Initial management of a neurotrophic corneal ulcer begins with determining its etiology. Common causes of neurotrophic keratopathy include dysfunction of the first division of the fifth cranial nerve, local eye disease such as herpes simplex or herpes zoster, long-standing diabetes, and the use of certain topical medications. Less commonly, long-standing contact lens wear or chemical exposure can be causative.
Treatment of neurotrophic keratopathy without an epithelial defect is primarily directed towards lubrication and protection of the ocular surface. Consideration should also be given towards discontinuing any toxic topical medications as well as any systemic medications that could lead to decreased tear production. Other recommendations that are often made include: the frequent use of non-preserved artificial tears or gels, avoiding ocular irritants such as smoke and fumes, wearing glasses with side shields or goggles, undergoing punctal occlusion, and possibly beginning oral doxycycline.
If the neurotrophic keratopathy is associated with an epithelial defect or ulceration, then the above measures should be instituted along with a more aggressive approach. Autologous serum tears can be helpful. Often protection of the ocular surface with tarsorrhaphy is required. If all else fails, a conjunctival flap can be utilized. If perforation of the cornea is imminent or has occurred then treatment with cyanoacrylate followed by placement of a bandage contact lens or lamellar keratoplasty are indicated. If a lamellar keratoplasty is undertaken, tarsorrhaphy at the same time is often performed to encourage the ocular surface to heal.