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Corneal Neurotization
Corneal Neurotization (CN) is the only definitive treatment for neurotrophic keratopathy (NK), a condition where the affected individuals develop numbness (anesthesia or hypoesthesia) on the clear front part of their eye (cornea). NK can result from various types of injuries to the trigeminal nerve.
The causes of NK can range from herpetic eye infections, eye surgery, topical eye drops to neurosurgical procedure and brain tumors. Regardless of the cause many patients who develop corneal anesthesia may progress to severe stages of NK that may result in blindness and even loss of the eye from corneal ulceration, scarring, and perforation respectively.
While there are many other available treatment options for NK, none have been definitively shown to address the loss of corneal innervation which is the underlying cause of NK. Therefore, these therapies do not result in long lasting success once they are discontinued or tapered off. In contrast to these interventions, CN aims to address the root cause of NK by transferring a healthy expendable donor nerve from the adjacent area of the face to the cornea, thereby re-establishing the critical nerve supply necessary to maintain long term integrity of the corneal surface.
Dr.Ilya Leyngold is one of the world’s leading pioneers in CN having published and presented his techniques in numerous peer reviewed journals, and national and international meetings respectively. He developed minimally invasive techniques to perform the surgery resulting in decreased operative time and faster recovery. One of the operations he designed involves direct transfer of the nerve above the affected eye through a small upper eyelid crease incision avoiding the need to harvest nerve grafts or make a large incision behind the hairline (previously described techniques). Another operation he developed involves the use of a cadaver nerve graft to connect the healthy donor nerve to the affected cornea. Patients travel from all over the country and the world to have the procedure with Dr.Leyngold. Initial consultation can be performed via a telemedicine platform. During your consultation Dr.Leyngold will discuss your candidacy for the surgery and the best surgical option for you.
Given that nerve regeneration is a relatively slow process it generally takes anywhere from 3-6 months after surgery to start noticing improvements in the cornea. However, the improvements may take much longer in some patients. The success is measured by resolution of corneal ulcerations, improved vision, and improved ability to feel the eye drops, wind, etc., in the eye. In addition, those with pre-existing corneal scarring are able to undergo successful corneal transplantation to restore their vision.
Resources
Leyngold IM, Kossler AL, Yen MT, eds. Techniques in Corneal Neurotization. St. Louis: Quality Medical Publishing, 2020.
https://www.qmp.com/product/techniques-in-corneal-neurotization/156
Video Feature on Healio Ocular Surgery News, January 23rd, 2020.
(https://www.healio.com/ophthalmology/cornea-external-disease/news/online/%7Bdb72004b-df20-44fc-a128-844c0b21d0bc%7D/video-leyngold-touts-corneal-neurotization-for-neurotrophic-keratopathy?fbclid=IwAR2gP-68gd-4Y8pMQlOVli-gcOuoM5D7AQYBuHMV_6zolzgZXKMsYkrv78Y)
“A Cure for the Neurotrophic Cornea?” CRST. Cornea/March 2019 by Angie E. Wen, MD
(https://crstoday.com/articles/2019-mar/a-cure-for-the-neurotrophic-cornea/)
Family Living Outside United States Sought Duke Specialist to Treat Child with Severe Neurotrophic Keratopathy
Bilateral corneal blindness, insensate cornea present risks for permanent blindness by Timothy Pitman in Duke Clinical Practice Today - Ophthalmology, Issue #122, May 21st 2019
(https://dukeeyecenter.duke.edu/news-events/family-living-outside-united-states-sought-duke-specialist-treat-child-severe)
Leyngold IM “Minimally invasive corneal neurotization” The Ophthalmologist, issue 0318, March, 2018
(https://theophthalmologist.com/issues/0318/minimally-invasive-corneal-neurotization/)
“Duke clinician-researchers present exciting new research” from Select Findings from AAO 2018 by Catherine Lewis, Nov.6th 2018.
