Fig 1.
Flowchart of patients recruitment, follow-up and analysis who underwent corneal neurotization using sural nerve graft coaptation to the contralateral supratrochlear nerve in unilateral neurotrophic keratopathy, non-responding to the medical measures.
Fig 2.
Surgical steps of corneal neurotization.
(A) Identification and exposure of sural nerve, (B) Desired length of 10-12cm of the sural nerve was traced distally. (C) Careful fascicle separation through the epineurium window at the distal end. (D) Donor supra-trochlear nerve identification, (E) Reverse sural nerve tunnelling across the nasal bridge and (F) courses through sub-brow blepharotomy incision. (G) Fine segregation and recognition of separated fascicles under a microscope. (H) Secure individual fascicle sub-conjunctively at the perilimbal region, (I) End-to-side Coaptation of donor supra-trochlear nerve to inter-positional sural nerve graft.
Table 1.
Demographic characteristics of the eyes with neurotrophic keratopathy, underwent corneal neurotization using sural nerve graft in the study.
Table 2.
Result of ocular surface evaluation tests (mean±SD) following corneal neurotization using sural nerve graft in eyes with neurotrophic keratopathy.
Fig 3.
Slit lamp photograph of the cornea, before and after corneal neurotization at sequential follow-up.
(A) Pre-operative clinical photograph showing NK grade 2 with inferior epithelial defect (arrow) and stromal oedema because of trigeminal and facial nerve involvement following brain tumour surgery. (B) One month postoperative photograph showed a marked reduction in epithelial defect and stromal oedema. (C) The six-month postoperative photograph revealed an increase in optical clarity with (D) Snellen best corrected visual acuity 20/20 at the 12-month follow-up.
Fig 4.
Representative slit lamp photograph of NK grade 2 owing to herpes simplex infection.
(A) Pre-operative clinical photograph demonstrating stromal haze and oedema at baseline. (B) One month postoperative photograph showed a significant reduction in stromal oedema and haze. (C) Six-month clinical photograph represents an escalation in corneal transparency and (D) achievement of 20/20 Snellen’s best-corrected vision at 12 months postoperative.
Table 3.
Clinical outcome of corneal neurotization [Mean±SD/Median (IQR)] on central and peripheral corneal sensation and central corneal sub-basal nerve fibre plexus in eyes with neurotrophic keratopathy.
Table 4.
Correlation of age and duration with central corneal sensation and subbasal nerve fiber density (SBNFD) at follow-up visits.
Table 5.
Effect of corneal neurotization on central corneal sensation and subbasal nerve fiber density at 6-month follow up, in all recruited eyes based on preoperative diagnosis and NK grade severity.
Fig 5.
A-F. Box and whiskers plots of corneal sensations. It is showing progressive and significant improvement in central and peripheral corneal sensations at postoperative sequential follow-up.
Fig 6.
Box and whiskers plots of subbasal nerve fiber density over serial follow-up.
The graphs depict continuing improvement in subbasal nerve fiber density over serial follow-up after corneal neurotization surgery, though normal contralateral values were not obtained.
Fig 7.
Representative in vivo confocal microscopy of central corneal subbasal nerve plexus.
(A) Preoperative subbasal nerve fiber plexus, scarcely detectable on ACC Metrics software. (B) One month postoperative, subbasal nerve fiber length became significantly apparent, (C and D) Significant increase in branching and subsequent subbasal nerve fiber density at 6 months and 12 months after the CN surgery.