Lee Brendon W H, Khan Muhammad A, Ngo Quan D, Tumuluri Krishna, Samarawickrama Chameen
Faculty of Medicine, University of New South Wales, Sydney, Australia.
Sydney Medical School, University of Sydney, Sydney, Australia.
Am J Ophthalmol Case Rep. 2022 May 20;27:101585. doi: 10.1016/j.ajoc.2022.101585. eCollection 2022 Sep.
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.
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.
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.
神经营养性角膜病变是一种退行性疾病，其特征是角膜神经受损，导致角膜感觉减退和麻木。由此导致的渐进性视力下降对现有的传统治疗方法无效。角膜神经化是一种新颖有效的外科手术，通过刺激新的角膜神经生长，直接针对神经损伤的潜在病理机制。本研究报告了澳大利亚首例使用同侧腓肠神经自体移植进行间接、微创角膜神经化的病例的手术结果以及术前和术后的体内共聚焦显微镜检查结果。
一名11岁男孩在桥小脑角蛛网膜囊肿手术减压后左眼出现角膜感觉减退。他被诊断为麦基1期神经营养性角膜病变。由于感觉减退，他在接触性运动中因异物导致反复发生微生物性角膜炎和角膜溃疡。就诊时，他自述有畏光和干眼症状，矫正远视力为6/18，Cochet-Bonnet触觉计显示角膜感觉减退（5 - 15毫米），泪液分泌试验I为15毫米，体内共聚焦显微镜检查显示角膜上皮下神经丛完全缺失。他接受了使用同侧滑车上神经和腓肠神经自体移植的间接、微创角膜神经化手术。患者在2个月时注意到角膜感觉有主观改善。用Cochet-Bonnet触觉计测量的客观改善在6个月时首次观察到，在21个月时稳步逐步改善至20 - 35毫米。重要的是，由于角膜感觉增加，患者未再出现任何角膜并发症。在12个月时，干眼症状消失，泪液分泌试验I改善至30毫米。在15个月时，矫正远视力提高到6/5，体内共聚焦显微镜检查显示有角膜再神经化的证据，神经穿过上皮下间隙，周围是健康且活跃的角膜细胞。
角膜神经化是治疗神经营养性角膜病变的武器库中的一项令人兴奋的进展，对于早期疾病的年轻患者可以考虑采用。
