EyeWorld India December 2021 Issue

CORNEA 30 EWAP DECEMBER 2021 by Ellen Stodola Editorial Co-Director Breaking down neurotrophic keratitis Contact information Ali: asim.ali@utoronto.ca Beckman: kenbeckman22@aol.com Holland: eholland@holprovision.com W ith neurotrophic keratitis (NK), there is a lot to consider in terms of staging, making a diagnosis, and treatment. Three experts discussed how they work up NK patients and some of the options for handling these cases. Stages of NK When staging NK, Kenneth Beckman, MD, said that he separates corneal sensation into normal, decreased, and absent. “Once I establish that they have decreased sensation, and if they have signs of keratitis, I usually separate into the three traditional categories: Stage 1 is punctate epithelial changes but no true defect. Stage 2 is a defect but no thinning. Stage 3 is a defect with thinning,” he said. “I don’t use the stage number per se, but I describe the cornea based on those criteria.” Edward Holland, MD, was involved in a neurotrophic keratitis study group that worked on an updated staging criteria for NK. “We put together a white paper that’s been submitted for publication,” he said. Dr. Beckman was part of this group as well, along with Albert Cheung, MD, Marjan Farid, MD, Nicole Fram, MD, Preeya Gupta, MD, W. Barry Lee, MD, Francis Mah, MD, Mark Mannis, MD, Jay Pepose, MD, and Elmer Tu, MD. The Mackie classification has been used for staging NK. It starts with Stage 1, which is staining of the inferior conjunctiva and decreased TBUT and punctate staining of the cornea. Stage 2 is epithelial defect with stromal folds and swelling, and Stage 3 is corneal ulcer and melting, Dr. Holland said. “We thought this didn’t represent all the various stages,” he said. The study group proposed the following classifications: • Stage 0: Altered sensation without any keratopathy • Stage 1: Corneal epitheliopathy without any stromal involvement • Stage 2: Punctate epithelial keratopathy with anterior stromal haze • Stage 3: Persistent or recurrent epithelial defects • Stage 4: Persistent or recurrent epithelial defects with stromal scarring but no ulceration • Stage 5: Persistent or recurrent epithelial defects with corneal ulceration • Stage 6: Corneal perforation “We have patients who have epitheliopathy without stromal involvement, and we have patients with epitheliopathy with This article originally appeared in the September 2021 issue of EyeWorld . It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. Stage 1 shows mild punctate staining. Stage 2 shows an epi defect with no thinning. Stage 3 shows an ep defect with stromal thinning. Source (all): Kenneth Beckman, MD