(https://physicians.dukehealth.org/articles/select-findings-aao-2018)
“First use of cadaver nerves to repair corneal anesthesia shows promise” Duke Eye Center Vision magazine, page 11. 2018.
https://issuu.com/dukeeyecenter-visionmagazine/docs/duke_vision_2018.final_pages/20
“First-of-Its-Kind Surgery for Severe Neurotrophic Keratopathy” by Catherine Lewis, Clinical Practice Today from Duke Health, October 2017, pp 10 -11
(https://physicians.dukehealth.org/articles/first-its-kind-surgery-severe-neurotrophic-keratopathy)
“First Use of Cadaver Nerves to Repair Corneal Anesthesia Shows Promise Halts Permanent Eye Damage, Promotes Faster Recovery” in Duke Health Blog by Deborah Geiger, September 08, 2017.
( https://www.dukehealth.org/blog/first-use-of-cadaver-nerves-repair-corneal-anesthesia-shows-promise)
If the path be beautiful,
let us not ask where it leads.
ANATOLE FRANCE
Frequently asked questions about corneal neurotization
Any patient suffering from neurotrophic keratopathy (NK) or corneal anesthesia (numb cornea) is a potential candidate for the surgery. NK can lead to vision loss and sometimes loss of the eye from corneal ulceration, scarring, and perforation respectively.
Corneal anesthesia may result from multiple causes. The most common culprits include certain viral infections (e.g., herpetic eye infections), radiation therapy, severe diabetes mellitus, and brain tumors or surgery. It may also arise as a result of head trauma, complication of eye surgery, contact lens overuse, certain eye drops, or congenital defects.
Alternative treatments for NK include artificial tears, contact lenses to bandage the cornea, topical antibiotics or anti-inflammatory drops, autologous serum tears, and nerve growth factor drops. Some of these topical treatments are very expensive and still have limited success rate. Surgical treatments include suturing the eyelids closed (tarsorrhaphy) to prevent corneal perforation (developing a hole in the cornea) and various corneal grafting and transplant procedures – none of which have shown to address the underlying problem of decreased or absent corneal nerve function.
Corneal neurotization is the only intervention that can potentially cure NK. While other treatments can temporarily improve the health of the cornea, they do not provide long-lasting results. Currently corneal neurotization is the only modality that restores corneal nerve function by transferring a healthy expendable nerve to the anesthetic cornea. As a result, patients are able to regain long term corneal health eventually eliminating the need for other intensive treatments.
The insurance company does not currently cover corneal neurotization. It may cover other adjunctive procedures that have to be performed at the same time with corneal neurotization.
Yes. Patients may go home the same day after the procedure.
The procedure is performed by making a small incision in the upper lid crease or just under the eyebrow to obtained an expendable donor nerve that can be then transferred to the affected eye. Occasionally, an incision needs to be made on the inside of the lower lid if the nerve above the eye is not healthy. The choice of the donor nerve is usually determined during preoperative evaluation. Sometimes, if there are no functional nerves on the same side as the affected eye, the donor nerve is borrowed from the other side of the face in the same fashion. It is then transferred underneath the skin of the bridge of the nose to the affected side. A nerve graft is frequently needed to allow for successful nerve transfer. The graft maybe harvested from your body (e.g., leg) or cadaveric nerve graft maybe used. Subsequently, the nerve or nerve graft is routed to the eye and buried under the conjunctiva (skin of the eye) near the cornea. At the end of the procedure the eye is temporarily closed with a suture and an eye shield. The suture is usually removed several days after surgery (see diagram below).
Depending on the type of technique, anesthesia, and other procedures performed the surgery can take anywhere from 1 to 3 hours. Dr.Leyngold will give you an estimate of time needed to perform your procedure(s) during your consultation.
For the first few weeks to months after surgery it is normal to have numbness (decreased feeling to touch, temperature, pain, etc.) in the skin area that is supplied by the donor nerve. For example, if the donor nerve is borrowed from the underneath the brow patients may experience temporary numbness in the skin of the forehead and scalp on that side. This is usually not bothersome to patients. Over time this numbness resolves in the vast majority of patients.
Several techniques for corneal neurotization have been described. However, two main approaches exist: indirect nerve transfer using a nerve graft or direct nerve transfer to the eye. In indirect nerve transfer either a nerve autograft (i.e., an expendable nerve taken from the patient’s leg or other distant body site) or cadaveric nerve graft (off the shelf product) is used to bridge the gap between the donor nerve and the eye. There are differences in opinions among experts regarding the best approach, but in examining the literature all of the techniques seem to have similar success rates. Dr.Leyngold offers all of the techniques and customizes each option to an individual patient.
