First-Line Medical Treatments for Stage 1 and 2

When you are diagnosed with Neurotrophic Keratitis (NK) in its early or middle stages (Mackie Stage 1 or 2), the goal of treatment is to protect the surface of your eye and kick-start the healing process that your nerves are no longer managing on their own ^[1]. Treatment follows a step-by-step approach depending on the severity of the damage, the presence of infection, and how your eye responds.

Stage 1: Stabilization and Protection

In Stage 1, the surface of your eye is intact but unstable. Treatment focuses on creating a “safe harbor” for your corneal cells to recover ^[2].

• Reduce Surface Toxicity: Many standard over-the-counter and prescription eye drops contain preservatives like benzalkonium chloride (BAK), which can be harmful to a neurotrophic cornea with frequent exposure ^[1]. Your doctor may switch your artificial tears to preservative-free versions. Important: Never stop or switch prescribed medications (such as glaucoma or antibiotic drops) without consulting your treating clinician, as preservative-free versions are not always available or appropriate ^[2].
• Maximized Lubrication: You will likely use preservative-free artificial tears frequently to keep the surface moist ^[1].
• Mechanical Protection: If your eyes don’t close fully while you sleep, your doctor may recommend eyelid taping or moisture chamber goggles ^[1]. Punctal plugs (tiny stoppers inserted into your tear ducts) may be used to keep natural tears on your eye longer, though they are usually avoided if you have an active infection ^[1].

Stage 2: Closing the “Hole”

If the top layer of your cornea breaks down into a Persistent Epithelial Defect (PED), it is now Stage 2. A PED requires prompt ophthalmic assessment and a highly individualized plan to prevent deeper scarring and infection ^[1]. Options include:

• Serum Tears: These are custom eye drops made from your own blood (autologous) or a donor’s blood (allogeneic) ^[3]. They supply growth factors and components that artificial tears cannot provide ^[4]. They require a blood draw and strict refrigeration ^[5].
• Amniotic Membrane Transplantation (AMT): A piece of specially treated human placental tissue is placed over your cornea ^[4]. It releases healing proteins and acts as a biological bandage to help the wound close ^[4][6].
• Therapeutic Lenses: A large, specialized bandage contact lens or scleral lens may be used to protect the surface from eyelid friction ^[1][7]. Caution: A poorly feeling cornea has a higher risk of unnoticed lens-related infection. These require specialist fitting, strict hygiene, and you should never sleep in them unless specifically directed by your specialist.

Cenegermin (Oxervate): Biological Nerve Support

Cenegermin (brand name Oxervate) is an FDA-approved treatment that uses a lab-made version of human Nerve Growth Factor (NGF) ^[8]. It is used for moderate-to-severe NK with persistent epithelial defects.

• The Regimen: You apply one drop six times a day (about every two hours) for exactly eight weeks ^[9][10]. Follow the product instructions carefully for vial handling and storage.
• The Evidence: In randomized clinical trials, roughly 70% of cenegermin-treated patients achieved complete healing of their eye surface by 8 weeks (compared to about 30% using a vehicle drop without the drug) ^[11].
• Risks and Side Effects:
  • Eye Pain: Eye pain is a reported adverse effect, occurring in many trial participants ^[12]. Do not assume that pain simply means the drug is “working.” New or severe pain, light sensitivity, or redness can also indicate infection or worsening of the ulcer ^[13]. Always report these symptoms to your specialist.
  • White Plaques & Calcium Deposits: In clinical practice and case reports, some patients develop white plaques or rapid calcific band keratopathy (calcium deposits) on the cornea, which can persist and sometimes require surgery ^[14][13]. Close monitoring by your specialist during the 8-week course is essential to catch these deposits early.

Choosing a Path

Your specialist will build a plan based on defect duration, depth, infection risk, and eyelid closure—not just stage alone. They may combine therapies, and an uncomplicated defect will be treated differently than one where infection or melting is suspected ^[1].