Unilateral Limbal Stem Cell Deficiency Research Articles

Limbal graft transplantation: a rare implementation in pediatric limbal stem cell deficiency.

To evaluate limbal graft transplantation success in pediatric patients with chemical injury-induced limbal stem cell deficiency (LSCD) using the 'LSCD Working Group' staging system. Medical records of 11 eyes of 11 children who underwent limbal graft transplantation (limbal autograft/limbal allograft) were included. Surgical success was defined as improvement in the post-operative 1st year LSCD stage. The mean age was 12 ± 5 (4-17) years. Causative agent was alkaline in 4(36.4%) and acid in 3(27.2%) patients. Limbal autograft was performed in 9 (81.8%) eyes with unilateral LSCD, and allograft transplantation was performed in 2 (18.2%) eyes with bilateral LSCD. The mean follow-up time was 33.89 ± 30.73 (12-102.33) months. The overall limbal graft transplantation success rate was 72.7%. Among 9 patients who receive limbal autograft, 8 had improvement in post-operative LSCD stage, 1 had stable LSCD stage. Of the 2 patients who receive limbal allograft, post-operative LSCD stage remained the same in 1 and worsened in 1 patient. The mean time between injury and the surgery was 30.47 ± 30.08 (7-108.47) months. Penetrating keratoplasty was performed in 3 (27.2%) of 11 patients following limbal graft transplantation. Management of LSCD in children is challenging and appears to be somewhat different from that of adults. Limited data in the literature indicate that cultivated or simple limbal epithelial transplantations (CLET/SLET) are primarily preferred in children. Although the tendency to take small tissue from the healthy eye is noteworthy, conventional limbal allograft and autograft transplantations also show promising results without any further complications in at least 1year follow-up period.

Outcomes of Simple Limbal Epithelial Transplantation Without Amniotic Membrane Grafting in Unilateral Limbal Stem Cell Deficiency: A Case Series of 6 Patients.

This study describes the technique of simple limbal epithelial transplantation (SLET) without amniotic membrane grafting (AMG) in limbal stem cell deficiency (LSCD). Retrospective, interventional case series of 6 patients who underwent SLET without AMG were included. The procedure followed the standard technique, involving limbal biopsy from the healthy eye, resection of symblephera, and pannus dissection in the affected eye. Following host bed preparation, limbal explants were placed on the bare cornea and secured with fibrin glue. A large-diameter bandage contact lens was applied post surgery. No amniotic membrane was used. Preoperative data, including age, gender, cause of LSCD, best-corrected visual acuity, and previous ocular surgeries, were recorded. Postoperative clinical information, such as the duration of follow-up and recurrence of LSCD, best-corrected visual acuity, and other ocular examination findings, was recorded in an excel sheet. Preoperatively, 2 patients had total LSCD (secondary to a firecracker injury and excision biopsy for ocular surface squamous neoplasia). 4 patients had partial LSCD (3 chemical injuries, 1 firecracker injury). The mean age of participants was 30.67 ± 15.91 years, with a mean follow-up duration of 9.33 ± 8.04 months. Intraoperatively, all patients exhibited a smooth corneal surface after pannus removal. Postoperatively, all limbal explants remained securely attached, with complete corneal epithelialization achieved within 2 to 3 weeks. The ocular surface remained stable throughout, and no recurrence of LSCD was observed in any patient. No loss of explants was seen. The present series suggests that AMG may not be a necessary step for performing SLET.

Long-term ocular surface stability in conjunctivolimbal autograft and ocular surface safety in the donor eyes.

