Corneal Neurotization: A Systematic Literature Review And Patient Selection Factors
Marco Swanson, MD1, Roy Swanson, MD2, Robert Clark, BS3, Anand Kumar, MD1, Edward Davidson, MD1.
1Case Plastic Surgery - University Hospitals, Cleveland, OH, USA, 2Case Ophthalmology - University Hospitals, Cleveland, OH, USA, 3Case Western Reserve University School of Medicine, Cleveland, OH, USA.
PURPOSE: Neurotrophic keratopathy (NK) is a well-described process caused by impairment of trigeminal corneal innervation leading to corneal epithelial damage, poor healing and ulceration. Etiologies can vary from congenital anomalies to acquired injury of the ophthalmic trigeminal nerve division. Corneal neurotization has continued to show promising results in restoring corneal sensation. Multiple techniques of corneal neurotization have now been described, whether direct or indirect with varying donor and recipient nerves. This study aims to characterize patient demographics, techniques, and outcomes in order to better elucidate the indications for corneal neurotization.
METHODS: Following PRISMA guidelines, the MEDLINE and EMBASE databases were searched to screen and extract all studies available on corneal neurotization. Only primary literature with patients and outcomes was included. All literature reviews, animal and cadaveric studies were excluded.
RESULTS: 79 studies were screened and 18 studies met our inclusion criteria, totaling 57 patients and 61 eyes. 49% were female, age at neurotization was 37.2 ± 30.3 years, denervation time was 70.1 ± 187.5 months. NK was congenitally caused in 28% and acquired in 72%. Acquired causes varied from tumor or iatrogenic (45%), herpetic (39%), trauma (11%), to other causes (5%). Neurotization was direct (38%), either ipsilaterally (52%) or contralaterally (48%), using the following donors: supraorbital nerve (SON) and supratrochlear nerve (STN) in 96% and great auricular nerve (GAN) in 4%. For indirect neurotization recipient nerves utilized were SON and/or STN (95%) and infraorbital nerve (ION) in 5%. Donor nerve grafts were sural nerve (92%), GAN (5%) and lateral antebrachial cutaneous nerve (3%). Average follow-up was 38.4 ± 47.9 months. NK Mackie staging improved in 76%, remained the same in 24% and did not worsen in any patient. Best-Corrected Visual Acuity improved in 66%, remained the same in 32% and only worsened in 1 patient due to poor compliance. Corneal sensation improved in all patients. No complications associated with the procedure were reported.
CONCLUSION: Duration of denervation is associated with severity of corneal scarring and is the strongest predictor of lack of improvement in visual acuity and NK staging. Further study is needed to elucidate the impact of technique, age, gender, and etiology on outcomes. Given the low complication rates, remarkable improvement in corneal sensation and benefit irrespective of etiology, corneal neurotization should be considered for all patients with NK early on in the disease course before irreversible corneal damage occurs.
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