Conjunctival Limbal Grafts Research Articles

Pseudopterygium After Limbal Dermoid Cyst Excision in a Child with Goldenhar Syndrome

Introduction : Goldenhar syndrome is a rare congenital disorder also known as oculoauricularvertebral dysplasia. Limbal dermoid associated with this syndrome. This case report aims to present an reccurent pseudopterygium after three times limbal dermoid cyst excision in patient with Goldenhar syndrome.
 Case Illustration : Patient 13 years old male with pseudopterygium in right eye. Visual acuity both eyes 6/6 snellen chart. Fibrovascular tissue from tarsal conjunctival inferotemporal to 2 mm limbal cornea in right eye. Patient had limbal dermoid cyst in right eye since birth and underwent limbal dermoid cyst excision for three times. First time surgery used amniotic membrane transplantation, then second and third surgery used conjunctival limbal graft. Goldenhar syndrome have been diagnosed since the age of 2 years old. External examination noticed asymmetrical hemifacial microsmia, grade III microtia right ear, conduction deafness, and laryngomalacia.
 Discussion : Limbal dermoid cyst is one of characteristic of Goldenhar syndrome. In this case pseudopterygium grade II in right eye developed after limbal dermoid cyst excision for three times. Limbal dermoid simple excision may lead to corneal vascularization persistent epithelial defect, scar, and pseudopterygium. Various surgical include superficial keratectomy, amniotic membrane transplantation and lamellar or penetrating keratoplasty. Pseudopterygium still occurs in this case, even though recurrence has been prevented by administration of amniotic membrane transplantation and conjunctival limbal graft.
 Conclusion : We should be concerned about management of limbal dermoid cyst with Goldenhar syndrome to prevent recurrent pseudopterygium.

A randomized clinical trial of freeze-dried amniotic membrane transplantation and conjunctival-limbal graft for pterygium excision and evaluation of conjunctival inflammation marker in tears

BACKGROUND Minimizing inflammation on the ocular surface after pterygium surgery is essential to prevent recurrence. Currently, limited data are available for the comparison between freeze-dried amniotic membrane (FD-AM) and conjunctival–limbal graft (CLG). Therefore, this study aimed to assess conjunctival inflammation and the interleukin (IL)-6 levels in tears after pterygium excision between both techniques.
 METHODS This prospective, single-blinded, randomized clinical trial included 26 eyes of 26 patients with primary or recurrent pterygium and who were indicated for pterygium surgery at Cipto Mangunkusumo Hospital, Indonesia from October 2017 until February 2018. The patients were scheduled for pterygium excision with FD-AM or CLG based on block randomization. Conjunctival inflammation and the level of IL-6 in tears were measured on day-7 and -28 after surgery.
 RESULTS The 26 eyes (13 in each group) were subjected to a complete 1-month follow-up period. Day-7 after the surgery, severe inflammation occurred in 4/13 (31%) eyes having FD-AM and 8/13 eyes (62%) having CLG (p = 0.59). The IL-6 tear level increased similarly in FD-AM (22.85 pg/ml) and CLG (23.51 pg/ml) in (p = 0.78). No severe adverse events occurred.
 CONCLUSIONS Pterygium excision using FD-AM yield a milder inflammation than CLG on day-7 and -28 after surgery. The tear IL-6 levels similarly increased on day-7.

Evolution of techniques of limbal stem cell transplantation for restoration of ocular surface in ocular surface disorder with limbal stem cell deficiency

Purpose: Evolution of techniques of limbal stem cell transplantation for restoration of ocular surface in ocular surface disorder with limbal stem cell deficiency. Materials and Methods: It is an observational study in which 32 eyes of LSCD were observed with different surgical techniques. Outcome parameters were evaluated in terms of visual acuity, corneal clarity, symblepharon score, vascularisation. Statistical analysis was done using Annova t-test with significance level P ( Result: The mean preoperative logMAR best-corrected visual acuity (BCVA) in CLAU, SLET, KLAU, and KLAL were 2.150.70, 2.700.20, 2.750.22 and 2.800.11 respectively which improved to 1.250.50, 2.000.42, 2.010.15 and 2.300.18 respectively after 6 months of follow up. Improvement in structural parameter were also seen in different surgical techniques. Conclusion: Patients in which CLAU and SLET technique were used, had shown better improvement in Visual and structural outcome as compared to those in which KLAU and KLAL technique were used. Keywords: Limbal stem cell deficiency (LSCD), Limbal stem cell transplantation (LSCT) Auto conjunctival limbal graft (CLAU), Simple limbal epithelial transplantation (SLET), Keratolimbal autograft (KLAU), Keratolimbal allograft (KLAU), Amniotic membrane transplant (AMT).