The current study is aimed to present the long-term results of the patients who underwent conjunctivolimbal autograft (CLAU) as the primary operation in unilateral limbal stem cell deficiency and the ocular surface safety of the donor eyes. The patients were followed up for fiveyears or longer. The records of all patients who underwent CLAU as the primary operation were retrospectively analyzed. Additional ocular surface operations, ocular surface stability, best-corrected visual acuity (BCVA), and ocular surface status of the donor eyes were investigated. The mean age of the patients at the time of transplantation was 35.07 ± 12.9 (12-60). Twenty-nine eyes of 29 patients were followed up for an average of 97.82 ± 34.45 (60-186) months. Additional ocular surface operation was required in 27.58% (8/29) of the eyes in order to achieve a stable ocular surface. Ocular surface stability was achieved in 82.75% (24/29) of the eyes at the end of the follow-up period. BCVA increased from 1.78 ± 0.82 to 0.91 ± 0.92 logMAR at the last visit (p < 0.001). Corneal ectasia and vascularization developed in one donor eye in the fifth postoperative year. CLAU tissues provide ocular surface stability with a successful vision result in the long term. CLAU theoretically carries risks including limbal stem cell deficiency in the donor eye. In the long-term follow-up of donor eyes after CLAU, ectasia and limbal stem cell deficiency were observed in one eye.

A Challenging Case of Simple Limbal Epithelial Transplantation (SLET) in Limbal Stem Cell Deficiency Following Chemical Injury: A Case Report

Introduction : Limbal stem cell deficiency (LSCD) often arises following trauma or inflammation that hinders corneal epithelium healing, commonly caused by chemical or thermal injuries. Despite significant advancements, treating LSCD remains challenging. This case highlights a challenging case of simple limbal epithelial transplantation (SLET) in LSCD following chemical injury.&#x0D; Case Illustration : A 20-year-old male presented with reduced vision in left eye following an alkaline chemical injury (grade III) was diagnosed with unilateral LSCD. Upon examination, conjunctivalization of the peripheral cornea, a central corneal cicatrix, and stromal neovascularization present after previous necrotomy, tenoplasty, and amniotic membrane transplantation (AMT). The patient then underwent SLET, with limbal biopsies from the collateral eye. Four months after surgery the visual acuity improved from 3/60 to 6/15 with spectacles. However, the cornea conjunctivalization still developed despite improved visual acuity.&#x0D; Discussion : To effectively manage the recurrence of stem cell deficiency, other stem cell transplantation techniques are needed to manage the problem. Combining different limbal stem cell transplantation approaches can be customised to address the problem and achieve lasting results.&#x0D; Conclusion : Prompt diagnosis and treatment of LSCD is crucial to prevent complications and blindness. SLET is a surgical option for LSCD after chemical injury, but this report highlights a challenging case and the need for the alternatives approaches.

Simultaneous simple limbal epithelial transplant and Descemet’s stripping automated endothelial keratoplasty for a case of presumed “Munchausen syndrome by proxy”: A novel surgical technique

We attempt to introduce the technique of the application of simple limbal epithelial transplantation (SLET) and Descemet stripping automated endothelial keratoplasty (DSAEK) in the same eye at the same sitting for a case of unilateral total limbal stem cell deficiency (LSCD) with endothelial decompensation and scarring. The operated eye showed significant healing within 6 months of the surgery. To our knowledge, this is the first case of unilateral total LSCD with endothelial decompensation and scarring managed by both SLET and DSAEK in the same eye.

Limbal Epithelial Stem Cells Transplantation in Cases with Unilateral Limbal Stem Cell Deficiency Syndrome

This review presents well-known surgical techniques aimed at the treatment of unilateral limbal insufficiency syndrome. Among the many available techniques, one should especially highlight the so-called “simple limbal epithelial transplantation”, which has proven to be an effective, safe and generally available method of treating unilateral limbal insufficiency syndrome (SLN). It should be noted that the risks of recurrence of SLN remain significant, and the mechanisms of engraftment of transplanted limbal epithelial stem cells on the recipient’s eye are not fully understood. The review also considers options for new promising approaches to the possible solution of existing problems in the transplantation of limbal epithelial stem cells.

Conjunctival Limbal Autograft Combined with Amnion-Assisted Conjunctival Epithelial Redirection for Unilateral Total Limbal Stem Cell Deficiency after Severe Chemical Burn.

