Corneal Neurotization, Recent Progress and Future Perspectives

Neurotrophic keratopathy (NK) is a rare degenerative disease caused by trigeminal nerve impairment, leading to corneal anesthesia, epithelial breakdown, and progressive vision loss. NK produces damage through the lack of pain. Conventional treatments focus on symptom management and preventing complications but do not address the underlying nerve dysfunction. Corneal neurotization (NT) has emerged as a promising surgical intervention aimed at restoring corneal sensation and improving ocular surface homeostasis. This review examines the outcomes of corneal neurotization in NK patients, while also comparing the effectiveness of direct (DNT) and indirect (INT) techniques. Studies report significant improvement in corneal sensitivity, with success rates ranging from 60.7% to 100% (average ~90%). Most patients showed corneal sensation recovery, as measured by the Cochet–Bonnet aesthesiometer. No significant differences were found between DNT and INT outcomes. Indirect neurotization with a sural nerve graft was the most performed procedure (63% of cases), with acellular allografts demonstrating comparable efficacy while simplifying the technique. Postoperative corneal sensitivity improved significantly from a preoperative average of 2.717 mm to 36.01 mm, with reinnervation occurring within 4–6 months and peaking at 12 months. In vivo confocal microscopy confirmed nerve regeneration. Neurotization was safe, with minimal donor-site complications, typically resolving within one year. While corneal neurotization enhances corneal sensation and tear film stability, visual acuity outcomes remain variable, influenced by pre-existing corneal damage. Early intervention is recommended to prevent irreversible scarring. Further studies with larger sample sizes are needed to refine surgical techniques and optimize patient selection, ensuring the best possible outcomes for NK patients.