Neurotrophic Keratopathy Secondary To Undifferentiated Nasopharyngeal Carcinoma : A Case Report.

Neurotrophic Keratitis (NK) is a rare and vision-threatening degenerative disease (ORPHA: 137596) of the corneal tissue, typically caused by impairment of the trigeminal nerve (V1). Its association with nasopharyngeal carcinoma(presented in this report) is an even rarer occurrence in clinical practice.

The primary objective is to highlight the diagnostic workup for rare tumoral etiologies through a multidisciplinary approach. Furthermore, it aims to demonstrate that while innovative treatments such as Cenegermin are revolutionary, they remain costly and should only be used as second-line therapy. A conventional and rigorous management (described below) can prove to be highly effective.

This case was managed at the Ophthalmology Department of the Central Army Hospital (HCA) in Algiers, Algeria. As a major university hospital, HCA provides a comprehensive multidisciplinary environment essential for this patient’s complex care. The institution includes the necessary departments—Ophthalmology, Otorhinolaryngology, Oncology, Radiotherapy, Medical Imaging, and Psychology—enabling coordinated management of both the corneal condition and the underlying malignancy.

We performed a comprehensive ophthalmological examination, including visual acuity measurement, slit-lamp biomicroscopy, fundus examination, and intraocular pressure measurement. Clinical assessment also included the Schirmer I test, corneal sensitivity testing using a cotton wisp, and a cranial nerve examination. Additional investigations comprised anterior segment optical coherence tomography (AS-OCT), magnetic resonance imaging (MRI) of the cavum and brain, positron emission tomography-computed tomography (PET-CT), and bone scintigraphy. Furthermore, pure-tone audiometry and histopathological analysis of a nasopharyngeal biopsy were conducted. These examinations were carried out through a multidisciplinary collaboration.

Visual acuity was 1/10 OD (10/10 OS). Slit-lamp exam showed a 4-mm central persistent epithelial defect with stromal edema and anterior chamber inflammation; Schirmer I was 5 mm/5 min and cotton-wisp testing showed complete corneal anesthesia. AS-OCT confirmed epithelial discontinuity with thinning (CCT 430 vs 520 µm). MRI revealed a nasopharyngeal mass with skull-base invasion and trigeminal sheath involvement; biopsy confirmed undifferentiated carcinoma and PET-CT showed no metastases. Mackie Grade 2 NK was diagnosed. After stopping preserved drops, debridement, patching and intensive preservative-free lubrication, re-epithelialization began in week 2 and near-complete healing by week 3, leaving only mild superficial punctate keratitis.

NK is a rare orphan disease (ORPHA:137596). Classical aetiologies are neurotropic viruses (HSV/VZV); rarer causes include neurosurgical complications and neoplasms involving trigeminal nerve, as in our patient. A hallmark of NK is the discrepancy between functional signs (redness/absence of pain) and severe physical findings, including corneal abnormalities and anterior chamber inflammation. Beyond the traditional Mackie classification, Di Zazzo et al. (2018) proposed an objective system based on AS-OCT and confocal microscopy.  The cornerstone of management is the immediate cessation of toxic preserved eye drops, replaced by intensive preservative-free lubrication. Our patient’s case highlights the effectiveness of this approach.