Neurotrophic Corneal Ulceration After Retinal Detachment Surgery with Retinectomy and Endolaser a Case Series

Research

Brief Report Neurotrophic Corneal Ulceration After Retinal Detachment Surgery With Retinectomy and Endolaser A Case Series

Philip J. Banerjee, FRCOphth; Aman Chandra, FRCOphth; Paul M. Sullivan, FRCOphth; David G. Charteris, FRCOphth

IMPORTANCE Trigeminal nerve lesions at differing levels can result in complete or partial corneal anesthesia and ensuing epithelial breakdown. Disease progression can lead to corneal ulceration, melt, and perforation. To our knowledge, neurotrophic corneal ulceration has not previously been reported after retinal detachment surgery and argon endolaser.

OBSERVATION Herein, we report a series of 5 cases of patients without diabetes who developed neuropathic corneal ulceration presumed secondary to long ciliary nerve compromise. This occurred within 5 to 10 weeks following vitrectomy surgery with endolaser and silicone oil tamponade for retinal detachment.

CONCLUSIONS AND RELEVANCE Clinicians should be mindful of the long ciliary nerves intraoperatively and, where possible, avoid heavy confluent treatment at these sites without compromising the need for adequate retinopexy. Where corneal anesthesia occurs, it is important to recognize this early and treat promptly to minimize the risk for ulceration and Author Affiliations: Vitreoretinal visual loss. Service, Moorfields Eye Hospital, London, England. Corresponding Author: Philip J. JAMA Ophthalmol. 2014;132(6):750-752. doi:10.1001/jamaophthalmol.2014.280 Banerjee, FRCOphth, Moorfields Eye Published online April 17, 2014. Hospital, London EC1V 2PD, England ([email protected]).

rigeminal nerve lesions at differing levels can result in of herpetic keratitis considered, with additional topical and complete or partial corneal anesthesia and ensuing systemic antiviral therapy instituted. Following a negative T epithelial breakdown. Disease progression can lead to viral polymerase chain reaction result and a lack of treat- corneal ulceration, melt, and perforation.1 Herein,wereport ment response, he was switched to intensive topical lubri- a series of 5 cases of nondiabetic patients who developed neu- cants. A botulinum toxin–induced ptosis aided resolution at ropathic corneal ulceration following vitrectomy surgery with 6 months but with 20% central corneal thinning and marked endolaser for retinal detachment. stromal scarring.

Case 2 Report of Cases A woman in her 70s required augmented barrier endolaser at oil removal 4 months post–rhegmatogenous retinal detach- Oral consent was obtained from all patients and documented ment repair with 180° retinectomy. Ten weeks later, she de- in the medical notes. Institutional review board approval was veloped a neurotrophic corneal ulcer. Resolution was achieved obtained from Moorfields Eye Hospital. after 3 weeks of treatment with prophylactic topical antibiotics and intensive topical ocular lubricants, with resultant mild Case 1 stromal thinning and residual scarring in the visual axis. A man in his 60s with a recurrent rhegmatogenous retinal detachment and proliferative vitreoretinopathy (PVR) Case 3 underwent a pars plana vitrectomy with 180° retinectomy; A woman in her 50s with recurrent PVR rhegmatogenous reti- confluent endolaser, including both horizontal meridia; and nal detachment required a 220° retinectomy, endolaser, and silicone oil to reattach the retina. Six weeks later, he devel- oil to reattach the retina. A painless paracentral corneal epi- oped a central epithelial defect with a secondary infective thelial defect (Figure 1) and fixed dilated pupil were noted crystalline keratopathy. He was treated with an intensive 5 weeks postoperatively. Complete resolution was achieved topical regimen using a fluoroquinolone. Corneal anesthesia after 3 weeks with combined topical antibiotics and intensive was documented 4 weeks later and a differential diagnosis topical ocular lubricants.

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Figure 1. Case 3 Figure 2. Case 5

The arrow highlights the paracentral corneal epithelial defect at presentation. The arrow highlights the paracentral corneal epithelial defect 1 week after presentation. Case 4 A woman in her 50s required a vitrectomy, PVR membrane peel, Figure 3. Corresponding Fundus Image of Case 3 and 270° retinectomy with oil following 3 previous failed retinal detachment repairs over a period of 1 month. She presented with a painless reduction in vision 10 weeks later and was diagnosed as having a neurotrophic ulcer. Complete resolution was achieved after 4 weeks of treatment with prophylactic topical antibiotics, intensive lubricants, and a switch to an unpre- served topical steroid.

