Restoration Of Corneal Sensation With Regional Nerve Transfers And Nerve Grafts: A New, Effective, Minimally Invasive Approach To A Difficult Problem
Gregory H. Borschel, MD, FACS, FAAP, Robert Bains, MBChB, FRCS(Plast), Uri Elbaz, MD, Asim Ali, MD, FRCSC, Ronald M. Zuker, MD, FACS, FRCSC, FAAP.
The Hospital for Sick Children, Toronto, ON, Canada.
Lack of corneal sensation leads to permanent loss of vision. We describe a novel minimally-invasive technique for corneal re-innervation (corneal neurotization) in a variety of corneal anesthetic conditions.
Corneal sensory reconstruction was performed using a segment of the medial cutaneous branch of the sural nerve in four cases. Two patients with unilateral trigeminal nerve anesthesia, one following basal skull fracture and another following large posterior fossa tumor resection underwent corneal sensory reconstruction using the contralateral supratrochlear nerve as the donor sensory nerve. One patient with a history of cerebellar hypoplasia and bilateral congenital corneal anesthesia underwent bilateral corneal sensory reconstruction using the respective ipsilateral supratrochlear nerves as the sensory donor nerves. Corneal anesthesia was evaluated preoperatively and postoperatively in the center of the cornea and in four corneal quadrants using a standard Cochet-Bonnet aesthesiometer (Luneau, Paris, France). Complications of the procedure as well as uncorrected visual acuity were also documented.
Four eyes of three patients were included in the study. All eyes had prior complications of corneal anesthesia and had no detectable corneal sensation in the affected eye(s) preoperatively. Two patients, one with cerebellar hypoplasia and the other with posterior fossa tumor resection, markedly improved their corneal sensation 6 months post-surgery (3 eyes, mean central aesthesiometry 55 ± 5 mm). A third patient with a history of basal skull fracture underwent unilateral corneal neurotization and recovered 15 mm aesthesiometry score centrally after 7.5 months of follow up. None of the patients experienced postoperative ocular complications, and none of the operated eyes have developed corneal anesthesia-related complications since reconstruction. There was no change in visual acuity post-surgery.
Corneal sensory reconstruction provides corneal sensation in previously anesthetic corneas. This can be achieved with minimal morbidity using sural nerve grafts. This multidisciplinary approach restores an ocular defense mechanism and may enable subsequent corneal transplant in this population.
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