Secondary Logo

Journal Logo

Surgeons' Corner

Corneal Neurotization: A Surgical Treatment for Neurotrophic Keratopathy

Kolseth, Clinton M. BS; Charlson, Emily S. MD, PhD; Kossler, Andrea L. MD

Author Information
Journal of Neuro-Ophthalmology: June 2020 - Volume 40 - Issue 2 - p e11-e12
doi: 10.1097/WNO.0000000000000879

Corneal neurotization is a surgical procedure for sensory reinnervation in neurotrophic keratopathy (1–9). Common causes of neurotrophic keratopathy include herpetic infections, chemical or thermal burns, diabetes, cranial nerve 5 injury, and chronic ocular surface disease or congenital causes (10). The severity of neurotrophic keratopathy is graded in 3 different stages, known as the Mackie classification. The goal of corneal neurotization is promote regrowth of corneal nerves to an insensate cornea (11).

CASE PRESENTATION

In this case, we present a 75-year-old man with history of microvascular decompression of trigeminal nerve and Bell's palsy secondary to previous radiotherapy. The patient developed a persistent epithelial defect with a corneal ulcer and hypopyon. After aggressive medical therapy and tarsorrhaphy, the patient was referred to our service for consideration of corneal neurotization.

At the time of surgery, the patient's visual acuity in the affected eye was 20/200. The patient lacked sensation over the V1, V2, and V3 dermatomes on the left side of his face. Corneal sensation by Cochet-Bonnet esthesiometry was found to be 1 mm in the superior and temporal regions and 5 mm in all other regions of the cornea. His cornea was significant for a dense central corneal scar.

CORNEAL NEUROTIZATION

As demonstrated in the accompanying video, we performed corneal neurotization using an autograft to the supraorbital nerve (See Supplemental Digital Content, Video, https://links.lww.com/WNO/A398). A sural nerve autograft was harvested from the leg in collaboration with our ENT colleagues. Cadaveric nerve allograft is also an acceptable alternative.

A skin and orbicularis incision is made in through the eyelid crease or sulcus. Dissection is carried down to the orbital rim periosteum, and the supraorbital notch is identified. The supraorbital nerve and if needed, the supratrochlear nerve, are exposed and released from the arcus marginalis. If contralateral neurotization is performed, a contralateral eyelid crease incision is made. The nerve graft is tunneled preperiostealy from the side of supraorbital exposure to the contralateral lid crease incision. A wright needle is used to connect the ipsilateral external eyelid incision to the superior medial fornix, taking care to avoid damaging the medial horn of the levator palpebral superiors muscle. The nerve graft is transferred through the forniceal incision.

The sural nerve is separated into 3–5 fascicles by dividing the epineurium. Attention is drawn to the ocular surface where perilimbal conjunctival incisions are made at 9, 12, 3, and 6 o' clock, 4 mm posterior the limbus to accommodate the nerve fascicles.

The epineurium around the fascicles is sutured to the corneal–scleral limbus at all 4 cardinal positions using 10-0 nylon or 8-0 vicryl suture. Scleral–corneal tunnels may also be created. The conjunctiva is closed to cover the nerve-corneal union.

Attention is then turned to the deep branch of the supraorbital nerve, which is transected over the orbital rim. The end of the sural nerve graft is sutured to the cut end of the supraorbital nerve, ensuring there is no tension on this union. This can be performed by end-to-end or end-to-side coaptation.

Tisseal is placed over the coaptation site with a porcine nerve connecter to protect the nerve union and to inhibit scar tissue formation. A tarsorrhaphy can be performed afterward to protect cornea from exposure.

We expect some return of sensation by 3 months, but on average, there is a maximum return of sensation by 6–9 months (12–16). In this particular patient, we saw a return of sensation of 60 mm in all quadrants of the cornea by post op Week 11.

