Updates on corneal neurotization surgery to enhance treatment of the neurotrophic cornea

Introduction: Although novel drugs are approved or under investigation, corneal neurotization (CN) represents the only curative surgical technique for neurotrophic keratopathy (NK). Areas covered: Characteristics and outcomes of all clinical studies focused on CN, putting the light on surgical procedure, technical refinements, donor nerve selection and timing of the surgery. Expert opinion: The choice of direct versus indirect approach and the selection of donor nerve should be reached according to patient condition, surgeon experience, equipment and interdisciplinary team availability. In selected cases, processed nerve allografts may allow shorter operative time, smaller surgical team and earlier sensation recovery but the risk of failure in longer gaps and issues related to cost, availability and storage should be considered. The endoscopic approach could provide advantages over both direct CN for the lower invasiveness and indirect CN for the avoidance of donor site morbidity; however, the steep learning curve and the risk of isolating an inadequate nerve length have limited its adoption. Ideally, CN should be considered after the failure of conservative treatments but before the formation of irreversible corneal opacity. Future studies should explore novel noncontact methods for evaluating corneal sensitivity and the synergistic use of neurotrophic factors for enhancing postoperative nerve regeneration.