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Neurotrophic Keratitis: Current Challenges and Future Prospects

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Neurotrophic Keratitis: Current Challenges and Future Prospects Journal name: Eye and Brain Article Designation: REVIEW Year: 2018 Volume: 10 Eye and Brain Dovepress Running head verso: Versura et al Running head recto: Neurotrophic keratitis: challenges and prospects open access to scientific and medical research DOI: http://dx.doi.org/10.2147/EB.S117261 Open Access Full Text Article REVIEW Neurotrophic keratitis: current challenges and future prospects Piera Versura Abstract: Neurotrophic keratitis (NK) is a degenerative corneal disease caused by damage of Giuseppe Giannaccare trigeminal corneal innervation, which leads to spontaneous epithelial breakdown and corneal Marco Pellegrini ulceration. The impairment of corneal sensory innervation causes the reduction of both protective Stefano Sebastiani reflexes and trophic neuromodulators that are essential for the vitality, metabolism, and wound Emilio C Campos healing of ocular surface tissues. A wide range of ocular and systemic conditions, including herpetic keratitis, ocular chemical burns, corneal surgery, diabetes, multiple sclerosis, and Ophthalmology Unit, Department of neurosurgical procedures, can cause NK by damaging trigeminal innervation. Diagnosis of NK Experimental, Diagnostic and Specialty Medicine (DIMES), Alma Mater requires careful investigation of any ocular and systemic condition associated with the disease, Studiorum University of Bologna, complete ocular surface examination, and quantitative measurement of corneal sensitivity. The Sant’Orsola-Malpighi Teaching clinical stages of NK range from corneal epithelial alterations (stage 1) to persistent epithelial For personal use only. Hospital, Bologna, Italy defect (stage 2) and ulcer (stage 3), which may progress to corneal perforation. Management of NK is based on clinical severity, and the aim of the therapy is to halt the progression of corneal damage and promote epithelial healing. Although several medical and surgical treatments have been proposed, no therapies are currently available to restore corneal sensitivity, and thus, NK remains difficult and challenging to treat. The purpose of this review is to summarize available evidence on the pathogenesis, diagnosis, and treatment of NK. Novel medical and surgical therapies including the topical administration of nerve growth factor and corneal neurotization are also described. Keywords: neurotrophic keratitis, neurotrophic corneal ulcer, corneal nerves Eye and Brain downloaded from https://www.dovepress.com/ by 137.204.99.249 on 05-Feb-2019 Introduction Neurotrophic keratitis (NK) is a rare degenerative corneal disease caused by damage of trigeminal innervation. Corneal nerves play an essential role in tear production and preservation of the normal metabolism and function of the ocular surface. Loss of sensitivity impairs corneal wound healing, leading to epithelial changes including punctate epithelial keratopathy, persistent epithelial defects, and corneal ulcer.1 Various ocular and systemic diseases can cause damage to the fifth cranial nerve at different levels, from the trigeminal nucleus to the corneal nerve endings. Common Correspondence: Piera Versura causes are herpetic keratitis, diabetes, chemical or surgical damage, and neurosurgi- Ophthalmology Unit, Department of 2,3 Experimental, Diagnostic and Specialty cal procedures. Medical treatment consists mainly of supportive measures that do Medicine (DIMES), Alma Mater not address the underlying cause of the disease. Recently, novel promising treatments Studiorum University of Bologna, Sant’Orsola-Malpighi Teaching Hospital, have been proposed and are currently under evaluation. These include mainly topical Via Pelagio Palagi 9, 40138 Bologna, Italy treatment with nerve growth factor (NGF) and surgical corneal neurotization. Such Tel +39 051 214 2850 approaches target the pathogenic elements of NK, carrying the potential of restoring Fax +39 051 636 2846 Email [email protected] normal corneal innervation and sensitivity. submit your manuscript | www.dovepress.com Eye and Brain 2018:10 37–45 37 Dovepress © 2018 Versura et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms. http://dx.doi.org/10.2147/EB.S117261 php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php). Powered by TCPDF (www.tcpdf.org) 1 / 1 Versura et al Dovepress Pathogenesis concentration increases after injury, and that administration The cornea is innervated by the ophthalmic branch of the of NGF accelerates corneal healing.10 trigeminal