(1) Background: To evaluate the efficacy of conjunctival limbal autograft (CLAU) combined with the amnion-assisted conjunctival epithelial redirection (ACER) procedure for patients with unilateral total limbal stem cell deficiency (LSCD) caused by severe chemical burn. (2) Methods: A retrospective interventional case series of unilateral total LSCD after chemical burn who underwent CLAU combined with ACER surgery between September 2021 and July 2023 was collected. Outcome measures included epithelialization of the cornea with donor limbus-derived epithelium, best corrected visual acuity (BCVA), and complications. (3) Results: Nine males and one female were included in this study. The mean age was 40.9 ± 9.63 (range, 26 to 55) years. The average duration between injury and CLAU combined with the ACER procedure was 7.67 ± 3.97 (range, 4 to 18) months. All patients achieved corneal epithelialization and improved BCVA. Postoperative complications occurred in four cases, including delayed corneal epithelial healing in one case, delayed amniotic membrane dissolution and detachment in two cases, and recurrence of symblepharon in one case. No complications were noted in the healthy donor eyes. (4) Conclusions: CLAU combined with ACER is a safe and effective treatment for unilateral total LSCD caused by severe chemical burn. This combined surgery restores visual function for patients with corneal blindness caused by chemical burn, reducing the burden on the families and society.

Cultivated autologous limbal epithelial cell (CALEC) transplantation: Development of manufacturing process and clinical evaluation of feasibility and safety.

To treat unilateral limbal stem cell (LSC) deficiency, we developed cultivated autologous limbal epithelial cells (CALEC) using an innovative xenobiotic-free, serum-free, antibiotic-free, two-step manufacturing process for LSC isolation and expansion onto human amniotic membrane with rigorous quality control in a good manufacturing practices facility. Limbal biopsies were used to generate CALEC constructs, and final grafts were evaluated by noninvasive scanning microscopy and tested for viability and sterility. Cultivated cells maintained epithelial cell phenotype with colony-forming and proliferative capacities. Analysis of LSC biomarkers showed preservation of "stemness." After preclinical development, a phase 1 clinical trial enrolled five patients with unilateral LSC deficiency. Four of these patients received CALEC transplants, establishing preliminary feasibility. Clinical case histories are reported, with no primary safety events. On the basis of these results, a second recruitment phase of the trial was opened to provide longer term safety and efficacy data on more patients.

Case Report: Simultaneous penetrating keratoplasty with autologous simple limbal epithelial transplantation as an alternative to keratoprosthesis

Introduction and importance: This case report highlights the multidisciplinary approach required to achieve successful anatomical and functional outcomes, in an eye with total limbal stem cell deficiency (LSCD) associated with underlying corneal scarring and thinning. Presentation of case: A 59-year-old gentleman had poor visual recovery in the right eye (RE) following accidental carbide blast, 1-year before presenting to us. The visual acuity was counting fingers and clinical examination revealed cicatricial entropion involving the upper eyelid, total LSCD, corneal scarring with a central descemetocele and cataract in the RE. Prior to ocular surface reconstruction, entropion correction was performed. Three months later, penetrating keratoplasty combined with cataract surgery and intraocular lens implantation (penetrating keratoplasty (PK) triple), with autologous simple limbal epithelial transplantation (SLET) was performed. The visual acuity was 20/100, 18 months after the surgery, with a clear well-epithelized corneal graft and stable ocular surface. Discussion: LSCD is caused by a decrease in the population and /or function of the limbal epithelial stem cells. Limbal stem cell transplantation (LSCT) is warranted in eyes with total LSCD. In eyes with coexisting corneal scarring, LSCT alone may be inadequate to restore the vision. These eyes require simultaneous or sequential lamellar or full-thickness corneal transplantation for visual rehabilitation. Though, the existing literature favors a sequential approach, where LSCT is performed first followed by corneal transplantation, under certain circumstances such as a thin underlying cornea like in our case, corneal transplantation may have to be combined with LSCT to achieve optimal outcomes. Conclusion: Combining autologous SLET with PK can be performed for visual rehabilitation in eyes with unilateral total LSCD and underlying corneal thinning. Corneal and limbal graft survival is prolonged if existing adnexal comorbidities are addressed before any surgical intervention is planned and adequate time interval is allowed for the surface inflammation to subside.

