Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Corneal Sensation: A Test Not to Omit

Corneal Sensation: A Test Not to Omit Anesthetic cornea causing neurotrophic keratitis is frequently missed when it presents early. It is important to check corneal sensation in any corneal defect, especially when there are no predisposing risk factors. Report of a case A 77-year-old male patient was referred to the eye casualty department. Examination showed a right corneal abrasion, laxity at the medial aspect of the right lower lid with no evidence of corneal exposure, and a good Bell phenomenon. There was no history of trauma or viral illness. Follow-up was organized for the abnormal lid position. The patient was still symptomatic and returned to the eye casualty department. The corneal defect was enlarged (Figure 1). Examination revealed a right, lower motor neuron seventh nerve palsy, prompting testing of corneal sensation, which was absent. In addition, there was no abduction of the right eye and lack of adduction of both eyes, consistent with one-and-a-half syndrome. There was no further neurological abnormality. Figure 1. View LargeDownload Anterior segment photograph showing the persistent epithelial defect, with smoothed rolled edges and lower lid ectropion secondary to the lower motor neuron seventh nerve palsy. His medical history disclosed heavy smoking and, over the previous 9 months, he had hemoptysis and significant weight loss. A radiograph of the chest showed a large left mediastinal mass (Figure 2). A computed tomographic scan of the brain showed a well-circumscribed mass lesion in the pons, explaining the gaze palsy (Figure 3). Histologic results from bronchoscopy subsequently revealed squamous cell carcinoma. Eight weeks after the initial presentation to the eye casualty department, he died of secondary bronchopneumonia. Figure 2. View LargeDownload Chest radiograph showing a large left mediastinal mass. Figure 3. View LargeDownload Computed tomographic scan of the brain showing a well-circumscribed mass lesion in the pons. Comment The trigeminal nerve is vital for maintaining corneal homeostasis and normal wound healing. Sensory denervation at any point along the nerve leads to reduced or absent corneal sensation, causing neurotrophic keratitis, which is not common but can be sight threatening.1,2 Acquired causes of reduced or absent corneal sensation include viral infection (herpes simplex and herpes zoster keratitis), chemical injury (including topical anesthetic abuse), trauma, fifth nerve compressive lesions, diabetes mellitus, corneal surgery, and leprosy.2,3 Cerebellopontine angle tumors need to be excluded since lack of corneal sensation can be the first sign of these lesions.4-6 Corneal sensation can often be reduced in the presence of an ulcer without neurotrophic keratitis. It is critical to test sensation of the upper cornea in an unaffected area and compare with the contralateral side. Checking sensation in any corneal defects is essential, especially where there are no predisposing risk factors, because absent corneal sensation is a sinister sign. Back to top Article Information Correspondence: Dr Kyprianou, Birmingham and Midland Eye Centre, Dudley Road, Birmingham B18 7QH, England (i_kyprianou@hotmail.com). Author Contributions:Study concept and design: Kyprianou and Tsaluomas. Acquisition of data: Jacks. Analysis and interpretation of data: Kyprianou, Mollan, Tsaluomas, and Jacks. Drafting of the manuscript: Kyprianou and Mollan. Critical revision of the manuscript for important intellectual content: Mollan, Tsaluomas, and Jacks. Administrative, technical, and material support: Kyprianou, Mollan, and Jacks. Study supervision: Tsaluomas. Financial Disclosure: None reported. References 1. Mackie IA Role of the corneal nerves in destructive disease of the cornea. Trans Ophthalmol Soc U K 1978;98343- 347PubMedGoogle Scholar 2. Chen HJPires RFTseng S Amniotic membrane transplantation for severe neurotrophic corneal ulcers. Br J Ophthalmol 2000;84826- 833PubMedGoogle ScholarCrossref 3. Bonini SRama POlzi DLambiase A Neurotrophic keratitis. Eye 2003;17989- 995PubMedGoogle ScholarCrossref 4. Jindra LFRicci AJ Keratitis in an old man with brain metastases. Hosp Pract (Off Ed) 1984;1932R, 32XPubMedGoogle Scholar 5. McCurrach FHurley ITaylor H Chronic corneal ulceration: an unusual presentation of metastatic breast carcinoma. Aust N Z J Ophthalmol 1993;21191- 192PubMedGoogle Scholar 6. Ibanez Flores NSanz Moreno S Bilateral neurotrophic keratitis secondary to encephalic trunk metastasis. Arch Soc Esp Oftalmol 2002;77681- 684PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Neurology American Medical Association

Loading next page...
 
