Corneal Neurotization using End-to-End Coaptation from the Supraorbital Nerve

Corneal neurotization is a “hot topic” in the treatment of neurotrophic keratopathy.  Options for the surgery include whether it is a direct or indirect procedure, donor nerve site, coaptation method, and type of nerve graft to use if an indirect procedure is performed.  This video demonstrates an indirect method from the contralateral supraorbital nerve using a cadaveric nerve and an end-to-end coaptation. 

This is Richard Allen in Houston, TX.  This video demonstrates corneal neurotization from the contralateral supraorbital nerve using end-to-end coaptation.  A lid crease incision is made on each side with a 15 blade.  The right side is the donor side, and dissection is carried out through the orbicularis muscle to the underlying orbital septum.  Dissection is then carried out superiorly along the surface of the orbital septum to the superior orbital rim.  The needle tip cautery is then used to incise the periosteum lateral to the supraorbital nerve.  A freer periosteal elevator is then used to elevate the periosteum and move medially where the supraorbital neurovascular bundle is identified.  Westcott scissors are used to better isolate the neurovascular bundle.  Attention is then directed to the left side where dissection is carried out to the underlying orbital septum. A freer periosteal elevator is then used to dissect medially to identify the superior medial orbital rim.  Attention is then redirected to the right side where blunt-tipped scissors are used to dissect medially across the bridge of the nose to the contralateral side.  This is performed in a subcutaneous plane and the tips of the scissors can be palpated on the left side.  Once the tunnel is established, a hemostat can be placed through the tunnel and a 4-0 silk suture is engaged and retrieved through the tunnel.  A 360-degree peritomy is then performed on the left with Westcott scissors. The orbital septum is then opened to expose the underlying levator aponeurosis.  Dissection is then carried out medial to the levator aponeurosis to the bulbar subconjunctival space.  A hemostat is then placed through this tunnel and the 4-0 Silk suture is engage and retrieved.  The 4-0 silk suture is then tied around the donor nerve graft.  The graft is then pulled through the two tunnels.  The end of the nerve graft is freshened and attention is redirected to the supraorbital nerve.  The nerve is transected.  This will be end to end coaptation.  The perineurium of the supraorbital nerve is then engaged with a 6-0 Prolene suture.  This suture then engages the perineurium of the donor nerve graft.  Three sutures are placed to complete the coaptation/anastomosis.  Attention is then directed to the other end of the nerve graft.  The perineurium is incised and the fascicles of the nerve are separated to give three branches which will be distributed along the surface of the sclera.  A 7-0 Vicryl suture is then used to make a partial thickness pass through the sclera.  This suture is then tied around the end of the nerve fascicle.  This is performed similarly for the remaining two fascicles.  The peritomy is then repaired with 7-0 Vicryl suture.  The lid crease incision on each side is repaired with interrupted 5-0 fast absorbing sutures.  A temporary suture tarsorrhaphy is then placed in this case with 4-0 Silk suture in a mattress fashion.  Antibiotic ointment will be placed over the repair and the patient will follow up in one week.