Supplement to September 2020 Francis S. Mah, MD Marjan Farid, MD UNDERSTANDING, Stephen C. Pflugfelder, MD DIAGNOSING, Karolinne Maia Rocha, MD, PhD AND TREATING NEUROTROPHIC KERATITIS IN 2020 Distributed with Provided by A CME activity provided by Evolve Medical Education LLC This activity is supported by an independent medical education grant from Dompé. Understanding, Diagnosing, and Treating Neurotrophic Keratitis in 2020 Release Date: August 2020 Expiration Date: September 2021 FACULTY FRANCIS S. MAH, MD MARJAN FARID, MD STEPHEN C. KAROLINNE MAIA ROCHA, Program Moderator Professor of Ophthalmology PFLUGFELDER, MD MD, PHD Director, Cornea and External Disease School of Medicine Professor of Ophthalmology Director, Cornea & Refractive Surgery Co-Director, Refractive Surgery Vice Chair, Ophthalmic Faculty James and Margaret Elkins Chair Storm Eye Institute Scripps Clinic Director, Cornea/External Disease, Director, Ocular Surface Center Baylor Medical University of South Carolina La Jolla, CA Cataract, and Refractive Surgery College of Medicine Charleston, SC Gavin Herbert Eye Institute Houston, TX University of California, Irvine Irvine, CA CONTENT SOURCE • Recognize the various potential causes of neurotrophic This continuing medical education (CME) activity captures keratitis and when referrals may be necessary. content from two webcasts. • Summarize mechanisms of action of newer treatments and when they should be introduced into treatment regimens ACTIVITY DESCRIPTION for neurotrophic keratitis. Eye care providers may not understand what neurotrophic • Identify the relationships between disease characteristics, keratitis is or how it differs from other corneal diseases. In drug, treatment frequency, visual, and anatomic outcomes. addition; eye care practitioners may be unaware of treatments in development, or the already approved treatments for GRANTOR STATEMENT neurotrophic keratitis. They also may not understand This activity is supported through an educational grant from the mechanism of action of these newer treatments. This Dompé. supplement features four experts in neurotrophic keratitis who review important issues related to managing patients, ACCREDITATION STATEMENT including the scope and causes of the disease, comorbid Evolve Medical Education LLC (Evolve) is accredited by systemic conditions, ocular exam, and corneal sensation. the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. TARGET AUDIENCE This certified CME activity is designed for anterior segment CREDIT DESIGNATION STATEMENT specialists, general ophthalmologists, and other eye care Evolve designates this enduring material for a maximum of providers involved in the management of corneal disorders. 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in LEARNING OBJECTIVES the activity. Upon completion of this activity, the participant should be able to: • Describe the stages of neurotrophic keratitis and how to differentiate it from similar diseases. 2 SUPPLEMENT TO CATARACT & REFRACTIVE SURGERY TODAY | SEPTEMBER 2020 TO OBTAIN CREDIT Stephen C. Pflugfelder, MD, and/or spouse/partner has had To obtain credit for this activity, you must read the activity a financial agreement or affiliation during the past year with in its entirety and complete the Pretest/Posttest/Activity the following commercial interests in the form of Consultant: Evaluation/Satisfaction Measures Form, which consists of a series Allergan and Kala. Grant/Research Support: Allergan. of multiple choice questions. To answer these questions online and receive real-time results, please visit http://evolvemeded. Karolinne Maia Rocha, MD, PhD, and/or spouse/partner has com/online-courses/2010-supplement. Upon completing the had a financial agreement or affiliation during the past year with activity and self-assessment test, you may print a CME credit the following commercial interests in the form of Consultant: letter awarding 1 AMA PRA Category 1 Credit™. Alternatively, Ace Vision, Alcon, Allergan, Avedro, Bausch + Lomb, Dompé, please complete the Posttest/Activity Evaluation/Satisfaction and Johnson & Johnson Vision. Form and mail or fax to Evolve Medical Education LLC, 353 West Lancaster Avenue, Second Floor, Wayne, PA 19087; EDITORIAL SUPPORT DISCLOSURES Fax: (215) 933-3950. The Evolve staff and planners have no financial relationships with commercial interests. Virginia Pickles, writer, and Nisha DISCLOSURE POLICY Mukherjee, MD, peer reviewer, have no financial relationships It is the policy of Evolve that faculty and other individuals with commercial interests. who are in the position to control the content of this activity disclose any real or apparent conflicts of interest relating to OFF-LABEL