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Vera-Duarte GR, Jimenez-Collado D, Kahuam-López N, Ramirez-Miranda A, Graue-Hernandez EO, Navas A, Rosenblatt MI. Neurotrophic keratopathy: General features and new therapies. Surv Ophthalmol 2024; 69:789-804. [PMID: 38679146 DOI: 10.1016/j.survophthal.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 04/12/2024] [Accepted: 04/22/2024] [Indexed: 05/01/2024]
Abstract
Neurotrophic keratopathy is an uncommon degenerative corneal disorder characterized by compromised corneal sensory innervation resulting in the formation of epithelial defects and nonhealing corneal ulcers. Various treatment modalities are available to stabilize disease progression, improve patient well-being, and prevent vision loss. For eligible patients, medical and surgical reinnervation have emerged as pioneering therapies, holding promise for better management. We present a comprehensive review of the disorder, providing an update relevant to ophthalmologists on pathogenesis, diagnosis, treatment options, and novel therapies targeting pathophysiological pathways.
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Affiliation(s)
- Guillermo Raul Vera-Duarte
- Department of Cornea and Refractive Surgery, Instituto de Oftalmología "Conde de Valenciana, Mexico City, Mexico
| | - David Jimenez-Collado
- Department of Cornea and Refractive Surgery, Instituto de Oftalmología "Conde de Valenciana, Mexico City, Mexico
| | - Nicolás Kahuam-López
- Department of Cornea and Refractive Surgery, Instituto de Oftalmología "Conde de Valenciana, Mexico City, Mexico
| | - Arturo Ramirez-Miranda
- Department of Cornea and Refractive Surgery, Instituto de Oftalmología "Conde de Valenciana, Mexico City, Mexico
| | - Enrique O Graue-Hernandez
- Department of Cornea and Refractive Surgery, Instituto de Oftalmología "Conde de Valenciana, Mexico City, Mexico
| | - Alejandro Navas
- Department of Cornea and Refractive Surgery, Instituto de Oftalmología "Conde de Valenciana, Mexico City, Mexico
| | - Mark I Rosenblatt
- Department of Ophthalmology and Visual Sciences, University of Illinois-Chicago (UIC), Chicago, IL 60612, USA.
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Crabtree JR, Mulenga C, Tran K, Hussain A, Boente CS, Ali A, Feinberg K, Borschel GH. Corneal Neurotization: Essentials for The Facial Paralysis Surgeon. Facial Plast Surg 2024; 40:424-432. [PMID: 38378042 DOI: 10.1055/a-2272-6077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024] Open
Abstract
Deficits in corneal innervation lead to neurotrophic keratopathy (NK). NK is frequently associated with facial palsy, and corneal damage can be accelerated by facial palsy deficits. Corneal nerves are important regulators of limbal stem cells, which play a critical role in epithelial maintenance and healing. Nonsurgical treatments of NK have undergone recent innovation, and growth factors implicated in corneal epithelial renewal are a promising therapeutic avenue. However, surgical intervention with corneal neurotization (CN) remains the only definitive treatment of NK. CN involves the transfer of unaffected sensory donor nerve branches to the affected cornea, and a variety of donor nerves and approaches have been described. CN can be performed in a direct or indirect manner; employ the supraorbital, supratrochlear, infraorbital, or great auricular nerves; and utilize autograft, allograft, or nerve transfer alone. Unfortunately, comparative studies of these factors are limited due to the procedure's novelty and varied recovery timelines after CN. Regardless of the chosen approach, CN has been shown to be a safe and effective procedure to restore corneal sensation and improve visual acuity in patients with NK.
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Affiliation(s)
| | | | - Khoa Tran
- Department of Surgery, Indiana University School of Medicine, Indiana
| | - Arif Hussain
- Department of Surgery, Indiana University School of Medicine, Indiana
| | - Charline S Boente
- Department of Ophthalmology, Indiana University School of Medicine, Indiana
| | - Asim Ali
- Department of Ophthalmology and Vision Sciences, Hospital for Sick Children, Toronto, Canada
| | | | - Gregory H Borschel
- Indiana University School of Medicine, Indianapolis, Indiana
- Department of Surgery, Indiana University School of Medicine, Indiana
- Department of Ophthalmology, Indiana University School of Medicine, Indiana
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3
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Venugopal A, Christy J, Raut V, P P, Patwardhan V, V V, Madkaikar A, P M, Meenakshi R, Ramakrishnan R. Viral Keratitis, Surgical Intervention in Viral Keratitis, Challenges in Diagnosis and Treatment of Viral Keratitis, HSV, HZV. Semin Ophthalmol 2024; 39:340-352. [PMID: 38303587 DOI: 10.1080/08820538.2024.2309533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 01/08/2024] [Indexed: 02/03/2024]
Abstract
Viral keratitis is a significant cause of ocular morbidity and visual impairment worldwide. In recent years, there has been a growing understanding of the pathogenesis, clinical manifestations, and diagnostic modalities for viral keratitis. The most common viral pathogens associated with this condition are adenovirus, herpes simplex (HSV), and varicella-zoster virus (VZV). However, emerging viruses such as cytomegalovirus (CMV), Epstein-Barr virus (EBV), and Vaccinia virus can also cause keratitis. Non-surgical interventions are the mainstay of treatment for viral keratitis. Antiviral agents such as Acyclovir, Ganciclovir, and trifluridine have effectively reduced viral replication and improved clinical outcomes. Additionally, adjunctive measures such as lubrication, corticosteroids, and immunomodulatory agents have alleviated symptoms by reducing inflammation and facilitating tissue repair. Despite these conservative approaches, some cases of viral keratitis may progress to severe forms, leading to corneal scarring, thinning, or perforation. In such instances, surgical intervention becomes necessary to restore corneal integrity and visual function. This review article aims to provide an overview of the current perspectives and surgical interventions in managing viral keratitis. The choice of surgical technique depends on the extent and severity of corneal involvement. As highlighted in this article, on-going research and advancements in surgical interventions hold promise for further improving outcomes in patients with viral keratitis.
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Affiliation(s)
- Anitha Venugopal
- Department of Cornea & Refractive services, Aravind Eye, Hospital and postgraduate institute of Ophthalmology, Tirunelveli, Tamil Nadu, India
| | - Josephine Christy
- Department of Cornea & Refractive services, Aravind Eye Hospital, Pondicherry, India
| | - Vaidehi Raut
- Post-Graduate in Ophthalmology Aravind Eye Hospital, Tirunelveli, Tamil Nadu, India
| | - Preethi P
- Post-Graduate in Ophthalmology Aravind Eye Hospital, Tirunelveli, Tamil Nadu, India
| | - Veena Patwardhan
- Medical Consultant, Cornea and Refractive Services, Aravind Eye Hospital, Tirunelveli, Tamil Nadu, India
| | - Veeramma V
- Fellow in Cornea and Refractive surgery, Aravind Eye Hospital, Tirunelveli, Tamil Nadu, India
| | - Aditee Madkaikar
- Department of Cornea & Refractive services, Aravind Eye Hospital, Tirunelveli, Tamil Nadu, India
| | - Mangala P
- Department of Cornea & Refractive services, Aravind Eye Hospital, Coimbatore, Tamil Nadu, India
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Sun Q, Li X, Zhu Z, Xiang X, Zhang S, Liu X, Long X, Zhang T. Innovative surgical approach for trigeminal trophic syndrome: Successful healing of facial ulcers through cross-face nerve grafts. Head Neck 2024; 46:E75-E79. [PMID: 38622973 DOI: 10.1002/hed.27773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 04/05/2024] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND Trigeminal trophic syndrome (TTS) is a rare condition caused by damage to the trigeminal nervous system, resulting in sensory disturbances and ulcers on the face. Treating TTS is complex and often requires medical or surgical intervention like flap reconstruction. However, there is limited research on surgical treatments for TTS ulcers. METHODS We report the case of a 19-year-old man with TTS. We employed an innovative surgical technique involving dual cross-face nerve grafts. In the initial procedure, corneal neuralization was accomplished using supraorbital and cross-face infraorbital nerve graft. The subsequent operation utilized auricular composite tissue flap transplantation repair and cross-face mental nerve graft. RESULTS This procedure led to rapid and sustained healing, as well as aesthetic improvement. CONCLUSION Cross-face nerve grafts is a promising tool in the treatment of refractory ulcers caused by diseases such as TTS.
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Affiliation(s)
- Qing Sun
- Division of Maxillofacial Surgery, Department of Stomatology, Peking Union Medical College Hospital & Chinese Academy of Medical Science, Beijing, China
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital & Chinese Academy of Medical Science, Beijing, China
| | - Xing Li
- Division of Maxillofacial Surgery, Department of Stomatology, Peking Union Medical College Hospital & Chinese Academy of Medical Science, Beijing, China
| | - Zhihui Zhu
- Division of Maxillofacial Surgery, Department of Stomatology, Peking Union Medical College Hospital & Chinese Academy of Medical Science, Beijing, China
| | - Xiting Xiang
- Division of Maxillofacial Surgery, Department of Stomatology, Peking Union Medical College Hospital & Chinese Academy of Medical Science, Beijing, China
| | - Shu Zhang
- Department of Dermatology, Peking Union Medical College Hospital & Chinese Academy of Medical Science, Beijing, China
| | - Xiaowei Liu
- Department of Ophthalmology, Peking Union Medical College Hospital & Chinese Academy of Medical Science, Beijing, China
| | - Xiao Long
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital & Chinese Academy of Medical Science, Beijing, China
| | - Tao Zhang
- Division of Maxillofacial Surgery, Department of Stomatology, Peking Union Medical College Hospital & Chinese Academy of Medical Science, Beijing, China
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Serra PL, Giannaccare G, Cuccu A, Bolognesi F, Biglioli F, Marcasciano M, Tarabbia F, Pagliara D, Figus A, Boriani F. Insights on the Choice and Preparation of the Donor Nerve in Corneal Neurotization for Neurotrophic Keratopathy: A Narrative Review. J Clin Med 2024; 13:2268. [PMID: 38673540 PMCID: PMC11050919 DOI: 10.3390/jcm13082268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 03/28/2024] [Accepted: 04/11/2024] [Indexed: 04/28/2024] Open
Abstract
The article introduces neurotrophic keratopathy (NK), a condition resulting from corneal denervation due to various causes of trigeminal nerve dysfunctions. Surgical techniques for corneal neurotization (CN) have evolved, aiming to restore corneal sensitivity. Initially proposed in 1972, modern approaches offer less invasive options. CN can be performed through a direct approach (DCN) directly suturing a sensitive nerve to the affected cornea or indirectly (ICN) through a nerve auto/allograft. Surgical success relies on meticulous donor nerve selection and preparation, often involving multidisciplinary teams. A PubMed research and review of the relevant literature was conducted regarding the surgical approach, emphasizing surgical techniques and the choice of the donor nerve. The latter considers factors like sensory integrity and proximity to the cornea. The most used are the contralateral or ipsilateral supratrochlear (STN), and the supraorbital (SON) and great auricular (GAN) nerves. Regarding the choice of grafts, the most used in the literature are the sural (SN), the lateral antebrachial cutaneous nerve (LABCN), and the GAN nerves. Another promising option is represented by allografts (acellularized nerves from cadavers). The significance of sensory recovery and factors influencing surgical outcomes, including nerve caliber matching and axonal regeneration, are discussed. Future directions emphasize less invasive techniques and the potential of acellular nerve allografts. In conclusion, CN represents a promising avenue in the treatment of NK, offering tailored approaches based on patient history and surgical expertise, with new emerging techniques warranting further exploration through basic science refinements and clinical trials.