Recovery varies depending on the exact procedure(s) performed and the individual patient. Generally, significant bruising and swelling are expected for the first few weeks after surgery. While it is normal to have soreness, significant pain is not normal and should be reported to your surgeon immediately. The eye will be temporarily closed with a stitch and an eye shield will be worn. The suture is usually removed a few days after surgery, but the eye shield has to be worn for 3 weeks after surgery. The front surface of the eye shield is fenestrated allowing for vision and easy to remove to instill eye drops.
Nerve regeneration occurs at a slow rate, with average pace reported to be approximately 1mm per day after about a 2–4-week latent period. Therefore, it takes time for the nerves to reach the cornea and restore the feeling in the eye. This can occur anywhere from 3 to 12 months and depends on the individual patient, donor nerve distance from the eye, age, and overall patient’s health. Occasionally, the improvement may take even longer. The restoration in corneal nerve function will be determined by your surgeon during your follow up. The good news is that once the results set in, they appear to be long lasting. The longest successful follow up reported has been 19 years after surgery.
The goal of the surgery is to stabilize the cornea (e.g., resolve recurrent or persistent corneal ulcers) by restoring proper nerve function. While all age groups do well (i.e., overall success rate reported around 90% by Dr. Leyngold and other groups), children tend to have the fastest and best outcomes. If there is already significant corneal scarring, cataract, amblyopia, retinal or optic nerve pathology the vision may not improve with corneal neurotization alone. However, successful corneal neurotization allows for corneal transplantation or cataract surgery in those patients who were previously poor candidates for these procedures due to NK. In turn, successful corneal transplantation and/or cataract surgery results in improved vision.
Good overall health is a very important prerequisite for safe and successful corneal neurotization surgery. Patients with poorly controlled diabetes and other poor wound healing conditions such as high blood pressure may not be good candidates for surgery. Smoking can also increase the risk of poor wound healing and nerve regeneration. In addition, active eye infections or inflammatory conditions, chemotherapy, or radiation therapy are contraindications to surgery. The procedure is generally not recommended for patients with bleeding disorders and those who are on blood thinners that cannot be discontinued for an adequate period before the surgery. A list of all medications and herbal supplements that increase the risk of bleeding will be given to you in advance before surgery. A thorough physical examination prior to surgery by your primary care physician is important to ensure you are healthy enough to undergo general anesthesia.
Many patients come to see Dr.Leyngold from out of town, including other countries. We will help arrange your hotel stay and consultation with Dr.Leyngold the day before the surgery. After surgery your follow up will be in 1-3 days postop at which time Dr.Leyngold will remove the eye patch and examine your surgical sites. After your first follow up you can travel back home (flying is allowed). Your subsequent follow ups are generally arranged at 1 month, 3 months, 6 months, 12 months, and 24 months after surgery. This can be arranged with your local ophthalmologist or with Dr.Leyngold depending on your preference.
While corneal neurotization has a proven track record of safety, every medical procedure has inherent risks. Dr.Leyngold will discuss the potential surgical risks with you during your consultation?
Please do not hesitate to discuss any questions or concerns you may have regarding surgery with Dr. Ilya Leyngold.
I strongly recommend this physician! Our family is extremely appreciative of all he has done for my daughter's vision!
by Stephanie C
★★★★★ 5/5
Dr. Ilya Leyngold did my daughter’s corneal neurotization surgery. My daughter is a complex case. She is 7 years old and has many medical complexities, hydrocephalus, chiari malformation, hearing and visual impairments, amongst other disabilities. Dr. Leyngold went above and beyond in caring for her and I am extremely impressed at how well her vision improved after the corneal neurotization and partial tarrsorraphies. He is extremely knowledgeable and has excellent bedside manners. She recovered extremely well and had no complications after Dr.Leyngold operated on her eyes. He was very thorough in explaining everything and I was quited impressed by his fast responses to any questions I had anytime I emailed him.
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