Corneal Reinnervation in Patients With Severe Neurotrophic Keratopathy Secondary to Herpes Zoster Ophthalmicus After Treatment With Autologous Serum Tear Drops

The purpose of this study was to assess potential corneal reinnervation and recovery of corneal sensation in patients with severe neurotrophic keratopathy (NK) secondary to herpes zoster ophthalmicus (HZO) after treatment with topical autologous serum tears (AST). Four cases of HZO with severe NK were followed clinically and by serial laser in vivo confocal microscopy (IVCM, HRT3/RCM, Heidelberg Engineering GmbH) before and during treatment with 20% AST drops 8 times a day. Two masked observers reviewed the IVCM images and assessed corneal nerve alterations. At baseline, all patients had complete loss of corneal sensation. In addition, IVCM showed complete lack of the subbasal corneal nerve plexus in all patients. All 4 patients were refractory to conventional therapies and were treated with AST drops. All patients demonstrated significant nerve regeneration by IVCM within 3 to 7 months of treatment. The total nerve density increased to a mean ± SEM of 10,085.88 ± 2,542.74 μm/mm2 at the last follow-up. Corneal sensation measured by Cochet–Bonnet esthesiometry improved to a mean ± SEM of 3.50 ± 1.30 cm. Interestingly, 3 of 4 patients developed stromal keratitis with stromal thinning within weeks of corneal reinnervation, which was reversed by adding topical steroids. Autologous serum tears are effective in restoring corneal subbasal nerves and sensation in patients with severe NK secondary to HZO. However, this group of patients may require concurrent topical immunomodulation and antiviral therapy while on AST to prevent stromal keratitis.