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Affiliation(s)
- Pietro Luciano Serra
- Plastic Surgery Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari University Hospital Trust, 07100 Sassari, Italy;
- Plastic Surgery and Microsurgery Unit, Department of Surgical Sciences, Faculty of Medicine and Surgery, University Hospital “Duilio Casula”, University of Cagliari, 09124 Cagliari, Italy; (A.F.); (F.B.)
| | - Giuseppe Giannaccare
- Eye Clinic, Department of Surgical Sciences, University of Cagliari, 09124 Cagliari, Italy;
| | - Alberto Cuccu
- Eye Clinic, Department of Surgical Sciences, University of Cagliari, 09124 Cagliari, Italy;
| | - Federico Bolognesi
- Department of Maxillo-Facial Surgery, Santi Paolo e Carlo Hospital, University of Milan, 20122 Milan, Italy; (F.B.); (F.B.); (F.T.)
| | - Federico Biglioli
- Department of Maxillo-Facial Surgery, Santi Paolo e Carlo Hospital, University of Milan, 20122 Milan, Italy; (F.B.); (F.B.); (F.T.)
| | - Marco Marcasciano
- Plastic and Reconstructive Surgery Unit, Division of Plastic and Reconstructive Surgery, Department of Surgery, China Medical University Hospital, Taichung, Taiwan, Magna Graecia University of Catanzaro, 88100 Catanzaro, Italy;
- Unit of Plastic and Reconstructive Surgery, Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy
| | - Filippo Tarabbia
- Department of Maxillo-Facial Surgery, Santi Paolo e Carlo Hospital, University of Milan, 20122 Milan, Italy; (F.B.); (F.B.); (F.T.)
| | - Domenico Pagliara
- Plastic-Reconstructive and Lymphedema Microsurgery Center, Mater Olbia Hospital, 07026 Olbia, Italy;
| | - Andrea Figus
- Plastic Surgery and Microsurgery Unit, Department of Surgical Sciences, Faculty of Medicine and Surgery, University Hospital “Duilio Casula”, University of Cagliari, 09124 Cagliari, Italy; (A.F.); (F.B.)
| | - Filippo Boriani
- Plastic Surgery and Microsurgery Unit, Department of Surgical Sciences, Faculty of Medicine and Surgery, University Hospital “Duilio Casula”, University of Cagliari, 09124 Cagliari, Italy; (A.F.); (F.B.)
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Aujla J, Tong JY, Curragh D, Caplash Y, Chehade M, Tumuluri K, Au A, Low N, Avisar I, Sagiv O, Barequet I, Ben Simon G, Selva D. Corneal Neurotization for Neurotrophic Keratopathy: A Multicentre Experience. Ophthalmic Plast Reconstr Surg 2024:00002341-990000000-00376. [PMID: 38624152 DOI: 10.1097/iop.0000000000002684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
PURPOSE Corneal neurotization is an emerging technique that offers potential for visual rehabilitation in neurotrophic keratopathy. This study reports on a multicenter experience and outcomes for both direct and indirect methods of corneal neurotization. METHODS Retrospective case series. Sixteen patients with neurotrophic keratopathy who underwent corneal neurotization across 5 centers in Australia and Israel were identified for inclusion. Corneal neurotization was performed via direct neurotization from the ipsilateral or contralateral supraorbital/supratrochlear nerve or by the use of an interpositional sural nerve graft. Change in corneal sensitivity (measured in millimeters by the Cochet-Bonnet aesthesiometer), visual acuity, and corneal health. RESULTS Over a mean follow-up period of 31.3 months (range: 3 months-8 years), mean corneal sensitivity improved from 3.6 mm (range: 0-25 mm) to 25.3 mm (range: 0-57 mm). Visual acuity improved on average from 20/380 to 20/260. Twelve of 16 patients (75.0%) improved in at least 2 out of the 3 main outcome measures. Nine patients (56.3%) showed an improvement in visual acuity; 13 (81.3%) showed an improvement in average corneal sensitivity; and 11 (68.8%) showed an improvement in corneal health. There were no intraoperative or postoperative complications. CONCLUSIONS Corneal neurotization is an emerging surgical treatment option for the management of neurotrophic keratopathy. With appropriate case selection, outcomes are favorable and complication rates are low, for a condition that is otherwise challenging to manage. Patients with severe neurotrophic keratopathy should be considered for this surgical treatment option.
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Affiliation(s)
| | - Jessica Y Tong
- South Australian Institute of Ophthalmology
- Department of Plastic and Reconstructive Surgery, Royal Adelaide Hospital, Adelaide
| | | | - Yugesh Caplash
- Department of Plastic and Reconstructive Surgery, Royal Adelaide Hospital, Adelaide
| | | | - Krishna Tumuluri
- Save Sight Institute, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney
| | - Alicia Au
- Monash Health Clayton, VIC, Australia
| | | | | | - Oded Sagiv
- Goldschleger Eye Institute, Sheba Medical Center, Tel-Hashomer, Israel
- Section of Ophthalmology, Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, U.S.A
| | - Irit Barequet
- Goldschleger Eye Institute, Sheba Medical Center, Tel-Hashomer, Israel
| | - Guy Ben Simon
- Goldschleger Eye Institute, Sheba Medical Center, Tel-Hashomer, Israel
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Vohra M, Gour A, Rajput J, Sangwan B, Chauhan M, Goel K, Kamath A, Mathur U, Chandru A, Sangwan VS, Bhowmick T, Tiwari A. Chemical (Alkali) Burn-Induced Neurotrophic Keratitis Model in New Zealand Rabbit Investigated Using Medical Clinical Readouts and In Vivo Confocal Microscopy (IVCM). Cells 2024; 13:379. [PMID: 38474343 DOI: 10.3390/cells13050379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 12/05/2023] [Accepted: 12/07/2023] [Indexed: 03/14/2024] Open
Abstract
PURPOSE Chemical eye injury is an acute emergency that can result in vision loss. Neurotrophic keratitis (NK) is the most common long-term manifestation of chemical injury. NK due to alkali burn affects ocular surface health and is one of its most common causes. Here, we established a rabbit model of corneal alkali burns to evaluate the severity of NK-associated changes. MATERIAL METHODS Alkali burns were induced in NZ rabbits by treating the cornea with (i) a 5 mm circular filter paper soaked in 0.75 N NaOH for 10 s (Mild NK) and (ii) trephination using a guarded trephine (5 mm diameter and 150-micron depth), followed by alkali burn, with a 5 mm circular filter paper soaked in 0.75 N NaOH for 10 s (a severe form of NK). Immediately after, the cornea was rinsed with 10 mL of normal saline to remove traces of NaOH. Clinical features were evaluated on Day 0, Day 1, Day 7, Day 15, and Day 21 post-alkali burn using a slit lamp, Pentacam, and anterior segment optical coherence tomography (AS-OCT). NK-like changes in epithelium, sub-basal nerve plexus, and stroma were observed using in vivo confocal microscopy (IVCM), and corneal sensation were measured using an aesthesiometer post alkali injury. After 21 days, pro-inflammatory cytokines were evaluated for inflammation through ELISA. RESULTS Trephination followed by alkali burn resulted in the loss of epithelial layers (manifested using fluorescein stain), extensive edema, and increased corneal thickness (550 µm compared to 380 µm thickness of control) evaluated through AS-OCT and increased opacity score in alkali-treated rabbit (80 compared to 16 controls). IVCM images showed complete loss of nerve fibers, which failed to regenerate over 30 days, and loss of corneal sensation-conditions associated with NK. Cytokines evaluation of IL6, VEGF, and MMP9 indicated an increased angiogenic and pro-inflammatory milieu compared to the milder form of NK and the control. DISCUSSION Using clinical parameters, we demonstrated that the alkali-treated rabbit model depicts features of NK. Using IVCM in the NaOH burn animal model, we demonstrated a complete loss of nerve fibers with poor self-healing capability associated with sub-basal nerve degeneration and compromised corneal sensation. This pre-clinical rabbit model has implications for future pre-clinical research in neurotrophic keratitis.
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Affiliation(s)
- Mehak Vohra
- Shroff-Pandorum Center for Ocular Regeneration, Dr. Shroff's Charity Eye Hospital, New Delhi 110002, India
- Pandorum Technologies Pvt. Ltd., Bangalore 560100, India
| | - Abha Gour
- Shroff-Pandorum Center for Ocular Regeneration, Dr. Shroff's Charity Eye Hospital, New Delhi 110002, India
| | - Jyoti Rajput
- Shroff-Pandorum Center for Ocular Regeneration, Dr. Shroff's Charity Eye Hospital, New Delhi 110002, India
- Pandorum Technologies Pvt. Ltd., Bangalore 560100, India
| | - Bharti Sangwan
- Shroff-Pandorum Center for Ocular Regeneration, Dr. Shroff's Charity Eye Hospital, New Delhi 110002, India
- Pandorum Technologies Pvt. Ltd., Bangalore 560100, India
| | - Monika Chauhan
- Shroff-Pandorum Center for Ocular Regeneration, Dr. Shroff's Charity Eye Hospital, New Delhi 110002, India
- Pandorum Technologies Pvt. Ltd., Bangalore 560100, India
| | - Kartik Goel
- Shroff-Pandorum Center for Ocular Regeneration, Dr. Shroff's Charity Eye Hospital, New Delhi 110002, India
- Pandorum Technologies Pvt. Ltd., Bangalore 560100, India
| | - Ajith Kamath
- Pandorum Technologies Pvt. Ltd., Bangalore 560100, India
| | - Umang Mathur
- Shroff-Pandorum Center for Ocular Regeneration, Dr. Shroff's Charity Eye Hospital, New Delhi 110002, India
| | - Arun Chandru
- Pandorum Technologies Pvt. Ltd., Bangalore 560100, India
| | - Virender Singh Sangwan
- Shroff-Pandorum Center for Ocular Regeneration, Dr. Shroff's Charity Eye Hospital, New Delhi 110002, India
| | - Tuhin Bhowmick
- Pandorum Technologies Pvt. Ltd., Bangalore 560100, India
| | - Anil Tiwari
- Shroff-Pandorum Center for Ocular Regeneration, Dr. Shroff's Charity Eye Hospital, New Delhi 110002, India
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Wajnsztajn D, Faraj LA, Sanchez-Tabernero S, Solomon A. Neurotrophic keratitis: inflammatory pathogenesis and novel therapies. Curr Opin Allergy Clin Immunol 2023; 23:520-528. [PMID: 37694830 DOI: 10.1097/aci.0000000000000942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
PURPOSE OF REVIEW Neurotrophic keratitis is a rare degenerative disease characterized by decrease or absence of corneal sensation. Neurotrophic keratitis varies from mild forms with mild epitheliopathy to severe manifestations such as corneal ulceration, melting and perforation that can lead to irreversible visual loss. The cause of neurotrophic keratitis comprises a long list of diseases, medications, congenital or genetic conditions as well as trauma. The mechanism of neurotrophic keratitis is complex and multifactorial and its understanding is crucial to better address the treatment strategies. We aimed to review neurotrophic keratitis pathology, mechanisms and management. RECENT FINDINGS Corneal nerves are critical for the homeostasis of a healthy ocular surface. The lack of nerve-derived neuromediators and corneal-released neuropeptides, neuro-trophins and neurotrophic factors in neurotrophic keratitis leads to a decrease in trophic supply to corneal cells in addition to a decrease in afferent signaling to the brain. This results in pathological tear secretion, decreased blinking rate, corneal healing along with ocular surface and corneal inflammation. Lately, nerve growth factor in special gained emphasis as a treatment strategy targeting the disease mechanism rather than its manifestations. Other therapies, including surgical interventions, are in the pipeline of neurotrophic keratitis management. However, there are still no proper therapeutic guidelines and neurotrophic keratitis treatment remains challenging. SUMMARY Neurotrophic keratitis may have a devastating outcome and treatment is still challenging. Understanding the disease pathology may assist in the development of new treatment strategies. Prompt disease recognition and immediate intervention are key factors to promote corneal healing and avoid further deterioration.
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Affiliation(s)
- Denise Wajnsztajn
- Department of Ophthalmology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Lana A Faraj
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | | | - Abraham Solomon
- Department of Ophthalmology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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9
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Thia ZZ, Ho YT, Shih KC, Tong L. New developments in the management of persistent corneal epithelial defects. Surv Ophthalmol 2023; 68:1093-1114. [PMID: 37301520 DOI: 10.1016/j.survophthal.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 05/24/2023] [Accepted: 06/05/2023] [Indexed: 06/12/2023]
Abstract
A persistent epithelial defect (PED) is a corneal epithelial defect that failed to heal after 2weeks. It is a condition that carries much morbidity, and our understanding of PED remains poor, with current treatment methods often having unsatisfactory outcomes. With PEDs becoming more prevalent, more efforts are required to establish reliable treatment modalities. Our reviews describe the causes of PEDs and the different approaches developed to manage them, as well as their associated limitations. Emphasis is placed on understanding various advances in the development of new treatment modalities. We have also described a case of a woman with a background of graft-versus-host disease on long-term topical corticosteroids who developed complicated PED involving both eyes. The current approach to managing PEDs generally involves exclusion of an active infection, followed by treatment modalities that aim to encourage corneal epithelial healing. Success rates, however, remain far from desirable, as treatment remains challenging due to multiple underlying etiologies. In summary, advances in the development of new therapies may be able to facilitate progress in the understanding and treatment of PED.
