Neurotrophic Keratitis Recurrent Corneal Erosion Syndrome

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Neurotrophic Keratitis Recurrent Corneal Erosion Syndrome

Neurotrophic Keratitis Dr Sue Ormonde Learning objectives: 1. Describe the aetiologies of recurrent corneal erosions 2. Understand the therapeutic options for recurrent corneal erosions 3. Identify the causes of exposure keratopathy 4. Understand management strategies for exposure keratopathy 5. Recognise and discuss the management of neurotrophic corneal ulcers Suggested reading: Davis EA. Dohlman CH. Neurotrophic keratitis. International Ophthalmology Clinics. 41(1):1-11, 2001. Das S. Seitz B. Recurrent corneal erosion syndrome. Survey of Ophthalmology. 53(1):3-15, 2008 Jan-Feb. Neurotrophic or neuropathic keratopathy occurs in anaesthetic cornea Corneal sensory nerves key to corneal metabolic activity & epithelial health Loss of neural influence promotes oedema & exfoliation of epithelial cells Acquired causes: - Herpes Simplex - Herpes Zoster - Transection CN 5 - Diabetes - Leprosy - Acoustic neuroma Congenital causes: - Familial dysautonomia (Riley-Day) - Anhidrotic ectodermal dysplasia - Congenital insensitivity to pain Diagnosis: - Often presents late as painless initially - Early - punctate keratopathy, epithelial irregularity - Later - persistent epithelial defect, round/oval, usually central/superior half, surrounding opaque epithelium with smooth rolled edges, may progress to corneal melt esp. if secondary infection or steroid use Treatment: - Preservative free lubricants, prophylactic preservative free antibiotics - Tarsorrhaphy or botulinum toxin ptosis. Patching ineffective. Recurrent corneal erosion syndrome • Epithelial basement membrane complex anchors corneal epithelium • Disturbance of this complex results in defective adhesion and “recurrent epithelial erosion” Aetiology 1. Corneal trauma 2. Corneal dystrophies – Map dot fingerprint (Cogan’s dystrophy, or epithelial basement membrane dystrophy) – Reis Bucklers dystrophy – Lattice Map dot fingerprint: Most common anterior dystrophy Grey patches,cysts,fingerprints Only 10% become symptomatic However 50% RCES have MDF Genetics Autosomal dominant No definite information available about genetic linkage Clinical presentation • Possible past history: trauma/RCES • Unilateral • Severe ocular pain on awakening • Lacrimation ++ • Resolve in hours to days • May last months or years • Worse in diabetics • Corneal abrasion of variable size • Stains strongly with fluorescein • May be microcysts or pseudodendrite • Exclude MDF in other eye Management • Acute erosions • Patching • Cycloplegic • Oc Chloramphenicol • Debridement • Prophylaxis • Lubrication QDS for 3 months • Ointment nocte for 6 months • Bandage contact lens • Excimer laser PTK • Anterior stromal puncture Exposure Keratopathy Inadequate wetting of cornea, despite normal tear production Inability of lids to resurface cornea with each blink 1. Facial nerve palsy 2. Severe ectropion 3. Proptosis 4. Nocturnal exposure Signs – Mild to severe – Inferior punctate epitheliopathy – Corneal ulceration – Infective keratitis – Neovascularisation – Corneal perforation Treatment – Artificial tears by day – Lubricant ointment by night – Taping of eyelids (temporary) – Botox ptosis – Corrective lid surgery .

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Corneal Changes in Neurosurgically Induced Neurotrophic Keratitis
Research Original Investigation | CLINICAL SCIENCES Corneal Changes in Neurosurgically Induced Neurotrophic Keratitis Alessandro Lambiase, MD, PhD; Marta Sacchetti, MD, PhD; Alessandra Mastropasqua, MD; Stefano Bonini, MD IMPORTANCE Neurotrophic keratitis (NK) represents a sight-threatening complication after trigeminal impairment. To our knowledge, the duration for which trigeminal injury may affect corneal structures and function has not been investigated previously. OBJECTIVE To describe the long-term clinical, morphological, and functional outcomes of NK after neurosurgical trigeminal damage. DESIGN, SETTING, AND PARTICIPANTS Observational case series performed at a corneal and ocular surface diseases referral center in 2010. Eight consecutive patients with monolateral NK from 1 to 19 years after neurosurgery and 20 age- and sex-matched healthy participants were included. MAIN OUTCOMES AND MEASURES Complete eye examination, tear film function tests, corneal staining, and Cochet-Bonnet esthesiometry were performed. The number and density of corneal nerves, number of hyperreflective keratocytes, and corneal epithelial, endothelial, and keratocyte cell densities were evaluated by in vivo slit scanning confocal microscopy. Clinical and morphological data were compared with the contralateral unaffected eyes and with the eyes of healthy control participants. RESULTS All patients showed superficial punctate keratitis and dry eye in the NK eye and a healthy contralateral eye. Decreased corneal sensitivity was observed in all affected eyes (mean [SD], 2.0 [1.9] mm in the affected eyes vs 5.8 [0.3] mm in the contralateral unaffected eyes; P = .01) and was related to decreased subbasal nerve length (P = .04; R = 0.895). Corneal epithelial and endothelial cell densities were significantly decreased and the number of hyperreflective keratocytes was significantly increased in NK eyes compared with contralateral unaffected eyes and with the eyes of healthy participants.
