Exploring surgical solution for recalcitrant neurotrophic keratopathy

Reviewed by Ilya M. Leyngold, MD Durham, NC-Direct corneal neurotization with supraorbital and/or supratrochlear nerve transposition is a promising technique for restoring corneal sensation, corneal clarity, and vision in eyes with neurotrophic keratopathy that have failed other treatment modalities, said Ilya M. Leyngold, MD. Dr. Leyngold first performed this novel surgery using a hemicoronal, eyelid, and conjunctival incisions when he was on the faculty at the University of South Florida Morsani College of Medicine in Tampa. He is now an assistant professor of ophthalmology, division of oculofacial plastic surgery, Duke Eye Center, Durham, NC. Dr. Leyngold has a few patients now who are candidates for corneal neurotization, and he plans on performing the procedure using a minimally invasive endoscopic technique. “My first patient did very well in terms of regaining corneal sensation and vision as well as cosmetically. However, a minimally invasive procedure is more desirable for limiting morbidity,” Dr. Leyngold said. Nerve transfer He noted there are a few published papers describing nerve transfer to restore corneal sensation. In those reports, patients had anesthetic corneas resulting from intracranial pathology, such as tumors or trauma injuring the trigeminal nerve. “Loss of corneal sensation in my first patient likely occurred as the result of multiple ocular surgeries damaging the long posterior ciliary nerves, but the rest of her trigeminal nerve function was intact,” Dr. Leyngold said. “We believe we are reporting the first successful case of corneal neurotization in a patient with local injury to the sensory innervation of the cornea,” he said. “Also, this is the first case of corneal neurotization performed solely by a team of ophthalmic surgeons.” About the procedure Frances Jacinto, MD, and Edgar Espana, MD, were Dr. Leyngold’s collaborators at University of South Florida, and their experience is described in an online article appearing in American Journal of Ophthalmology Case Reports. The procedure involved creation of a hemicoronal incision behind the hairline from midline to the auricular helix and subperiosteal dissection for retrieval of the supraorbital nerve. After making an incision in the medial portion of the upper eyelid crease and a blepharotomy medial to the medial horn of the levator aponeurosis, the nerve fibers were routed into the superior conjunctival fornix. Then, the conjunctiva was incised at 12 o’clock 7 mm above the corneal scleral limbus, and the nerve fibers were tunneled under the conjunctiva 360° around the cornea, and the conjunctiva was closed over the nerves. An amniotic membrane graft was also sutured to the ocular surface. The patient presented with corneal scarring, haze, and neovascularization. Her best-corrected visual acuity (BCVA) was counting fingers. Findings after 2 years The findings were improved by 3 months postoperatively with re-established corneal sensation, and when the patient was last seen at 2 years after surgery, the corneal scarring, haze, and neovascularization were completely resolved, and the patient’s BCVA was 20/30. Dr. Leyngold suggested that the procedure might be a good option for restoring corneal sensation in eyes with neurotrophic keratopathy secondary to prior herpetic infections among other causes. Patients with bilateral trigeminal nerve palsy would not be appropriate candidates as they lack intact donor nerves, and patients who are not good surgical candidates because of medical comorbidities would also be excluded. In addition, Dr. Leyngold said he would hesitate to perform the procedure in patients who have extensive conjunctival scarring that would limit the ability to tunnel the nerves under the conjunctiva, and he would also avoid patients with active infectious or inflammatory disorders of the ocular surface. Ilya M. Leyngold, MD E: ileyngo1@gmail.com Dr. Leyngold has no relevant financial interests to disclose.