A case report of exposure and neurotrophic keratopathy after acoustic neuroma

A case report of exposure and neurotrophic keratopathy after acoustic neuroma surgery resulting in perforation if not managed appropriately and timely is presented. benign tumours which constitute more than 90% of all cerebellopontine angle tumours and more than 10% of all primary brain tumours. Surgical excision of these tumours is one of the most Torisel challenging neurosurgical procedures because of their location close to vital structures such as the anterior inferior cerebellar artery (AICA) or the 7th and 8th cranial nerves [1]. When the tumour exceeds 3?cm it might involve the trigeminal nerve causing a depressed corneal reflex which Torisel is accompanied by peripheral facial nerve paresis leading to the development of exposure and neurotrophic keratopathy. This condition especially with poor Bell’s phenomenon is usually resistant to conventional therapies and has a very unfavourable prognosis. Loss of the sensory innervation of the cornea decreased the number of corneal stem cells [2] decreased metabolic and mitotic rates in the corneal epithelium and reduced acetylcholine and choline acetyltransferase concentrations [3 4 resulting in the development of persistent epitheliopathy. This chronic epithelial breakdown enables proteolytic enzymes to degrade the extracellular matrix components because they cannot protect corneal structural and signaling matrix proteins anymore. This condition may progress to corneal ulceration perforation and loss of the eye. The ophthalmic goal of treatment is to protect the cornea from external irritating factors to stop its progressive degradation and to support its healing. 2 Case Report The patient was a 64-year-old female with a 4-year history of exposure and neurotrophic keratopathy in the right eye due to unresolved peripheral facial nerve and trigeminal nerve palsies after acoustic neuroma surgery. The patient underwent bilateral cataract surgery at the age of 61 and except for mild hypertension remained healthy. After 2 years of satisfactory treatment of lagophthalmos with a gold eyelid weight it was necessary to remove the weight from the right upper eyelid in order to perform an MRI scan. Despite the use of moisturizing drugs and eye taping severe corneal ulcer developed 6 months after the removal of the weight. After 2 months of ineffective conservative treatment the patient was referred to our clinic. On admission the corrected distance visual acuity (CDVA) was 0 1 (Snellen chart) and intraocular pressure (IOP) was 14?mmHg in the right eye. CDVA was 1 0 in the left eye. Peripheral right facial nerve palsy lagophthalmos of 5 millimetres with paralytic ectropion poor Bell’s phenomenon and complete corneal anaesthesia were noted in the right eye. Slit lamp examination revealed ulceration with descemetocele in the lower part of the cornea in the right eye. The intraocular lens (IOL) was in place TLR1 and other ocular structures and the left eye were without any pathological changes. Urgent amniotic membrane transplant (AMT) and complete tarsorrhaphy were performed in the right eye. The patient was discharged home on topical 0 5 levofloxacin and was followed-up in an outpatient clinic. 15 days after initial clinical improvement and partial removal of the tarsorrhaphy sutures the patient came to our emergency room with a corneal perforation in the right eye (Figure 1(a)). The Torisel patient noticed vision deterioration and admitted to having touched her cornea during the instillation of the eye drops. The patient Torisel was admitted to our clinic. Urgent inferiorly decentred penetrating keratoplasty was performed ([5] Figure 1(b)) due to the size of the perforation its localisation and vascularisation of the lower limbus. A new 1 8 of gold weight (safe for MRI) was placed in the pretarsal space of the right eye and a correction of the paralytic ectropion was performed. Triple systemic immunosuppression (cyclosporine A mycophenolate mofetil and prednisone) was administered. After 1 month the gold weight was extruded from the scarred tissue of the right upper eyelid (Figure 1(c)). Despite eye taping systemic immunosuppression and visually normal upper limbus no reepithelialization was noted. Graft rejection with.