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Ophthalmic Herpes Zoster
OPHTHALMIC HERPES ZOSTER RONALD J. MARSH and MATTHEW COOPER London SUMMARY Fig. 1 shows the age and sex distribution, which is A current review of ophthalmic zoster is presented biased in favour of females and compares with 50.7% including its virology, immunology, epidemiology and males, 49.3% females in another series.5 The 1981 census pathogenesis. We give our findings in 1356 patients for Greater London recorded 48% males and 52% referred to the Zoster Clinic at Moorfields Ey e Hospital, females. London. The treatment of the disease and its ocular com ONSET plications is discussed. There is a prodromal influenza-like illness of varying Ophthalmic herpes zoster is a disease varying in severity duration, with headache, pyrexia, malaise, depression, and from devastating, threatening life and sight, to so mild that sometimes neck stiffness, which may last up to a week it may pass unnoticed. The ophthalmic division of the fifth before the rash appears. This is shortly followed by local cranial nerve is affected in 7-17.5% of herpes zoster ised pain over the distribution of the ophthalmic nerve, patients. 1-5 Ocular involvement complicates approxi lymph node swelling in the corresponding drainage areas mately 50% of these cases and very rarely cases of maxil and, occasionally, a red eye. The localised pain is well lary herpes zoster,l affecting many of the tissues of the known to precede the rash by several days in some cases. globe and orbit by highly varied types of lesions. This probably represents the replication and migration We felt it would be helpful to report our experience with phase of the disease and is possibly accompanied by a lim the disease because the large number of cases we have ited viraemia.
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Diagnosis and Treatment of Neurotrophic Keratopathy
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Herpetic Corneal Infections
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Herpes Zoster Ophthalmicus—Diagnosis and Management
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Herpes Zoster-Shingles Review
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Neurotrophic Keratitis
Eye (2003) 17, 989–995 & 2003 Nature Publishing Group All rights reserved 0950-222X/03 $25.00 www.nature.com/eye 1;3 2 1 1;3 Neurotrophic S Bonini , P Rama , D Olzi and A Lambiase CAMBRIDGE OPHTHALMOLOGICAL SYMPOSIUM keratitis Abstract an impairment of corneal sensitivity.2 Systemic diseases such as diabetes, multiple sclerosis, Neurotrophic keratopathy is a degenerative and leprosy may decrease sensory nerve corneal disease induced by an impairment of function or damage sensory fibres leading to trigeminal nerve. Impairment of loss of corneal anaesthesia.3,4 The corneal epithelium is corneal sensory innervation is responsible for the first target of the disease showing corneal epithelial defects, ulcer, and dystrophic changes and defects with poor perforation. In the present report, we reviewed tendency to spontaneous healing. The the pathogenesis, diagnosis, and therapeutic progression of the disease may lead to corneal aspects of this disease. An accurate history and ulcers, melting, and perforation.5 While the clinical examination, including the function of clinical diagnosis is easily oriented from the cranial nerves, together with the clinical history and clinical findings, the management of features of the ocular surface are essential for a this condition is one of the most difficult and prompt diagnosis. The evaluation of the challenging among all corneal diseases. corneal sensitivity and tear film function are important diagnostic steps as well. Specific medical and surgical treatments, based on the Pathophysiology clinical staging of the disease, are often able to halt its progression. Future developments in The cornea is provided with the richest the medical treatment including the innervation of all body tissues (40 times more administration of neuropeptide and growth than the tooth pulp and 400 times more than 1 factors are presented.
