Restoration Of Corneal Sensation In A Neurotrophic Keratopathy Of Unknown Aetiology With The Use Of Autologous Serum Drops.

Neurotrophic keratopathy (NK) is a chronic condition ranging in severity from corneal epitheliopathy and persistent epithelial defect to stromal ulceration and melt, whose management pose a clinical challenge. The purpose of this case is to report restoration of corneal sensation with non-invasive treatment with autologous serum drops and to highlight the advantages of using a dry amniotic membrane, OmniLenz, to successfully treat epitheliopathy and persistent epithelial defect secondary to NK in outpatient setting without the need for surgical intervention.  

Western Eye Hospital, Tertiary Ophthalmic Centre, Imperial College London NHS Trust, Outpatient Cornea Clinic, London UK 

A 27 year old female presented with a 2x1mm corneal ulcer in the left eye and unaided Snellen visual acuity (VA) of 6/6 and 6/12 in right and left eye, respectively. Past medical history revealed cold sores. Treatment with hourly G Moxifloxacin was commenced. After 3 days, corneal scrapes showed no growth. There was no symptomatic improvement with a 1x2.5mm central epithelial defect (ED), corneal haze, superficial punctate keratopathy (SPK), no infiltrate and significantly reduced corneal sensation. The fellow eye examination showed SPK. G Moxifloxacin QDS and lubricating drops were continued. Two weeks later there was a 1x1.75mm persistent ED. Treatment was changed to Oc Ganciclovir 5x day. Two weeks later, ED was unchanged. Facial nerve function was normal. Viral swabs were obtained and MRI brain to exclude compressive causes of neurotrophic keratitis - both were negative. Antiviral treatment was stopped and topical antibiotics with lubricating drops continued. Three weeks later, ED was 1x1.5mm with rolled edges. Four punctal plugs were inserted. Two weeks later, ED epithelialised with remaining rolled edge and severe SPK. OmniLenz was inserted. Within 3 weeks, epithelial appearances significantly improved and pinhole VA in left eye was 6/7.5. There was still SPK and reduced corneal sensation. Serum drops were commenced. Within 2.5 months corneal epithelium was clear and the patient regained corneal sensation in all 4 quadrants of the cornea with no recurrence to date.  

NK treatment is challenging as medical therapy is often insufficient in moderate to severe disease, whereas surgical interventions such as tarsorraphy, conjunctival flaps and amniotic membrane graft obscure the visual axis. This case highlights the role of serum drops in NK management. Further studies are required as the evidence in the literature is scarce with only a few cases of successful re-innervation of cornea in paediatric NK. Nonetheless, this offers an important new treatment avenue with a potential to cure NK. Furthermore, the authors highlight the role of dry amnion membrane in the management of NK related ocular surface disease as a beneficial outpatient procedure.