Case Report: Simultaneous penetrating keratoplasty with autologous simple limbal epithelial transplantation as an alternative to keratoprosthesis

Introduction and importance: This case report highlights the multidisciplinary approach required to achieve successful anatomical and functional outcomes, in an eye with total limbal stem cell deficiency (LSCD) associated with underlying corneal scarring and thinning. Presentation of case: A 59-year-old gentleman had poor visual recovery in the right eye (RE) following accidental carbide blast, 1-year before presenting to us. The visual acuity was counting fingers and clinical examination revealed cicatricial entropion involving the upper eyelid, total LSCD, corneal scarring with a central descemetocele and cataract in the RE. Prior to ocular surface reconstruction, entropion correction was performed. Three months later, penetrating keratoplasty combined with cataract surgery and intraocular lens implantation (penetrating keratoplasty (PK) triple), with autologous simple limbal epithelial transplantation (SLET) was performed. The visual acuity was 20/100, 18 months after the surgery, with a clear well-epithelized corneal graft and stable ocular surface. Discussion: LSCD is caused by a decrease in the population and /or function of the limbal epithelial stem cells. Limbal stem cell transplantation (LSCT) is warranted in eyes with total LSCD. In eyes with coexisting corneal scarring, LSCT alone may be inadequate to restore the vision. These eyes require simultaneous or sequential lamellar or full-thickness corneal transplantation for visual rehabilitation. Though, the existing literature favors a sequential approach, where LSCT is performed first followed by corneal transplantation, under certain circumstances such as a thin underlying cornea like in our case, corneal transplantation may have to be combined with LSCT to achieve optimal outcomes. Conclusion: Combining autologous SLET with PK can be performed for visual rehabilitation in eyes with unilateral total LSCD and underlying corneal thinning. Corneal and limbal graft survival is prolonged if existing adnexal comorbidities are addressed before any surgical intervention is planned and adequate time interval is allowed for the surface inflammation to subside.

Midterm Outcomes of Autologous Glueless Simple Limbal Epithelial Transplantation for Unilateral Limbal Stem Cell Deficiency.

The aim of this study was to report the midterm outcomes of glueless simple limbal epithelial transplantation (G-SLET) as a novel modification of limbal stem cell transplantation in patients with unilateral limbal stem cell deficiency (LSCD). This was a single-center, retrospective, interventional case series. Analysis of the 6 months interim outcomes was performed for 11 patients with unilateral LSCD who underwent G-SLET without simultaneous keratoplasty. The primary outcome measure was clinical success, which was defined as a completely epithelialized, avascular, and stable corneal surface. Secondary outcome measures included LSCD staging, improvement in visual acuity, and corneal grading of the recipient eye before and after the intervention. Adverse events were monitored throughout the study period. At 6-month follow-up, clinical success was achieved in 9 of the 11 cases (81.8%) and partial success was observed in 2 cases (18.2%). Among the patients in the cohort, 54.5% improved to stage 0 LSCD. Seven patients experienced enhancement in visual acuity. All corneal grading parameters improved significantly. Six adverse events were registered in 5 cases and were successfully managed. An extended scar in the donor eye was observed in 1 patient. This study demonstrated the high efficacy and safety of the G-SLET technique in the management of unilateral LSCD. G-SLET should be considered as a viable alternative to the"classic" SLET technique, specifically in the geographic areas where the availability of the fibrin glue is limited due to regulatory, economical, or any other reasons.