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Affiliation(s)
- Zhang Zhe Thia
- Singapore Eye Research Institute, Singapore, Singapore; National University Hospital, Singapore, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yik To Ho
- Hong Kong University, Pok Fu Lam, Hong Kong
| | | | - Louis Tong
- Singapore Eye Research Institute, Singapore, Singapore; Singapore National Eye Center, Singapore, Singapore; Duke-NUS Medical School, Singapore, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
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10
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Morel M, Severinsky B, Kim HJ, Behshad S. Semiscleral Contact Lens Use After Direct Corneal Neurotization for Neurotrophic Keratopathy. Eye Contact Lens 2023; 49:471-474. [PMID: 37616173 DOI: 10.1097/icl.0000000000001028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2023] [Indexed: 08/26/2023]
Abstract
PURPOSE To describe a case of a patient treated for neurotrophic keratopathy (NK) with direct corneal neurotization (CN), where a modification to the CN technique allowed for semiscleral contact lens use postoperatively. OBSERVATION Our patient had successful CN with improved corneal sensation. During the procedure, a 1.0 mm gutter was created between the limbus and nerve graft to allow for semiscleral contact lens fitting. CONCLUSIONS With the use of preoperative planning and a limbal gutter during CN, a semiscleral contact lens can serve as a well-tolerated postoperative management option to improve visual acuity and protect the corneal surface in patients with NK.
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Affiliation(s)
- Mark Morel
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA
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11
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Daeschler SC, Woo JH, Hussein I, Ali A, Borschel GH. Corneal Neurotization: Preoperative Patient Workup and Surgical Decision-making. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5334. [PMID: 37829104 PMCID: PMC10566830 DOI: 10.1097/gox.0000000000005334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 08/24/2023] [Indexed: 10/14/2023]
Abstract
Background The use of sensory nerve transfers to the anesthetic cornea has transformed the treatment of neurotrophic keratopathy by restoring ocular surface sensation and activating dysfunctional epithelial repair mechanisms. However, despite numerous reports on surgical techniques, there is a scarcity of information on the interdisciplinary management, preoperative assessment, and surgical decision-making, which are equally critical to treatment success. Methods This Special Topic presents a standardized, interdisciplinary preoperative workup based on our 10-year experience with corneal neurotization in 32 eyes of patients with neurotrophic keratopathy. Results Our assessment includes a medical history review, ophthalmic evaluation, and systematic facial sensory donor nerve mapping for light touch and pain modalities. This approach enables evidence-based patient selection, optimal surgery timing, and suitable donor nerve identification, including backup options. Conclusions Based on a decade-long experience, this special topic highlights the importance of interdisciplinary collaboration and provides a practical roadmap for optimizing patient selection and surgical decision-making in patients undergoing corneal neurotization.
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Affiliation(s)
- Simeon C. Daeschler
- From the SickKids Research Institute, Neuroscience and Mental Health Program, Toronto, Ontario, Canada
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, Department of Plastic and Hand Surgery, University of Heidelberg, BG Trauma Hospital, Ludwigshafen, Germany
| | - Jyh Haur Woo
- Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
- Singapore National Eye Centre, Singapore, Singapore
| | - Isra Hussein
- Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Asim Ali
- Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Gregory H. Borschel
- From the SickKids Research Institute, Neuroscience and Mental Health Program, Toronto, Ontario, Canada
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind
- Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, Ind
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12
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Aronson S, Applebaum SA, Kelsey LJ, Gosain AK. Evidence-Based Practices in Facial Reanimation Surgery. Plast Reconstr Surg 2023; 152:520e-533e. [PMID: 37647378 DOI: 10.1097/prs.0000000000010539] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Describe the causes and preoperative evaluation of facial paralysis. 2. Discuss techniques to restore corneal sensation and eyelid closure, elevation of the upper lip for smile, and depression of the lower lip for lip symmetry. 3. Outline treatment goals, surgical treatment options, timing of repair, and other patient-specific considerations in appropriate technique selection. SUMMARY Congenital facial paralysis affects 2.7 per 100,000 children; Bell palsy affects 23 per 100,000 people annually; and even more people are affected when considering all other causes. Conditions that impair facial mimetics impact patients' social functioning and emotional well-being. Dynamic and static reconstructive methods may be used individually or in concert to achieve adequate blink restoration, smile strength and spontaneity, and lower lip depression. Timing of injury and repair, patient characteristics such as age, and cause of facial paralysis are all considered in selecting the most appropriate reconstructive approach. This article describes evidence-based management of facial paralysis.
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Affiliation(s)
- Sofia Aronson
- From the Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine
- Division of Pediatric Plastic Surgery, Ann & Robert H. Lurie Children's Hospital
| | - Sarah A Applebaum
- Division of Pediatric Plastic Surgery, Ann & Robert H. Lurie Children's Hospital
| | - Lauren J Kelsey
- Division of Pediatric Plastic Surgery, Ann & Robert H. Lurie Children's Hospital
| | - Arun K Gosain
- From the Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine
- Division of Pediatric Plastic Surgery, Ann & Robert H. Lurie Children's Hospital
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13
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Khilji M, Tanveer S, Khan FZ, Yazdan DA, Khilji A. Neurotrophic Keratopathy and Topical Insulin Therapy: A Case Report. Cureus 2023; 15:e46242. [PMID: 37908963 PMCID: PMC10613931 DOI: 10.7759/cureus.46242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2023] [Indexed: 11/02/2023] Open
Abstract
Neurotrophic keratopathy is a rare disorder caused by the loss of corneal sensation. It is characterized by persistent epithelial defects, corneal ulceration, and, ultimately, corneal perforation if not managed in a timely manner. The management includes aggressive lubrication, prophylactic topical antibiotics, therapeutic contact lenses, tarsorrhaphy, and amniotic membrane transplantation. Some novel therapeutic options are also available, one of which is topical insulin therapy. We report the clinical course of a patient with neurotrophic keratopathy that was successfully treated with topical insulin. A 64-year-old male presented to our outpatient department with a three-month history of painless blurring of vision following prior episodes of herpetic keratitis. Ocular examination showed a bilateral reduction in corneal sensations, bilateral corneal opacities, and a corneal ulcer in the left eye. He was diagnosed as a case of neurotrophic keratopathy secondary to prior herpetic keratitis. He was then treated with topical and oral acyclovir along with topical insulin drops. There was a remarkable improvement in his condition after a month with a reduction in the size of the ulcer and, after two months, the ulcer was completely re-epithelialized. This case report illustrates the use of topical insulin in the initial management of neurotrophic keratopathy as opposed to its conventional use in refractory neurotrophic corneal ulcers.
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Affiliation(s)
- Maryum Khilji
- Ophthalmology, Khyber Medical College/Khyber Teaching Hospital, Peshawar, PAK
| | - Shafiq Tanveer
- Ophthalmology, Khyber Medical College/Khyber Teaching Hospital, Peshawar, PAK
| | - Fahd Zafar Khan
- Community Medicine, Khyber Medical College, Peshawar, PAK
- Ophthalmology, Khyber Medical College/Khyber Teaching Hospital, Peshawar, PAK
| | - Dilawar Ali Yazdan
- Ophthalmology, Khyber Medical College/Khyber Teaching Hospital, Peshawar, PAK
| | - Ayesha Khilji
- Internal Medicine, Hayatabad Medical Complex, Peshawar, PAK
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14
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Su D, Zhang J, Wu Y, Wang W, Wang W, Shao C, Li J. Evaluation of Corneal Nerve Regeneration After Minimally Invasive Corneal Neurotization. Asia Pac J Ophthalmol (Phila) 2023; 12:427-436. [PMID: 37527446 DOI: 10.1097/apo.0000000000000626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 05/31/2023] [Indexed: 08/03/2023] Open
Abstract
PURPOSE To evaluate the corneal nerve regeneration after minimally invasive corneal neurotization (MICN) and to further clarify the recovery patterns of sensory and trophic functions of the corneal nerves. DESIGN A retrospective cohort study based in the Shanghai Ninth People's Hospital. METHODS Eighteen patients (18 eyes) who underwent MICN for neurotrophic keratopathy due to intracranial surgery was conducted to analyze their follow-up data at 6, 12, 18, and 24 months after surgery. RESULTS At 12 months postoperatively, the growth of the central and peripheral corneal nerve fiber density (CNFD) was 11.47±8.56 and 14.73±8.08 n/mm 2 with subsequent improvement slowing down, and the patient's corneal epithelium defect was healed ahead of the accomplishment of corneal nerve regeneration. The number of dendritic cells also reached its peak. At 18 months postoperatively, the recovery of central and peripheral corneal sensation was 37.22±23.06 mm and 39.38±18.08 mm with no subsequent improvement, and the growth of the central and peripheral corneal nerve branch density (CNBD) was 29.69±11.05 and 43.75±1.41 n/mm 2 , with a positive and significant correlation between corneal sensation and CNBD (at central r =0.632, P <0.005; at peripheral r =0.645, P <0.005). At 24 months postoperatively, mean CNFD, CNBD, and corneal sensation recovered significantly compared with preoperative, but a few patients' corneal sensation recovered insignificantly with good CNFD recovery and poor CNBD recovery. CONCLUSIONS After MICN, the trophic function of the corneal nerve recovers before the sensory function, and in particular, the recovery of sensation is based on the coexistence of the corneal nerve trunk and branches.
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Affiliation(s)
- Dai Su
- Department of Ophthalmology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Ophthalmology, Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai, China
| | - Jiaying Zhang
- Department of Ophthalmology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Ophthalmology, Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai, China
| | - Yue Wu
- Department of Ophthalmology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Ophthalmology, Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai, China
| | - Wenjin Wang
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wei Wang
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chunyi Shao
- Department of Ophthalmology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Ophthalmology, Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai, China
| | - Jin Li
- Department of Ophthalmology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Ophthalmology, Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai, China
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15
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Feinberg K, Tajdaran K, Mirmoeini K, Daeschler SC, Henriquez MA, Stevens KE, Mulenga CM, Hussain A, Hamrah P, Ali A, Gordon T, Borschel GH. The Role of Sensory Innervation in Homeostatic and Injury-Induced Corneal Epithelial Renewal. Int J Mol Sci 2023; 24:12615. [PMID: 37628793 PMCID: PMC10454376 DOI: 10.3390/ijms241612615] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 08/02/2023] [Accepted: 08/05/2023] [Indexed: 08/27/2023] Open
Abstract
The cornea is the window through which we see the world. Corneal clarity is required for vision, and blindness occurs when the cornea becomes opaque. The cornea is covered by unique transparent epithelial cells that serve as an outermost cellular barrier bordering between the cornea and the external environment. Corneal sensory nerves protect the cornea from injury by triggering tearing and blink reflexes, and are also thought to regulate corneal epithelial renewal via unknown mechanism(s). When protective corneal sensory innervation is absent due to infection, trauma, intracranial tumors, surgery, or congenital causes, permanent blindness results from repetitive epithelial microtraumas and failure to heal. The condition is termed neurotrophic keratopathy (NK), with an incidence of 5:10,000 people worldwide. In this report, we review the currently available therapeutic solutions for NK and discuss the progress in our understanding of how the sensory nerves induce corneal epithelial renewal.
