1. Endoscopic assisted Small Incision corneal reinnervation reduces vascularisation when combined with Keratoplasty and Gold weight implant

    Cases with combined facial nerve and trigeminal nerve involvement do present with complex issues as elucidated by Allevi et al (1) . This article helped us immensely in managing our case and we are grateful to the authors and the journal.

    A male patient suffering from fifth nerve and seventh nerve palsy presented to us with similar issues with severely vascularised hypertrophic insensitive bulging cornea with zero corneal sensations on anaesthesiometer .

    Leyngold et al (2) (3) suggested endoscopic approach with scalp incision and Bains et al (4) suggested a microincision approach.We combined these approaches and did a corneal trasplant as well, as we had no option since the cornea would otherwise perforate

    The facial palsy was treated with gold weight implant and corneal insensitivity with reinnervation and opacity with keratoplasty. Corneal reinnervation was done with a different combined approach and we did a small microincision surgery with endoscopical help , but did not take the scalp incision and instead anastomoses was done on one side with the contralateral supraorbital and supratrochlear nerve and the other end of the sural nerve graft was tunnelled from contralateral side to the ipsilateral side ,along the line connecting the eyebrows on either side ,and then across the ipsilateral eyelid , between the gold weight implant and the medial horn of leavator palpebrea superioris and then tunnelled subconjunctival as well as subtenons and after being dissected into fascicles , the fascicles were inserted into four scleral tunnels and sutured intrascleral. We got good short term result at two months and corneal sensations have returned and we await long term results before publishing the case . But in the interim we realised that we did see some findings which could help others in the interim , like we were helped by this article .

    The corneal vascularisation reduced markedly as the corneal nerves started growing and sensations returned ad the patient started feeling the eyedrops and actual complained of pain !The palisades of Vogt thickened and pigmentation was seen migrating into the cornea and corneal vascularisation was seen reduced significantly in areas where the pigmentation advanced into the cornea . There was no ptosis which we had expected since we thought the levator would be damaged during the procedure.

    Corneal innervation is known to be necessary to maintain stemness of stem cells and in the cornea nerves and neovessels are hypothesised to inhibit each other (5) but we saw this clinically with areas of corneal vascularisation disappearing as the corneal nerves grew and sensations returned.

    We thank all authors for the techiniques and would want to point out that journals like British Journal of Case Report with its open access policy and speedy publication of recent advances , need to be applauded for such articles which help us in the developing countries help our poor patients with the latest advances as soon as they occur.

    References :-

    1) Allevi F, Fogagnolo P, Rossetti L, Biglioli F. Eyelid reanimation, neurotisation, and transplantation of the cornea in a patient with facial palsy. BMJ Case Reports. 2014;2014:bcr2014205372. doi:10.1136/bcr-2014- 205372. 2) Leyngold I, Weller C, Leyngold M, Espana E, Black KD, Hall KL, Tabor M.Endoscopic Corneal Neurotization: Cadaver Feasibility Study. Ophthal Plast Reconstr Surg. 2017 May 2. doi: 10.1097/IOP.0000000000000913. 3) Leyngold I, Weller C, Leyngold M, Tabor M. Endoscopic Corneal Neurotization:Technique and Initial Experience. Ophthal Plast Reconstr Surg. 2017 Nov 27. doi: 10.1097/IOP.0000000000001023 4) Bains RD, Elbaz U, Zuker RM, Ali A, Borschel GH. Corneal neurotization from the supratrochlear nerve with sural nerve grafts: a minimally invasive approach. Plast Reconstr Surg. 2015 Feb;135(2):397e-400e. doi:10.1097/PRS.0000000000000994. 5) Ferrari G, Hajrasouliha AR, Sadrai Z, Ueno H, Chauhan SK, Dana R. Nerves and neovessels inhibit each other in the cornea. Invest Ophthalmol Vis Sci. 2013 Jan 28;54(1):813-20. doi: 10.1167/iovs.11-8379.

    Conflict of Interest:

    None declared

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