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• W4229031103 abstract "Neurotrophic keratopathy (NK) is a condition in which corneal anaesthesia, and corresponding lack of protective mechanisms, leads to persistent epithelial defects (PEDs), stromal ulceration, and corneal perforation.1Dua HS Said DG Messmer EM et al.Neurotrophic keratopathy.Prog Retin Eye Res. 2018; 66: 107-131Crossref PubMed Scopus (218) Google Scholar In children, corneal anaesthesia is usually caused by intracranial lesions, neurosurgery, head trauma, and congenital syndromes or as an isolated idiopathic finding.2Lambley RG Pereyra-Muñoz N Parulekar M Mireskandari K Ali A. Structural and functional outcomes of anaesthetic cornea in children.Br J Ophthalmol. 2015; 99: 418-424Crossref PubMed Scopus (16) Google Scholar This contrasts with adult patients, in whom NK is most commonly caused by herpetic infections. NK also may occur with chronic contact lens use, chronic topical medications such as anaesthetic and glaucoma eye drops, and chemical burns.3Saad S Abdelmassih Y Saad R et al.Neurotrophic keratitis: frequency, etiologies, clinical management and outcomes.The Ocular Surface. 2020; 18: 231-236Crossref PubMed Scopus (38) Google Scholar In rare cases, NK has been reported in association with ocular laser procedures, such as ciliary body cycloablation, argon endolaser for retinal detachment, and panretinal photocoagulation for diabetic retinopathy.4Tinley CG Gray RH. Routine, single session, indirect laser for proliferative diabetic retinopathy.Eye (Lond). 2009; 23: 1819-1823Crossref PubMed Scopus (9) Google Scholar, 5Banerjee PJ Chandra A Sullivan PM Charteris DG. Neurotrophic corneal ulceration after retinal detachment surgery with retinectomy and endolaser: a case series.JAMA Ophthalmol. 2014; 132: 750-752Crossref PubMed Scopus (19) Google Scholar, 6Johnson SM. Neurotrophic corneal defects after diode laser cycloablation.Am J Ophthalmol. 1998; 126: 725-727Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar The pathophysiology of laser-associated NK is presumed to be secondary to ciliary nerve damage.5Banerjee PJ Chandra A Sullivan PM Charteris DG. Neurotrophic corneal ulceration after retinal detachment surgery with retinectomy and endolaser: a case series.JAMA Ophthalmol. 2014; 132: 750-752Crossref PubMed Scopus (19) Google Scholar The two long ciliary nerves pass nasally and temporally through the suprachoroidal space to supply sensory fibres to the cornea.7Forrester JV Dick AD McMenamin PG Roberts F Pearlman E. Anatomy of the eye and orbit.in: Forrester J Dick A McMenamin P Roberts F Pearlman E The Eye. 4th ed. W.B. Saunders, Philadelphia2015Google Scholar It has been suggested that a confluent laser at the 3 and 9 o'clock positions can injure the ciliary nerves.5Banerjee PJ Chandra A Sullivan PM Charteris DG. Neurotrophic corneal ulceration after retinal detachment surgery with retinectomy and endolaser: a case series.JAMA Ophthalmol. 2014; 132: 750-752Crossref PubMed Scopus (19) Google Scholar Fortunately, eventual resolution of NK has been reported in most of these patients.5Banerjee PJ Chandra A Sullivan PM Charteris DG. Neurotrophic corneal ulceration after retinal detachment surgery with retinectomy and endolaser: a case series.JAMA Ophthalmol. 2014; 132: 750-752Crossref PubMed Scopus (19) Google Scholar The mainstay of treatment for NK is to promote epithelial healing and prevent complications, the most serious being stromal melting leading to corneal perforation. General treatments include topical lubrication, protective contact lenses, and punctal occlusion.3Saad S Abdelmassih Y Saad R et al.Neurotrophic keratitis: frequency, etiologies, clinical management and outcomes.The Ocular Surface. 2020; 18: 231-236Crossref PubMed Scopus (38) Google Scholar Topical nerve growth factor has shown promise, but it is prohibitively expensive, and long-term outcomes are unknown.3Saad S Abdelmassih Y Saad R et al.Neurotrophic keratitis: frequency, etiologies, clinical management and outcomes.The Ocular Surface. 2020; 18: 231-236Crossref PubMed Scopus (38) Google Scholar Lateral tarsorrhaphy is highly effective at healing and reducing the risk of PEDs, preventing stromal melt, and providing adequate long-term protection.2Lambley RG Pereyra-Muñoz N Parulekar M Mireskandari K Ali A. Structural and functional outcomes of anaesthetic cornea in children.Br J Ophthalmol. 2015; 99: 418-424Crossref PubMed Scopus (16) Google Scholar Severe cases of NK may require corneal neurotization surgery.3Saad S Abdelmassih Y Saad R et al.Neurotrophic keratitis: frequency, etiologies, clinical management and outcomes.The Ocular Surface. 2020; 18: 231-236Crossref PubMed Scopus (38) Google Scholar Herein we describe the first case of bilateral NK caused by an ocular procedure in a pediatric patient who received prophylactic circumferential laser retinopexy for lattice degeneration, high myopia, and a family history of retinal detachments. A 6-year-old girl with autism spectrum disorder, developmental delay, and congenital hypothyroidism was referred for ophthalmic assessment given her extensive family history of retinal detachment. She was found to have pathologic myopia (spherical equivalent –13.0 and –16.00 D; axial lengths 27.7 and 28.6 mm OS and OD, respectively) and best-corrected visual acuity of 20/60 OD and 20/70 OS. Fundus examination revealed 360-degree lattice degeneration with atrophic holes bilaterally (Fig. 1A, 1B). The remainder of the ocular examination and the systemic assessment showed no other abnormalities. The family refused genetic testing. Because of the patient's