Sutureless amniotic membrane transplantation for partial limbal stem cell deficiency

PURPOSE: To evaluate the results of sutureless amniotic membrane (AM) transplantation using fibrin glue for reconstructing corneal surfaces with partial limbal stem cell deficiency (LSCD). DESIGN: Retrospective noncomparative interventional case series. METHODS: Eleven eyes of nine patients that had LSCD with 120 degrees to almost 360 degrees of limbal involvement underwent superficial keratectomy to remove the conjunctivalized pannus followed by AM transplantation using fibrin glue. Additional sutureless AM patch (ProKera; Bio-Tissue, Inc, Miami, Florida, USA) was used in seven patients, and mitomycin C was applied on the cornea in four eyes and during fornix reconstruction in seven eyes. The surgery was repeated in three eyes for residual pannus. RESULTS: During a mean follow-up of 14.2 +/- 7.7 months (range, six to 26 months), all eyes maintained a smooth and stable corneal epithelial surface without recurrent erosion or persistent epithelial defect, and showed less stromal cloudiness and vascularization. Best-corrected visual acuity improved in nine eyes (81.8%). Corneal epithelialization proceeded by epithelial growth over AM (n = 4), accompanied by dissolution of AM (n = 4) or a combination of both (n = 3). No complication was noted regarding initial or repeated uses of fibrin glue. CONCLUSION: AM transplantation using fibrin glue appears to be a safe and effective method of restoring a stable corneal epithelium for cases with partial LSCD. This approach avoids the need of transplanting limbal epithelial stem cells.     

角膜缘干细胞移植与羊膜移植治疗翼状胬肉疗效比较

目的 比较角膜缘干细胞移植联合丝裂霉素C与羊膜移植联合丝裂霉素C治疗翼状胬肉疗效.方法 将54例(65只眼)患者随机分为两组,角膜缘干细胞移植组(28例35只眼):采用角膜缘干细胞移植联合丝裂霉素C治疗翼状胬肉;羊膜移植组(26例30只眼):采用羊膜移植联合丝裂霉素C治疗翼状胬肉.术后随访6至12个月,分析不同手术复发率及角膜创面愈合时间.结果 角膜缘干细胞移植组1只眼复发,复发率为2.86%;羊膜移植组7只眼复发,复发率为23.33%,两组比较有显著性差异(x2=4.532,P<0.05).角膜创面平均愈合时间角膜缘干细胞移植组为4.67d,羊膜移植组为6.48d,两组比较有显著性差异(t=5.92,P<0.05).结论 角膜缘干细胞移植联合丝裂霉素C能有效地治疗翼状胬肉,角膜创而修复较快,复发率低,是一种安全、有效的手术方法.     

Post-chemotherapy bilateral limbal stem cell deficiency

We report an extremely rare case of bilateral total limbal stem cell deficiency (LSCD) induced by long-term systemic chemotherapy for squamous cell carcinoma of the lung, and the outcomes of bilateral keratolimbal allograft transplantation (KLAT) in such a case. A 34-year-old male patient had underlying disease of squamous cell carcinoma in the right upper lung with extensive mediastinum and lymph node metastasis and received a series of systemic chemotherapy, including a combination of vinorelbine and cisplatin and a combination of gemcitabine, cisplatin, and docetaxel. According to clinical manifestations of ocular surface disorder, pathology findings, and immunostaining of cytokeratin 13 (CK13), LSCD secondary to systemic chemotherapy was diagnosed. KLAT was performed in both eyes. Although graft rejection developed in the right eye, complete re-epithelialization with favorable visual acuity occurred in the left eye 3 years after limbal transplantation.     

Homologous penetrating central limbo-keratoplasty (HPCLK) in bilateral limbal stem cell insufficiency

PURPOSE: Bilateral stem cell deficiency can be overcome only by keratoplasty plus additional homologous limbal transplantation. We have four years' experience with a new surgical one-stage procedure, homologous penetrating central limbo-keratoplasty (HPCLK). METHODS: A clinical trial was performed in order to evaluate the effectiveness of this new method. The first 25 eyes after HPCLK for limbal stem cell deficiency have been followed for more than 12 months. The eccentrically trephined unmatched grafts contained 40% limbus and were transplanted centrally in the host. Systemic cyclosporin A (CSA) was administered for at least one year. Central clear graft survival was the main outcome criterion. RESULTS: 18 grafts failed, mostly because of postoperative surface disorders. Seven grafts have remained centrally clear 12-41 months after HPCLK. CONCLUSIONS: In the majority of the grafts the transplanted limbal stem cells underwent immune destruction. The survival of seven grafts, however, shows that HPCLK is principally a promising new procedure. Further progress can be expected from the use of well HLA-matched grafts instead of unmatched grafts and from further improved systemic immune modulation.     

