EyeWorld India December 2021 Issue

CORNEA 32 EWAP DECEMBER 2021 Dr. Ali agreed that scleral lenses can be helpful, particularly the PROSE treatment. These can work well for someone with stable NK, he said, as they help with the epithelial surface. Autologous serum tears are another potential treatment for NK. “They provide growth factors that aid in epithelial healing,” Dr. Beckman said. There may be some challenges in access and obtaining these. Dr. Beckman works with a local lab that draws the blood and spins it down to remove the blood cells, leaving the serum to be converted into the tear formula. “It is important to establish a relationship with a local lab to do the draw and spinning,” he said. “Then a compounding pharmacy can make the formulation.” Dr. Beckman noted that there are sterility risks since the tears are not preserved. “Typically, they are kept frozen, and a small amount can be thawed but kept refrigerated for use,” he said, adding that the compounding pharmacy will let the patient know the expiration date. “There is a small risk for infection because it is non- preserved and made from blood products, but it is typically well tolerated,” he said. “I often tell patients that they can use the drops even 4–6 times per day as needed.” Amniotic membrane is another treatment option. Dr. Ali said he uses this, though noted that it doesn’t work all the time. Conjunctival grafts can be used in the treatment of NK, though Dr. Beckman said that this is not as common since Oxervate (cenegermin-bkbj, Dompe) is now available, and other treatments like amniotic membrane or tarsorrhaphy can be used. However, this option may be useful for advanced non-responsive cases. Dr. Ali also said conjunctival grafts can be useful, but they don’t restore sight. These prevent breakdown and infections, but you’re damaging the ocular surface permanently, he said. Once you do a conjunctival graft, you can’t go back easily. Dr. Ali likes to employ lateral tarsorrhaphy when possible because he said it’s very effective. “Patients generally don’t want them for obvious cosmetic reasons,” he said. “I think this is one of the most underused procedures we have to manage corneal disease, especially in NK,” Dr. Holland said. Dr. Holland said whether tarsorrhaphy is used often depends on the patient’s age and whether or not it’s socially acceptable. A young patient who is active doesn’t want a 70% tarsorrhaphy, he said, but if you have an elderly patient with poor visual potential in this eye who isn’t driving and isn’t very active, it could be a good option, particularly if it’s a patient who has to see the eyecare provider frequently for a persistent epithelial defect. It can help get the patient stable, prevent progression, heal the defect, and reduce their dependence on someone taking them to appointments, he added. “Every tarsorrhaphy can be reversed, but it’s a bit more difficult to get buy-in from younger patients,” Dr. Holland said. Dr. Beckman said he prefers a traditional sutured tarsorrhaphy as it may need to remain for an indefinite period because the underlying cause of NK may continue indefinitely. Oxervate Oxervate is the first medication approved for treatment of NK. It is a recombinant form of human nerve growth factor that helps regenerate nerve function in the cornea and restore the health of the corneal surface, Dr. Beckman said. “It is covered by insurance, but often requires going through some hoops to get it approved,” he said. “In my experience, it works very well. I have treated numerous patients with Oxervate and have been impressed.” Dr. Holland said he has had good experience so far using Oxervate. It works in some patients extremely well and in others not as well, he said. “I see it work well when the NK is not extremely longstanding and the patients are a bit younger.” Severe NK in older patients doesn’t tend to respond as well, he said. Corneal neurotization Corneal neurotization is a newer treatment approach. Both Dr. Beckman and Dr. Holland said they are not currently performing this procedure. Dr. Beckman noted that he works with another specialist who is performing the procedure and said it seems promising. Dr. Ali was involved in pioneering this approach. He’s had about 6 years of experience, having been involved in publications 1,2 that described the technique. He uses nerve grafts but noted that allografts and nerve transfers can also be used in this process. EWAP References 1. Elbaz U, et al. Restoration of corneal sensation with regional nerve transfers and nerve grafts: a new approach to a difficult problem. JAMA Ophthalmol . 2014;132:1289–1295. 2. Bains RD, et al. Corneal neurotization from the supratrochlear nerve with sural nerve grafts: a minimally invasive approach. Plast Reconstr Surg. 2015;135:397e–400e. Editors’ note: Dr. Ali is Professor of Ophthalmology & Vision Sciences, University of Toronto, The Hospital for Sick Children, Toronto, Canada, and declared no relevant financial interests. Dr. Beckman is Clinical Assistant Professor of Ophthalmology, Ohio State University, Columbus, Ohio. Dr. Holland is Professor of Ophthalmology, University of Cincinnati, Cincinnati, Ohio. Dr. Beckman and Dr. Holland have interests with Dompe.