Corneal Neurotization using End-to-Side Coaptation from the Infraorbital Nerve

In this example of corneal neurotization, the ipsilateral infraorbital nerve is used as the donor with an end-to-side coaptation using a cadaveric nerve.  In general, the first evidence of sensation is expected at about 3 months with a maximum sensation at about 6 months.  I think this is a very exciting treatment for neurotrophic keratopathy. 

This is Richard Allen in Houston, TX.  This video demonstrates corneal neurotization using the ipsilateral infraorbital nerve. A transconjunctival incision is made with the needle tip cautery and dissection is carried out inferiorly between the orbicularis muscle and the orbital septum to the inferior orbital rim.  The periosteum of the inferior orbital rim is then incised and the periosteum is elevated from the orbital floor.  The infraorbital nerve is identified and the bone above the infraorbital nerve is removed to expose it.  This can be performed with the suction and completed anteriorly with a Kerrison rongeur.  A freer periosteal elevator is then used to mobilize the nerve.  Attention is then directed to the eye where a 360-degree peritomy is performed with Westcott scissors.  Steven’s scissors are then used to bluntly dissect into the inferior lateral quadrant toward the orbital floor.  This is a safe quadrant to enter and avoids the inferior oblique muscle.  A hemostat is then placed in the tunneled incision and engages a 4-0 silk suture.  The silk suture is then tied around the end of a cadaveric nerve graft.  The suture is then used to transfer the nerve through the tunnel.  Attention is then redirected to the infraorbital nerve where the perineurium is incised with Westcott scissors.  The nerve is incised superiorly with the Westcott scissors.  This will be an end to side coaptation.  A 6-0 Prolene suture then engages the perineurium of the infraorbital nerve.  The end of the donor graft is freshened and the suture then engages the perineurium of the donor graft.  The suture is tied to bring the cut end of the nerve graft into contact with the disrupted infraorbital nerve.  Additional sutures are then placed to oppose the nerve graft to the infraorbital nerve.  Attention is then directed to the other end of the nerve graft.  The nerve fascicles are gently separated with Westcott scissors.  In this case, three fascicles will be sutured to the surface of the sclera.  7-0 Vicryl suture is then placed partial thickness through the surface of the sclera approximately 2-3 mm posterior to the limbus.  The suture is then tied around the end of one of 19the nerve fascicles.  This is performed for each of the nerve fascicles.  The transconjunctival incision is then closed with interrupted 7-0 Vicryl sutures.  The redundant end of one of the nerve fascicles is excised.  The peritomy is then repaired with 7-0 Vicryl sutures.  A suture tarsorrhaphy is placed with 5-0 Vicryl sutures.  Antibiotic ointment is placed into the eye and the eye is patched.