角膜缘干细胞移植及羊膜移植联合丝裂霉素C治疗复发性翼状胬肉

目的:研究角膜缘干细胞移植及羊膜移植联合丝裂霉素C治疗复发性翼状胬肉的临床效果。方法:收集复发性翼状胬肉47例54眼,随机分成A,B两组,均在显微镜下手术,A组行胬肉切除+羊膜移植术(24例28眼),B组行胬肉切除+角膜缘干细胞移植+羊膜移植联合丝裂霉素C(23例26眼),随访2a,观察术后复发情况。结果:A组治愈22眼,复发6眼,复发率21%,B组治愈25眼,复发1眼,复发率4%,采用SPSS统计字软件分析χ2=11.6452,P=0.0006,复发率有显著性差异,B组复发率明显低于A组。结论:角膜干细胞移植,羊膜移植联合丝裂霉素C治疗复发性翼状胬肉,术后复发率低,术后远期效果需进一步观察。     

Long-term results of allogeneic penetrating limbo-keratoplasty in total limbal stem cell deficiency

OBJECTIVE: To determine the prognosis of allogeneic penetrating limbo-keratoplasty in patients with total limbal stem cell deficiency and to find out if donor limbal stem cells survive in the long run. DESIGN: Noncomparative prospective case series. PARTICIPANTS: Forty-eight patients with total limbal stem cell deficiency. INTERVENTION: Allogeneic penetrating limbo-keratoplasty. All patients received systemic cyclosporin A and/or mycophenolate mofetil in the postoperative course. Thirteen patients received grafts with 0 to 1 HLA mismatches in the HLA-A, HLA-B, and HLA-DR loci; 13 patients received grafts with 2 to 6 mismatches; and 22 patients received untyped grafts. MAIN OUTCOME MEASURES: Long-term clear graft survival and survival of donor limbal stem cells. RESULTS: Five years postoperatively, 65% of the grafts with 0 to 1 mismatches, 41% of the grafts with 2 to 6 mismatches, and 14% of the untyped grafts were clear centrally (estimation according to Kaplan-Meier log rank test, P = 0.03). Immunogenetic analysis of epithelial cells from the surface of the graft could be performed successfully in 7 of 9 patients and revealed donor DNA in the epithelium of 5 of these 7 patients up to 56 months postoperatively. CONCLUSIONS: Long-term survival of donor epithelium could be demonstrated immunogenetically in patients undergoing allogeneic penetrating limbo-keratoplasty. Human leukocyte antigen-matched grafts seem to deliver better results than untyped grafts. Progress with matching and immunosuppressive strategies may further improve current results.     

Survival analysis of conjunctival limbal grafts and amniotic membrane transplantation in eyes with total limbal stem cell deficiency

PURPOSE: 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. DESIGN: Prospective, noncomparative, interventional case series. METHODS: Thirty-three eyes of 31 patients with total LSCD that underwent conjunctival limbal grafts and AMT at the Department of Ophthalmology, Federal University of S?o Paulo were included in this study. Cumulative graft survival as well as the influence of several variables on surgical outcome was analyzed. RESULTS: 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). CONCLUSIONS: 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.     

活体异体结膜缘和羊膜移植治疗化学性眼外伤造成的角膜缘干细胞缺失(英文)

目的:评价利用活体异体结膜缘和羊膜移植治疗化学性眼外伤造成的角膜缘干细胞缺失的临床效果。方法:从2005-07/2007-12,本研究包括了9名男性化学性眼外伤患者(10眼)。所有患者接受了亲属活体异体结膜缘和羊膜移植,2例眼接受了睑缝术。用环孢菌素和泼尼松龙进行全身性免疫抑制。结果:在3例眼中观察到完全角膜上皮化(30%),其中1例在术后1.5mo出现免疫排斥,角膜溶解引起穿孔,加大全身性免疫抑制剂量来控制病情。3例眼中植片无法在角膜表面重新形成上皮,被定为原发性失败。其余4眼有部分上皮形成,但上皮细胞无法完全覆盖角膜表面。术前最佳矫正视力从手动到1m处数指,术后最佳矫正视力从光感到20/80。有5眼视力得到改进,不需其他治疗。手术失败的主要原因为干眼症和持续性炎症。结论:对于能控制泪量和眼部炎症的病例,亲属活体异体角膜缘和羊膜移植是治疗化学性眼外伤造成的角膜缘干细胞缺失最佳方法之一。     

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.     