Clinical Trial of Autologous Cultivated Limbal Epithelial Cell Sheet Transplantation for Patients with Limbal Stem Cell Deficiency

To confirm the efficacy and safety of Good Manufacturing Practice (GMP)-compliant autologous cultivated limbal epithelial cell sheets in government-controlled clinical trials that adhered to Good Clinical Practice stipulations for patients with unilateral limbal stem cell deficiency (LSCD). A prospective, multicenter, open-label, uncontrolled, single-arm clinical trial. Ten consecutive eyes of 10 patients with unilateral LSCD were followed for 2 years after surgery. Preoperative LSCD stage was IIB in 4 eyes and III in 6 eyes. A limbal tissue biopsy was obtained from the healthy eye, after which limbal stem cells were dissociated and cultivated on temperature-responsive culture surfaces. All cell sheets were fabricated in a GMP-grade facility under established standard operating procedures. Cell sheets were evaluated using defined shipment criteria before transplantation, and only those that met the criteria were used. The cell sheet was transplanted onto each of the patients' diseased eye after removing the conjunctival scar tissue that covered the corneal surface. The severity of LSCD was determined according to a staging method agreed on by global consensus, with eyes evaluated as being in stages IA-C representing successful corneal epithelial reconstruction. Diagnosis and staging of LSCD were determined by the trial's Eligibility Judgment Committee and Effect Assessment Committee using slit-lamp photographs including fluorescein staining. Both committees comprised 2 or 3 third-party cornea specialists, who were provided with information anonymously and randomly. Corneal epithelial reconstruction rate was the primary end point. Corneal epithelial reconstruction was successful in 6 of 10 eyes (60%) 1 year postoperatively and was significantly higher than the 15% clinically significant efficacy rate achieved by allogeneic limbal transplantation. The reconstruction rate was 70% of eyes 2 years postoperatively. Additionally, improvements in visual acuity were noted in 50% and 60% of eyes at 1 and 2 years, respectively. No clinically significant transplantation-related adverse events were observed. The efficacy and safety of cultivated limbal epithelial cell sheet transplantation were thus confirmed, and the cell sheet, named "Nepic," is now approved as a cellular and tissue-based product in Japan. Proprietary or commercial disclosure may be found after the references. Proprietary or commercial disclosure may be found after the references.

Understanding Ocular Surface Inflammation in Tears Before and After Autologous Cultivated Limbal Epithelial Stem Cell Transplantation.

We aimed to determine the expression of inflammatory cytokines in the tears of patients with unilateral total limbal stem cell deficiency (TLSCD) caused by chemical burns before and after autologous cultivated limbal epithelial stem cell transplantation (CLET). Tear samples were collected from both eyes of 23 patients with unilateral TLSCD and 11 healthy controls, at fixed timepoints before and after CLET. Dissolved molecules were extracted from Schirmer's strips using a standardised method and analysed on an array plate of ten inflammatory cytokines (V-Plex Proinflammatory Panel 1 Human Kit, MSD). IL1β expression was significantly elevated in the TLSCD eye compared with the unaffected eye at baseline (p < 0.0001) but decreased to normal 3months post-CLET (p = 0.22). IL6 and IL8 were unaffected at baseline but significantly elevated in the TLSCD eyes at 1month post-CLET (p = 0.001 and p < 0.0001, respectively). IL6 returned to normal at 3months and IL8 at 6months post-CLET. There was a significant renewed increase in IL1β, IL6 and IL8 expression at 12months post-CLET (p < 0.0001, p = 0.0001 and p = 0.0003, respectively). IFNγ, IL10 and IL12p70 expression were significantly reduced in both eyes of patients with unilateral TLSCD at all timepoints. IL1β is a specific marker of inflammation in TLSCD eyes that could be therapeutically targeted pre-CLET to improve stem cell engraftment. At 12months post-CLET the spike in levels of IL1β, IL6 and IL8 coincides with cessation of topical steroids, suggesting ongoing subclinical inflammation. We therefore recommend not discontinuing topical steroid treatment in cases where penetrating keratoplasty is indicated; however, further investigation is needed to ascertain this. European Union Drug Regulating Authorities Clinical Trials Database (EuDRACT 2011-000608-16); ISRCTN (International Standard Randomised Controlled Trial Number (isrctn51772481).