REFERENCES

1. Terzis JK, Dryer MM, Bodner BI. Corneal neurotization: a novel solution to neurotrophic keratopathy. Plast Reconstr Surg. 2009;123:112–120.
2. Elbaz U, Bains R, Zuker RM, Borschel GH, Ali A. Restoration of corneal sensation with regional nerve transfers and nerve grafts: a new approach to a difficult problem. JAMA Ophthalmol. 2014;132:1289–1295.
3. Benkhatar H, Levy O, Goemaere I, Borderie V, Laroche L, Bouheraoua N. Corneal neurotization with a great auricular nerve graft: effective reinnervation demonstrated by in vivo confocal microscopy. Cornea. 2018;37:647–650.
4. Leyngold IM, Yen MT, Tian J, Leyngold MM, Vora GK, Weller C. Minimally invasive corneal neurotization with acellular nerve allograft: surgical technique and clinical outcomes. Ophthalmic Plast Reconstr Surg. 2018;35:133–140.
5. Leyngold I, Weller C, Leyngold M, Tabor M. Endoscopic corneal neurotization: technique and initial experience. Ophthalmic Plast Reconstr Surg. 2018;34:82–85.
6. Jowett N, Pineda Ii R. Corneal neurotisation by great auricular nerve transfer and scleral-corneal tunnel incisions for neurotrophic keratopathy. Br J Ophthalmol. 2018;103:1235–1238.
7. Allevi F, Fogagnolo P, Rossetti L, Biglioli F. Eyelid reanimation, neurotisation, and transplantation of the cornea in a patient with facial palsy. BMJ Case Rep. 2014;2014:bcr2014205372.
8. Jacinto F, Espana E, Padilla M, Ahmad A, Leyngold I. Ipsilateral supraorbital nerve transfer in a case of recalcitrant neurotrophic keratopathy with an intact ipsilateral frontal nerve: a novel surgical technique. Am J Ophthalmol Case Rep. 2016;4:14–17.
9. Bains RD, Elbaz U, Zuker RM, Ali A, Borschel GH. Corneal neurotization from the supratrochlear nerve with sural nerve grafts: a minimally invasive approach. Plast Reconstr Surg. 2015;135:397e–400e.
10. Dua HS, Said DG, Messmer EM, Rolando M, Benitez-Del-Castillo JM, Hossain PN, Shortt AJ, Geerling G, Nubile M, Figueiredo FC, Rauz S, Mastropasqua L, Rama P, Baudouin C. Neurotrophic keratopathy. Prog Retin Eye Res. 2018;66:107–131.
11. Müller LJ, Marfurt CF, Kruse F, Tervo TMT. Corneal nerves: structure, contents and function. Exp Eye Res. 2003;76:521–542.
12. Fung SSM, Catapano J, Elbaz U, Zuker RM, Borschel GH, Ali A. In vivo confocal microscopy reveals corneal reinnervation after treatment of neurotrophic keratopathy with corneal neurotization. Cornea. 2018;37:109–112.
13. Weis E, Rubinov A, Al-Ghoul AR, Yau FM. Sural nerve graft for neurotrophic keratitis: early results. Can J Ophthalmol. 2018;53:24–29.
14. Ting DSJ, Figueiredo GS, Henein C, Barnes E, Ahmed O, Mudhar HS, Figueiredo FC. Corneal neurotization for neurotrophic keratopathy: clinical outcomes and in vivo confocal microscopic and histopathological findings. Cornea. 2018;37:641–646.
15. Sepehripour S, Lloyd MS, Nishikawa H, Richard B, Parulekar M. Surrogate outcome measures for corneal neurotization in infants and children. J Craniofac Surg. 2017;28:1167–1170.
16. Malhotra R, Elalfy MS, Kannan R, Nduka C, Hamada S. Update on corneal neurotisation. Br J Ophthalmol. 2019;103:26–35.

Supplemental Digital Content

Copyright © 2020 by North American Neuro-Ophthalmology Society