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Affiliation(s)
- Konstantin Feinberg
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Kiana Tajdaran
- Program in Neurosciences and Mental Health, Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
| | - Kaveh Mirmoeini
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
- Program in Neurosciences and Mental Health, Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
| | - Simeon C. Daeschler
- Program in Neurosciences and Mental Health, Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Hospital, Department of Plastic and Hand Surgery, University of Heidelberg, 67071 Ludwigshafen, Germany
| | - Mario A. Henriquez
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Katelyn E. Stevens
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Chilando M. Mulenga
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Arif Hussain
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Pedram Hamrah
- Cornea Service, New England Eye Center, Tufts Medical Center, Department of Ophthalmology, Tufts University School of Medicine, Boston, MA 02111, USA
- Center for Translational Ocular Immunology, Department of Ophthalmology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA 02111, USA
| | - Asim Ali
- Department of Ophthalmology and Vision Sciences, Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON M5T 3A9, Canada
| | - Tessa Gordon
- Program in Neurosciences and Mental Health, Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
| | - Gregory H. Borschel
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
- Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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16
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Posarelli M, Romano D, Tucci D, Giannaccare G, Scorcia V, Taloni A, Pagano L, Borgia A. Ocular-Surface Regeneration Therapies for Eye Disorders: The State of the Art. BIOTECH 2023; 12:48. [PMID: 37366796 DOI: 10.3390/biotech12020048] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/10/2023] [Accepted: 06/13/2023] [Indexed: 06/28/2023] Open
Abstract
The ocular surface is a complex structure that includes cornea, conjunctiva, limbus, and tear film, and is critical for maintaining visual function. When the ocular-surface integrity is altered by a disease, conventional therapies usually rely on topical drops or tissue replacement with more invasive procedures, such as corneal transplants. However, in the last years, regeneration therapies have emerged as a promising approach to repair the damaged ocular surface by stimulating cell proliferation and restoring the eye homeostasis and function. This article reviews the different strategies employed in ocular-surface regeneration, including cell-based therapies, growth-factor-based therapies, and tissue-engineering approaches. Dry eye and neurotrophic keratopathy diseases can be treated with nerve-growth factors to stimulate the limbal stem-cell proliferation and the corneal nerve regeneration, whereas conjunctival autograft or amniotic membrane are used in subjects with corneal limbus dysfunction, such as limbal stem-cell deficiency or pterygium. Further, new therapies are available for patients with corneal endothelium diseases to promote the expansion and migration of cells without the need of corneal keratoplasty. Finally, gene therapy is a promising new frontier of regeneration medicine that can modify the gene expression and, potentially, restore the corneal transparency by reducing fibrosis and neovascularization, as well as by stimulating stem-cell proliferation and tissue regeneration.
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Affiliation(s)
- Matteo Posarelli
- St. Paul's Eye Unit, Department of Corneal Diseases, Royal Liverpool University Hospital, Liverpool L7 8YE, UK
- Ophthalmology Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
| | - Davide Romano
- Eye Clinic, Department of Neurological and Vision Sciences, University of Brescia, 25123 Brescia, Italy
- Eye Unit, University Hospitals of Leicester, NHS Trust, Leicester LE1 5WW, UK
| | - Davide Tucci
- Department of Biomedical and Surgical Sciences, Section of Ophthalmology, S. Maria Della Misericordia Hospital, University of Perugia, 06123 Perugia, Italy
| | - Giuseppe Giannaccare
- Department of Ophthalmology, University Magna Græcia of Catanzaro, 88100 Catanzaro, Italy
| | - Vincenzo Scorcia
- Department of Ophthalmology, University Magna Græcia of Catanzaro, 88100 Catanzaro, Italy
| | - Andrea Taloni
- Department of Ophthalmology, University Magna Græcia of Catanzaro, 88100 Catanzaro, Italy
| | - Luca Pagano
- St. Paul's Eye Unit, Department of Corneal Diseases, Royal Liverpool University Hospital, Liverpool L7 8YE, UK
| | - Alfredo Borgia
- St. Paul's Eye Unit, Department of Corneal Diseases, Royal Liverpool University Hospital, Liverpool L7 8YE, UK
- Eye Unit, Humanitas-Gradenigo Hospital, 10153 Turin, Italy
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17
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Said DG, Rallis KI, Al-Aqaba MA, Ting DSJ, Dua HS. Surgical management of infectious keratitis. Ocul Surf 2023; 28:401-412. [PMID: 34592475 DOI: 10.1016/j.jtos.2021.09.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 09/18/2021] [Indexed: 12/27/2022]
Abstract
The successful management of infectious keratitis is usually achieved with a combination of tools for accurate diagnosis and targeted timely antimicrobial therapy. An armamentarium of surgical interventions is available in the acute stage which can be resorted to in a step wise manner or in combination guided by the response to treatment. Simple surgical modalities can facilitate accurate diagnosis e.g. corneal biopsy and alcohol delamination. Surgery to promote epithelial healing can vary from tarsorrhaphy, amniotic membrane transplantation or conjunctival flaps depending on the extent of infection, visual prognosis, availability of tissue and surgeon's experience. Collagen crosslinking has been increasingly utilized with successful results to strengthen the cornea and reduce the infective load consequently the need for further elaborate surgical interventions. It has shown encouraging results specially in superficial bacterial and fungal keratitis but for deeper infections, viral and acanthamoeba keratitis, its use remains questionable. When globe integrity is compromised, corneal gluing is the most commonly used procedure to seal small perforations. In larger perforations/fulminant infections a tectonic/therapeutic graft is advisable. Partial thickness grafts are increasingly popular to treat superficial infection or internally tamponade perforations. Peripheral therapeutic grafts face challenges with potential requirement for a manually fashioned graft, and increased risk of rejection due to proximity to the limbal vessels. Late stage visual rehabilitation is likely to require further surgical interventions after complete resolution of infection and inflammation. A preliminary assessment of corneal sensation and integrity of the ocular surface are key for any successful surgical intervention to restore vision.
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Affiliation(s)
- Dalia G Said
- Academic Ophthalmology, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK; Department of Ophthalmology, Queen's Medical Centre, Nottingham, UK; Research Institute of Ophthalmology, Cairo, Egypt.
| | | | | | - Darren S J Ting
- Academic Ophthalmology, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK; Department of Ophthalmology, Queen's Medical Centre, Nottingham, UK
| | - Harminder S Dua
- Academic Ophthalmology, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK; Department of Ophthalmology, Queen's Medical Centre, Nottingham, UK
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18
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Corneal Neurotization—Indications, Surgical Techniques and Outcomes. J Clin Med 2023; 12:jcm12062214. [PMID: 36983215 PMCID: PMC10059768 DOI: 10.3390/jcm12062214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/05/2023] [Accepted: 03/11/2023] [Indexed: 03/16/2023] Open
Abstract
Corneal neurotization is a promising surgical approach for the treatment of moderate to severe neurotrophic keratopathy. This technique aims to restore corneal sensation by transferring healthy nerves, either directly or via a conduit, to the anesthetic cornea. This review provides a report on the current state of development, evidence, and experience in the field. We summarize the data available from clinical reports and case series, placing an emphasis on the diversity of the surgical techniques reported. While these data are encouraging, they also highlight the need for a consensus in reporting outcomes and highlight how the next step will involve validating putative outcome parameters when researching and reporting corneal neurotization surgery.
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19
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Bilateral Corneal Neurotization for Ramos-Arroyo Syndrome and Developmental Neurotrophic Keratopathy: Case Report and Literature Review. Cornea 2023; 42:369-371. [PMID: 36197333 DOI: 10.1097/ico.0000000000003143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 07/29/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of this study was to report the use of bilateral corneal neurotization for neurotrophic keratitis in the setting of Ramos-Arroyo syndrome. METHODS The case report and surgical technique are described in detail in this article, as well as a review of the literature on corneal neurotization for congenital corneal anesthesia. RESULTS We report a 17-year-old patient who underwent bilateral corneal neurotization for neurotrophic keratitis secondary to corneal anesthesia in Ramos-Arroyo syndrome. Corneal neurotization was performed with great auricular nerve transfers extended by sural nerve autografts. CONCLUSIONS We present the treatment of neurotrophic keratopathy with corneal neurotization in a patient with Ramos-Arroyo syndrome. We describe how bilateral corneal neurotization using the great auricular nerve technique is a safe and effective procedure for patients with congenital/developmental corneal anesthesia.
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20
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Ting DS, Pradhan SP, Barnes E, Ahmed OA, Figueiredo FC. Minimally invasive corneal neurotization for neurotrophic keratopathy: The potential effect of age, denervation chronicity and lesion location. Am J Ophthalmol Case Rep 2023; 29:101804. [PMID: 36718433 PMCID: PMC9883617 DOI: 10.1016/j.ajoc.2023.101804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 01/01/2023] [Accepted: 01/13/2023] [Indexed: 01/23/2023] Open
Abstract
Purpose Neurotrophic keratopathy (NK) is an uncommon but challenging clinical condition characterized by altered corneal nerves and sensation leading to corneal damage. Corneal neurotization, a surgical technique that aims to "re-innervate" the cornea, has gained increasing popularity in view of the potential to permanently improve or even restore the normal corneal sensation. In this study, we aimed to report the outcomes of two cases of NK that underwent indirect minimally invasive corneal neurotization (MICN) with a sural nerve autograft, and to provide plausible explanations for the observed clinical outcomes. Observations This was an interventional case series of two patients who underwent MICN for severe unilateral NK. The MICN technique was adapted from the technique originally described by Elbaz et al., in 2014. Clinical severity of NK was graded according to Mackie's grading system. Corneal sensation was measured using the Cochet-Bonnet esthesiometer (0-60mm) and corneal nerves were examined using in vivo confocal microscopy (IVCM) with Heidelberg HRT3 Rostock Corneal Module. Patient 1 was a 70-year-old man with a right grade III NK following trigeminal nerve decompression for trigeminal neuralgia. Patient 2 was a 62-year-old man with a left grade II NK following a left-sided acoustic neuroma resection. The denervation time was 23 years for both patients. Following the MICN surgery, none of the patients achieved sustained improvement in the corneal sensation (though patient 1 achieved a transient improvement in central corneal sensation to 20mm at 4 months' postoperative before returning to 0mm at 6 months' postoperative). IVCM did not reveal any changes in the corneal nerve density and morphology post-MICN. Conclusions and Importance Based on our observations and the literature, we postulate that long denervation time, proximal injury to the trigeminal nerve and older patient age may serve as poor prognostic factors for MICN. As CN is being increasingly adopted in clinical practice for treating NK, understanding of these potential factors will facilitate better risk-benefit stratification and patient counselling. Future larger studies are required to elucidate these findings.
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Affiliation(s)
- Darren S.J. Ting
- Birmingham and Midland Eye Centre, Birmingham, UK
- Academic Unit of Ophthalmology, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- Academic Ophthalmology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Sayali P. Pradhan
- Department of Ophthalmology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Eric Barnes
- Department of Ophthalmology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Omar A. Ahmed
- Department of Plastic Surgery, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Francisco C. Figueiredo
- Department of Ophthalmology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
- Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Corresponding author. partment of Ophthalmology, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP, UK.
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21
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Saad S, Labani S, Goemaere I, Cuyaubere R, Borderie M, Borderie V, Benkhatar H, Bouheraoua N. Corneal neurotization in the management of neurotrophic keratopathy: A review of the literature. J Fr Ophtalmol 2023; 46:83-96. [PMID: 36473789 DOI: 10.1016/j.jfo.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 09/28/2022] [Accepted: 09/29/2022] [Indexed: 12/12/2022]
Abstract
Neurotrophic keratopathy (NK) is a rare degenerative disease in which damage to the corneal nerves leads to corneal hypoesthesia or anesthesia. Neurotrophic corneal ulcers are notoriously difficult to treat and can lead to blindness. Corneal neurotization (CN) is a recent surgical technique aimed at restoring corneal sensation and may offer a definitive treatment in the wake of NK. Herein, we review the surgical techniques utilized in direct and indirect CN. Technical considerations, outcomes, current limitations and future perspectives are also discussed. This article highlights the key points of this promising procedure and biological aspects that will help provide the best treatment options for patients with severe NK.
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Affiliation(s)
- S Saad
- CHNO des Quinze-Vingts, IHU FOReSIGHT, Inserm-DGOS CIC 1423, 28, rue de Charenton, 75012 Paris, France
| | - S Labani
- CHNO des Quinze-Vingts, IHU FOReSIGHT, Inserm-DGOS CIC 1423, 28, rue de Charenton, 75012 Paris, France
| | - I Goemaere
- CHNO des Quinze-Vingts, IHU FOReSIGHT, Inserm-DGOS CIC 1423, 28, rue de Charenton, 75012 Paris, France
| | - R Cuyaubere
- CHNO des Quinze-Vingts, IHU FOReSIGHT, Inserm-DGOS CIC 1423, 28, rue de Charenton, 75012 Paris, France
| | - M Borderie
- CHNO des Quinze-Vingts, IHU FOReSIGHT, Inserm-DGOS CIC 1423, 28, rue de Charenton, 75012 Paris, France
| | - V Borderie
- CHNO des Quinze-Vingts, IHU FOReSIGHT, Inserm-DGOS CIC 1423, 28, rue de Charenton, 75012 Paris, France; Sorbonne université, Inserm, CNRS, institut de la vision, 17, rue Moreau, 75012 Paris, France
| | - H Benkhatar
- CHNO des Quinze-Vingts, IHU FOReSIGHT, Inserm-DGOS CIC 1423, 28, rue de Charenton, 75012 Paris, France; Versailles Hospital Center, Department of Otorhinolaryngology-Head and Neck Surgery, Le Chesnay, France
| | - N Bouheraoua
- CHNO des Quinze-Vingts, IHU FOReSIGHT, Inserm-DGOS CIC 1423, 28, rue de Charenton, 75012 Paris, France; Sorbonne université, Inserm, CNRS, institut de la vision, 17, rue Moreau, 75012 Paris, France.