Stem cells versus keratoprostheses

AbstractRoutine penetrating keratoplasty will not survive well in some circumstances, including harsh ocular surface environment, stem cell deficiency and chronic ocular inflammation. Fortunately, there have been advances to restore vision in these conditions in two directions: artificial keratoplasty and limbal stem cell transplantation. The recipient eye should have an intact lid mechanism and good tear film for stem cell transplantations. There may also be a need for future lamellar or penetrating keratoplasty with a chance for graft rejection. Treatment of unilateral limbal stem cell deficiency is relatively simple with three surgical options: Conjunctival Limbal Autograft (CLAU), Cultivated Limbal Epithelial Transplantation (CLET) and Simple Limbal Epithelial Transplantation (SLET). However, most patients have bilateral diseases like Stevens‐Johnson syndrome (SJS), aniridia and mucous membrane pemphigoid (MMP). In this scenario, an allogenic source for limbal stem cells is needed.Moreover, systemic immunosuppressive will be required to decrease the chance of rejection. Another option is Cultured Oral Mucosal Epithelial Transplantation (COMET) which usually provides less optimal visual acuity. The last option is keratoprosthesis (KPro). Many KPro devices have come and gone through, and two clear winners have emerged: Boston Keratoprosthesis KPro type I Osteo‐odonto‐keratoprosthesis, also known as the ‘OOKP’ OOKP is suitable for patients with severe dry eye and permanent lid damage. These patients should be excluded from any type of stem cell transplantation due to the inevitable chance of failure. However, Boston KPro type I may be considered as an alternative option for stem cell transplantation. Recent meta‐analysis for comparison of Keratolimbal Allograft (KLAL) and Boston KPro I in eyes affected by chemical burn has shown quite similar outcomes. Though, it should be mentioned that there are many limitations in included studies that make it difficult to reach an accurate conclusion. KPro has the advantages of shorter rehabilitation time and no need for systemic immunosuppression.Nevertheless, there is more chance of complications or loss of visual potential with KPro. Corneal surgeons should, in fact, be familiar with both options of KPro and stem cell transplantation to guide their patients towards the correct choice of treatment. The learning curve of such surgical techniques is steep. An extended follow‐up time is necessary to evaluate the safety of any method.

Mini-Conjunctival Limbal Autograft (Mini-CLAU) Using Platelet-Rich Plasma Eye Drops (E-PRP): A Case Series.

The purpose of this study was to introduce a new method of limbal stem cell transplantation using autologous platelet-rich plasma (E-PRP) eye drops for unilateral total limbal stem cell deficiency. Patients with total unilateral limbal stem cell deficiency due to chemical burn underwent mini-conjunctival limbal autograft using autologous E-PRP drops. One small limbal block, measuring 2 × 2 mm, was harvested from the patients' contralateral healthy eye and transplanted to the diseased eye. All patients received E-PRP drops until achieving complete corneal epithelialization. Subsequent corneal transplantation was performed in eyes with significant stromal opacification. Corneal buttons obtained during corneal transplantation underwent immunohistochemistry for the evaluation of limbal stem cell markers (ABCG2 and P63). Visual acuity, epithelial healing, corneal clarity, and regression of corneal conjunctivalization/vascularization were evaluated after surgery. Ten patients with acid (n = 7) or alkali (n = 3) burn were included. The mean follow-up period was 21.7 ± 5.8 months (range, 12-32 months). Corneas were completely reepithelialized within 14.9 ± 3.5 days (range, 11-21 days). Corneal conjunctivalization/vascularization dramatically regressed 1 to 2 months after surgery in all cases, and corneal clarity considerably improved in 7 patients. In the 3 eyes with significant stromal opacification, subsequent optical penetrating keratoplasty was performed. The ocular surface was stable throughout the follow-up period in all eyes. BSCVA improved to 0.60 ± 0.0.32 and 0.46 ± 0.0.25 logMAR in eyes with and without corneal transplantation, respectively, at the final follow-up visit. ABCG2 and P63 markers were detected on corneal buttons after keratoplasty. Based on our clinical and laboratory findings, mini-conjunctival limbal autograft using E-PRP can be considered as a promising alternative to ocular surface reconstruction.