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Oral Pharmaceuticals in Anterior Segment Disease
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Prevalence of Ocular Manifestations and Visual Outcomes in Patients with Herpes Zoster Ophthalmicus
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Renewed Sensation
234_AAO 2020 Enduring Monograph_8 pgs rev 2.qxp_Layout 1 3/5/21 1:52 PM Page 1 CME MONOGRAPH ReNewed Sensation IMPROVING AWARENESS, DIAGNOSIS, AND TREATMENT OF NEUROTROPHIC KERATITIS Original Release: April 1, 2021 Expiration: April 30, 2022 VISIT HTTPS://TINYURL.COM/NKCME2021 FOR ONLINE TESTING AND INSTANT CME CERTIFICATE INSTRUCTIONS FOR OBTAINING CREDIT FACULTY To obtain AMA PRA Category 1 Credit™ for this activity, please read the monograph, consult referenced sources as necessary, and complete the posttest and evaluation online. Upon Edward J. Holland, MD (Chair) passing with a score of 70% or higher, a certiﬁcate will be made available immediately. Professor of Clinical Ophthalmology University of Cincinnati DISCLOSURE POLICY Director, Cornea Services MedEdicus requires that anyone who is in a position to control the content of this educational Cincinnati Eye Institute activity disclose all relevant ﬁnancial relationships with any commercial interest. Financial Cincinnati, Ohio relationship information is collected and resolved prior to the educational activity. FACULTY Preeya K. Gupta, MD Preeya K. Gupta, MD, is a consultant for Dompé US, Inc. Associate Professor of Ophthalmology Cornea & Refractive Surgery Edward J. Holland, MD, is a consultant for Aerie Pharmaceuticals, Inc, Akros Pharma Inc, Duke University Eye Center Alcon, Aldeyra Therapeutics, Allegro Ophthalmics, LLC, Allergan, Azura Ophthalmics Ltd, Durham, North Carolina BlephEx, BRIM Biotechnology, Inc, Claris Bio, CorneaGen, CorNeat Vision Ltd, Dompé US, Inc, Expert Opinion,
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CORNEAL NEUROTISATION for NEUROTROPHIC KERATOPATHY: CLINICAL OUTCOME, in VIVO CONFOCAL MICROSCOPIC and HISTOPATHOLOGIC FINDINGS Darren S
CORNEAL NEUROTISATION FOR NEUROTROPHIC KERATOPATHY: CLINICAL OUTCOME, IN VIVO CONFOCAL MICROSCOPIC AND HISTOPATHOLOGIC FINDINGS Darren S. J. Ting, FRCOphth1, Gustavo Figueiredo, MBChB, PhD1,2, Christin Henein, MBBS, MRes1,2, Eric Barnes, FRCOphth1,2, Omar Ahmed, FRCS (Plast)3, Hardeep S. Mudhar, FRCPath, PhD4, Francisco C. Figueiredo, FRCOphth, MD, PhD1,2 1Newcastle Eye Centre, Royal Victoria Infirmary 2Newcastle University, Newcastle upon Tyne, NE1 4LP, UK. 3Department of Plastic Surgery, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP, UK. 4National Specialist Ophthalmic Pathology Service, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK. Corresponding author: Darren Shu Jeng Ting Email: [email protected] Conflict of interest: None Funding / support: None Key words: Corneal anaesthesia; corneal neurotisation; aesthesiometer; in vivo confocal microscopy; neurotrophic keratopathy; keratitis; meningioma 1 ABSTRACT (Word count: 288 words; max. 250 words) Purpose: To describe the long-term outcome, in vivo confocal microscopic (IVCM) and histopathologic findings following corneal neurotisation surgery for unilateral neurotrophic keratopathy. Methods: Two patients with severe unilateral neurotrophic keratopathy secondary to cerebellopontine angle meningioma were included. Corneal neurotisation surgery was performed at a tertiary referral centre. Corneal sensation was measured using Cochet-Bonnet aesthesiometer. IVCM was performed using Heidelberg HRT3 laser scanning technology combined with Rostock Corneal Module. Histopathologic examination was performed on the excised corneo-scleral disc of patient 2. Results: Preoperatively the corneal sensations of the affected eyes of patients 1 and 2 were 0.5mm and 0mm, respectively. Following the corneal neurotisation surgery, patient 1 noticed subjective improvement of corneal sensation at two months and objective improvement by thirteen months (60mm in 3 quadrants).
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Advances in the Treatment of Neurotrophic Keratitis New Approaches for Corneal Healing
CME MONOGRAPH VISIT HTTPS://TINYURL.COM/NKCME FOR ONLINE TESTING AND INSTANT CME CERTIFICATE. ADVANCES IN THE TREATMENT OF NEUROTROPHIC KERATITIS NEW APPROACHES FOR CORNEAL HEALING Original Release: June 1, 2020 Expiration: June 30, 2021 LEARNING METHOD AND MEDIUM FACULTY This educational activity consists of a supplement and ten (10) study questions. The participant should, in order, read the learning objectives contained at the beginning of this supplement, Kenneth A. Beckman, MD, FACS (Chair) read the supplement, answer all questions in the post test, and complete the Activity Evaluation/ Clinical Assistant Professor of Ophthalmology Credit Request form. To receive credit for this activity, please follow the instructions provided on Ohio State University the post test and Activity Evaluation/Credit Request form. This educational activity should take a Columbus, Ohio maximum of 1.0 hour to complete. Director of Corneal Surgery ACTIVITY DESCRIPTION Comprehensive Eye Care of Central Ohio The health of the corneal surface depends on a feedback mechanism that involves sensory Westerville, Ohio innervation. This feedback loop can be disrupted by both ocular and systemic conditions that damage trigeminal innervation of the cornea, leading to the corneal condition neurotrophic Mark S. Milner, MD, FACS keratitis, which is characterized by disrupted tearing and progressive corneal damage that does Associate Clinical Professor not readily heal. Until very recently, a lack of effective treatments to reinnervate and heal eyes Department of Ophthalmology affected by neurotrophic keratitis served to further hamper efforts toward timely diagnosis. Now that an effective treatment is available, clinicians must strive to identify patients who might Yale University School of Medicine benefit before the disease progresses to the point of corneal perforation and subsequent loss of New Haven, Connecticut visual acuity.
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