The Second Division of Trigeminal Nerve for Corneal Neurotization: A Novel One-Stage Technique in Combination With Facial Reanimation

Abstract

Corneal neurotization represents an effective surgical strategy to restore corneal sensibility in patients affected by neurotrophic keratopathy. Corneal sensibility is essential in preserving structure and function of the eye. Loss of corneal sensibility can lead to a degenerative condition of the cornea known as neurotrophic keratopathy. Moreover, patients suffering from facial palsy show failure of full eyelid closure resulting in chronic corneal exposure and subsequent progressive damage. Reports have shown that the use of the contralateral ophthalmic division of the trigeminal nerve can be effective in restoring corneal sensibility. In the present study the authors expose a new technique by means of which direct neurotization of the anesthetic cornea was achieved using the homolateral second division of the trigeminal nerve. Effectiveness of the technique was evaluated using in vivo confocal microscopy. To the best of authors’ knowledge, this is the first report of this technique in literature.

Corneal Neurotization—Indications, Surgical Techniques and Outcomes

“…They created four intrastromal pockets, where the nerve fascicles endings were placed. Gennaro et al described a case of direct corneal neurotization where the coronal incision is avoided by using an intact ipsilateral infraorbital nerve for reinnervation through a subpalpebral incision [ 43 ]. This is also the first report in which the second division (V2) of the trigeminal nerve was used for direct corneal neurotization.…”

“…Once the nerve fascicles are brought to the cornea, they can be fixated to the limbus in several ways. Some groups use fibrin glue and others simply suture the nerve fascicles to the limbus, while others leave them free in the sub-Tenon’s space ( Figure 6 B) [ 27 , 36 , 38 , 39 , 40 , 41 , 43 , 44 , 45 , 47 , 49 , 51 , 54 , 56 , 65 , 66 , 67 , 68 ]. Subsequent reports have adapted the technique by introducing a novel way of securing the peripheral fascicles into corneoscleral tunnel incisions.…”

“…Pathological changes in the corneal epithelium can manifest as increased proliferation, increased density of basal epithelial cells, and reduced superficial epithelial cell density, reflecting the higher loss of surface epithelium and epithelial defects seen in disease states [ 94 , 95 ]. Using IVCM, both DCN and ICN methods have shown objective improvements in corneal epithelial morphology [ 43 , 45 , 55 ]. In one case, Meniccaci et al found that the density of the epithelial superficial cell layer increased over a follow-up period of 1.5 years, while the number of epithelial basal cells showed a progressive reduction which approached a more physiological phenotype and was ultimately comparable to the contralateral healthy eye [ 21 ].…”

“… Direct corneal neurotization: ( A ) Representation of (1) coronal incision, (2) supratrochlear nerve, (3) supraorbital nerve, and (4) infraorbital nerve; ( B ) Contralateral supratrochlear and supraorbital [ 36 , 37 , 38 , 39 ]; ( C ) Contralateral supraorbital [ 27 , 41 , 42 ]; ( D ) Ipsilateral infraorbital [ 43 ]; ( E ) Ipsilateral supraorbital [ 42 , 44 , 45 ]; ( F ) Bilateral ipsilateral supraorbital [ 42 ]. …”

Granulomatous cheilitis: differential diagnosis in patients with macrocheilia

“…Due the inconsistency of the pathological clinical features and considering the importance of a biopsy in same case, it is necessary to schedule an MR to characterise the lesion. MR narrows the diagnosis excluding, for example, vascular lesion and, moreover, allows to find out cleavage plan to programme an eventual surgery radical excision, especially if it could lead to nerve damage 5–7…”