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Di Girolamo N. Biologicals and Biomaterials for Corneal Regeneration and Vision Restoration in Limbal Stem Cell Deficiency. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2024:e2401763. [PMID: 38777343 DOI: 10.1002/adma.202401763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 05/15/2024] [Indexed: 05/25/2024]
Abstract
The mammalian cornea is decorated with stem cells bestowed with the life-long task of renewing the epithelium, provided they remain healthy, functional, and in sufficient numbers. If not, a debilitating disease known as limbal stem cell deficiency (LSCD) can develop causing blindness. Decades after the first stem cell (SC) therapy is devised to treat this condition, patients continue to suffer unacceptable failures. During this time, improvements to therapeutics have included identifying better markers to isolate robust SC populations and nurturing them on crudely modified biological or biomaterial scaffolds including human amniotic membrane, fibrin, and contact lenses, prior to their delivery. Researchers are now gathering information about the biomolecular and biomechanical properties of the corneal SC niche to decipher what biological and/or synthetic materials can be incorporated into these carriers. Advances in biomedical engineering including electrospinning and 3D bioprinting with surface functionalization and micropatterning, and self-assembly models, have generated a wealth of biocompatible, biodegradable, integrating scaffolds to choose from, some of which are being tested for their SC delivery capacity in the hope of improving clinical outcomes for patients with LSCD.
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Affiliation(s)
- Nick Di Girolamo
- Mechanisms of Disease and Translational Research, School of Biomedical Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, 2052, Australia
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Nurozler Tabakci B, Burcu A, Yalnız Akkaya Z, Şıngar E, Ozbek-Uzman S, Örnek F. Long-term ocular surface stability in conjunctivolimbal autograft and ocular surface safety in the donor eyes. Int Ophthalmol 2024; 44:75. [PMID: 38349582 DOI: 10.1007/s10792-024-03035-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 01/12/2024] [Indexed: 02/15/2024]
Abstract
PURPOSE 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 five years or longer. METHODS 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. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- Burcu Nurozler Tabakci
- Ophthalmology Department, Basaksehir Cam and Sakura City Hospital, Basaksehir, Istanbul, Turkey.
| | - Ayşe Burcu
- Ophthalmology Department, University of Health Sciences Ankara Training and Research Hospital, Ankara, Turkey
| | - Züleyha Yalnız Akkaya
- Ophthalmology Department, University of Health Sciences Ankara Training and Research Hospital, Ankara, Turkey
| | - Evin Şıngar
- Ophthalmology Department, University of Health Sciences Ankara Training and Research Hospital, Ankara, Turkey
| | - Selma Ozbek-Uzman
- Ophthalmology Department, University of Health Sciences Ankara Training and Research Hospital, Ankara, Turkey
| | - Firdevs Örnek
- Ophthalmology Department, University of Health Sciences Ankara Training and Research Hospital, Ankara, Turkey
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Yao TY, Wang JS, Geng W, Xie HT, Zhang MC. Conjunctival Limbal Autograft Combined with Amnion-Assisted Conjunctival Epithelial Redirection for Unilateral Total Limbal Stem Cell Deficiency after Severe Chemical Burn. J Clin Med 2023; 12:6235. [PMID: 37834878 PMCID: PMC10573734 DOI: 10.3390/jcm12196235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 09/14/2023] [Accepted: 09/25/2023] [Indexed: 10/15/2023] Open
Abstract
(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.
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Affiliation(s)
| | | | | | - Hua-Tao Xie
- Department of Ophthalmology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; (T.-Y.Y.); (J.-S.W.); (W.G.)
| | - Ming-Chang Zhang
- Department of Ophthalmology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; (T.-Y.Y.); (J.-S.W.); (W.G.)
