Neurotrophic keratitis (NK) is a degenerative corneal disease caused by impaired sensory innervation — and its hallmark is a dangerous disconnect between how bad the eye looks and how little the patient feels. Two cornea specialists, Drs. Kendall Donaldson and Sumitra Khandelwal, share their 2026 treatment algorithms, emphasizing that early intervention is critical to preventing permanent scarring and vision loss.

For stage 1 disease (sensation loss without epithelial defect), both experts favor conservative measures: preservative-free artificial tears, discontinuing toxic topical drops, and treating the underlying cause (herpetic, diabetic, or postsurgical). Once a persistent epithelial defect appears (stage 2) or stromal thinning is present (stage 3), cenegermin (Oxervate) — an FDA-approved recombinant human nerve growth factor — becomes the cornerstone of therapy. However, its complex prior authorization process can delay delivery by 1–6 weeks, making bridging therapies essential.

Key Takeaways:

• Start the cenegermin authorization process early — even before patients reach stage 2 — to avoid dangerous treatment gaps
• Bridging options include autologous serum tears (50%), bandage contact lenses, amniotic membrane, punctal plugs, and prophylactic topical antibiotics
• Off-label topical insulin (~1 unit/mL, four times daily) is gaining traction as a fast, accessible option for epithelial healing
• Cenegermin achieves complete corneal healing in up to 85% of patients; non-responders may benefit from a second course or corneal neurotization surgery

Why it matters: NK has historically been difficult to treat, but the expanding toolkit — from cenegermin to topical insulin to corneal neurotization — means more patients can preserve vision if clinicians act early and strategically.