Deep anterior lamellar limbo-keratoplasty for bilateral limbal stem cell deficiency with corneal scarring in chemical injury sequelae: Two case reports

Femtosecond laser-assisted large-diameter lamellar corneal-limbal keratoplasty in ocular chemical burns

Purpose

This study highlights the feasibility of femtosecond laser-assisted large-diameter lamellar corneal-limbal keratoplasty and its efficacy in the treatment of ocular surface failure caused by bilateral ocular chemical injury.

Observations

The series included 3 patients with ocular surface failure caused by bilateral ocular chemical burns. After dissection of the host cornea, a femtosecond laser-assisted large-diameter lamellar corneoscleral button, with varying thickness of 250-400 μm, was sutured to the recipient bed. Postoperatively, patients were maintained on topical corticosteroids drops and systemic immunosuppression. Patients were followed up for a minimum of 16 months. The preoperative best corrected visual acuity was counting fingers, hand motions, and hand motions respectively. Postoperatively, the preoperative best corrected visual acuity reached 20/50, 20/50 and 20/40 at the last follow-up, respectively. A stable ocular surface was achieved in all but one eye, due to the cessation of immunosuppressive drugs. Postoperative anterior segment optical coherence tomography revealed well apposed graft interface in all cases.

Conclusions and importance

Compared with conventional techniques, femtosecond laser is useful to create varying thickness corneoscleral graft to rehabilitate ocular surface and visual acuity in patients with bilateral ocular chemical burns.

Infectious scleritis: a review of etiologies, clinical features, and management strategies

Infectious scleritis is a severe and potentially vision-threatening inflammation of the sclera caused by microbial invasion. Unlike autoimmune scleritis, infectious scleritis is less common with a prevalence of 5%-10% of all cases of scleritis. The initial clinical presentation may often resemble autoimmune scleritis, thus resulting in a delayed diagnosis and poorer outcomes. A high level of suspicion is required in such cases and risk factors such as with a history of trauma or surgery and worsening or refractory to immunosuppressive medications as these may well be infectious. While in established cases, the classical clinical features enable us to diagnose as infectious etiology without much difficulty, the management remains a challenge. Majority of these cases require an aggressive approach with a combination of antimicrobial therapy and surgical treatment. Poor prognostic factors include delayed diagnosis, fungal etiology, and the presence of keratitis or endophthalmitis. In this review, the authors have summarized the prevalence, clinical and microbiological profile, and management strategies of infectious scleritis and their outcomes.

Oral Cyclosporine in Vernal Keratoconjunctivitis: Indications, Outcomes, and Effect on Corticosteroid Use

PURPOSE

The purpose of this study was to report the indications and outcomes of oral cyclosporine A (oCsA) use in vernal keratoconjunctivitis (VKC) and to assess its effect on corticosteroid use.

METHODS

This retrospective review of VKC cases included patients who were prescribed oCsA. Data on clinical characteristics, demographic profile, and treatment were collected. An acute episode was defined as one requiring oral/topical corticosteroids. The outcome measure was the difference in the number of acute episodes before and after oCsA use.

RESULTS

The study included 27 cases (54 eyes) of VKC from 2016 to 2024. The median age was 20 years. Thirty eyes had sequelae due to VKC, the most common of which was limbal stem cell deficiency (46%). The median duration of follow-up was 11 months. Indications for oCsA were recalcitrant disease (23/27, 85%) and severe active allergy in steroid-induced glaucoma/steroid responders (4/27, 15%). None of the cases experienced progression of sequelae with oCsA use. Forty-two acute episodes were observed before oCsA initiation over 403 person-months, which reduced to 10 episodes over 250 person-months with oCsA use. Without oCsA use, the odds of developing an acute exacerbation of the ocular allergy were 2.6 times (95% confidence interval: 1.3-5.2) higher compared with that with oCsA usage.

CONCLUSIONS

Oral cyclosporine reduces corticosteroid use in VKC and can be considered in recalcitrant disease or in eyes with steroid-induced glaucoma and active allergy. Oral cyclosporine significantly reduced the risk of acute exacerbations, proving to be an effective modality for controlling inflammation in VKC.

Eccentric Superficial Anterior Lamellar Keratoplasty for Bilateral Limbal Stem Cell Deficiency

PURPOSE

To describe and report the outcomes of allogeneic eccentric superficial anterior lamellar keratoplasty (SALK), a novel surgical technique, in the management of total bilateral limbal stem cell deficiency (LSCD).

METHODS

Data were collected retrospectively on all patients with total bilateral LSCD who underwent SALK. Previous surgery, preexisting glaucoma, conjunctivalization, vascularization, lens status, and preoperative best-corrected visual acuity (BCVA) were collected from medical notes.

RESULTS

Fifteen eyes underwent eccentric SALK between November 2018 and October 2021. The average age of patients at the time of SALK was 50.3 (SD ± 21.0). There were 4 male and 11 female patients, 9 left eyes and 6 right eyes. The mean difference between pre- and post-BCVA scores were 0.43 LogMAR (95% CI, 0.23-0.63). Ten patients noted an improvement in the features of LSCD with an improvement in BCVA. Five cases were deemed a complete success with a complete resolution of corneal epithelium, no recurrence of LSCD features and an improvement in BCVA. Patients who developed fungal keratitis had poor outcomes.

CONCLUSIONS

This study describes a new surgical technique of eccentric SALK to treat anterior stromal opacity and restore limbal stem cell function without systemic immunosuppression. The surgery improves the vision in most patients. However, in this complicated patient group, close postsurgical management is vital to recognize complications and intervene with treatment as needed.

Allogeneic limbo-deep anterior lamellar keratoplasty (Limbo-DALK)-A novel surgical technique in corneal stromal disease and limbal stem cell deficiency

PURPOSE

To describe a novel corneal surgical technique combining Deep Anterior Lamellar Keratoplasty (DALK) with grafting of allogeneic limbus (Limbo-DALK) for the treatment of eyes with corneal stromal pathology and limbal stem cell deficiency (LSCD).

METHODS

Clinical records of six Limbo-DALKs performed in five patients diagnosed with LSCD and corneal stromal pathology requiring keratoplasty were retrospectively reviewed. All patients were diagnosed with LSCD due to various pathologies including thermal and chemical burns, congenital aniridia or chronic inflammatory ocular surface disease. Parameters analysed included demographics, diagnoses, clinical history, thickness measurements using anterior segment OCT, visual acuity, and epithelial status. Regular follow-up visits were scheduled at 6 weeks as well as 3, 6, 9, and 12 and 18 months postoperatively. Main outcome measures were time to graft epithelialisation and the occurrence of corneal endothelial decompensation.

RESULTS

Two grafts showed complete epithelial closure at 2 days, two at 14 days. In one eye, complete epithelial closure was not achieved after the first Limbo-DALK, but was achieved one month after the second Limbo-DALK. No endothelial decompensation occurred except in one patient with silicone oil associated keratopathy. Endothelial graft rejection was not observed in any of the grafts.

CONCLUSION

Based on the data from this pilot series, limbo-DALK appears to be a viable surgical approach for eyes with severe LSCD and corneal stromal pathology, suitable for emergency situations (e.g. corneal ulceration with impending corneal perforation), while minimising the risk of corneal endothelial decompensation.

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.