Minimally Invasive Corneal Neurotization

A new paradigm in managing neurotrophic keratopathy

By Ilya Leyngold

March 2018

At a Glance

  • Neurotrophic keratopathy – the loss of corneal sensation – has a poor prognosis with limited available treatment options
  • Current techniques for corneal neurotization can restore corneal sensation, but may be associated with significant morbidity
  • I describe two minimally invasive techniques for corneal neurotization: using a cadaveric nerve graft and an endoscopic approach
  • More ophthalmologists learning – and performing – these minimally invasive procedures may help more patients before devastating and irreversible damage occurs.

Neurotrophic keratopathy can be a devastating disease (See Box 1. Neurotrophic keratopathy pathology). Lost corneal sensation may lead to corneal scarring, ulceration and thinning, which can lead to corneal perforation and vision loss. It’s a debilitating condition for patients, and doctors have limited treatment options. Multiple ‘temporizing’ treatments try to decrease the chance of infection, ulceration and scarring, such as ocular lubricants, topical antibiotics, autologous serum drops, contact lenses, amniotic membrane grafts, and tarsorrhaphy. But none restore corneal sensation or the ability of the eye to respond appropriately to stimuli and maintain a healthy ocular surface. Furthermore, patients with neurotrophic keratopathy do poorly with corneal transplantation to replace the damaged tissue, because the same condition will recur in the corneal graft resulting in failure. 

The traditional standard of care for severe cases is to suture the eyelids together to protect the surface of the eye – a disfiguring procedure, which at best limits the patient’s field of vision and may lead to functional blindness if the entire palpebral aperture is closed. Some patients end up with permanently closed eyelids because corneal decompensation recurs upon re-opening. A novel surgical treatment has been described – corneal neurotization (1) – but the original techniques involve a significant undertaking. They involve either a coronal (ear-to-ear) incision with peeling the scalp and forehead tissues down to the level of the eye socket, or use of a nerve autograft harvested from a patient’s leg. Why? To route supraorbital and supratrochlear nerves from the contralateral side, tunnel them across the bridge of the nose, and to the corneoscleral limbus of the affected ‘anesthetic’ eye (1). These techniques for corneal neurotization have demonstrated successful outcomes – patients developed improved corneal sensibility, corneal health, and vision in some cases. But the means of getting there involve quite an invasive surgery with potential for significant donor site morbidity.

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