Autologous Blood Versus Suture Conjunctival Limbal Graft as Pterygium Surgery Treatment


 
 
 Introduction and Objective: 
 A Pterygium is an elevated, superficial, external ocular mass that usually forms over the perilimbal conjungtiva and extends onto the corneal surface. A Pterygium can cause a significant alteration in visual function in advanced cases. It become inflamed, resulting in redness and ocular irritation. Pterygium excision surgery has been using many methods. There are three choices of method to attach the graft: by suturing, fibrin glue or autologous blood. The purpose of this study is to learn about the efficacy of autologous blood versus suturing conjungtival limbal graft (CLG) on pterygium excision surgery 
 Methods: 
 Retrospective study of 18 patients underwent Pterygium excision surgery with autologous blood gluing compared to suturing the graft. Six patients underwent CLG surgery with suturing and 12 patients were treated with autologous blood gluing. Suturing process was done with nylon 10-0 and the suture was released 7 days after surgery, whereas the graft on the patient with autologous blood CLG was placed and left there for about 10 minutes. Both groups were evaluated after day 1, 1st week, 2nd week and 1st month. Any report of irritating sensation, graft loss, and healing process were recorded thoroughly. Result: 
 Patients with sutured CLG were complaining of uncomfortable sensation on their cornea until one week before suture was released, all grafts were attached until a month. Out of 12 patients with autologous blood CLG method, there were no complain of irritability on cornea until a week, 4 patients lost the graft on the first day, two patients grew granuloma on the second week, 10 patients start healing on the second week. 
 Conclusion: 
 There are still limitations to pterygium excision with autologous blood CLG compared to pterygium excision with CLG suture technique. 
 
 

Conjunctival-limbal autograft in total unilateral limbal stem cell deficiency

Background : Corneal epithelium is renewed by stem cells (SC) that reside at the corneal limbus. Reduced number of SC or their abnormal function lead to the ocular surface disease called limbal stem cell deficiency (LSCD), characterized by corneal conjunctivalization, vascularization, persistent epithelial defects, chronic inflammation, and loss of vision. In a case of total unilateral LSCD, autologous transplantation of limbal epithelial stem cells (LESC) from the healthy eye is needed. We describe the surgical technique of choice for autologous limbal transplantation, called conjunctival limbal autograft (CLAU) that we combined with amniotic membrane (AM) use. We present the results of CLAU in three patients with total unilateral LSCD due to chemical injury. Methods : Autologous limbal transplantation CLAU begins with the removal of fibrovascular pannus from the diseased corneal surface and the harvesting of two conjunctival-limbal grafts from the healthy eye. The grafts are then transplanted on to the limbal area of the recipient eye. AM is used as a patch to cover the denuded cornea and limbal grafts, as well as a barrier preventing the conjunctival epithelium from encroaching on to the temporal and nasal side of the corneal surface. In the donor eye, AM is used to cover the donor sites. CLAU with the use of AM was performed in 3 patients with unilateral LSCD due to chemical eye injury. In one patient limbal transplantation was combined with symblepharon lysis for entropium repair. In all cases AM was removed 3–6 days postoperatively to assess the growth of new epithelium from the limbal grafts. In all patients the ocular surface was covered with another AM until the cornea was completely epithelized and the new epithelium stable. In one patient the corneal regrafting and cataract removal was performed subsequently. Results : CLAU was successful in 2 patients and partially successful in 1 patient during the follow up. In all cases the growth of new epithelium from the limbal grafts was noted on day 3–6 after CLAU. The cornea was completely epithelized within 2 weeks in 2 patients and after 35 days in one patient. In two patients the corneal epithelium remained clear, smooth and stable during the follow up of 3.5 years and 4 months, respectively. In one patient, uneven epithelium probably representing a mosaic of corneal and conjunctival cells was noted in the central corneal region, where a small corneal ulcer developed 5 months after CLAU. In donor eyes no postoperative complications were noted, the donor sites epithelized within few days. Conclusions : Autologous limbal transplantation according to CLAU surgical technique combined with the use of AM is a successful and safe therapy for restoring corneal surface in total unilateral LSCD after chemical injury. It enables further surgical procedures for restoring the vision such as corneal transplantation and cataract surgery.