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Korkmaz I, Palamar M, Egrilmez S, Gurdal M, Yagci A, Barut Selver O. Evaluation of Limbal Stem Cell Transplant Success in Ocular Chemical Injury. EXP CLIN TRANSPLANT 2023; 21:684-690. [PMID: 34981716 DOI: 10.6002/ect.2021.0393] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES We evaluated limbal stem cell transplant success in limbal stem cell deficiency due to chemical injury at a tertiary eye care center in Turkey with a novel system for describing limbal stem cell deficiency, as developed by the Limbal Stem Cell Working Group. MATERIALS AND METHODS Medical records of 80 eyes of 80 patients after limbal stem cell transplant for limbal stem cell deficiency secondary to chemical injury were included, with patients grouped according to surgical procedure, ie, limbal autograft, limbal allograft, and cultivated limbal epithelial cell transplant. Surgical success was defined as improvement in postoperative year 1 of limbal stem cell deficiency stage. RESULTS Patients' mean age was 37.9 ± 15.7 years (range, 4-71 years). Male/female ratio was 2.4. Forty-five patients (56.3%) were injured with alkaline substance, and 16 (20%) with acid substance. Mean follow-up time was 60.3 ± 30.6 months (range, 6-118.6 months). Limbal autograft, allograft, and cultivated limbal epithelial cell transplants were performed in 58 (72.5%), 12 (15%), and 10 (12.5%) eyes, respectively. Intervals between injury and surgery in limbal autograft, limbal allograft, and cultivated limbal epithelial cell transplants were 43.3 ± 94.1 months (range, 0.5-592 months), 14.5 ± 10.6 months (range, 2.4-32.5 months), and 122.8 ± 158.9 months (range, 21.1-504 months),respectively (P = .02); and surgical success rates in each group were 65.5%, 41.7%, and 90%, respectively (P = .03). Overall surgical success rate was 65%. CONCLUSIONS Accurate determination of the limbal stem cell deficiency stage is crucial for proper evaluation of surgical success. Surgery type and interval between injury and surgery were the most important factors associated with higher surgical success rates. Despite the limited number of patients in the subgroups, the results were remarkable to emphasize the significance of a novel limbal stem cell deficiency scoring system.
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Affiliation(s)
- Ilayda Korkmaz
- From the Department of Ophthalmology, Ege University, Izmir, Turkey
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Soleimani M, Cheraqpour K, Koganti R, Baharnoori SM, Djalilian AR. Concise Review: Bioengineering of Limbal Stem Cell Niche. BIOENGINEERING (BASEL, SWITZERLAND) 2023; 10:bioengineering10010111. [PMID: 36671683 PMCID: PMC9855097 DOI: 10.3390/bioengineering10010111] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/01/2023] [Accepted: 01/10/2023] [Indexed: 01/15/2023]
Abstract
The corneal epithelium is composed of nonkeratinized stratified squamous cells and has a significant turnover rate. Limbal integrity is vital to maintain the clarity and avascularity of the cornea as well as regeneration of the corneal epithelium. Limbal epithelial stem cells (LESCs) are located in the basal epithelial layer of the limbus and preserve this homeostasis. Proper functioning of LESCs is dependent on a specific microenvironment, known as the limbal stem cell niche (LSCN). This structure is made up of various cells, an extracellular matrix (ECM), and signaling molecules. Different etiologies may damage the LSCN, leading to limbal stem cell deficiency (LSCD), which is characterized by conjunctivalization of the cornea. In this review, we first summarize the basics of the LSCN and then focus on current and emerging bioengineering strategies for LSCN restoration to combat LSCD.