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22
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A Surgeon's Armamentarium for Ocular Management in Facial Paralysis: A Comprehensive Review. J Craniofac Surg 2023; 34:214-221. [PMID: 36608099 DOI: 10.1097/scs.0000000000009089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 09/04/2022] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE To review the current management paradigm of the eye in patients with facial paralysis. METHODS A PubMed and Cochrane search was done with no date restrictions for English-language literature on facial synkinesis. The search terms used were "ocular," "facial," "synkinesis," "palsy," "neurotization," and various combinations of the terms. A total of 65 articles were included. RESULTS Facial paralysis may result in devastating ocular sequelae. Therefore, assessment of the eye in facial paralysis is a critical component of patient management. Although the management should be individualized to the patient, the primary objective should include an ophthalmologic evaluation to implement measures to protect the ocular surface and preserve visual acuity. The degree of facial paralysis, lacrimal secretion, corneal sensation, and position of the eyelids should be assessed thoroughly. Patients with the anticipated recovery of facial nerve function may respond to more conservative temporizing measures to protect the ocular surface. Conversely, patients with expected prolonged paralysis should be appropriately identified as they will benefit from surgical reconstruction and rehabilitation of the periorbital complex. The majority of reconstructive measures within a facial surgeon's armamentarium augment coverage of the eye but are unable to restore blink. Eyelid reanimation restores the esthetic proportionality of the eye with blinking and reestablishes protective functions necessary for ocular preservation and function. CONCLUSIONS Ocular preservation is the primary priority in the initial management of the patient with facial paralysis. An accurate assessment is a critical component in identifying the type of paralysis and developing an individualized treatment plan.
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Abstract
Neurotrophic keratopathy (NK), or neurotrophic keratitis, is a degenerative condition that results from decreased innervation to the cornea. The cornea is innervated by the ophthalmic branch of the trigeminal nerve. Neurotrophic keratopathy is most commonly caused by herpes keratitis however, any condition that disrupts the normal corneal innervation can cause NK. Neurotrophic keratopathy is a clinical diagnosis and is classified into three stages based on the disease severity. Stage 1 has mild epithelial defects, such as punctate keratopathy, stage 2 disease has persistent epithelial defects, and stage 3 is defined by the presence of ulcers. Current treatment modalities consist of medical and surgical options. Stage 1 is treated with lubrication through artificial tears, eyelid taping, and punctal plug/cautery. Stage 2 treatment can involve therapeutic contact lenses, topical autologous or allogenic serum, tarsorrhaphy, botulinum toxin injections, and possibly anti-inflammatory medications. Stage 3 disease may require human nerve growth factor, amniotic membrane transplantation, conjunctival flap, or corneal neurotization. New therapies, such as matrix regenerating therapy, plasma rich in growth factors, Thymosin β4, Substance P/Insulin like growth factor-1, and nicergoline represent exciting future options.KEY MESSAGESNeurotrophic keratopathy is a rare degenerative disease defined by decreased innervation to the cornea that is associated with significant morbidity.Treatment options range from lubrication alone to various medical and surgical treatments.Matrix regenerating therapy, plasma rich in growth factors, Thymosin β4, Substance P/Insulin like growth factor-1, and nicergoline are exciting novel therapies that will influence how neurotrophic keratopathy is treated in the future.
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Affiliation(s)
- Erin NaPier
- John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
| | - Matthew Camacho
- John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
| | - Timothy F McDevitt
- Section of Ophthalmology, Department of Surgery, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI, USA
| | - Adam R Sweeney
- Section of Ophthalmology, Department of Surgery, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI, USA
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Le Nguyen M, Naoum M, Andre C, Lethier L, Limat S, Fagnoni-Legat C, Guillaume Y, Gauthier A. Physicochemical and microbiological stability of insulin eye drops in an artificial tear vehicle used in the treatment of refractory neurotrophic keratopathy. J Fr Ophtalmol 2022; 45:860-871. [DOI: 10.1016/j.jfo.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 04/14/2022] [Accepted: 04/21/2022] [Indexed: 11/29/2022]
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Xie C, Liu B, Zhao X, He Q, Liu L, Wei R. Characteristics of the ocular surface in neurotrophic keratitis induced by trigeminal nerve injury following neurosurgery. Int Ophthalmol 2022; 43:1229-1240. [PMID: 36115903 PMCID: PMC10113358 DOI: 10.1007/s10792-022-02521-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 09/11/2022] [Indexed: 11/28/2022]
Abstract
Abstract
Purpose
To analyse and quantify ocular surface parameters in patients with unilateral neurotrophic keratitis (NK) induced by trigeminal nerve injury post-neurosurgery.
Methods
The study included 26 unilateral NK patients who had undergone neurosurgery, and 20 matched normal controls. Demographic and clinical characteristics of all participants were collected and analysed. Slit-lamp examination, Cochet–Bonnet aesthesiometry, Keratograph 5 M, and LipiView interferometer were performed on both eyes of 17 mild NK patients. For nine moderate/severe NK patients, sub-basal nerve density was measured by in vivo confocal microscopy.
Results
Of the 26 patients, nine had acoustic neuroma, nine had trigeminal neuralgia, and eight had neoplasms. Facial nerve paralysis was observed in one of the 17 mild NK eyes (5.9%) and seven of the nine moderate/severe NK eyes (77.8%). Compared to contralateral and normal control eyes, 26 NK eyes showed significantly reduced sensitivity in five corneal regions (P < 0.05). Corneal sensitivity in moderate/severe NK eyes was significantly lower than in mild NK eyes (P < 0.05). Moderate/severe NK eyes had poor visual acuity, and their sub-basal nerve density was lower than that of the controls. The onset of the moderate/severe NK was from 0.5 to 24 months (median [Q1, Q3], 1 [0.5, 2.5] months) after neurosurgery. For the mild NK eyes, the number of total blinks, the first non-invasive tear breakup time (NITBUT) and average NITBUT were significantly lower than contralateral and normal control eyes (P < 0.05), and the number of partial blinks and partial blinking rate were significantly higher than the other two control groups (P < 0.05).
Conclusions
Patients with NK induced by trigeminal nerve injury following neurosurgery had decreased corneal sensitivity to various degrees accompanied by increased partial blinks and shortened NITBUT. The severity of NK is related to the severity of the corneal sensory impairment. Facial nerve paralysis can worsen the clinical progression of NK.
Trial registration Chinese Clinical Trial Registry (ChiCTR2100044068, Date of Registration: March 9, 2021).
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Affiliation(s)
- Caiyuan Xie
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Fukang Road, Nankai District, Tianjin, China
| | - Bo Liu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Xiaoyu Zhao
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Fukang Road, Nankai District, Tianjin, China
| | - Qing He
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Fukang Road, Nankai District, Tianjin, China
| | - Lin Liu
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Fukang Road, Nankai District, Tianjin, China
| | - Ruihua Wei
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Fukang Road, Nankai District, Tianjin, China.
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Lee BW, Khan MA, Ngo QD, Tumuluri K, Samarawickrama C. Minimally invasive, indirect corneal neurotization using an ipsilateral sural nerve graft for early neurotrophic keratopathy. Am J Ophthalmol Case Rep 2022; 27:101585. [PMID: 35664449 PMCID: PMC9156881 DOI: 10.1016/j.ajoc.2022.101585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 05/10/2022] [Accepted: 05/11/2022] [Indexed: 11/17/2022] Open
Abstract
Purpose Neurotrophic keratopathy is a degenerative disease characterized by damage to the corneal nerves leading to corneal hypoesthesia and anaesthesia. The resultant progressive visual deterioration is refractory to existing conventional treatment options. Corneal neurotization is a novel and effective surgical procedure that directly targets the underlying pathology of nerve loss by stimulating new corneal nerve growth. This study reports the outcomes and the pre- and postoperative in vivo confocal microscopy findings of the first published Australian case of indirect, minimally invasive, corneal neurotization using an ipsilateral sural nerve autograft. Observations An 11-year-old boy developed corneal hypoesthesia in the left eye following surgical debulking of a cerebellopontine angle arachnoid cyst. He was diagnosed with Mackie Stage 1 neurotrophic keratopathy. Due to his hypoesthesia, he had developed recurrent microbial keratitis and corneal ulceration secondary to foreign bodies sustained during contact sports. At presentation, he reported photophobia and dry eye symptoms, corrected-distance visual acuity was 6/18, Cochet-Bonnet aesthesiometer demonstrated reduced corneal sensation (5–15mm), Schirmer's I test was 15mm, and in vivo confocal microscopy showed a complete absence of a subepithelial corneal plexus. He underwent indirect, minimally invasive, corneal neurotization using the ipsilateral supratrochlear nerve and a sural nerve autograft. Subjective improvement in corneal sensation was noticed by the patient at 2 months. Objective improvement, measured on Cochet-Bonnet aesthesiometer, was first observed at 6 months with steady stepwise improvement to 20–35mm at 21 months. Importantly, due to the increase in corneal sensation, the patient did not develop any further corneal complications. At 12 months, dry eye symptoms resolved and Schirmer's I test improved to 30mm. At 15 months, corrected-distance visual acuity improved to 6/5 and in vivo confocal microscopy demonstrated evidence of corneal reinnervation with nerves running through the subepithelial space surrounded by healthy and active keratocytes. Conclusions and importance Corneal neurotization represents an exciting development in the armamentarium for the treatment of neurotrophic keratopathy and can be considered for younger patients with early-stage disease.
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Affiliation(s)
- Brendon W.H. Lee
- Faculty of Medicine, University of New South Wales, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
- Westmead Institute of Medical Research, Sydney, Australia
| | - Muhammad A. Khan
- Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Quan D. Ngo
- Faculty of Medicine, University of New South Wales, Sydney, Australia
| | | | - Chameen Samarawickrama
- Faculty of Medicine, University of New South Wales, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
- Westmead Institute of Medical Research, Sydney, Australia
- Corresponding author. Westmead Institute of Medical Research, Sydney, Australia.
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Syed SF, Marshall A, Hossain P, Sadiq SA. Blink Reflex in Neurotrophic Keratopathy: An Electrophysiological Evaluation. Ophthalmic Plast Reconstr Surg 2022; 38:433-437. [PMID: 35170564 DOI: 10.1097/iop.0000000000002141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Neurotrophic keratitis (NK) is a rare condition which may result in visual loss. This case review investigates if there may be an association between NK and the blink reflex in the absence of facial nerve palsy and lagophthalmos. METHODS This is a retrospective case review of 5 patients with trigeminal nerve damage referred to the oculoplastic department with suspected anesthetic corneae. Information on etiology, symptoms, duration, associated medical conditions, medications, examination findings including Mackie stage of keratopathy, management of keratopathy, and blink electrophysiology results was obtained. RESULTS All 5 patients demonstrated absence of corneal sensation. All patients had preserved facial nerve function with no evidence of lagophthalmos. Keratopathy ranged from Mackie stage 0-2. Management ranged from ocular lubricants to Botulinum-toxin-induced ptosis. Blink studies demonstrated reduction in amplitude as well as increased latency in 2 patients, conferring reduced blink strength. Two patients demonstrated an absent blink reflex on the affected side. One patient had blink latency within the normative range; this patient recovered corneal sensation and was discharged. CONCLUSIONS Our finding of reduced amplitude in blink studies offers both a factor in pathogenesis of NK and a potential therapeutic target. Additionally, blink studies may provide prognostic information for recovery and therefore guide management. We suggest performing blink electrophysiology in patients with trigeminal nerve damage to assess nerve function.