Cultured Autologous Corneal Epithelia for the Treatment of Unilateral Limbal Stem Cell Deficiency: A Case Series of 15 Patients.

Damage to limbal epithelial stem cells can lead to limbal stem cell deficiency (LSCD). Current autologous treatment procedures for unilateral LSCD bear a significant risk of inducing LSCD in the donor eye. This complication can be avoided by grafting a stem cell containing cultured autologous corneal epithelium (CACE). The primary objective of this study was to demonstrate the safety of CACE grafted on eyes with LSCD. The secondary objective was to assess the efficacy of a CACE graft in restoring a self-renewing corneal surface with adequate anatomic structures, as well as improving the best corrected visual acuity (BCVA). Fifteen patients were grafted with a CACE on a fibrin gel produced from a 3 mm2 limbal biopsy harvested from the donor eye. Data were collected at baseline and after grafting. Follow-ups from 1 to 5 years were conducted. No major adverse events related to the CACE graft were observed. For every visit, an anatomic score based on corneal opacity as well as central vascularization and a functional score based on BCVA were determined. Safety was demonstrated by the low occurrence of complications. Anatomical (93%) and functional (47%) results are promising for improving vision in LSCD patients. Combined functional success and partial success rates with inclusion of BCVA were 53% [CI95: 27–79%] one year after CACE grafting. At the last follow-up, 87% [CI95: 60–98%] of the patients had attained corneal clarity. The outcomes demonstrate the safety of our technique and are promising regarding the efficacy of CACE in these patients.

Cultivated Limbal Epithelial Transplant Versus Conjunctival Limbal Auto Transplant in Uniocular Limbal Stem Cell Deficiency: Long-Term Results

Purpose: To evaluate and compare long-term efficacy of cultivated limbal epithelial cell transplant (CLET) and conjunctival limbal autograft (CLAU) in uniocular limbal stem cell deficiency (LSCD) in chemically injured eyes. Methods: This was a retrospective, interventional, comparative study, and comprised of sixty- one patients with unilateral severe LSCD who underwent CLET (10) and CLAU (51 patients). Surgical Procedure: Surgical procedure in CLET included superficial keratectomy, excision of fibrovascular tissue, securing amniotic membrane supporting cultured limbal stem cells and placement of bandage contact lens. CLAU included superficial keratectomy, excision of fibrovascular tissue, securing limbal stem cells graft with / without amniotic membrane transplant (AMT). Results: Following CLET ocular surface improved in all 10 patients and visual acuity improved significantly in three cases. CLAU was performed in 33 eyes and combined CLAU + AMT in 18 eyes. Visual acuity improved significantly in 26 (51%) eyes. Ocular surface and symblepharon grades improved in all patients during a mean 58.7±21.9 months follow up. Conclusion: CLET and CLAU is safe and effective in rehabilitating the ocular surface before penetrating keratoplasty (PKP) in uniocular severe LSCD. CLET has the advantage of avoiding iatrogenic limbal stem cell deficiency. CLAU enabled us to repair symblepharon simultaneously by taking extra conjunctiva.

Surgical Management of Unilateral Partial Limbal Stem Cell Deficiency: Conjunctival Autografts versus Simple Limbal Epithelial Transplantation.