significant risk of retinal detachment with limited ability to communicate symptoms, she underwent uncomplicated prophylactic bilateral circumferential laser retinopexy in 3–5 rows using a 810 nm diode laser (2648 shots OD, 3388 shots OS at 240–300 mW of power; Fig. 1C, 1D). Two weeks later, the patient presented with painless red eyes bilaterally. Her best-corrected visual acuity was decreased to 20/80 OD and 20/125 OS. She was found to have bilateral large epithelial defects with smooth, rolled edges. There were no apparent tear film abnormalities, and she had qualitative loss of corneal sensation using cotton tip applicator testing (Fig. 2A, 2B). Magnetic resonance imaging of the brain showed no intracranial or orbital abnormalities. There was minimal improvement despite preservative-free topical lubrication and prophylactic antibiotics 6 times daily. Because the patient's developmental delay precluded other nonsedated treatments for PEDs, bilateral lateral permanent tarsorrhaphies were performed 1 week after presentation. The epithelial defects healed without complication and with minimal punctate epitheliopathy (Fig. 2C). Over 4 years of follow-up, the patient remained stable with mild residual paracentral subepithelial corneal haze in the left eye and return to her baseline vision (Fig. 2D, 2E). She had no further episodes of epithelial defects, and her retinal examinations remained stable with no breaks or detachment. Cochet–Bonnet aesthesiometry confirmed spontaneous recovery of normal corneal sensation (55 mm) bilaterally. To our knowledge, this is the first report of pediatric bilateral NK secondary to circumferential laser retinopexy requiring lateral tarsorrhaphy for management of PEDs and eventual recovery of corneal sensation. Cases of NK after retinal procedures have been reported in adults, including after panretinal photocoagulation for proliferative diabetic retinopathy.4Tinley CG Gray RH. Routine, single session, indirect laser for proliferative diabetic retinopathy.Eye (Lond). 2009; 23: 1819-1823Crossref PubMed Scopus (9) Google Scholar One case series of 5 patients described corneal ulceration after vitrectomy and argon endolaser, with varying degrees of resolution with conservative measures.5Banerjee PJ Chandra A Sullivan PM Charteris DG. Neurotrophic corneal ulceration after retinal detachment surgery with retinectomy and endolaser: a case series.JAMA Ophthalmol. 2014; 132: 750-752Crossref PubMed Scopus (19) Google Scholar In adults, circumferential laser retinopexy has been found to be associated with persistent decreases in subbasal corneal nerve plexus density, corneal sensation, and epithelial thickness.8Bouheraoua N Hrarat L Parsa CF et al.Decreased corneal sensation and subbasal nerve density, and thinned corneal epithelium as a result of 360-degree laser retinopexy.Ophthalmology. 2015; 122: 2095-2102Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar Laser-induced NK is a rare but serious potential complication of retinopexy. It can be vision threatening in the pediatric population owing to complications such as corneal scarring, melting, or perforation, as well as from secondary amblyopia.2Lambley RG Pereyra-Muñoz N Parulekar M Mireskandari K Ali A. Structural and functional outcomes of anaesthetic cornea in children.Br J Ophthalmol. 2015; 99: 418-424Crossref PubMed Scopus (16) Google Scholar Early intervention, including use of tarsorrhaphy, is an important prognostic factor leading to good structural outcomes.2Lambley RG Pereyra-Muñoz N Parulekar M Mireskandari K Ali A. Structural and functional outcomes of anaesthetic cornea in children.Br J Ophthalmol. 2015; 99: 418-424Crossref PubMed Scopus (16) Google Scholar Fortunately, despite the absence of pain and our patient's inability to communicate subjective concerns, her parents recognized the patient's red eyes as a sign of a problem. This allowed us to intervene early and avoid long-term sequelae. Our case highlights that corneal sensation should be assessed in patients developing corneal pathology following retinal laser procedures to allow for prompt recognition of NK. In patients who fail conservative treatment for NK, lateral tarsorrhaphy should be strongly considered to prevent further complications such as infection, corneal melting, or perforation. Prophylactic laser of asymptomatic retinal holes in the lattice may be considered controversial. Our patient had multiple risk factors for retinal detachment, and her developmental delay and autism limited her ability to verbalize ocular concerns. Considering these circumstances, prophylactic laser retinopexy was discussed with the family, and informed consent was obtained. Although NK was not specifically discussed as a not previously recognized complication in children, the ultimate outcome did not cause long-term sequelae. Furthermore, laser has proven successful at preventing severe vision loss from a retinal detachment with 4 years of follow-up. Finally, the risks and benefits of retinal lasers must be carefully weighed during an informed-consent process. Despite its potential risks, prophylactic laser retinopexy may be the most appropriate option in some complex patients, including pediatric patients in whom retinal detachment can have a poor prognosis. The authors have no proprietary or commercial interest in any materials discussed in this communication." @default.
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• W4229031103 title "Neurotrophic keratopathy following laser retinopexy for high myopia in an autistic child" @default.
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