Avtologni veznično-limbalni presadek pri enostranskem popolnem pomanjkanju limbalnih epitelnih matičnih celic

Background: Corneal epithelium is renewed by stem cells (SC) that reside at the corneal limbus. Reduced number of SC or their abnormal function lead to the ocular surface disease called limbal stem cell deficiency (LSCD), characterized by corneal conjunctivalization, vascularization, persistent epithelial defects, chronic inflammation, and loss of vision. In a case of total unilateral LSCD, autologous transplantation of limbal epithelial stem cells (LESC) from the healthy eye is needed. We describe the surgical technique of choice for autologous limbal transplantation, called conjunctival limbal autograft (CLAU) that we combined with amniotic membrane (AM) use. We present the results of CLAU in three patients with total unilateral LSCD due to chemical injury.Methods: Autologous limbal transplantation CLAU begins with the removal of fibrovascular pannus from the diseased corneal surface and the harvesting of two conjunctival-limbal grafts from the healthy eye. The grafts are then transplanted on to the limbal area of the recipient eye. AM is used as a patch to cover the denuded cornea and limbal grafts, as well as a barrier preventing the conjunctival epithelium from encroaching on to the temporal and nasal side of the corneal surface. In the donor eye, AM is used to cover the donor sites. CLAU with the use of AM was performed in 3 patients with unilateral LSCD due to chemical eye injury. In one patient limbal transplantation was combined with symblepharon lysis for entropium repair. In all cases AM was removed 3–6 days postoperatively to assess the growth of new epithelium from the limbal grafts. In all patients the ocular surface was covered with another AM until the cornea was completely epithelized and the new epithelium stable. In one patient the corneal regrafting and cataract removal was performed subsequently.Results: CLAU was successful in 2 patients and partially successful in 1 patient during the follow up. In all cases the growth of new epithelium from the limbal grafts was noted on day 3–6 after CLAU. The cornea was completely epithelized within 2 weeks in 2 patients and after 35 days in one patient. In two patients the corneal epithelium remained clear, smooth and stable during the follow up of 3.5 years and 4 months, respectively. In one patient, uneven epithelium probably representing a mosaic of corneal and conjunctival cells was noted in the central corneal region, where a small corneal ulcer developed 5 months after CLAU. In donor eyes no postoperative complications were noted, the donor sites epithelized within few days.Conclusions: Autologous limbal transplantation according to CLAU surgical technique combined with the use of AM is a successful and safe therapy for restoring corneal surface in total unilateral LSCD after chemical injury. It enables further surgical procedures for restoring the vision such as corneal transplantation and cataract surgery.

Amniotic membrane transplantation: Current indications in a tertiary eye hospital of eastern Nepal.

Amniotic membrane has unique properties that can be helpful to treat different ocular surface diseases. To report our experience with 100% glycerol preserved amniotic membrane at 4°C and fresh amniotic membrane transplantation (AMT) with and without limbal graft for ocular surface reconstruction. Retrospective case study of 211 eyes of 211 patients was conducted at Biratnagar Eye Hospital from June 2008 to March 2014. The cases were evaluated in terms of demographic parameters, preoperative diagnosis and the type of surgery performed. The most common indication for surgery was Pterygium (90 eyes, 42.65%), followed by symblepharon (57 eyes, 27.01%), chemical injury (35 eyes, 16.58%), socket reconstruction (9 eyes, 4.26%), shield ulcer (6 eyes, 2.84%), PED (4 eyes, 1.89%), Steven Jonson's syndrome (5 eyes, 2.36%), dry Eye (2 eyes, 0.94%), Corneal Degeneration (2 eyes, 0.94%), bullous keratopathy (1 eye, 0.47%). The mean age was 28.12 ±17.2 years (age range 3-78 years). More men (161, 76.30%) underwent surgery than women (50 eyes, 23.69%). Symblepharon (24 eyes, 36.36%) was the major cause of surgery in pediatric group. The mean follow-up was 7 months (range 2-36, months). Resurgery was needed in (18 eyes, 8.53%) of which symblepharon (7eyes, 39%) was the major cause. AMT was done in 189 (89.57%) eyes and AMT with conjunctival limbal graft was done in 22(10.42 %) cases. Infectious, inflammatory, or allergic reactions were not encountered in any patient. All patient experienced increased ocular comfort with anatomical restoration of corneal and conjunctival surfaces. AMT alone or in combination with limbal graft aids in ocular surface reconstruction.

Removal of Tenon fortified by conjunctival-limbal autograft in treatment of pterygium.

To describe a simple and effective technique for the prevention of pterygium recurrence. This is a retrospective consecutive single-center case series with recurrence rate as the main outcome measure. Dissection of the conjunctiva, the Tenon's layer, and the sclera was continued up to the insertion of medial rectus. The exposed Tenon's layer was excised for 2 to 3mm. The entire free edges of the conjunctiva was tacked firmly to the sclera. The conjunctival-limbal graft was sutured firmly to the sclera, recipient limbus, and to the conjunctiva incorporating the reciprocal edges. We report findings in a total of 36 patients, with 20 (%55.5) males and 16 (%44.4) females. Median age of the patients was 44.5years (range 16-80). The mean follow-up period was 23.1±6.5months. The mean size of pterygium in mm length was 3.8±0.7. Recurrence did not occur in any patient. Diplopia was not reported by any patients. Conjunctival-limbal autograft combining with selective exicison of Tenon's layer but without damage to any essential tissue such as the semilunar fold or Tenon's capsule pulley is a relatively simple and effective procedure.