自体角膜缘干细胞移植联合丝裂霉素C治疗翼状胬肉

目的:观察自体角膜缘干细胞移植联合丝裂霉素C治疗翼状胬肉的疗效。方法:对60例68眼翼状胬肉应用自体角膜缘干细胞移植,并术中应用0.2g/L丝裂霉素C5min。结果:随访6～24mo,60例未见复发及严重并发症。结论:应用自体角膜缘干细胞移植联合丝裂霉素C治疗翼状胬肉是安全有效的方法。     

Amniotic membrane transplantation for partial limbal stem cell deficiency

AIM: To examine the efficacy, safety, and long term outcomes of amniotic membrane transplantation for corneal surface reconstruction in cases of partial limbal stem cell deficiency. METHODS: 17 eyes of 15 patients with partial limbal stem cell deficiency underwent superficial keratectomy of the conjunctivalised corneal surface followed by amniotic membrane transplantation. Cases were followed up for at least a year. RESULTS: All eyes exhibited a stable, intact corneal epithelial surface after a mean follow up period of 25.8 months with no eyes developing recurrent erosion or persistent epithelial defect. The mean time to re-epithelialisation was 22.8 days. Overall improvement in visual acuity was observed in 92.9% of 14 eyes with visual potential. Of those, five eyes gained six or more lines, two eyes gained between four and five lines, six eyes gained between one and three lines, and one eye lost three lines of Snellen acuity. Pain and photophobia were abolished in 86% of cases and substantially reduced in 14%, with all eyes exhibiting decreased vascularisation and inflammation at final follow up. CONCLUSIONS: Amniotic membrane transplantation appears to be a safe and effective method of restoring a stable corneal epithelium for cases of partial limbal stem cell deficiency and can be considered as an alternative to limbal autograft or allograft.     

Sectorial conjunctival epitheliectomy and amniotic membrane transplantation for partial limbal stem cells deficiency

CASE REPORT: A 74-year-old man developed a partial limbal stem cell deficiency secondary to a chemical injury in the left eye. He was treated with a sectorial conjunctival epitheliectomy and amniotic membrane transplantation. After 3 weeks there was an intact, smooth and stable corneal epithelium. DISCUSSION: This case report emphasizes that conjunctival epitheliectomy and amniotic membrane transplantation appears to be a safe and effective method of restoring a stable corneal epithelium for cases of partial limbal stem cell deficiency.     

Transplantation of conjunctival limbal autograft and amniotic membrane vs mitomycin C and amniotic membrane in treatment of recurrent pterygium

AIM: To compare the efficacy and complications of conjunctival limbal autograft (CLAU) and amniotic membrane transplantation (AMT) vsintraoperative mitomycin C (MMC) and AMT for treatment of recurrent pterygium.METHODS: Forty eyes of 40 patients with recurrent pterygium underwent CLAU and AMT (20 eyes) or intraoperative MMC (0.02%, 3 min) and AMT (20 eyes). Three eyes (15%) had symblepharon before surgery in each group. Recurrence was compared in each group by using chi(2) test.RESULTS: No major postoperative complications occurred during 6-19 months of follow-up. In CLAU/AMT group, no pterygium recurrence was observed. Recurrence occurred in four eyes (20%) in MMC/AMT group after 3 and 4 months (P-value=0.035, chi(2) test). No recurrence of pterygium or symblepharon was seen in six eyes with recurrent pterygium and symblepharon (three eyes in each group).CONCLUSION:CLAU with AMT seems to be more effective than intraoperative MMC with AMT for treatment of recurrent pterygium.     

Simultaneous deep anterior lamellar keratoplasty and limbal allograft in bilateral limbal stem cell deficiency

Purpose  

To report the efficacy of simultaneous keratolimbal allograft (KLAL) surgery and deep anterior lamellar keratoplasty (DALK) for limbal stem cell deficiency (LSCD).