Adnexal Surgery in Patients Undergoing Ocular Surface Stem Cell Transplantation

Abstract

To examine the role of adnexal disease and surgery in the outcome of ocular surface stem cell transplantation. Retrospective, noncomparative case series. Twenty-two patients (23 eyes) with severe corneal stem cell deficiency undergoing ocular surface stem cell transplantation. Consecutive cases of stem cell grafting for ocular surface disease over a 6-year period at a single institution were studied. Main outcome measures were 2-fold: (1) nature of eyelid, fornix, and lacrimal abnormalities encountered; indications for treatment; methods; and outcome of adnexal surgery; (2) stem cell allograft success with respect to underlying disease, indication for stem cell grafting, preoperative adnexal involvement, and adnexal surgery after stem cell grafting. Twenty-nine limbal stem cell grafts on 23 eyes of 22 patients were identified during the study. Seventeen ex vivo expanded stem cell allografts, 11 keratolimbal allografts, and 1 living-related donor limbal allograft were performed, with combined stem cell techniques used in 5 patients. Median follow-up was 26.5 months (standard deviation, 18.6 months). Overall, stem cell graft success at final review was 69%. Thirty-four percent (10/29) of cases had eyelid involvement and 41% (12/29) had fornix involvement at the time of stem cell grafting. Trichiasis and symblepharon were the most common abnormalities. Fornix involvement was associated with a 50% chance of stem cell graft failure. After stem cell grafting, 66% (19/29) of cases required adnexal surgery. This was for lagophthalmos in 11 cases (46%), eyelid malposition in 7 cases (23%), fornix shortening in 5 cases (19%), and punctal patency in 8 cases (31%). Punctal patency and lagophthalmos frequently required repeated procedures for successful correction. Epithelial healing promptly followed correction of the adnexal abnormality with surgery; however, the need for adnexal surgery was associated with a 50% chance of stem cell graft failure. Concurrent adnexal abnormalities are associated with worse graft outcomes after stem cell transplantation and can compromise epithelial healing if uncorrected. Surgery for eyelid malposition and closure is essential before and after transplantation for surface epithelial integrity and often requires multiple procedures. The author(s) have no proprietary or commercial interest in any materials discussed in this article.