A 95-year-old female presented to the clinic with decreased vision in her left eye secondary to a persistent corneal ulcer. Multiple therapies were initiated over several weeks and months to decrease the size of the ulcer, but the therapeutic efforts were unsuccessful. Corneal polymerase chain reaction was performed to ensure there was not an underlying infectious agent causing the corneal ulcer to worsen. She did not have full resolution until topical cenegermin-bkbj ophthalmic solution 0.002% (Oxervate; Dompé) rhNGF was initiated.
Presentation
On initial examination, diffuse superficial punctate keratopathy (SPK) was observed in the left cornea (Figure 1). She did not report any pain or irritation. A 4-mm-horizontal by 2-mm-vertical epithelial defect with an underlying stromal infiltrate of the same size was present. There was no stromal thinning in the left eye at the initial presentation; however, throughout a several week follow-up, the vision fluctuated as the size of the ulcer changed and the stroma became more involved. The size of the ulcer slowly improved by less than one millimeter a week, but the stroma continued to thin under the ulcer (Figure 2).
Figure 1. A persistent corneal ulcer in a 95-year-old patient.
Figure 2. As the size of the ulcer reduced throughout treatment, the stroma became more involved.
Other medical history included Type 2 diabetes, hypertension, anemia, and arthritis. She was taking several medications including amlodipine, glipizide, aspirin, buprenorphine transdermal patch, fluticasone propionate, furosemide, gabapentin, AREDs, ropinirole, HCl, and ondansetron.
Diagnosis and Treatment
The patient was diagnosed with a persistent corneal ulcer OS and neurotrophic keratitis (NK) OU. There was minimal improvement with multiple interventions, including bandage contact lenses, punctal plugs, frequent lubrication, and two amniotic membranes. Doxycycline 100mg BID was initiated during the treatment along with mild topical steroids and an antibiotic. The corneal ulcer did not start to heal or improve until an 8-week course of topical cenegermin-bkbj was added to her treatment plan. The degree of improvement is most evident when comparing corneal fluorescein staining before and after treatment (Figure 3).
Figure 3. Corneal fluorescein staining before (A) and after (B) treatment with cenegermin-bkbj.
Discussion
The case demonstrates the role of emerging therapeutic options in treating complex corneal ulcers. NK is a difficult to treat clinical entity that has multiple stages which can require different tiers of treatment plans. Because cenegermin-bkbj targets the pathogenesis and underlying cause of NK, there is strong rationale for its use in the treatment of complex and persistent cases. The use of cenegermin-bkbj has been found to be beneficial in all stages of NK.
It is important to first rule out an underlying infectious cause before diagnosing a cornea as neurotrophic. The patient should be monitored closely to ensure no co-infection occurs, and that there is no worsening of signs and symptoms. Patient education is also tremendously important to help prevent further complications or recurrence. Long-term frequent lubrication should be continued even after full resolution of NK to minimize future problems.
