trauma (Versura et al, 2018).

The goal of treatment and management is preserving corneal health and vision. Depending on severity, management strategies include artificial tears, biological solutions, human growth factor, cenegermin, amniotic membrane, tarsorrhaphy, and therapeutic contact lenses.

Case 1

A 44-year-old female patient presented with blurred vision of her right eye for the previous eight months. She had a history of soft contact lens use and was currently using artificial tears. With glasses, her visual acuity was OD 20/400. Her right cornea had moderate punctate keratitis. The consulting clinician made a diagnosis of keratitis that was possibly viral in origin. The patient’s visual acuity improved to 20/40 after two months using a combination of treatments including mild topical steroids, oral antivirals, and amniotic membrane. However, she had persistent corneal keratitis. A referral led to a diagnosis of NK with findings of decreased corneal sensitivity.

She was put on a course of cenegermin that failed to improve her condition. At this stage, the patient was referred for scleral lens fitting of her right eye to provide her cornea protection and continuous hydration. A free-form 16.5mm scleral lens immediately improved her visual acuity to 20/25. After seven months of daily wear, her vision was 20/20 with the scleral lens, and her corneal surface was smooth without punctate keratitis (Figures 1 and 2).

Case 2

A 76-year-old male presented with a history of NK post-herpes zoster infection of his left eye five years prior. He was wearing a continuous-wear bandage soft contact lens (Figure 3) with visual acuity of 20/80. Additionally, he was on oral antivirals and topical fluoroquinolone b.i.d. Examination revealed moderate superficial punctate keratitis, stromal scar, and neovascularization. A course of cenegermin improved his visual acuity to 20/60, but he couldn’t discontinue bandage soft contact lens use secondary to discomfort. Although a scleral lens could probably improve visual acuity, he declined this option.

NK can be successfully managed with bandage soft contact lenses or scleral lenses (Witsberger and Schornack, 2021). From these patient examples, it is evident that, in some cases, contact lenses can be crucial for improving corneal health, visual acuity, and patient comfort. CLS

References

1. Semeraro F, Forbice E, Romano V, et al. Neurotrophic keratitis. Ophthalmologica. 2014;231(4):191-197.
2. Versura P, Giannaccare G, Pellegrini M, Sebastiani S, Campos EC. Neurotrophic keratitis: current challenges and future prospects. Eye Brain. 2018 Jun 28;10:37-45.
3. Witsberger E, Schornack M. Scleral Lens Use in Neurotrophic Keratopathy: A Review of Current Concepts and Practice. Eye Contact Lens. 2021 Mar 1;47:144-148.