2 The condition, current treatments and procedure

2 The condition, current treatments and procedure

The condition

2.1 The cornea is innervated by the ophthalmic branch of the trigeminal nerve. This innervation maintains the health of the cornea. It does this by providing trophic factors to the corneal cells, activating protective blink reflexes, and stimulating tear production.

2.2 Damage to the trigeminal nerve can result in a decrease or loss of corneal sensation. The trigeminal nerve can be damaged by various diseases, chemical burns, physical injuries, or by surgery. Loss of innervation to the cornea can result in neurotrophic keratitis (also known as neurotrophic keratopathy). People with neurotrophic keratitis typically have corneal epithelium defects, poor corneal healing, and can develop sight loss. They are also prone to corneal infections.

Current treatments

2.3 Current treatment for neurotrophic keratitis aims to stop progression to later stages of the disease and promote regeneration of the epithelium. This can include topical lubricants and artificial tears. Antibiotic tear drops may be needed to prevent infections. Options for severe disease include lateral tarsorrhaphy (using sutures to partially or fully close the eyelids), topical nerve growth factor, topical collagenase inhibitors and amniotic membrane grafting.

The procedure

2.4 Nerve graft to restore corneal sensation is done under general anaesthesia. The nerve graft can be either an autograft, when the graft is taken from the person having the procedure, or an allograft, when the graft is a processed nerve from a deceased donor. Several types of grafts have been described in the literature, including the sural nerve, lateral antebrachial cutaneous nerve, great auricular nerve and a nerve from a deceased donor.

2.5 The nerve graft is harvested or prepared. At the same time, an incision is made on the contralateral side. This is to access an orbital nerve (the supratrochlear, supraorbital or infraorbital nerve) of the eye that still has normal sensation (the 'donor' nerve). In some people, the ipsilateral supratrochlear, supraorbital or infraorbital nerve, or the ipsilateral great auricular nerve is used as a donor nerve. The nerve graft is attached to the donor nerve and then subcutaneously tunnelled to the perilimbal area of the affected eye. The nerve fascicles can either be placed around the entire limbal circumference and secured to the sclera or are inserted into corneoscleral tunnels. The nerve fascicles are secured with sutures or fibrin glue, or both. The conjunctiva is closed and a temporary lateral tarsorrhaphy may be placed. A patch and topical lubricants may be prescribed after surgery. Over time, new nerve endings grow into the cornea. A corneal transplant may be needed to fully restore sight in people with loss of corneal clarity.

  • National Institute for Health and Care Excellence (NICE)