Expert consensus on the identification, diagnosis, and treatment of neurotrophic keratopathy

Abstract

Background Neurotrophic keratopathy (NK) is a relatively uncommon, underdiagnosed degenerative corneal disease that is caused by damage to the ophthalmic branch of the trigeminal nerve by conditions such as herpes simplex or zoster keratitis, intracranial space-occupying lesions, diabetes, or neurosurgical procedures. Over time, epithelial breakdown, corneal ulceration, corneal melting (thinning), perforation, and loss of vision may occur. The best opportunity to reverse ocular surface damage is in the earliest stage of NK. However, patients typically experience few symptoms and diagnosis is often delayed. Increased awareness of the causes of NK, consensus on when and how to screen for NK, and recommendations for how to treat NK are needed. Methods An 11-member expert panel used a validated methodology (a RAND/UCLA modified Delphi panel) to develop consensus on when to screen for and how best to diagnose and treat NK. Clinicians reviewed literature on the diagnosis and management of NK then rated a detailed set of 735 scenarios. In 646 scenarios, panelists rated whether a test of corneal sensitivity was warranted; in 20 scenarios, they considered the adequacy of specific tests and examinations to diagnose and stage NK; and in 69 scenarios, they rated the appropriateness of treatments for NK. Panelist ratings were used to develop clinical recommendations. Results There was agreement on 94% of scenarios. Based on this consensus, we present distinct circumstances when we strongly recommend or may consider a test for corneal sensitivity. We also present recommendations on the diagnostic tests to be performed in patients in whom NK is suspected and treatment options for NK. Conclusions These expert recommendations should be validated with clinical data. The recommendations represent the consensus of experts, are informed by published literature and experience, and may improve outcomes by helping improve diagnosis and treatment of patients with NK.

Delphi Panel Consensus Regarding Current Clinical Practice Management Options for Demodex blepharitis

“…This methodology has been used across multiple professions, including numerous areas of medicine and, specifically, eyecare. [20][21][22][23][24][25][26][27][28][29][30][31][32][33]…”

An Adaptation of the RAND/UCLA Modified Delphi Panel Method in the Time of COVID-19

“… 19 It has also been used to identify circumstances when spinal mobilization and manipulation are inappropriate for patients with chronic low back pain 5 and when and how to screen for neurotrophic keratopathy. 20 Guidelines have been developed using the method to enhance the use of medical and surgical measures for recurrent stroke prevention, 21 to identify systemic treatments for unresectable metastatic well-differentiated carcinoid tumors, 3 and to determine the appropriateness of various biologics for Crohn’s disease. 22 The method has helped determine adequate follow up intervals for patients with Cushing’s Disease at different phases in their treatment course 4 and to describe specific circumstances when it is appropriate to consider tapering thrombopoietin receptor agonists in primary immune thrombocytopenia.…”

Neurotrophic keratitis: inflammatory pathogenesis and novel therapies

“…Staging of the disease using Mackie classification is dependent on the staining pattern of the cornea, corneal epithelial healing, and level of stromal involvement [38 ▪ ]. Mild stage I NK involves corneal epithelial changes.…”

“…Management of NK is dependent on severity of the disease and on the primary cause of abnormal corneal sensation. The aim of the treatment is promoting healing of the corneal epithelium and to prevent further progression of the disease [38 ▪ ]. The strategies range from monotherapy with lubricating eye drops and staggers to aggressive surgical reconstruction.…”

“…Along with the above provisions, topical preservative free antibiotics are often used to prevent secondary infection in stage II and III of NK. Topical corticosteroid eye drops and calcineurin inhibitors such as tacrolimus or cyclosporin eye drops are sometimes used to reduce ocular surface inflammation and provide a conducive environment to wound healing in NK, although this has to be balanced against the increased risk of corneal melting associated with corticosteroid use [38 ▪ ].…”