Case 5 A man in his 50s with dense strabismic amblyopia required a vitrectomy and 210° retinectomy with oil for a PVR retinal detachment in his better eye. He underwent pars plana vitrectomy, oil removal, epiretinal membrane peel, and augmented barrier laser with sulphahexaflouride 10 weeks later. One month postoperatively, he developed a contralateral cutaneous herpes zoster infection without ocular involvement, which resolved with systemic antivirals. Four weeks later (8 The arrows indicate extensive confluent chorioretinal scarring at the 3- and 9-o’clock positions. weeks after oil removal and augmented barrier laser), he presented to his local ophthalmic unit with a painless reduction in vision in his operated-on eye and was diagnosed as having All 5 eyes were treated with Argon (532-nm) endolaser, with a neurotrophic ulcer (Figure 2). Systemic antivirals were re- standard power and duration and frequency settings (200- commenced, in addition to topical antibiotics and infrequent 250 mW,0.2 second, and 0.2 second, respectively). Fundus ex- lubricants. One week later, on review at our institution, sys- amination findings showed marked confluent chorioretinal temic therapy was discontinued and resolution was achieved scarring at the 3- and 9-o’clock positions in each case (Figures 3 at 3 weeks with intensive lubricants, with residual central stro- and 4). We concluded that confluent intraoperative endola- mal scarring and 30% thinning. ser at these sites compromised long ciliary nerve function, with resultant corneal anesthesia and ulceration. Concurrent short Case Findings and Treatment ciliary nerve damage may have occurred in case 3, who also In these cases, there was no history of diabetes mellitus and had mydriasis. No other clinical signs suggested a lesion else- no cases had undergone previous corneal surgery or intraop- where in the trigeminal nerve nor a polyneuropathy. erative epithelial debridement. The preceding episode of contralateral cutaneous herpes zoster ophthalmicus in case 5 was deemed to be coincidental; although bilateral corneal nerve Discussion alteration has recently been described in unilateral herpes zoster ophthalmicus,2 contralateral corneal ulceration has not. Fur- Corneal sensation is derived from the ophthalmic branch of the thermore, resolution was achieved following discontinua- trigeminal nerve, predominantly via the long ciliary nerves. Neu- tion of antiviral therapy. There was no history of herpetic eye rotrophic keratopathy following transcleral cyclodiode laser is disease in the other 4 cases. well known3 and treatment in the regions of the long ciliary

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thought to be due to short and long ciliary nerve damage, re- Figure 4. Corresponding Fundus Image of Case 5 spectively. Reduction in corneal sensitivity following retinal detachment surgery with sectoral scleral buckles and encircling bands has been reported.6 Internal ophthalmoplegia and neurotrophic ulceration has recently been reported in an exprema- ture child following diode laser and an encircling buckle7;this was again presumed secondary to ciliary nerve damage. The presence of silicone oil in all 5 eyes may have contrib- uted to the observed corneal changes.8 However, the tempo- ral relationship between the onset of the keratopathy and the operative intervention favors a perioperative event (ie, endolaser) over oil toxicity as the cause. In our series, corneal ulceration occurred between 5 and 10 weeks postintervention. A more favorable outcome was achieved where the diagnosis was made early and appropriate treatment commenced (cases 2, 3, and 4). Where alternative underlying causes were ini- tially entertained (cases 1 and 5), the outcome appears to have The arrows indicate extensive confluent chorioretinal scarring at the 3- and been less favorable. 9-o’clock positions. To our knowledge, this is the first reported series of cases where neurotrophic corneal ulceration has occurred second- nerves is avoided. Retinal surgeons are not afforded the same ary to endolaser in adults. Clinicians should be mindful of the luxury as treatment-immune sites because confluent retino- long ciliary nerves intraoperatively and, where possible, avoid pexy may be required for sustained retinal reattachment. Reti- heavy confluent treatment at these sites, without compromis- nal laser–induced internal ophthalmoplegia has been reported ing adequate retinopexy. Where corneal anesthesia occurs, it in diabetic patients following diode photocoagulation4 and cor- is important to recognize this early and treat promptly to mini- neal sensitivity reduction after argon retinal laser5; this is mize the risk for ulceration and visual loss.

ARTICLE INFORMATION Conflict of Interest Disclosures: None reported. 5. Menchini U, Scialdone A, Pietroni C, Carones F, Submitted for Publication: June 11, 2013; final Brancato R. Argon versus krypton panretinal revision received September 24, 2013; accepted REFERENCES photocoagulation side effects on the anterior December 10, 2013. 1. Mackie I. Neuroparalytic Keratitis. In: Fraunfelder segment. Ophthalmologica. 1990;201(2):66-70. Published Online: April 17, 2014. FRF, Meyer SM, eds. Current Ocular Therapy. 6. Gibson RA. Reduction of corneal sensitivity after doi:10.1001/jamaophthalmol.2014.280. Philadelphia, PA: WB Saunders; 1995:452-454. retinal detachment surgery. Br J Ophthalmol.1981; 65(9):614-617. Author Contributions: Drs Banerjee and Charteris 2. Hamrah P, Cruzat A, Dastjerdi MH, et al. had full access to all of the data in the study and Unilateral herpes zoster ophthalmicus results in 7. Valldeperas X, Arango A, Blazquez A, Romano M. take responsibility for the integrity of the data and bilateral corneal nerve alteration: an in vivo Tonic pupil and corneal anesthesia after vitrectomy the accuracy of the data analysis. confocal microscopy study. Ophthalmology.2013; and encircling band for retinal detachment in an Study concept and design: Banerjee, Charteris. 120(1):40-47. ex-premature child. Case Rep Ophthalmol.2010; Acquisition, analysis, or interpretation of data: All 3. Johnson SM. Neurotrophic corneal defects after 1(2):66-70. authors. diode laser cycloablation. Am J Ophthalmol. 1998; 8. Green K, Cheeks L, Stewart DA, Trask D. Role of Drafting of the manuscript: Banerjee, Chandra, 126(5):725-727. toxic ingredients in silicone oils in the induction of Charteris. 4. Patel JI, Jenkins L, Benjamin L, Webber S. increased corneal endothelial permeability. Lens Critical revision of the manuscript for important Dilated pupils and loss of accommodation following Eye Toxic Res. 1992;9(3-4):377-384. intellectual content: All authors. diode panretinal photocoagulation with sub-tenon Administrative, technical, or material support: local anaesthetic in four cases. Eye (Lond). 2002;16 Banerjee, Chandra, Charteris. (5):628-632. Study supervision: Sullivan, Charteris.

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