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Affiliation(s)
| | - Andrew Marshall
- Faculty of Science, Liverpool John Moores Liverpool, University, United Kingdom
| | - Parwez Hossain
- Eye Unit, Clinical & Experimental Sciences, University of Southampton, Southampton General Hospital, Southampton, United Kingdom
| | - Saghir Ahmed Sadiq
- Faculty of Science, Liverpool John Moores Liverpool, University, United Kingdom
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Daeschler SC, Mirmoeini K, Gordon T, Chan K, Zhang J, Ali A, Feinberg K, Borschel GH. Sustained Release of Tacrolimus From a Topical Drug Delivery System Promotes Corneal Reinnervation. Transl Vis Sci Technol 2022; 11:20. [PMID: 35984668 PMCID: PMC9419461 DOI: 10.1167/tvst.11.8.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose Corneal nerve fibers provide sensation and maintain the epithelial renewal process. Insufficient corneal innervation can cause neurotrophic keratopathy. Here, topically delivered tacrolimus is evaluated for its therapeutic potential to promote corneal reinnervation in rats. Methods A compartmentalized neuronal cell culture was used to determine the effect of locally delivered tacrolimus on sensory axon regeneration in vitro. The regenerating axons but not the cell bodies were exposed to tacrolimus (50 ng/mL), nerve growth factor (50 ng/mL), or a vehicle control. Axon area and length were measured after 48 hours. Then, a biodegradable nanofiber drug delivery system was fabricated via electrospinning of a tacrolimus-loaded polycarbonate–urethane polymer. Biocompatibility, degradation, drug biodistribution, and therapeutic effectiveness were tested in a rat model of neurotrophic keratopathy induced by stereotactic trigeminal nerve ablation. Results Sensory neurons whose axons were exposed to tacrolimus regenerated significantly more and longer axons compared to vehicle-treated cultures. Trigeminal nerve ablation in rats reliably induced corneal denervation. Four weeks after denervation, rats that had received tacrolimus topically showed similar limbal innervation but a significantly higher nerve fiber density in the center of the cornea compared to the non-treated control. Topically applied tacrolimus was detectable in the ipsilateral vitreal body, the plasma, and the ipsilateral trigeminal ganglion but not in their contralateral counterparts and vital organs after 4 weeks of topical release. Conclusions Locally delivered tacrolimus promotes axonal regeneration in vitro and corneal reinnervation in vivo with minimal systemic drug exposure. Translational Relevance Topically applied tacrolimus may provide a readily translatable approach to promote corneal reinnervation.
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Affiliation(s)
- Simeon C Daeschler
- Neurosciences & Mental Health Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Kaveh Mirmoeini
- Neurosciences & Mental Health Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Tessa Gordon
- Neurosciences & Mental Health Program, SickKids Research Institute, Toronto, Ontario, Canada.,Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Katelyn Chan
- Neurosciences & Mental Health Program, SickKids Research Institute, Toronto, Ontario, Canada.,Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer Zhang
- Neurosciences & Mental Health Program, SickKids Research Institute, Toronto, Ontario, Canada.,Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Asim Ali
- Department of Ophthalmology and Vision Science, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Konstantin Feinberg
- Neurosciences & Mental Health Program, SickKids Research Institute, Toronto, Ontario, Canada.,Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Gregory H Borschel
- Neurosciences & Mental Health Program, SickKids Research Institute, Toronto, Ontario, Canada.,Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada.,Department of Ophthalmology and Vision Science, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.,Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, IN, USA
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Rathi A, Bothra N, Priyadarshini SR, Achanta DSR, Fernandes M, Murthy SI, Kapoor AG, Dave TV, Rath S, Yellinedi R, Nuvvula R, Dendukuri G, Naik MN, Ramappa M. Neurotization of the human cornea - A comprehensive review and an interim report. Indian J Ophthalmol 2022; 70:1905-1917. [PMID: 35647955 PMCID: PMC9359267 DOI: 10.4103/ijo.ijo_2030_21] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
We present a comprehensive review of existing literature on surgical corneal neurotization (SCN) as a treatment modality for neurotrophic keratopathy (NK) with an interim report of seven cases where SCN was performed using the indirect approach and followed up till 18 months postoperatively to look for improvement in ocular surface, corneal sensations, and nerve regeneration by using in vivo confocal microscopy (IVCM). A literature search was performed for publications with keywords “corneal nerves,” “neurotization,” “esthesiometry,” “corneal anesthesia,” and “neurotrophic keratopathy.” All literature available till December 31, 2020 was reviewed and included to describe NK and its management options, particularly SCN. NK is associated with absent or reduced corneal sensations and is managed using a step-ladder algorithm ranging from medical management for symptomatic relief to surgical corneal neurotization. Both direct and indirect approaches of SCN have a favorable outcome with reduced surgical morbidity in the indirect approach using sural nerve graft. Post neurotization, corneal sensation recovery may take up to 3–6 months, while nerve regeneration on confocal microscopy can take as long as 6 months–1 year.
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Affiliation(s)
- Anubha Rathi
- The Cornea Institute, KAR Campus; Centre for Rare Eye Diseases and Ocular Genetics, L V Prasad Eye Institute, Hyderabad, Telangana, India
| | - Nandini Bothra
- Ophthalmic Plastic Surgery Service, L V Prasad Eye Institute; Centre for Rare Eye Diseases and Ocular Genetics, L V Prasad Eye Institute, Hyderabad, Telangana, India
| | | | - Divya S R Achanta
- The Cornea Institute, KAR Campus; Centre for Rare Eye Diseases and Ocular Genetics, L V Prasad Eye Institute, Hyderabad, Telangana, India
| | - Merle Fernandes
- The Cornea Institute, KAR Campus, Hyderabad, Telangana; The Cornea Institute, GMRV Campus, L V Prasad Eye Institute, Vijayawada, Andhra Pradesh, India
| | | | - Anasua G Kapoor
- Ophthalmic Plastic Surgery and Aesthetics, Ocular Oncology, KVC Campus, L V Prasad Eye Institute, Vijayawada, Andhra Pradesh, India
| | - Tarjani V Dave
- Ophthalmic Plastic Surgery Service, L V Prasad Eye Institute, Hyderabad, Telangana, India
| | - Suryasnata Rath
- Ophthalmic Plastic Surgery and Aesthetics, Ocular Oncology, L V Prasad Eye Institute, Bhubaneswar, Odisha, India
| | - Rajesh Yellinedi
- Basavatarakam, Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
| | - Rambabu Nuvvula
- Basavatarakam, Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
| | - Gautam Dendukuri
- Ophthalmic Plastic Surgery, Aesthetics and Faciomaxillary Surgery Service, L V Prasad Eye Institute, Hyderabad, Telangana, India
| | - Milind N Naik
- Ophthalmic Plastic Surgery Service, L V Prasad Eye Institute, Hyderabad, Telangana, India
| | - Muralidhar Ramappa
- The Cornea Institute, KAR Campus; Centre for Rare Eye Diseases and Ocular Genetics, L V Prasad Eye Institute; Jasti V Ramanamma Children's Eye Care Center, L V Prasad Eye Institute, Hyderabad, Telangana, India
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Corneal Neurotization: A Meta-analysis of Outcomes and Patient Selection Factors. Ann Plast Surg 2022; 88:687-694. [PMID: 35502965 DOI: 10.1097/sap.0000000000003117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Corneal neurotization describes reinnervation of the anesthetic or severely hypoesthetic cornea with a healthy local nerve or graft. Preliminary evidence has shown corneal neurotization to improve corneal sensation, visual acuity, and ocular surface health. Factors that improve patient selection and lead to better neurotization outcomes have yet to be elucidated, limiting ability to optimize perioperative decision-making guidelines. METHODS A systematic review with meta-analysis was performed of the MEDLINE and Embase databases using variations of "corneal," "nerve transfer," "neurotization," and "neurotization." The primary outcomes of interest were corrected visual acuity, NK Mackie stage, and central corneal sensation. Regression analyses were performed to identify the effects of surgical technique, duration of denervation, patient age, and etiology of corneal pathology on neurotization outcomes. RESULTS Seventeen studies were included. Corneal neurotization resulted in significant improvement in NK Mackie stage (0.84 vs 2.46, P < 0.001), visual acuity (logarithm of minimum angle of resolution scale: 0.98 vs 1.36, P < 0.001), and corneal sensation (44.5 vs 0.7, P < 0.001). Nerve grafting was associated with greater corneal sensation improvement than nerve transfer (47.7 ± 16.0 vs 35.4 ± 18.76, P = 0.03). Denervation duration was predictive of preneurotization visual acuity (logarithm of minimum angle of resolution scale; R2 = 0.25, P = 0.001), and older age (ß = 0.30, P = 0.03) and acquired etiology (ß = 0.30, P = 0.03) were predictive of improved visual acuity. CONCLUSIONS Corneal neurotization provides significant clinical improvement in visual acuity, NK Mackie staging, and corneal sensation in patients who experience NK. Both nerve grafting and nerve transfer are likely to yield similar levels of benefit and ideally should be performed early to limit denervation time.
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Woo JH, Daeschler SC, Mireskandari K, Borschel GH, Ali A. Minimally Invasive Corneal Neurotization Provides Sensory Function, Protects Against Recurrent Ulceration, and Improves Visual Acuity. Am J Ophthalmol 2022; 241:179-189. [PMID: 35513030 DOI: 10.1016/j.ajo.2022.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 04/23/2022] [Accepted: 04/24/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE To measure sensory recovery after minimally invasive corneal neurotization, and to identify and quantify the extent to which patient and technical factors influence sensory recovery, ulceration rate, and visual outcomes. DESIGN Retrospective case series. METHODS This study included 23 patients with neurotrophic keratopathy who underwent indirect corneal neurotization. The primary outcome measure was corneal sensitivity with Cochet-Bonnet aesthesiometry (CBA), and the secondary outcome measure was epithelial breakdown. RESULTS Over a 7-year period, 28 eyes of 23 patients (mean age, 15.6 ± 13.6 years) were included in the study. The CBA measurements improved from 3.5 ± 9.1 mm at baseline to 44.1 ± 18.2 mm at 24 months after surgery (P < .001). Maximum CBA was reached after 11.1 ± 6.2 months (median, 9 months). Compared to eyes neurotized with a contralateral donor nerve, eyes with an ipsilateral donor nerve achieved a higher mean CBA (36.0 ± 10.9 vs 10.4 ± 14.0 mm, P = .001) at 3 months. Both the number of fascicles (Spearman correlation coefficient, rs -0.474, P = .11) and insertions (rs -0.458, P = .014) negatively correlated with the final CBA. Nine eyes (32.1%) experienced at least 1 episode of epithelial breakdown after surgery. Visual acuity improved in the neurotized corneas from logMAR 0.57 ± 0.79 at baseline to 0.39 ± 0.66 at 12 months (P = .043). CONCLUSIONS Corneal sensation improves over time after corneal neurotization. There is resultant improvement in visual acuity and protection against epithelial breakdown. It is important to maximize sensory recovery to protect against recurrent ulceration.
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Lau N, Osborne SF, Vasquez-Perez A, Wilde CL, Manisali M, Jayaram R. Corneal Neurotization Using the Great Auricular Nerve for Bilateral Congenital Trigeminal Anesthesia. Cornea 2022; 41:654-657. [PMID: 34839333 DOI: 10.1097/ico.0000000000002951] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 10/12/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of this study was to describe an indirect corneal neurotization (CN) technique for congenital bilateral trigeminal anesthesia using the greater auricular nerve (GAN) as a donor. METHOD CN was performed to preserve the integrity of the only seeing eye in a 4-year-old boy with pontine tegmental cap dysplasia and bilateral trigeminal anesthesia. He had recurrent corneal ulceration and scarring despite full medical treatment. The GAN was used as a donor, and the sural nerve was harvested and used as a bridge which was tunneled to the sub-Tenon space in the inferior fornix. The fascicles were distributed into the 4 quadrants and sutured to the sclera near the limbus. RESULT This technique resulted in providing corneal sensation and improving stability of the epithelium. Corneal opacity gradually decreased allowing significant visual improvement evidenced in the early postoperative months. CONCLUSIONS Using the GAN technique for CN bypasses trigeminal innervation and has the potential to improve corneal sensation. The GAN is a large caliber nerve and provides a large amount of axons and robust neurotization. This technique would be desirable for cases with bilateral congenital trigeminal anesthesia, such as pontine tegmental cap dysplasia.
