A Novel Surgical Option In The Armamentarium Against A Challenging Foe: Minimally Invasive, Indirect, Corneal Neurotisation Using An Ipsilateral Sural Nerve Autograft For Neurotrophic Keratopathy

Neurotrophic keratopathy is a degenerative disease of corneal nerves leading to corneal hypoesthesia and anaesthesia. The resultant progressive visual deterioration is refractory to conventional treatment options. Corneal neurotisation represents a novel and effective surgical procedure that directly targets the underlying pathophysiology by stimulating corneal nerve growth. 

We present the outcomes, surgical video, and in-vivo confocal microscopy (IVCM) findings of a 11-year-old boy diagnosed with Mackie Stage 1 neurotrophic keratopathy following intracranial surgery. 

He had developed recurrent red eye and microbial keratitis and 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 IVCM showed a complete absence of a subepithelial corneal plexus. 

He underwent indirect, minimally invasive, corneal neurotisation using a sural nerve autograft with end-to-end coaptation to the ipsilateral supratrochlear nerve. Subjective improvement in corneal sensation was noticed at 2 months, while objective improvement was first observed at 6 months with steady progress to 20-35mm by 21 months. His symptoms resolved and Schirmer’s I test was 30mm at 12 months. At 15 months, corrected-distance visual acuity was 6/5 and IVCM showed evidence of nerves in the subepithelial space surrounded by keratocytes. He had no further corneal complications over 4 years of follow-up.

Corneal neurotisation represents an exciting development in the armamentarium for the treatment of neurotrophic keratopathy and can be considered for younger patients with early-stage disease.