Author: Claude (AI), from PubMed abstracts · Reviewed by: Dr Mina Abdelmseih · Reviewed: 2026-11-15 · Review due: 2027-11-15

Educational content only. Not personalised medical advice. Clinical decisions remain the responsibility of the treating clinician.

Neurotrophic keratopathy

Neurotrophic keratopathy (NK) is a degenerative corneal disease caused by damage to corneal sensory nerves, leading to epithelial breakdown, impaired healing, ulceration and, if untreated, keratolysis and perforation [S5] [S8] [S10]. Causes include herpetic infection, trauma, diabetes, drug toxicity, contact lens overuse and ocular or neurosurgical surgery [S8] [S9]. It is chronic and can progress even after periods of apparent stability [S10].

Key points - Check corneal sensation early in any non-healing epithelial defect [S10]. - First-line care at every stage: preservative-free lubricants, punctal occlusion, blood-derived drops, and removal of toxic or preserved medications [S10]. - Cenegermin (recombinant human nerve growth factor) improved healing over vehicle in RCTs, on low-certainty evidence overall [S1] [S8]. - Tarsorrhaphy may be needed in refractory or rapidly progressing cases [S10]. - A descemetocele needs urgent intervention because perforation is imminent [S3].

Evidence last checked: 2026-10-17 (PubMed abstracts).

Red flags

• Persistent epithelial defect with reduced corneal sensation [S1] [S10].
• Stromal thinning, melting or descemetocele: imminent risk of perforation, needing urgent intervention [S3].
• Rapid progression despite lubrication: timely tarsorrhaphy may be necessary [S10].
• History of herpes zoster ophthalmicus, especially with recurrences, which increase NK risk [S9].
• Toxic or preservative-containing drops that may be worsening the surface [S10].

Recognise it

• Definition. Dysfunction of corneal innervation with loss of corneal sensation, leading to epithelial breakdown and ultimately keratolysis if untreated [S10].
• Causes. Infection, inflammation, chemical or mechanical trauma, diabetes, drug toxicity, contact lens overuse and surgery [S8]; herpetic disease including HZO is frequent [S9]; intracranial tumours [S4].
• Course. Uncommon, though prevalence is likely higher than previously estimated [S5] [S10]. It can cause ulceration, corneal opacification and perforation [S5].

Confirm it

• Test corneal sensation early; the Neurotrophic Keratitis Study Group classification stresses this and separates epithelial and stromal disease [S10].
• Identify the root cause, which is needed for the best chance of treatment success [S9].
• Stage the disease to guide treatment [S4] [S10].

Manage it

Before acting on this section, check the national and local guidelines, product information and regulatory approvals that apply where you practise. See the medical disclaimer.

Tier A (primary care / no specialist)

• Refer any non-healing corneal defect (see "Refer when").
• Stop unnecessary toxic or preserved drops where possible, with eye-team advice [S10].

Tier B (general eye clinic)

• Supportive care at all stages: preservative-free tears, gels and ointments; punctal occlusion; and removal of toxic or preservative-containing medications [S10].
• Blood-derived drops: autologous serum, umbilical cord serum or platelet-rich plasma [S10].
• Topical insulin. A systematic review of 13 studies (268 patients) reported improved corneal healing without adverse effects using 0.5 to 2 U/ml, typically four times daily, as reported in [S6]. Its accessibility and low cost make it a possible alternative or adjunct to serum or amniotic membrane [S6]. Evidence is mainly observational.
• Tarsorrhaphy for refractory or rapidly progressing disease [S10].
• HZO prevention. Vaccination and suppressive valacyclovir are recommended to reduce HZO recurrences and NK risk, in an expert review [S9].

Tier C (specialist centre)

• Cenegermin. In the NGF0214 RCT (48 patients), cenegermin 20 µg/ml 6 times daily for 8 weeks (as reported in [S1]) healed 69.6% of lesions versus 29.2% with vehicle; adverse effects were mostly local, mild and transient [S1]. A Cochrane review of 7 RCTs found rhNGF may slightly improve re-epithelialisation (RR 1.88) but may not improve visual acuity, on low-certainty evidence [S8]. In children, 20 of 26 treated eyes improved in case reports and series [S7].
• Amniotic membrane. One small trial found little to no effect versus tarsorrhaphy or bandage contact lens (very low certainty) [S8].
• Corneal neurotization. In 54 eyes, central corneal sensation and logMAR acuity improved (mean gain 0.41), with maximal sensation return at a median of 8 months; children did better than adults [S2]. It is suggested for refractory NK, especially in children [S2].
• Descemetocele or perforation. Options include bandage contact lenses, tissue adhesive, amniotic membrane, patch grafts, keratoplasty and conjunctival flaps, chosen by size, location and cause [S3]. Keratoplasty in NK is high risk and needs aggressive supportive therapy and close follow-up [S10].

Refer when

Pitfalls

• Not testing corneal sensation in a non-healing defect [S10].
• Continuing toxic or preserved drops [S10].
• Delaying tarsorrhaphy in rapidly progressing disease [S10].
• Treating stability as cure; NK can progress later [S10].

Evidence notes

• The Cochrane review found only low or very low certainty evidence, and 5 of 7 trials reporting funding were industry sponsored [S8].
• Most treatment recommendations come from narrative reviews (expert opinion) [S4] [S5] [S10].
• Topical insulin evidence is mainly observational and includes other surface diseases [S6].
• Not covered by these sources: cost and availability of cenegermin in low-resource settings, preparation of serum and insulin drops, and corneal sensation testing methods without an aesthesiometer.

Related articles

• Herpes zoster ophthalmicus
• Herpes simplex keratitis
• Chemical eye injury

References

See the numbered source list below. Each marker [S#] links to its PubMed and DOI record.