PurposeTo evaluate the clinical outcomes of conjunctival autograft (CAG) versus simple limbal epithelial transplant (SLET) for management of unilateral partial limbal stem cell deficiency (LSCD).MethodsThis retrospective, comparative, interventional case series evaluated 30 eyes of 30 patients with unilateral partial LSCD. After corneal pannus dissection, 17 patients underwent CAG where graft was harvested from the ipsilateral or contralateral eye, while 13 patients underwent SLET where limbal biopsy was harvested from the contralateral eye. The primary outcome measure was anatomical success in the form of restoration of a completely epithelised, stable, and avascular corneal surface at last follow-up.ResultsBoth groups were comparable in terms of age at time of surgery, preoperative best-corrected visual acuity, median duration since injury, number of clock hours of limbus involved, and number of previous surgeries performed. The most common etiology for LSCD was chemical burns in both groups. The median duration of post-operative follow-up was 5.6 months [interquartile range [(IQR): 3.6–15.1] in the CAG group versus 6.2 months (IQR: 4.5–12.2) in the SLET group (p=0.75)]. The anatomical success rates were 86.5 ± 8.9% in the CAG group and 28.3 ± 13.7% in the SLET group at final follow-up visit (p = 0.025). Most failures in both groups occurred within the first 8 months after surgery.ConclusionFor eyes with unilateral partial LSCD secondary to chemical burns, CAG is a safe and effective method for restoring the corneal epithelium. Limbal transplantation may not be necessary for the treatment of partial LSCD.

Simple limbal epithelial transplantation (SLET) : Asimple technique for the treatment of unilateral complete limbal stem cell deficiency. Video article

The aim of simple limbal epithelial transplantation (SLET) is the regeneration of the corneal surface in unilateral complete limbal stem cell deficiency (LSCD). SLET is indicated for unilateral complete LSCD. Contraindications include bilateral LSCD, severe corneal thinning, pronounced keratoconjunctivitis sicca, chronic inflammatory condition of the ocular surface, malposition of the eyelids and pronounced adhesions of the conjunctiva with trichiasis. A1‑h biopsy is obtained from the superior limbus of the healthy donor eye. A360° peritomy is performed on the LSCD eye and pannus tissue covering the cornea is removed. An amniotic membrane (AM) is glued to the corneal surface with fibrin. The donor tissue is then divided into 8-10 small pieces, which are placed on the AM sparing the visual axis and fixed by fibrin glue. Acontact lens is placed on the eye. Asurgical video, which is available online, shows the surgical technique in detail. Examinations are necessary within the first postoperative week and 1 month after SLET, then every 3 months within the first postoperative year. Antibiotic eye drops should be applied 5times daily until complete epithelialization. Topical steroids should be applied 6times daily in the early postoperative period and can be tapered thereafter. Artificial tears can improve epithelial healing. Ideally, all eye drops should be preservative-free. The contact lens can be removed after 7-10days. The AM dissolves within afew weeks. An epithelialization of the corneal surface can be observed by the second postoperative week. Arecent systematic review reported astable epithelialized corneal surface in 78% of SLET cases after 1.5years. An improvement of visual acuity of at least two lines was found in 69% of SLET cases.

A Rare Presentation of Bilateral Vogt-Koyanagi-Harada (VKH) Disease in a Patient with Unilateral Limbal Stem Cell Deficiency (LSCD) with Corneal Perforation

Purpose-To report a rare presentation of Vogt-Koyanagi-Harada (VKH) disease in a 55 year old female patient with unilateral limbal stem cell deficiency (LSCD) with corneal perforation. Observations-Patient presented to the out patient department with recurrent episodes of watering, pain, redness in the left eye. Examination revealed LSCD with areas of pannus and infiltration. She was treated medically. Patient came back after a year with a corneal perforation in her left eye. The perforation was sealed using cyanoacrylate glue. Six weeks later, she presented with a drop in vision in both eyes. Optical Coherence Tomography (OCT) in both eyes showed multiple sub retinal fluid pockets and Fundus Fluorescein Angiography (FFA) revealed multiple pinpoint leakages typical of Harada disease. The patient was investigated for systemic associations, which were found to be normal. She was managed with tapering doses of oral steroids. OCT showed resolution of fluid pockets at one month. There was a good control of the disease, with no signs of recurrence at 6 months follow up. Conclusion-The clinical association between the two entities has not been published in literature till date. Further data or reports on such cases would help throw light on any possible association between LSCD and VKH disease.