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K. Hunter, J. Affeldt, M.R. Agarwal; Efficacy of Staged Punctal Occlusion for Treatment of Neurotrophic Keratitis . Invest. Ophthalmol. Vis. Sci. 2003;44(13):4747.
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Purpose: Recommended therapy for neurotrophic keratitis (NTK) tends to promulgate the historically successful but cosmetically undesirable modalities of tarsorrhaphy or even conjunctival flap. The purpose of this report was to document for the first time the efficacy of staged punctal occlusion in a large consecutive series of NTK patients. Methods: Clinical suspicion and staging of NTK utilized the Mackie system, while confirmatory central corneal sensation was quantitated with the Cochet-Bonnet aesthesiometer. Exclusion criteria included active infectious or inflammatory processes, chemical or thermal burns, medicamentosa, exposure, limbal stem cell deficiency, microcystic edema, anterior segment ischemia, or topical beta-blocker induced NTK. Staged punctal occlusion utilizing Herrick silicone intracanalicular plugs progressed from inferior to superior puncta, followed by inferior to superior deep thermal punctal cautery as clinically indicated. Results: Fifty-four eyes with stages I-III NTK were identified, all of which had failed aggressive topical lubricant therapy. Central corneal sensation averaged 5.0 mm as compared to 56.3 mm for controls (p=0.0001). Following staged punctal occlusion, 44 of the 54 eyes (81%) showed complete NTK resolution, 8 (15%) demonstrated only mild residual punctate keratopathy, while 2 (4%) required tarsorrhaphy for NTK control. Conclusions: Staged punctal occlusion is a currently under-emphasized but extremely effective modality for treatment of neurotrophic keratitis. In this series, it almost completely eliminated the need for tarsorrhaphy, while conjunctival flap was not required for any patients.
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