STATEMENT the topics of this educational activity. Evolve has full policies in This educational activity may contain discussion of published place that will identify and resolve all conflicts of interest prior and/or investigational uses of agents that are not indicated by to this educational activity. the FDA. The opinions expressed in the educational activity are those of the faculty. Please refer to the official prescribing The following faculty/staff members have the following information for each product for discussion of approved financial relationships with commercial interests: indications, contraindications, and warnings. Marjan Farid, MD, and/or spouse/partner has had a financial DISCLAIMER agreement or affiliation during the past year with the following The views and opinions expressed in this educational activity commercial interests in the form of Consultant: Allergan, Biotissue, are those of the faculty and do not necessarily represent the CorneaGen, Dompé, Johnson & Johnson Vision, and Novartis. views of Evolve, Cataract & Refractive Surgery Today, or Dompé. Francis S. Mah, MD, and/or spouse/partner has had a financial DIGITAL EDITION agreement or affiliation during the past year with the follow- To view the online version of the material, please go to ing commercial interests in the form of Consultant and Speaker’s http://evolvemeded.com/online-courses/2010-supplement. Bureau: Dompé. SEPTEMBER 2020 | SUPPLEMENT TO CATARACT & REFRACTIVE SURGERY TODAY 3 PLEASE COMPLETE PRIOR TO ACCESSING THE MATERIAL AND SUBMIT WITH POSTTEST/ACTIVITY EVALUATION/SATISFACTION MEASURES INSTRUCTIONS FOR CME CREDIT. 1. Please rate your confidence in your ability to identify and treat patients 7. To which stage of neurotrophic keratitis does the following with neurotrophic keratitis (based on a scale of 1 to 5, with 1 = “Not at all description apply: “Persistent epithelial defect with smooth rolled edges; confident” and 5= “Very confident”). stromal opacity”? a. 1 a. Stage 1 b. 2 b. Stage 2 c. 3 c. Stage 3 d. 4 e. 5 8. Which of the following is an appropriate therapy for stage 3 neurotrophic keratitis? 2. A 53-year-old woman with a diagnosis of neurotrophic keratitis presents a. Recombinant human nerve growth factor to your office. Which of the following are reasonable options for treatment b. Preservative free artificial tears (more than one may apply)? c. Punctal occlusion a. Artificial tears d. Hydrogel contact lens b. Topical Ointment c. Latanoprost topical drops 9. A 67-year-old female with a nonhealing corneal epithelial defect d. Cenegermin presents to your office. She has a history of bilateral LASIK and herpes zoster ophthalmicus. She has previously attempted amniotic membrane 3. What is the most common etiology of neurotrophic keratitis? allograft, bandage contact lens, and autologous serum tears for a. Postsurgical damage to ciliary nerves treatment, yet her persistent epithelial defect remains. Which of the b. Postherpetic infections following is an appropriate treatment for this patient? c. Diabetes mellitus a. Start cenegermin 20 mcg/mL d. Corneal dystrophies b. Punctal occlusion c. Preservative free artificial tears 4. What is the hallmark finding of neurotrophic keratitis? a. Punctate epithelial erosions 10. In the cenegermin clinical trials, what was the most common b. Abnormal Schirmer test adverse reaction? c. Abnormal corneal sensitivity testing a. Eye irritation d. Lid laxity b. Red eye c. Eye pain following instillation 5. A 72-year-old man with primary open-angle glaucoma presents with blurry vision. On exam, he has an epithelial defect with rolled edges. 11. A 40-year-old male with a history of diabetes and bilateral LASIK He has decreased corneal sensitivity. Which of the following made him OU presents with diffuse punctate epitheliopathy, decreased tear at risk for this diagnosis (more than one may apply)? break-up time, and stromal haze. Which of the following is an appropriate a. Use of multiple topical glaucoma medications treatment for this patient? b. Blepharitis a. Scleral lens c. His age b. Preservative free artificial tears d. History of glaucoma c. Amniotic membrane d. Tarsorrhaphy 6. Which of the following is an example of a quantitative corneal sensitivity test? a. Cochet-Bonnet esthesiometer b. Cotton swab c. Dental floss 4 SUPPLEMENT TO CATARACT & REFRACTIVE SURGERY TODAY | SEPTEMBER 2020 UNDERSTANDING, DIAGNOSING, AND TREATING NEUROTROPHIC KERATITIS IN 2020 Understanding, Diagnosing, and Treating Neurotrophic Keratitis in 2020 BREAKING THE CYCLE OF RECURRENCE Novel recombinant human nerve growth factor heals persistent epithelial defects. BY FRANCIS S. MAH, MD eurotrophic keratitis is a rare, degenerative disease of