Neurotrophic Keratitis Post-Retinal Detachment Surgery

Neurotrophic keratitis (NK) is a degenerative corneal disease characterized by decreased or absent corneal sensation, leading to epithelial breakdown, impairment of healing, and ultimately corneal ulceration, melting, and perforation.¹ Although it results from partial or total impairment of the trigeminal nerve, the underlying cause is often unknown, and most cases are identified based on loss of corneal sensation. However, NK has been reported as a rare complication of retinal detachment (RD) repair.² There have also been case reports of NK after retinal detachment surgery with endolaser photocoagulation.^3,4

Presentation

A highly myopic 50-year-old white male presented to my clinic after RD surgery OS with a complaint of poor vision (20/400 OS). Medical history included posterior vitreous detachment and RD OS repaired with gas bubble in 2023 by a retinal surgeon; nuclear cataract OU; dry eye OU previously treated with autologous serum in 2023; hypercholesterolemia; hypertension; and gastroesophageal reflux disease. The patient was on a number of medications:

• Tyrvaya 0.03 mg/spray nasal spray (varenicline tartrate; Oyster Point Pharma)
• Ursodiol 300 mg capsule
• Pravastatin 80 mg tablet
• Omeprazole 40 mg capsule, delayed release
• Metoprolol succinate 25 mg Tb24
• Hydrochlorothiazide 25 mg tablet
• Finasteride 5 mg tablet
• Doxepin 10 mg capsule
• Cyclobenzaprine 10 mg tablet
• Amlodipine 5 mg tablet
• Allopurinol 100 mg tablet

An examination revealed 3+ NK with reduced corneal sensitivity OS (dental floss test), 3+ nuclear sclerosis OS, and macular scar OS (Figure 1). The patient desired a second opinion from a retinal surgeon, but first needed a clear ocular surface and cataract surgery. The patient was diagnosed with NK OS, nuclear sclerosis OS, and macular scar OS.

Treatment

The patient was treated with a Prokera Biologic Corneal Bandage (BioTissue) for 5 days, followed by a second Prokera for 5 days, then cenegermin-bkbj ophthalmic solution 0.002% (Oxervate, Dompé) for 10 weeks. At the 10-week follow-up, corneal sensation was restored, and no punctate keratitis was observed (Figure 2). The patient was referred for a cataract consultation and will ultimately see a second retinal surgeon for an opinion on his macular scar.

Summary and Discussion

This case spurred me to check corneal sensitivity more frequently. I believe there are many more patients out there who could benefit from NK screening and treatment. I keep dental floss in each exam room now, and when a patient presents with punctate keratitis, I use it to test corneal sensitivity. Since I have a younger patient base, I have not yet found a candidate for Oxervate treatment since this particular case, but I am more inclined to test for NK since this patient’s corneal surface and corneal sensation were completely restored.