Corneal Neurotization Using the Great Auricular Nerve for Bilateral Congenital Trigeminal Anesthesia

Abstract

Purpose:The purpose of this study was to describe an indirect corneal neurotization (CN) technique for congenital bilateral trigeminal anesthesia using the greater auricular nerve (GAN) as a donor.Method: CN was performed to preserve the integrity of the only seeing eye in a 4-year-old boy with pontine tegmental cap dysplasia and bilateral trigeminal anesthesia. He had recurrent corneal ulceration and scarring despite full medical treatment. The GAN was used as a donor, and the sural nerve was harvested and used as a bridge which was tunneled to the sub-Tenon space in the inferior fornix. The fascicles were distributed into the 4 quadrants and sutured to the sclera near the limbus.Result: This technique resulted in providing corneal sensation and improving stability of the epithelium. Corneal opacity gradually decreased allowing significant visual improvement evidenced in the early postoperative months. Conclusions: Using the GAN technique for CN bypasses tri-geminal innervation and has the potential to improve corneal sensation. The GAN is a large caliber nerve and provides a large amount of axons and robust neurotization. This technique would be desirable for cases with bilateral congenital trigeminal anesthesia, such as pontine tegmental cap dysplasia.

Bilateral Corneal Neurotization for Ramos-Arroyo Syndrome and Developmental Neurotrophic Keratopathy: Case Report and Literature Review

“…9 The successful use of CN in patients with congenital insensate corneas has since been reported in idiopathic cases and those secondary to trigeminal hypoplasia and other neurological associations. 10–13 Pediatric patients experience substantial gains in BCVA and corneal sensitivity after CN. 4…”

“…[10][11][12][13] Pediatric patients experience substantial gains in BCVA and corneal sensitivity after CN. 4 Our case is distinguishable from those previously reported 13 due to the simultaneous completion of the procedure bilaterally using the GAN technique. The major advantage of this concomitant technique is that it is no longer necessary to stage this operation and cause delays in the treatment of the other eye.…”

“…9 The successful use of CN in patients with congenital insensate corneas has since been reported in idiopathic cases and those secondary to trigeminal hypoplasia and other neurological associations. [10][11][12][13] Pediatric patients experience substantial gains in BCVA and corneal sensitivity after CN. 4 Our case is distinguishable from those previously reported 13 due to the simultaneous completion of the procedure bilaterally using the GAN technique.…”

Corneal Neurotization—Indications, Surgical Techniques and Outcomes

“…While most authors use supratrochlear and supraorbital nerves for neurotization, some authors chose the ipsilateral great auricular nerve (GAN) as the sensory source while keeping the sural nerve as an interponate [ 61 , 62 , 63 ]. The main arguments for using the GAN are that it contains a large number of sensory axons and that the loss of sensation is confined to a small part of the earlobe.…”

“… Indirect corneal neurotization using autograft: ( A ) Representation of (1) major occipital nerve, (2) supratrochlear (ST) nerve, (3) supraorbital (SO) nerve, (4) infraorbital (IO) nerve, (5) great auricular nerve (GAN), (6) sural nerve, (7) lateral antebrachial cutaneous (LAC) nerve; ( B ) Ophthalmic-sural-major occipital anastomosis [ 22 ]; ( C ) End-to-end sural [ 28 , 49 , 50 , 51 , 52 , 53 , 54 ] or GAN to contralateral ST nerve anastomosis [ 55 ]; ( D ) End-to-side sural to contralateral ST anastomosis [ 49 , 51 , 56 ]; ( E ) End-to-end sural [ 28 , 47 , 50 , 55 , 57 , 58 ] or LAC to contralateral SO nerve [ 59 ] anastomosis; ( F ) End-to-end sural to contralateral ST and SO [ 47 , 48 ]; ( G ) Bilateral end-to-end sural to ipsilateral ST [ 56 ]; ( H ) End-to-side sural to ipsilateral ST [ 47 ]; ( I ) End-to-end sural to ipsilateral ST [ 50 , 60 ]; ( J ) End-to-end sural to ipsilateral SO [ 47 ]; ( K ) End-to-end sural to ipsilateral IO [ 50 , 51 ]; ( L ) End-to side sural to GAN [ 61 , 62 ], bilateral case report [ 63 ]. …”