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Affiliation(s)
- Nicola Lau
- Ophthalmology Department at St George's Hospital, Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom ; and
| | - Sarah F Osborne
- Ophthalmology Department at St George's Hospital, Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom ; and
| | - Alfonso Vasquez-Perez
- Ophthalmology Department at St George's Hospital, Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom ; and
| | - Caroline L Wilde
- Ophthalmology Department at St George's Hospital, Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom ; and
| | - Mehmet Manisali
- Maxillofacial Surgery Department, St George's Hospital NHS Foundation Trust, London, United Kingdom
| | - Rahul Jayaram
- Maxillofacial Surgery Department, St George's Hospital NHS Foundation Trust, London, United Kingdom
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Koay SY, Larkin DFP. New Pharmacological Approaches for the Treatment of Neurotrophic Keratitis. Front Pharmacol 2022; 13:796854. [PMID: 35392574 PMCID: PMC8981034 DOI: 10.3389/fphar.2022.796854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 03/07/2022] [Indexed: 11/24/2022] Open
Abstract
Neurotrophic keratitis (NK) is a rare degenerative condition that is caused by damage to the trigeminal nerve, with partial or complete loss of corneal sensory innervation. The loss of innervation leads to impaired healing of corneal epithelium, which subsequently results in punctate epithelial erosions, persistent epithelial defects, corneal ulcers and corneal perforation. Management of NK is often supportive and aims to promote epithelial healing and prevent progression of disease. Multiple novel pharmacological approaches have been proposed to address the underlying pathophysiology of NK, which are discussed in this paper.
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Affiliation(s)
- Su Yin Koay
- Cornea and External Diseases Service, Moorfields Eye Hospital, London, United Kingdom
| | - Daniel F P Larkin
- Cornea and External Diseases Service, Moorfields Eye Hospital, London, United Kingdom
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Roumeau S, Dutheil F, Sapin V, Baker JS, Watson SL, Pereira B, Chiambaretta F, Navel V. Efficacy of treatments for neurotrophic keratopathy: a systematic review and meta-analysis. Graefes Arch Clin Exp Ophthalmol 2022; 260:2623-2637. [DOI: 10.1007/s00417-022-05602-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 01/13/2022] [Accepted: 02/21/2022] [Indexed: 11/24/2022] Open
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Kumar A, Yun H, Funderburgh ML, Du Y. Regenerative therapy for the Cornea. Prog Retin Eye Res 2022; 87:101011. [PMID: 34530154 PMCID: PMC8918435 DOI: 10.1016/j.preteyeres.2021.101011] [Citation(s) in RCA: 51] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 09/08/2021] [Accepted: 09/09/2021] [Indexed: 12/13/2022]
Abstract
The cornea is the outmost layer of the eye, unique in its transparency and strength. The cornea not only transmits the light essential for vision, also refracts light, giving focus to images. Each of the three layers of the cornea has properties essential for the function of vision. Although the epithelium can often recover from injury quickly by cell division, loss of limbal stem cells can cause severe corneal surface abnormalities leading to corneal blindness. Disruption of the stromal extracellular matrix and loss of cells determining this structure, the keratocytes, leads to corneal opacity. Corneal endothelium is the inner part of the cornea without self-renewal capacity. It is very important to maintain corneal dehydration and transparency. Permanent damage to the corneal stroma or endothelium can be effectively treated by corneal transplantation; however, there are drawbacks to this procedure, including a shortage of donors, the need for continuing treatment to prevent rejection, and limits to the survival of the graft, averaging 10-20 years. There exists a need for new strategies to promote regeneration of the stromal structure and restore vision. This review highlights critical contributions in regenerative medicine with the aim of corneal reconstruction after injury or disease. These approaches include corneal stromal stem cells, corneal limbal stem cells, embryonic stem cells, and other adult stem cells, as well as induced pluripotent stem cells. Stem cell-derived trophic factors in the forms of secretomes or exosomes for corneal regeneration are also discussed. Corneal sensory nerve regeneration promoting corneal transparency is discussed. This article provides description of the up-to-date options for corneal regeneration and presents exciting possible avenues for future studies toward clinical applications for corneal regeneration.
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Affiliation(s)
- Ajay Kumar
- Department of Ophthalmology, University of Pittsburgh, Pittsburgh, PA 15213
| | - Hongmin Yun
- Department of Ophthalmology, University of Pittsburgh, Pittsburgh, PA 15213
| | | | - Yiqin Du
- Department of Ophthalmology, University of Pittsburgh, Pittsburgh, PA, 15213, USA; Department of Developmental Biology, University of Pittsburgh, Pittsburgh, PA, 15213, USA; McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, 15213, USA.
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Rollon-Mayordomo A, Mataix-Albert B, Espejo-Arjona F, Herce-Lopez J, Lledo-Villar L, Caparros-Escudero C, Infante-Cossio P. Neurotrophic Keratitis in a Pediatric Patient With Goldenhar Syndrome and Trigeminal Aplasia Successfully Treated by Corneal Neurotization. Ophthalmic Plast Reconstr Surg 2022; 38:e49-e51. [PMID: 34798657 DOI: 10.1097/iop.0000000000002086] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Herein, the authors report an unusual case of a 6-year-old boy with right-sided Goldenhar syndrome and trigeminal nerve aplasia who developed neurotrophic keratopathy (NK). Despite the use of therapeutic contact lenses and multiple temporary tarsorrhaphy, NK worsened showing a central corneal scar, neovascularization, and significant stromal thinning, with risk of corneal perforation. Cochet-Bonnet esthesiometry revealed complete corneal anesthesia. To minimize additional corneal complications, the patient underwent indirect corneal neurotization by a sural nerve autograft anastomosed to the contralateral supratrochlear nerve. At 24-month follow up, no epithelial defects, complications, or recurrence were observed. Significant improvements in corneal sensitivity with esthesiometry score of 20 mm and reflex blinking were achieved. This case highlights corneal anesthesia should be suspected among Goldenhar syndrome ophthalmologic abnormalities and monitored before corneal changes become irreversible. Since corneal neurotization can successfully improve corneal sensation, it could be considered as an early therapeutic option to avoid refractory NK.
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Affiliation(s)
- Angel Rollon-Mayordomo
- Department of Oral and Maxillofacial Surgery, Virgen Macarena University Hospital, Seville, Spain
| | | | | | - Javier Herce-Lopez
- Department of Oral and Maxillofacial Surgery, Virgen Macarena University Hospital, Seville, Spain
| | - Leticia Lledo-Villar
- Department of Ophthalmology, Virgen Macarena University Hospital, Seville, Spain
| | | | - Pedro Infante-Cossio
- Department of Surgery, School of Medicine, University of Seville, Seville, Spain
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Horen SR, Hamidian Jahromi A, Konofaos P. Direct Neurotization: Past, Present, and Future Considerations. Ann Plast Surg 2022; 88:308-312. [PMID: 34611091 DOI: 10.1097/sap.0000000000003006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Direct neurotization is a method that involves direct implantation of nerve fascicles into a target tissue, that is, muscle fibers, skin, cornea, and so on, with the goal of restoring aesthetic, sensation and or functional capacity. This technique has been implemented since the early 1900s, with numerous experimental and clinical reports of success. Applications have included both sensory and motor neurotization of muscle, as well as protective sensory provision for other organs. These techniques have been used to restore corneal sensation, repair brachial plexus injuries, reestablish tongue movement and function through direct tongue neurotization, and reinnervate multiple facial muscles in patients with facial paralysis. Most recently, these methods have even been used in conjunction with acellular cadaveric nerve grafts to directly neurotize skin. Indications for direct neurotization remain limited, including those in which neural coaptation is not feasible (ie, surgical or traumatic damage to neuromuscular junction, severe avulsion injuries of the distal nerve); however, the success and wide-range application of direct neurotization shows its potential to be implemented as an adjunct treatment in contrast to views that it should solely be used as a salvage therapy. The purpose of the following review is to detail the historic and current applications of direct neurotization and describe the future areas of investigation and development of this technique.
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Affiliation(s)
- Sydney R Horen
- From the Division of Plastic & Reconstructive Surgery, Rush University Medical Center (RUMC), Chicago, IL
| | - Alireza Hamidian Jahromi
- From the Division of Plastic & Reconstructive Surgery, Rush University Medical Center (RUMC), Chicago, IL
| | - Petros Konofaos
- Department of Plastic Surgery, University of Tennessee Health Science Center (UTHSC), Memphis, TN
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Wu Y, Zhang J, Ding W, Chen G, Shao C, Li J, Wang W, Wang W. Clinical Outcomes of Minimally Invasive Corneal Neurotization after Cerebellopontine Angle (CPA) Neurosurgical Procedures. Curr Eye Res 2022; 47:670-676. [PMID: 35179100 DOI: 10.1080/02713683.2022.2025843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE To report 12 patients with neurotrophic keratopathy (NK) due to the trigeminal nerve injury after intracranial tumor surgeries underwent minimally invasive corneal neurotization (MICN) and evaluate the outcomes of corneal reinnervation. METHODS 12 patients (12 eyes) with NK caused by the trigeminal nerve injury after intracranial surgeries received MICN. All the preoperative central corneal sensation (CCS) was under 5mm and MICN was performed over 6 months after the intracranial surgery. Follow-up was conducted 1 week and 1 month after the surgery, and then every 3 months. Twelve healthy age-matched participants were enrolled as controls. The indicators included corneal sensation, best-corrected visual acuity (BCVA), corneal nerve fiber length and branch density, diameter of nerve trunk, corneal ulcer lesion ratio and sensation of the contralateral forehead. RESULTS Mean follow-up was 24.7 ± 7.1 months. Mean CCS rose from 0.4 ± 1.4 to 31.7 ± 21.8 mm. Corneal nerve fiber length improved from 9.56 ± 5.00 to 14.96 ± 4.65 mm/mm2 and corneal nerve branch density and diameter of nerve trunk both increased (p < 0.01 and p < 0.05 respectively). Corneal lesion ratio decreased from 0.17 ± 0.12 to 0.10 ± 0.10 (p < 0.01). CONCLUSIONS MICN promotes corneal reinnervation for patients with NK induced by the trigeminal nerve injury after intracranial surgeries. The process of corneal reinnervation after MICN often lasts over 12 months and it takes about 18 months to return to a higher level. Corneal sensation and corneal nerve fiber length are related to clinical outcomes such as corneal ulcer lesion and BCVA. The effect on the sensation of the contralateral side forehead is temporary and most patients can restore normal forehead sensation of the contralateral side.
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Affiliation(s)
- Yue Wu
- Department of Ophthalmology, Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai 200025, P.R.China.,Department of Ophthalmology, Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai, China
| | - Jiaying Zhang
- Department of Ophthalmology, Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai 200025, P.R.China.,Department of Ophthalmology, Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai, China
| | - Wei Ding
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai 200025, P.R.China
| | - Gang Chen
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai 200025, P.R.China
| | - Chunyi Shao
- Department of Ophthalmology, Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai 200025, P.R.China.,Department of Ophthalmology, Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai, China
| | - Jin Li
- Department of Ophthalmology, Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai 200025, P.R.China.,Department of Ophthalmology, Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai, China
| | - Wenjin Wang
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai 200025, P.R.China
| | - Wei Wang
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai 200025, P.R.China
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Facial Nerve Revascularization Strategies in Facial Restoration. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4038. [PMID: 35047325 PMCID: PMC8758059 DOI: 10.1097/gox.0000000000004038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 11/09/2021] [Indexed: 11/26/2022]
Abstract
Facial transplants represent the current exemplar in the reconstruction of severely damaged faces, whereas conventional free flap reconstruction has its limitations in restoring both function and surface cover.
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40
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How Should Corneal Nerves be Incorporated Into the Diagnosis and Management of Dry Eye? CURRENT OPHTHALMOLOGY REPORTS 2022; 9:65-76. [PMID: 35036080 DOI: 10.1007/s40135-021-00268-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Purpose a)Confocal microscopy and aethesiometry have allowed clinicians to assess the structural and functional integrity of corneal nerves in health and disease. This review summarizes literature on nerves in dry eye disease (DED) and discusses how this data can be applied to DED diagnosis and treatment. Recent findings b)Subjects with DED have a heterogenous symptom and sign profile along with variability in nerve structure and function. Most studies have reported lower nerve density and sensitivity in aqueous tear deficiency, while findings are more inconsistent for other DED subtypes. Examining nerve status, along with profiling symptoms and signs of disease, can help categorize subjects into disease phenotypes (structural and functional patterns) that exist under the umbrella of DED. This, in turn, can guide therapeutic decision-making. Summary c)Due to the heterogeneity in symptoms and signs of DED, corneal nerve evaluations can be valuable for categorizing individuals into disease sub-types and for guiding clinical decision making.
