28 EWAP MARCH 2024 CORNEA also play a role and reduce corneal sensitivity. Dr. Nijm agreed that the easiest and fastest test for corneal sensitivity is with the use of a cotton swab. She said to be sure to test both eyes and look for patients’ blink to stimulus. A more formal test that can be used is the esthesiometer, which can allow a numeric assessment, looking at different quadrants. “As dryness and corneal sensitivity often go hand in hand, I also observe the blink rate and tear breakup time, and I’ve come to use osmolarity more frequently to help distinguish dry eyes from other potential causes of inflammation on the ocular surface that might mimic dry eyes,” Dr. Nijm said. “If I see the osmolarity is high, I will also look more carefully at corneal sensation. Studies have shown that over time, high osmolarity will cause damage to corneal nerves.” There are many treatment options available for various stages of NK. It can be simply eliminating some of the factors that are preventing the healing, Dr. Mah said. If the patient is on glaucoma medications as well as medications for dry eyes, decreasing the overall volume of preservatives is going to be helpful. Environmental factors are also important to consider. These can include ceiling fans, air blowing on their face, computer use, etc. Dr. Mah said lowering the screen or having them blink more frequently can be helpful. Patients can use preservativefree lubricants, like artificial tears, gels, or ointments, Dr. Mah said, reiterating the importance of limiting preservatives. “We then typically go to a bandage contact lens,” he said. Allowing a lot of oxygen through the contact lens is helpful, and he likes to prescribe a preservative-free antibiotic eye drop when using a bandage contact lens. The next thing you would typically think of is either serum tears or platelet-enriched growth factor, or an amniotic membrane. “After that, we’re thinking about Oxervate [cenegermin-bkbj, Dompe],” he said. “The first time I see a patient, I’m wondering what they’ve done or haven’t done,” he said. Dr. Mah said he might jump to a bandage contact lens in the office, or he might try Prokera (BioTissue). Because Oxervate can take a while to get, he might start the ball rolling for that. “[For] Stage 1 of the Mackie classification, where there’s alterations of the corneal epithelium that shows some SPK, I usually start with some type of increased lubrication, ointments, or preservative-free tears,” Dr. Nijm said. If there’s progression or it’s someone who is closer to Stage 2, she would consider adding punctal plugs and/or topical antibiotic to decrease the likelihood of infection. She considers the use of amniotic membrane and cenegermin-bkbj treatment as well. Dr. Nijm said she prefers to be aggressive at early stages to get the cornea to improve as quickly as possible because it’s preferable to prevent further progression or a perforation. If these treatment options don’t work, Dr. Nijm said tarsorrhaphy is an option. Scleral contact lenses and autologous serum drops are also useful, she said. Patients have to be watched carefully. You need to stop progression of the defect, she said. “Identifying it earlier and being more cognizant of the different treatment options will hopefully decrease the number of patients who reach Stage 3,” she said. Corneal neurotization is also an option that may address the underlying concern. “It’s a complex surgery that requires dedication from corneal and plastics teams and something that is performed typically only in academic institutions,” Dr. Nijm said. Dr. Nijm said she will choose to move forward with treatment quickly if the cornea isn’t Persistent corneal epithelial defect, grayish-white edge, heaped-up epithelium edge, frequently central, faint stromal haze. Source: Francis Mah, MD
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