A novel surgical technique to reinnervate the lacrimal gland can improve tear secretion and decrease the need for frequent artificial drop instillation for patients with neurodeprivative dry eye disease that developed from facial nerve palsy, according to a study published in Cornea. The procedure, lacrimal gland neurotization, is effective either alone or in combination with corneal neurotization, the report explains.
Researchers reviewed the procedure through a case series of 10 patients (4 men, 6 women; mean [SD] age 47.1 [7.1] years) who had experienced facial palsy from various etiologies (5 from acoustic neuroma, 2 from meningioma, 2 from astrocytoma, and 1 from chondrosarcoma).
All patients underwent a vertical crossface using a sural nerve graft. The procedure entails removing the submandibular gland, and harvesting a sural nerve graft from the patient’s leg. The technique uses the sural nerve graft to connect the lacrimal gland with the contralateral submandibular gland (“vertical crossface”) to restore tear secretion.
Patients were followed for a mean [SD] 18.7 [7.18] months postoperatively and were evaluated using Schirmer testing. The results show improvements for 7 out of 9 patients who attended their 1-year postoperative visits (the remaining patient was lost to follow-up after the 6-month visit). The increase in Schirmer scores was statistically significant at 1-year, compared with baseline (7.56±7.84 vs 0±0 mm/5 min; P =.02). For the remaining 2 patients, scores were unchanged from baseline at 1 year. These findings did not vary significantly between those who underwent lacrimal gland neurotization as the only procedure and those who also underwent corneal neurotization (respectively, 8.40±10.31 vs 6.50±4.43 mm/5 min, P =.74). No major postoperative complications occurred. All patients reported at least some loss of sensation in the skin area innervated by the sural nerve during each follow-up visit. No patients complained of xerostomia after surgery.
The vertical crossface using a sural nerve graft was able to successfully connect the lacrimal gland with the parasympathetic branch of the lingual nerve directed to the contralateral submandibular gland. Researchers report that the surgery can improve tear secretion and decrease the need for frequent instillation of artificial tears, whether performed alone or with corneal neurotization.
“Unlike other surgical strategies for DED, the approach described herein for the first time is able to correct the specific underlying cause (lacrimal gland denervation) by-passing the affected neural pathway,” study authors explain. “It is possible to combine this surgery with facial reanimation allowing to further help tear secretion thanks to the improved ability to close the eyelid and blink.”
Limitations include the small, 10-patient sample size, and the lack of comprehensive evaluation of ocular surface parameters using tear film break-up time, corneal fluorescein staining, or vertical palpebral aperture.
Giannaccare G, Bolognesi F, Fogagnolo P, et al. Sural nerve vertical cross-face graft for lacrimal gland neurotization to improve tear secretion in neurodeprivative dry eye. Cornea. Published online August 25, 2022. doi:10.1097/ICO.0000000000003126