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Smith LM, Ismail OM, Mojica G. Ocular Manifestations of Herpes Simplex Virus in the Pediatric Population. Int Ophthalmol Clin 2022; 62:73-81. [PMID: 34965227 DOI: 10.1097/iio.0000000000000394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
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Brzheskiy VV, Popov VY, Efimova EL, Golubev SY. [Modern capabilities in diagnosis and treatment of neurotrophic keratopathy]. Vestn Oftalmol 2022; 138:123-132. [PMID: 36573956 DOI: 10.17116/oftalma2022138061123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
In recent years, the problem of diagnosing and treating neurotrophic keratopathy (NK) has become relevant in view of its prevalence reaching 1.6-11.0 per 10000 people. While previously it was associated only with neuroparalytic keratitis, at present the violation of sensitive and trophic innervation of the cornea with the development of characteristic keratopathy is observed in many diseases and injuries of the organ of vision. Diagnosis of NK is based on anamnestic information and assessment of clinical and functional parameters: determination of the stability of the tear film, tear production and assessment of staining of the ocular surface with vital dyes. The main role in the diagnosis of NK belongs to corneal sensitivity determined with the Cochet-Bonnet esthesiometer. Treatment of NK is designed to restore or increase corneal sensitivity and involves tear replacement therapy, instillations of preparations derived from patient's own blood, anti-inflammatory, metabolic and antibacterial therapy. However, instillations of human erve growth factor (NGF) - the drug Cenegermin (registered in Europe in 2017 at a dose of 20 μg/ml under the name Oxervate), a recombinant form of human rhNGF from Escherichia coli bacteria - exhibit the highest pathogenetic orientation. Its «target» is the affected nerve fibers (specific receptors for their growth factor), which makes it possible to eliminate the violation of reparative processes in neural and epithelial cells. A high and long-term clinical efficacy of a course of six (with an interval of 2 hours) instillations of the drug for 8 weeks in the treatment of children and adults with NK has been established. Among the pathogenetically justified methods of surgical treatment, there is the so-called surgical neurotization of the cornea involving the contralateral supraorbital, supratrochlear, great auricular and other nerves, which has a long-term clinical effect.
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Affiliation(s)
- V V Brzheskiy
- Saint Petersburg State Pediatric Medical University, Saint Petersburg, Russia
| | - V Yu Popov
- Saint Petersburg State Pediatric Medical University, Saint Petersburg, Russia
| | - E L Efimova
- Saint Petersburg State Pediatric Medical University, Saint Petersburg, Russia
| | - S Yu Golubev
- Institute of Biomedical Problems, Moscow, Russia
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Qureshi S, Ferguson TJ, Lim M, You JY, Goshe JM, Hood CT. Acute Calcific Band Keratopathy as an Adverse Effect of Recombinant Human Nerve Growth Factor (Cenegermin): A Multicenter Case Series. Cornea 2022; 41:52-59. [PMID: 34582138 DOI: 10.1097/ico.0000000000002767] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 03/29/2021] [Indexed: 01/10/2023]
Abstract
PURPOSE Cenegermin, (OXERVATE) a recently Food and Drug Administration-approved topical formulation of recombinant human nerve growth factor, has been used for the treatment of neurotrophic keratopathy (NK). Corneal deposits have been previously reported as a potential adverse effect; however, the clinical characteristics, visual significance, and treatment options have not been fully described. The purpose of this article is to better characterize corneal deposits occurring during treatment with cenegermin for neurotrophic keratopathy. METHODS This was a retrospective, multicenter consecutive case series. RESULTS We identified 5 patients from 3 institutions who developed a white opacity in varying layers of the cornea, consistent with calcium deposition, during treatment with cenegermin. In all cases, the opacity occurred rapidly over the course of a few weeks after initiation of treatment. Histopathologic examination of the cornea from one corneal patient demonstrated extensive calcification of the stroma extending to 90% depth. Before treatment, all patients had stage 2 or 3 NK (Mackie classification). The deposits were visually significant in all patients and did not resolve after cessation of cenegermin. There were no differences in age, sex, etiology of the NK, corneal transplant status, or concurrent medications between the patients who developed a deposit and 15 other patients with stage 2 or 3 NK who did not. One patient was successfully treated with superficial keratectomy with ethylenediaminetetraacetic acid chelation, one patient underwent penetrating keratoplasty, and one patient received a Boston keratoprosthesis. CONCLUSIONS We report the rapid onset of a corneal opacity after initiation of treatment with cenegermin in patients with stage 2 or 3 NK, consistent with acute calcific band keratopathy. This visually significant adverse finding has not previously been described. We could not identify any risk factors for development. We recommend close monitoring of patients receiving cenegermin therapy because the opacity may be irreversible and may require keratoplasty for visual rehabilitation.
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Affiliation(s)
- Sana Qureshi
- Department of Ophthalmology and Visual Sciences, W. K. Kellogg Eye Center, University of Michigan, Ann Arbor, MI
| | | | - Mira Lim
- Department of Ophthalmology, California Pacific Medical Center, San Francisco, CA; and
| | - Jae Young You
- Department of Ophthalmology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Christopher T Hood
- Department of Ophthalmology and Visual Sciences, W. K. Kellogg Eye Center, University of Michigan, Ann Arbor, MI
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Gushchina MB, Butsan SB, Salikhov KS, Sergeeva VY. [Treatment of neurotrophic keratopathy in combined lesions of the trigeminal and facial nerves]. Vestn Oftalmol 2022; 138:102-109. [PMID: 35801888 DOI: 10.17116/oftalma2022138031102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Ocular symptomatology in lesions of the facial nerve is associated with disturbed innervation of the circular muscle of the eye that leads to disruption of the protective function of the eyelids and the development of exposure symptoms, and is accompanied by a breach in corneal tear film integrity. The main clinical manifestation of the trigeminal nerve damage is the loss of sensory innervation of the cornea and disruption of the supply of neurotransmitters to its cells, manifesting as corneal hypo- or anesthesia. This triggers a cascade of pathological processes that lead to the development of neurotrophic keratopathy. In combined pathology of the facial and trigeminal nerves, a number of interrelated and mutually aggravating problems arise that require correction of lagophthalmos and functional restoration of the trigeminal nerve, since there is an interaction between the corneal epithelium and trigeminal neurons through trophic neuromodulators, which normally contribute to the proliferation of epithelial cells, their differentiation, migration and adhesion, and are essential for vital functions, metabolism and healing of surface lesions of the eye. Classical methods of treating neurotrophic keratopathy aim to protect the ocular surface, and are palliative or auxiliary, do not provide radical relief of the symptoms of neurotrophic keratopathy. Modern surgical technique of neurotization of the cornea allows restoring the structural growth of the nerve, which provides nerve trophism and corneal sensitivity, and is the only pathogenetically substantiated method of effective treatment of neurotrophic keratopathy. At the same time, direct neurotization has undeniable advantages over methods involving intercalary donor nerves, since neuropeptides from nerve fibers are immediately released into the recipient tissue and start reparative processes. Taking into account the accumulated positive experience of neurotization surgeries, scientific and clinical research should be continued in order to improve the most effective methods of corneal neurotization and promote their wider implementation into clinical practice.
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Affiliation(s)
- M B Gushchina
- Central Research Institute of Dental and Maxillofacial Surgery, Moscow, Russia
- Kaluga branch of S.N. Fedorov National Medical Research Center «MNTK «Eye Microsurgery», Kaluga, Russia
| | - S B Butsan
- Central Research Institute of Dental and Maxillofacial Surgery, Moscow, Russia
| | - K S Salikhov
- Central Research Institute of Dental and Maxillofacial Surgery, Moscow, Russia
| | - V Y Sergeeva
- Central Research Institute of Dental and Maxillofacial Surgery, Moscow, Russia
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Abstract
Corneal neurotization is a fast-evolving surgical procedure for sensory reinnervation in neurotrophic keratopathy. After neurotization, prior reports document return of corneal sensation on average 8 months after surgery with 38 mm of sensation gain measured via cochet bonnet esthesiometer testing. Here, the authors describe a dual nerve grafting approach via simultaneous parallel sural nerve grafts from both the supratrochelar and supraorbital nerves to the affected contralateral cornea with return of sensation by postoperative week 11.
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Affiliation(s)
- Emily Sarah Charlson
- Oculofacial, Orbital and Aesthetic Plastic Surgery, Department of Ophthalmology, Pacific Eye Associates, California Pacific Medical Center, San Francisco, California
| | - John Paul Pepper
- Division of Ophthalmic Plastic and Reconstructive Surgery, Department of Ophthalmology, Byers Eye Institute, Stanford University, Palo Alto
| | - Andrea Lora Kossler
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology—Head and Neck Surgery, Stanford University, Stanford, California, U.S.A
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Chao J, Rao R, Gupta C. Gómez-López-Hernández syndrome: a case report on pediatric neurotrophic corneal ulcers and review of the literature. J AAPOS 2021; 25:373-375. [PMID: 34678507 DOI: 10.1016/j.jaapos.2021.08.299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 07/01/2021] [Accepted: 08/01/2021] [Indexed: 11/28/2022]
Abstract
We present a case of Gómez-López-Hernández syndrome (GLHS), a rare neurocutaneous syndrome, in a 10-month-old girl with neurotrophic keratopathy secondary to trigeminal anesthesia.
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Affiliation(s)
- Jonathan Chao
- Beaumont Eye Institute, William Beaumont Hospital, Royal Oak, Michigan.
| | - Rajesh Rao
- Beaumont Eye Institute, William Beaumont Hospital, Royal Oak, Michigan; Children's Eye Care, Detroit, Michigan
| | - Chirag Gupta
- Beaumont Eye Institute, William Beaumont Hospital, Royal Oak, Michigan
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Clinical Outcomes and Patient Satisfaction After Corneal Neurotization. Cornea 2021; 40:1377-1386. [PMID: 34633356 DOI: 10.1097/ico.0000000000002759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 03/10/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE The aim of this study was to assess clinical outcomes of corneal neurotization (CN) and determine patient perception of postoperative results. METHODS This was a retrospective study involving 29 eyes in 28 patients who underwent CN. Chart review data included demographic and clinical history; ophthalmic examination including visual acuity, ocular surface quality, and corneal sensation; surgical technique; and postoperative course. Subjective self-reported patient outcomes of surgical success were also assessed. Only eyes with at least 6 months of follow-up were included in the statistical analysis. RESULTS A total of 24 eyes and 23 patients were included in statistical analyses. The median postoperative follow-up time was 12.2 months (interquartile range 10.9-18.5 mo). Twenty-three eyes (92%) achieved improvement in ocular surface quality. Eleven of 13 (85%) demonstrated healing of persistent epithelial defects at their last follow-up. Patients gained a median of 2.3 cm in Cochet-Bonnet esthesiometry measurements of sensation. No significant difference was found between preoperative and postoperative visual acuity. All 17 patients who provided self-assessment of their surgical outcome indicated they would undergo CN again if given the choice. Most of the patients reported that the postoperative pain was tolerable, with a median pain score of 3.0 on a 10-point scale (interquartile range 0.0-4.0). Sixteen patients (94%) reported full or partial return of skin sensation along the donor nerve distribution. CONCLUSIONS CN provides improvement in corneal health and sensibility, with high patient satisfaction and minimal postoperative pain and morbidity.
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Abstract
ABSTRACT This brief definitive review of herpes zoster (HZ) will cover the current state of knowledge and questions that remain to be answered regarding HZ in general and HZ ophthalmicus in particular. A question-and-answer format will be used to address various important topics related to this common and serious disease. Questions to be addressed relate to common misconceptions, contagiousness of infection, unknowns regarding pathogenesis, rising incidence, risk factors and complications, relationship with temporal arteritis, vaccination, and current and future antiviral treatment. In addition, the importance of the Zoster Eye Disease Study to determine the efficacy of suppressive valacyclovir treatment in preventing complications of HZ ophthalmicus and the need to support enrollment will be discussed.
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Affiliation(s)
| | - Bennie H Jeng
- Department of Ophthalmology and Visual Sciences, University of Maryland School of Medicine, Baltimore, MD
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Jowett N, Pineda R. Corneal and Facial Sensory Neurotization in Trigeminal Anesthesia. Facial Plast Surg Clin North Am 2021; 29:459-470. [PMID: 34217450 DOI: 10.1016/j.fsc.2021.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Trigeminal anesthesia may yield blindness and facial disfigurement, secondary to neurotrophic keratopathy and trigeminal trophic syndrome. This article summarizes contemporary medical and emerging surgical approaches for the therapeutic management of this rare and devastating disease state.
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Affiliation(s)
- Nate Jowett
- Department of Otolaryngology-Head & Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, 243 Charles Street, Boston, MA 02114, USA.
| | - Roberto Pineda
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, 243 Charles Street, Boston, MA 02114, USA
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