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ARTICLE
Year : 1961  |  Volume : 9  |  Issue : 3  |  Page : 66-67

Two Cases of Neuroparalytic Keratitis Following Treatment of Trigeminal Neuralgia


Department of Ophthalmology, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication7-Apr-2008

Correspondence Address:
Lalit P Agarwal
Department of Ophthalmology, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Agarwal LP, Mohan M, Malik S. Two Cases of Neuroparalytic Keratitis Following Treatment of Trigeminal Neuralgia. Indian J Ophthalmol 1961;9:66-7

How to cite this URL:
Agarwal LP, Mohan M, Malik S. Two Cases of Neuroparalytic Keratitis Following Treatment of Trigeminal Neuralgia. Indian J Ophthalmol [serial online] 1961 [cited 2021 Mar 6];9:66-7. Available from: https://www.ijo.in/text.asp?1961/9/3/66/40277

Occurrence of corneal, degenera­tive changes following damage to triqeminal nerve were first described by Magendie in 1824. In the last few decades the incidence of neuro­paralytic keratitis has increased due probably to surgical treatment given for trigeminal neuralgia. The com­monly practised procedures being (1) Gasserian ganglionectomy (sen­sory root) by various approaches (2) Injection of procain for diag­nostic and temporary therapeutic value (3) Injection of alcohol into lower two divisions of the Gasserian qanglion as they emerge from the cranial cavity (4) Injection of alcohol in the root sheath of Gasserian ganglion by the lateral approach (Harris 1912) or direct approach (Hertel 1914).

The case reports that are being presented show the common error of leaving the eye unprotected after an attack on the Gasserian ganglion. The danger to the eye is further more increased if complications like involvement of the facial nerve occurs due to the above procedures. It is necessary, therefore, to lay stress on the desirability of pro­phylactic tarsorrhaphy to prevent damage to the cornea. The follow­ing case rep oris clearly bring home the inadvisibility of leaving the cornea unprotected.

Case 1. Bhurwan Devi, female, 50 yrs. attended dental clinic of a local hospital for severe pain in right upper premolar radiating towards the nose, in July, 1958. Scraraing of teeth and later extraction of right upper, right lower and left premolars was done one by one but without any relief. In August, 1960 alcohol injection was given by Hertel's method into foramen ovale. Immediately after the operation patient noticed flushing of the right side of the face, felt giddy and start­ed vomiting. These complaints last­ed for about a week when she dis­covered that she could not close her right eye and that fluid dribbled out from the right angle of the mouth. A week later she noticed dulling of sensation on the right side of the face. There was no history of trauma, fever or ear discharge. On examination : There was facial asymmetry with angle of the mouth drawn to the left and there was right lagophthalmos.

In the eye, patient had signs of healed trachoma and first degrees of cicatricial entropion of both upper lids. The bulbar conjunctiva of right eye was dry, lustreless and slightly congested. Cornea showed a central ulcer 3 mm. in diameter with surrounding area of haziness and vascularisation and marked circum-corneal congestion. The cornea was insensitive. In the anterior chamber hypopy on was seen filling the lower one third of the anterior chamber. iris was muddy and pupil small and sluggish.

Examination of cranial nerves showed complete paralysis of the sensory part of the 5th and complete involvement of the abdu­cent, Facial and Auditory nerves.

Note: "As a complication of ganglion block by alcohol injection, if the needle is pushed slightly deep into the skull the fluid is injected into the subarachinoid space. This will not only spill over the petrous tip, but also may diffuse into the lateral cistern and bathe the cranial nerves in the cerebellopontine angle affecting 6th, 7th and 8th nerves." Dandy 1929 Treatment :-Patient was given energetic routine treatment of ulcer along with Vit. A, Vit. B, and B12 for four days but the response was poor. Then a temporary central tarsorrhaphy was done and the hypopyon gradually absorbed and the condition was relieved, but it left a dense central leucoma.

Case II. Bhoo Devi, female, of 28 years, while sleeping one night suddenly developed pain in the right eye and noticed redness of the eye and diminution of vision in the morning, about one month back. This episode was not associated with any photophobia, lacrimation or discharge from the eye. During the past 3 years she used to have attacks of pain on the right side of the face which was aggravated by talking or by taking cold drink for which all her teeth were removed. This also did not relieve her of pain and was advised operation.

In September, 1960 she was ope­rated and trigeminal ganglionec­tomy of sensory part was done. This relieved her of all her pain and she became comfortable except that she could not close the eyes completely. On examination there was slight facial asymmetry with angle of the mouth drawn towards left side. There were signs of in­franuclear type of 7th nerve palsy and loss of sensation on the right side of the face. Eye examination revealed lagophthalmos, congestion of conjuctiva more marked in the limbal area. The surface of cornea was dull and an ulcer of about 4 mm. diameter was present in the centre surrounded by zone of haziness, of subsiantia propia. The cornea was insensitive. Treatment:-Patient res­ponded dramatically to tarsorrhaphy along with routine ulcer treatment.


  Summary Top


Two cases of trigeminal neuralgia treated on the surgical side by alcohol injection developed neuro­paralytic keratitis with hypopyon.. In one there was the added compli­cation of 6th, 7th and 8th nerve paralysis.

Tarsorrhaphy improved the ocular condition which shows the value of protective tarsorrhaphy in ganglion -surgery.[4]

 
  References Top

1.
Dandy, W. E. (1929) Arch of Surg. 18, 687-734.  Back to cited text no. 1
    
2.
Harris,- W. (1912) Lancet 1. 218-221.  Back to cited text no. 2
    
3.
Hartel, F. F. (1914) Deutsch Ztschr. Chir. 126, 429.  Back to cited text no. 3
    
4.
Magendie, J de Phys. (1824) 176. as quoted from Duke-Elder's Text-Book of Ophthalmology. Vol. II p. 1953.  Back to cited text no. 4
    




 

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