nerve as well as by autonomic nerves. Nerve These complex reciprocal relations between epithelial bundles enter the cornea at the limbus, move toward the center cells and nerves are crucial for the corneal physiologic below the anterior third of the stroma, penetrate Bowman’s renewal and wound healing. An impairment of corneal sen- layer, and create a dense network of nerve fibers between sitivity interrupts these trophic relations and may produce Bowman’s layer and basal epithelial cells (i.e., sub-basal the pathologic changes typical of NK. nerve plexus).4 The great number of sensory nerve endings makes the cornea the most densely innervated tissue in the Causes human body.5 Nerves have a key role in maintaining a healthy All conditions that impair trigeminal innervation at any ocular surface, both by triggering protective reflexes after level can cause NK, such as ocular surface diseases, sys- injury, and by providing trophic factors to the corneal cells. temic diseases, and central or peripheral nervous damages Corneal denervation causes decreased vitality, metabolism, (Figure 1).12,13 and mitosis of epithelial cells, with subsequent epithelial Herpes simplex and herpes zoster eye infections are changes including intracellular edema, loss of microvilli, and among the most common conditions leading to corneal abnormal development of the basal lamina.6,7 anesthesia. In a large case series from Bonini et al, herpetic Corneal sensory innervation reacts to mechanical, keratitis was the most common cause of NK (27% of the chemical, and thermal stimuli with two reflex arcs: a motor patients).2 A severe reduction of sub-basal nerve plexus arc eliciting blinking, and an autonomous arc stimulating density was demonstrated in herpetic keratitis.14 tear secretion. Therefore, the reduction of corneal sensation Corneal surgeries like laser-assisted in situ keratomi- impairs these two reflexes with an alteration of production leusis, keratoplasty, and corneal incisions for cataract may and stability of the tear film.8 disrupt corneal innervation and cause NK.15,16 After nerve For personal use only. Corneal nerves and epithelial cells support each other transection at the peripheral cornea, the distal nerves undergo mutually through the release of trophic factors promoting Wallerian degeneration with immediate loss of sensation to epithelial cell proliferation, migration, and differentiation the corresponding region. Nerve regeneration occurs gradu- as well as nerve development and survival. Corneal nerves ally over months with variable return of corneal sensitivity.15 express many epitheliotrophic neuromediators, such as Other ocular surface conditions associated with NK are substance P, calcitonin gene-related peptide, acetylcholine, corneal chemical and traumatic injuries, corneal dystrophies, noradrenaline, serotonin, neuropeptide Y, and vasointestinal contact lens wearing, and chronic use of topical medications peptide. On the other side, corneal epithelial cells release (such as anesthetics, beta-blockers, antivirals, glaucoma various neurotrophic growth factors, including NGF, ciliary medications, antibiotics, and nonsteroidal anti-inflammatory 12,13 Eye and Brain downloaded from https://www.dovepress.com/ by 137.204.99.249 on 05-Feb-2019 neurotrophic factor, and glial-cell-derived neurotrophic fac- drugs). tor. These factors are fundamental in ocular surface homeo- Surgical procedures for the treatment of trigeminal stasis and wound healing.4 neuralgia may induce permanent damage to the trigeminal In particular, NGF is a neurotrophin discovered in the nerve with subsequent corneal anesthesia. The main surgi- early 1950s by R. Levi-Montalcini that promotes neuronal cal options include microvascular decompression, balloon sprouting by intact and injured neurons. It provides trophic compression, radiofrequency thermocoagulation, and gamma support to neurons after injury and reverses pathologic knife radiosurgery. The intraoperative damage occurs at changes induced by peripheral nerve damage.9 NGF exerts the preganglionic or ganglionic region of the nerve and is its biologic functions by binding to low-affinity p75NTR not associated with a reduction of sub-basal nerve plexus (neurotrophin receptor, a member of the tumor necrosis fac- density.17 Other less common causes of trigeminal palsy are tor receptor superfamily) and high-affinity TrkA receptor (a intracranial and orbital tumors, facial trauma, aneurysm, tyrosine kinase receptor family). The human cornea produces and stroke.1,12 NGF and expresses high-affinity NGF receptors.10 NGF dem- Systemic conditions
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