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Affiliation(s)
- Mohammad Soleimani
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran 1336616351, Iran
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Kasra Cheraqpour
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran 1336616351, Iran
| | - Raghuram Koganti
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Seyed Mahbod Baharnoori
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Ali R. Djalilian
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL 60612, USA
- Correspondence:
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Masood F, Chang JH, Akbar A, Song A, Hu WY, Azar DT, Rosenblatt MI. Therapeutic Strategies for Restoring Perturbed Corneal Epithelial Homeostasis in Limbal Stem Cell Deficiency: Current Trends and Future Directions. Cells 2022; 11:3247. [PMID: 36291115 PMCID: PMC9600167 DOI: 10.3390/cells11203247] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 10/11/2022] [Accepted: 10/12/2022] [Indexed: 02/03/2023] Open
Abstract
Limbal stem cells constitute an important cell population required for regeneration of the corneal epithelium. If insults to limbal stem cells or their niche are sufficiently severe, a disease known as limbal stem cell deficiency occurs. In the absence of functioning limbal stem cells, vision-compromising conjunctivalization of the corneal epithelium occurs, leading to opacification, inflammation, neovascularization, and chronic scarring. Limbal stem cell transplantation is the standard treatment for unilateral cases of limbal stem cell deficiency, but bilateral cases require allogeneic transplantation. Herein we review the current therapeutic utilization of limbal stem cells. We also describe several limbal stem cell markers that impact their phenotype and function and discuss the possibility of modulating limbal stem cells and other sources of stem cells to facilitate the development of novel therapeutic interventions. We finally consider several hurdles for widespread adoption of these proposed methodologies and discuss how they can be overcome to realize vision-restoring interventions.
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Affiliation(s)
- Faisal Masood
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, College of Medicine, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Jin-Hong Chang
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, College of Medicine, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Anosh Akbar
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, College of Medicine, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Amy Song
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, College of Medicine, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Wen-Yang Hu
- Department of Urology, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Dimitri T. Azar
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, College of Medicine, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Mark I. Rosenblatt
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, College of Medicine, University of Illinois at Chicago, Chicago, IL 60612, USA
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Clare G, Bunce C, Tuft S. Amniotic membrane transplantation for acute ocular burns. Cochrane Database Syst Rev 2022; 9:CD009379. [PMID: 36047788 PMCID: PMC9435439 DOI: 10.1002/14651858.cd009379.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Ocular surface burns can be caused by chemicals (alkalis and acids) or direct heat. One effect of the burn is damage to the limbal epithelial stem cells of the ocular surface with delayed re-epithelialisation, stem cell failure, and conjunctivalisation of the cornea. Amniotic membrane transplantation (AMT) performed in the acute phase (day 0 to day 7) following an ocular surface burn is claimed to reduce pain and accelerate healing. The surgery involves securing a layer of amniotic membrane (AM) to the eyelid margins as a patch to cover the entire ocular surface. However, there is debate about the severity of an ocular burn that may benefit from AMT and uncertainty of whether AMT improves outcomes. OBJECTIVES To compare the effect of AMT with medical therapy in the first seven days after an ocular surface burn, compared to medical therapy alone. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; which contains the Cochrane Eyes and Vision Trials Register; 2021, Issue 9); Ovid MEDLINE; Ovid Embase; LILACS; the ISRCTN registry; ClinicalTrials.gov and the WHO ICTRP. We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 29 September 2021. SELECTION CRITERIA We included randomised trials that compared an AMT applied in the first seven days following an ocular surface burn in addition to medical therapy with medical therapy alone. The outcome measures were failure of re-epithelialisation by day 21 post injury, visual acuity at final follow-up, corneal neovascularisation, symblepharon, time to re-epithelialisation and adverse effects. DATA COLLECTION AND ANALYSIS Two review authors independently screened search results, assessed the included studies for risk of bias and extracted relevant data. We contacted trial investigators for missing information. We summarised data using risk ratios (RRs) and mean differences (MDs) as appropriate. MAIN RESULTS We analysed two RCTs, but excluded individual patients who had been treated outside the acute phase in one of the studies (data provided by study authors). In total, 36 moderate burns from one RCT and 92 severe burns from two RCTs were evaluated separately. For