Topical insulin shows real-world benefit in neurotrophic keratopathy

Topical insulin demonstrated meaningful healing and a favorable safety profile in patients with neurotrophic keratopathy (NK), according to a retrospective real-world analysis evaluating its use across multiple disease etiologies.

Investigators reviewed outcomes from 29 eyes of 28 patients with NK treated with topical insulin (25 IU/mL) at a single center, with a mean follow-up of 32.7 weeks. Infectious causes accounted for just over half of cases, most commonly herpes simplex virus and varicella zoster virus. Most eyes had stage 2 or 3 disease.

Among eyes with stage 2 or 3 NK, complete epithelial healing was achieved in 78.3% of cases, with a median time to healing of 33.5 days. The cumulative healing rate reached 43.5% by 8 weeks. Healing success was not significantly influenced by epithelial defect size or underlying etiology. For stage 1 disease, treatment success was defined by improvement in corneal staining and epithelial integrity.

Recurrence after treatment discontinuation was uncommon. Of 8 patients who stopped insulin after healing, only 1 experienced recurrence, which resolved after therapy was restarted. Adverse events were minimal, with 1 case of mild punctate keratopathy that resolved despite continued treatment.

Overall, topical insulin was associated with substantial epithelial healing across diverse causes of NK, low recurrence rates, and good tolerability. While healing may occur more slowly than with FDA-approved options, the authors noted that the large cost differential suggests topical insulin may represent a cost-effective first-line option for refractory neurotrophic keratopathy.

Reference
Padda E, Hanafimosalman M, Racine L, et al. Real-world effectiveness of topical insulin for neurotrophic keratopathy: a retrospective case series of 29 eyes. Can J Ophthalmol. 2025;S0008-4182(25)00474-0. doi: 10.1016/j.jcjo.2025.11.009. Epub ahead of print. PMID: 41453402.