/lp/american-medical-association/corneal-sensation-a-test-not-to-omit-9V0Wns8Vbi
Publisher
American Medical Association
Copyright
Copyright © 2006 American Medical Association. All Rights Reserved.
ISSN
0003-9942
eISSN
1538-3687
DOI
10.1001/archneur.63.11.1656
Publisher site
See Article on Publisher Site

Abstract

Anesthetic cornea causing neurotrophic keratitis is frequently missed when it presents early. It is important to check corneal sensation in any corneal defect, especially when there are no predisposing risk factors. Report of a case A 77-year-old male patient was referred to the eye casualty department. Examination showed a right corneal abrasion, laxity at the medial aspect of the right lower lid with no evidence of corneal exposure, and a good Bell phenomenon. There was no history of trauma or viral illness. Follow-up was organized for the abnormal lid position. The patient was still symptomatic and returned to the eye casualty department. The corneal defect was enlarged (Figure 1). Examination revealed a right, lower motor neuron seventh nerve palsy, prompting testing of corneal sensation, which was absent. In addition, there was no abduction of the right eye and lack of adduction of both eyes, consistent with one-and-a-half syndrome. There was no further neurological abnormality. Figure 1. View LargeDownload Anterior segment photograph showing the persistent epithelial defect, with smoothed rolled edges and lower lid ectropion secondary to the lower motor neuron seventh nerve palsy. His medical history disclosed heavy smoking and, over the previous 9 months, he had hemoptysis and significant weight loss. A radiograph of the chest showed a large left mediastinal mass (Figure 2). A computed tomographic scan of the brain showed a well-circumscribed mass lesion in the pons, explaining the gaze palsy (Figure 3). Histologic results from bronchoscopy subsequently revealed squamous cell carcinoma. Eight weeks after the initial presentation to the eye casualty department, he died of secondary bronchopneumonia. Figure 2. View LargeDownload Chest radiograph showing a large left mediastinal mass. Figure 3. View LargeDownload Computed tomographic scan of the brain showing a well-circumscribed mass lesion in the pons. Comment The trigeminal nerve is vital for maintaining corneal homeostasis and normal wound healing. Sensory denervation at any point along the nerve leads to reduced or absent corneal sensation, causing neurotrophic keratitis, which is not common but can be sight threatening.1,2 Acquired causes of reduced or absent corneal sensation include viral infection (herpes simplex and herpes zoster keratitis), chemical injury (including topical anesthetic abuse), trauma, fifth nerve compressive lesions, diabetes mellitus, corneal surgery, and leprosy.2,3 Cerebellopontine angle tumors need to be excluded since lack of corneal sensation can be the first sign of these lesions.4-6 Corneal sensation can often be reduced in the presence of an ulcer without neurotrophic keratitis. It is critical to test sensation of the upper cornea in an unaffected area and compare with the contralateral side. Checking sensation in any corneal defects is essential, especially where there are no predisposing risk factors, because absent corneal sensation is a sinister sign. Back to top Article Information Correspondence: Dr Kyprianou, Birmingham and Midland Eye Centre, Dudley Road, Birmingham B18 7QH, England (i_kyprianou@hotmail.com). Author Contributions:Study concept and design: Kyprianou and Tsaluomas. Acquisition of data: Jacks. Analysis and interpretation of data: Kyprianou, Mollan, Tsaluomas, and Jacks. Drafting of the manuscript: Kyprianou and Mollan. Critical revision of the manuscript for important intellectual content: Mollan, Tsaluomas, and Jacks. Administrative, technical, and material support: Kyprianou, Mollan, and Jacks. Study supervision: Tsaluomas. Financial Disclosure: None reported. References 1. Mackie IA Role of the corneal nerves in destructive disease of the cornea. Trans Ophthalmol Soc U K 1978;98343- 347PubMedGoogle Scholar 2. Chen HJPires RFTseng S Amniotic membrane transplantation for severe neurotrophic corneal ulcers. Br J Ophthalmol 2000;84826- 833PubMedGoogle ScholarCrossref 3. Bonini SRama POlzi DLambiase A Neurotrophic keratitis. Eye 2003;17989- 995PubMedGoogle ScholarCrossref 4. Jindra LFRicci AJ Keratitis in an old man with brain metastases. Hosp Pract (Off Ed) 1984;1932R, 32XPubMedGoogle Scholar 5. McCurrach FHurley ITaylor H Chronic corneal ulceration: an unusual presentation of metastatic breast carcinoma. Aust N Z J Ophthalmol 1993;21191- 192PubMedGoogle Scholar 6. Ibanez Flores NSanz Moreno S Bilateral neurotrophic keratitis secondary to encephalic trunk metastasis. Arch Soc Esp Oftalmol 2002;77681- 684PubMedGoogle ScholarCrossref

Journal

Archives of NeurologyAmerican Medical Association

Published: Nov 1, 2006

Keywords: cornea,sensory perception

References