both categories, the certainty of the evidence was downgraded principally as a result of high risks of performance and detection biases, and because of imprecision indicated by very wide confidence intervals. In addition, follow-up was insufficiently frequent to calculate time-to-epithelialisation precisely. Moderate severity ocular burns (Roper-Hall classification II-III) The relative risk of AMT on failure of epithelialisation by day 21 was 0.18 (0.02 to 1.31), and LogMAR visual acuity was 0.32 lower (0.55 to 0.09 lower) in the treatment group (i.e. better), suggesting a possible benefit of AMT. The GRADE assessment for failure of epithelialisation by day 21 was downgraded to very low due to the risk of bias and imprecision (very wide confidence intervals including no effect). The GRADE assessment for visual acuity at final follow-up was downgraded to low due to the risk of bias and imprecision (optimal information size not met). The relative effects of AMT on corneal neovascularisation (RR 0.56; 0.21 to 1.48), symblepharon (RR 0.41; 0.02 to 9.48) and time-to-epithelialisation (13 days lower; 26.30 lower to 0.30 higher) suggest possible benefit of AMT, but the wide confidence intervals indicate that both harm and benefit are possible. GRADE assessments for these outcomes were once again downgraded to very low due to the risk of bias and imprecision. Since adverse effects are rare, the small sample would have fewer occurrences of rare but potentially important adverse effects. The GRADE assessment for adverse effects was therefore considered to be low. Severe ocular burns (Roper-Hall classification IV) The relative risk of AMT on failure of epithelialisation by day 21 was 1.03 (0.94 to 1.12), and LogMAR visual acuity was 0.01 higher (0.29 lower to 0.31 higher) in the treatment group (i.e, worse), indicating no benefit of AMT. GRADE assessments for failure of epithelialisation by day 21 and final outcomes were downgraded to low. The relative effects of AMT on corneal neovascularisation (RR 0.84; 0.66 to 1.06), symblepharon (RR 0.89; 0.56 to 1.42) and time-to-epithelialisation (1.66 days lower; 11.09 lower to 7.77 higher) may include both benefit and harm. GRADE assessments for corneal neovascularisation, symblepharon and time-to-epithelialisation were downgraded to low due to risk of bias and imprecision. For adverse effects, the GRADE assessment was downgraded to low, reflecting the small sample sizes in the RCTs. AUTHORS' CONCLUSIONS There is uncertain evidence to support the treatment of moderate acute ocular surface burns with AMT in addition to standard medical therapy as a means of preventing failure of epithelialisation by day 21, improving visual outcome and reducing corneal neovascularisation, symblepharon formation and time-to-epithelialisation. For severe burns, the available evidence does not indicate any significant benefit of treatment with AMT.
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Affiliation(s)
- Gerry Clare
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | | | - Stephen Tuft
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
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Kate A, Basu S. Mini-conjunctival autograft combined with deep anterior lamellar keratoplasty for chronic sequelae of severe unilateral chemical burn: A case report. Int J Surg Case Rep 2021; 88:106508. [PMID: 34656930 PMCID: PMC8521227 DOI: 10.1016/j.ijscr.2021.106508] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 10/10/2021] [Accepted: 10/11/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction and importance This case describes a novel technique combining a mini-conjunctival limbal autograft (CLAU) with a deep anterior lamellar keratoplasty (DALK) in a case of chemical injury sequelae. Case presentation A 19-year-old female presented with total limbal stem cell deficiency (LSCD) and a vascularized corneal scar in the visual axis of the left eye, 4 years following a chemical injury. In order to treat the LSCD and simultaneously visually rehabilitate the patient, a mini-CLAU with DALK was carried out. Two separate one clock-hour CLAUs were harvested from the right eye and secured in the left. The graft was clear in the initial postoperative period and maintained its clarity over 15 months of follow period with a visual acuity of 20/30 with scleral contact lenses. The mini-CLAUs sustained a stable and well epithelialized corneal surface during the same period. Clinical discussion The use of the mini-CLAUs instead of the traditional CLAU circumvents the complication of an iatrogenic LSCD in the donor eye as the size of the donor grafts is smaller (1–2 clock hours versus 6–8 clock hours). Despite the smaller size, these grafts are efficacious in maintaining a well epithelialized corneal surface even in cases of total LSCD. The autologous nature of the graft defers the need for immunosuppression and its peripheral location facilitates ease of the surgical technique when combined with a keratoplasty. Conclusion This novel single-staged procedure is an effective technique to reestablish a stable ocular surface and to visually rehabilitate cases of chronic chemical injury with good long-term outcomes. Severe ocular burns need both corneal and limbal transplantation. Anterior lamellar keratoplasty is preferred over penetrating grafts. Mini-conjunctival limbal grafts can be obtained safely from the healthy fellow eye. The need for long-term systemic immunosuppression is minimized in this approach. This combined technique leads to good and sustainable functional recovery.
