A Novel Treatment for Neurotrophic Corneal Ulcer Using Topical Cenegermin (OXERVATE™) Containing Recombinant Human Nerve Growth Factor

Neurotrophic keratitis represents a complex degeneration of the cornea that can result in debilitating symptoms and serious sight-threatening complications. Patients with neurotrophic keratitis (NK) usually present with a history of corneal injury or past surgical intervention involving damage to the corneal nerves; as well as, chronic ocular surface disease. This nerve damage results in sensory loss and poor healing to the corneal tissues. This poor ability to heal results in the downward spiral of events that NK patients are subject to, which can include corneal surface breakdown, ulceration, melting, and total perforation. Treatments to attempt to support the cornea to heal and then protect it have recently advanced beyond traditional treatments and may include amniotic membrane application, autologous serum eye drops, biologic eye drops, and various other supportive treatments. Even aggressive combinations of these, and many other treatments, can leave NK patients still uncontrolled and progressing to end-stage disease that would require invasive intervention resulting in an even worse prognosis. This case report describes a patient who demonstrated all three stages of NK. Multiple interventions were initiated, including tarsorrhaphy, autologous serum eye drops, Prokera amniotic membrane, antibiotics, bandage contact lenses (BCL) therapy, and PKP. However, the patient experienced variable and transient improvement with relapse within a few weeks with recurrent and persistent epithelial erosion and stromal ulceration. A novel eye drop, cenegermin (OXERVATE^TM), an ophthalmic solution containing 20 μg/mL of a recombinant form of human nerve growth factor (NGF), was added to her treatment regimen allowing for successful management of NK and restoration of corneal integrity.

Recent innovations with drugs in clinical trials for neurotrophic keratitis and refractory corneal ulcers

Introduction: Corneal ulcers normally resolve spontaneously because of the proliferative ability of the corneal epithelium; however, sometimes, epithelial healing is diminished, even when standard treatments are administered. Hence, the treatment of refractory corneal ulcers is challenging and is the subject of ongoing efforts in preclinical and clinical development. Emerging treatment approaches include thymosine β4, CODA001, and topical insulin. Cenegermin eye drops, containing recombinant human nerve growth factor and ReGenerating Agent, a matrix therapy agent, have recently been commercialized for the treatment of moderate to severe neurotrophic keratitis in adults.Areas covered: We describe emerging therapeutic approaches for the management of refractory corneal ulcers and treatments recently introduced to the market. Pubmed and Clinicaltrial.gov databases were first searched including the terms: "corneal ulcer" or "neurotrophic keratopathy" and "treatment." Each treatment was searched in the same databases separately.Expert opinion: Affections of the sensory corneal nerves are the main factor contributing to the pathophysiology of neurotrophic keratopathy; this explains the healing difficulties of this form of ulcer. Cenegermin is a promising therapy acting as a neurotrophic agent for corneal healing. ReGenerating Agent has led to rapid pain relief and corneal healing, but randomized clinical trials are still necessary for further assessment.