Conjunctival Limbal Autograft and Allograft Transplantation Using Fibrin Glue

Conjunctival limbal autograft is the surgical treatment of choice for visually significant unilateral limbal stem cell deficiency. The use of fibrin glue, which has been reported extensively in pterygium and other conjunctival surgeries, has not been fully described in limbal stem cell transplantation. The authors reviewed 3 cases of conjunctival limbal autograft and 1 of living related conjunctival limbal allograft using only fibrin glue to secure the graft. Main outcome measures included ocular surface stability, visual acuity, and postoperative complications. At most recent follow-up, all 4 patients (100%) maintained a stable ocular surface. Mean epithelial healing time was 10 days. Mean visual acuity improved from 20/400 to 20/53. All grafts were successful with no postoperative dislocations or displacements. The findings demonstrate that fibrin glue can be used safely and effectively to secure conjunctival limbal grafts in limbal stem cell deficiency. This novel approach has the potential to decrease operative time, increase ease of technique, and improve patient comfort postoperatively.

Survival Analysis of Conjunctival Limbal Grafts and Amniotic Membrane Transplantation in Eyes With Total Limbal Stem Cell Deficiency

To evaluate the survival of conjunctival limbal grafts and amniotic membrane transplantation (AMT) for total limbal stem cell deficiency (LSCD) and the influence of several parameters as cause of LSCD, dry eye, keratinization, eyelid abnormalities, HLA compatibility, systemic immunosuppression, and keratoplasty (PKP) on surgical outcome. Prospective, noncomparative, interventional case series. Thirty-three eyes of 31 patients with total LSCD that underwent conjunctival limbal grafts and AMT at the Department of Ophthalmology, Federal University of São Paulo were included in this study. Cumulative graft survival as well as the influence of several variables on surgical outcome was analyzed. Ten eyes (30%) underwent conjunctival limbal autograft and 23 (70%) underwent conjunctival limbal allograft from living HLA-matched donor. Graft survival was seen in 13 eyes (40%) at 1 year and in 11 eyes (33.3%) at 2 years, with a cumulative survival of 33% after a mean follow-up time of 33 months. Increase in postoperative visual acuity was observed in 20 eyes (60.6%) during this period. Marked impact on graft survival was observed for patients with Stevens-Johnson syndrome, dry eye, keratinization, eyelid abnormalities, and allogeneic conjunctival limbal transplantation (independently of HLA compatibility) (P < .05). Preoperative dry eye was the most important prognostic parameter for surgical outcome (P < .001). Conjunctival limbal grafts associated with AMT are useful for restoring corneal epithelium phenotype in eyes with total LSCD. However, the cumulative survival declines substantially over a 2-year period. Considering all investigated variables, dry eye was the most important prognostic parameter.

Amniotic membrane transplantation with conjunctival limbal autograft for total limbal stem cell deficiency

Purpose To evaluate the outcomes of corneal surface reconstruction with conjunctival limbal autograft when combined with amniotic membrane transplantation on both the donor and recipient eyes. Design Retrospective, noncomparative, interventional small case series. Participants Five eyes of five patients with total limbal stem cell deficiency (LSCD) resulting from pseudopemphigoid (n = 1), chemical burns (n = 3), and extensive removal of conjunctival intraepithelial neoplasia (n = 1) were operated on by one surgeon (SCGT). Intervention After the removal of fibrovascular pannus from the corneal surface, two conjunctival limbal free grafts were harvested from the fellow eyes in all five patients with unilateral LSCD. Amniotic membrane, with the basement membrane side up, was grafted onto the defect created at the donor site and onto the recipient corneal and limbal sclera before placement of conjunctival limbal grafts. Main outcome measures Symptomatic relief, improvement in visual acuity, fornix deepening, and rapid healing and restoration of normal cornea and limbus in the recipient and donor eyes were assessed. Results During the mean follow-up of 22 months (range, 11–48 months), all eyes experienced symptomatic relief. All recipient eyes had a mean improvement in visual acuity of nine lines (range, 7–12). The three eyes with stromal vascularization showed regression, and all recipient eyes had marked improvement in corneal clarity. Three eyes receiving simultaneous symblepharon lysis and fornix reconstruction successfully regained deep, stable fornices. The donor eyes showed rapid healing and restoration of the normal limbal landmark, even in one eye where nearly the entire limbus was removed. Conclusions Limbal conjunctival transplantation is an effective procedure for restoring the corneal surface integrity in eyes with total LSCD. The additional use of amniotic membrane may contribute to a higher rate of success in the recipient eye and a lower rate of complications in the donor eye, as well as allow the simultaneous correction of concomitant cicatricial abnormalities.