Aim We have assessed whether corneal confocal microscopy can be used to detect alterations in nerve morphology following an improvement in risk factors associated with diabetic neuropathy. Methods Twenty-five patients with diabetes with mild to moderate neuropathy and 18 control subjects underwent corneal confocal microscopy to quantify corneal nerve fibre density, branch density, length) and tortuosity at baseline and after 24 months from first visit. This was not planned as an intervention trial and was simply an observational follow-up. Results At baseline, nerve fibre density (18.8 ± 2.1 vs. 46.0 ± 3.8 number/mm2, P = 0.001), nerve branch density (6.9 ± 1.5 vs. 35.6 ± 6.7 number/mm2, P < 0.0001), nerve fibre length (8.3 ± 0.9 vs. 13.5 ± 0.8 mm/mm2, P < 0.0001) and nerve fibre tortuosity (19.8 ± 1.6 vs. 22.7 ± 2.2, P < 0.05) were significantly lower in patients with diabetes than in control subjects. At follow-up, glycaemic control (HbA1c 64 ± 3 to 58 ± 2 mmol/mol, P = 0.08), total cholesterol (4.9 ± 0.2 to 4.2 ± 0.2 mmol/l, P = 0.01), systolic blood pressure (145.8 ± 4.9 to 135.9 ± 3.7 mmHg, P = 0.09) and diastolic blood pressure (77.8 ± 2.7 to 70.8 ± 2.5, P = 0.03) improved. Nerve fibre density (24.1 ± 2.0, P = 0.05), nerve branch density (11.1 ± 1.3, P = 0.01) and nerve fibre tortuosity (22.6 ± 1.5, p=0.05) increased significantly, with no change in nerve fibre length (8.4 ± 0.5). Improvement in nerve fibre density correlated significantly with the improvement in HbA1c (r = −0.51, P = 0.008). Via four multifactorial regressions, this confirms the negative association between HbA1c and nerve fibre density (P = 0.02). Conclusions This study shows that corneal confocal microscopy may be employed in longitudinal studies to assess progression of human diabetic neuropathy and also supports the hypothesis that improvements in risk factors for diabetic neuropathy, in particular HbA1c, may lead to morphological repair of nerve fibres.

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Paraesophageal hernias are considered to be benign entities which are usually managed conservatively. We present a case of a middle-aged male with no previous history of esophageal hernia who presented with acute chest and abdominal pain. The patient was diagnosed to have a type 2 paraesophageal hernia with gastro-thorax. Laparotomy was performed during which it was found that herniated segment of the stomach had strangulated and gangrenous. Thoracotomy was performed and gangrenous stomach segment resected. A roux-en-Y esophagojejunostomy was performed. Diaphragmatic defect was plicated. Patient recovered with adequate post operative support. A review of the literature revealed that paraesophageal hernias presenting as acute abdominal pain is a rare clinical entity and those with gastric gangrene is even rarer, with high mortality rates. We suggest that paraesophageal hernias require to be managed actively considering the seriousness of potential complications and the relative safety of newer elective surgical modalities. A high index of suspicion is needed in order to avoid missing this diagnosis in patients presenting with chest pain.

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