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Affiliation(s)
- Anahita Kate
- The Cornea Institute, KVC Campus, LV Prasad Eye Institute, Vijayawada, India
| | - Sayan Basu
- The Cornea Institute, KAR Campus, LV Prasad Eye Institute, Hyderabad, Telangana, India; Prof. Brien Holden Eye Research Centre (BHERC), LV Prasad Eye Institute, Hyderabad, Telangana, India.
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Prabhasawat P, Chirapapaisan C, Ngowyutagon P, Ekpo P, Tangpagasit W, Lekhanont K, Sikarinkul R, Matamnan S, Boonwong C, Pinitpuwadol W, Thamphithak R, Sukon N, Neti N. Efficacy and outcome of simple limbal epithelial transplantation for limbal stem cell deficiency verified by epithelial phenotypes integrated with clinical evaluation. Ocul Surf 2021; 22:27-37. [PMID: 34214675 DOI: 10.1016/j.jtos.2021.06.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 06/13/2021] [Accepted: 06/28/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE To evaluate the efficacy and outcome of simple limbal epithelial transplantation (SLET) for limbal stem cell deficiency (LSCD) using epithelial phenotype detection integrated with clinical manifestation. METHODS This prospective multicenter study included patients with LSCD who underwent autologous SLET (autoSLET) and living-related allogenic SLET (Lr-alloSLET). All patients were assessed by slit-lamp biomicroscopy, in vivo confocal microscopy (IVCM), and impression cytology with immunofluorescence staining (ICIF) before and after surgery. The criteria for success were the presence of a clinically non-conjunctivalized cornea and corneal epithelium detected by IVCM or ICIF. Otherwise, the case would be considered a failure. Visual improvement and risk factors for SLET failure were analyzed. RESULTS A total of 28 eyes of 26 patients (11 autoSLET and 17 Lr-alloSLET) were included. The median age was 53 years (range, 35-63), and the follow-up time was 29.5 months (range, 17.5-39.8). The overall survival rate was 89.3% at 2 years and 75.6% at 3 years with no difference between autoSLET and Lr-alloSLET (p = 0.24). Seven eyes subsequently underwent penetrating keratoplasty. Immunohistochemistry analysis showed that all corneal buttons had corneal epithelium and limbal stem cell markers. Visual improvement was achieved in both SLET groups (p < 0.001). Failed SLET developed between 5 and 32 months postoperatively. However, absolute risk factors for SLET failure were unidentified. CONCLUSION The efficacy of autoSLET and Lr-alloSLET for LSCD was excellent. Limbal explants can regenerate and restore the corneal surface while maintaining the characteristics of limbal stem cells as shown by epithelial phenotype detection and immunohistochemistry integrated with clinical evaluation.
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Affiliation(s)
- Pinnita Prabhasawat
- Department of Ophthalmology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chareenun Chirapapaisan
- Department of Ophthalmology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| | - Panotsom Ngowyutagon
- Department of Ophthalmology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pattama Ekpo
- Department of Immunology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand; Research Division, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Wimolwan Tangpagasit
- Department of Ophthalmology, Faculty of Medicine, Thammasat University, Prathumthani, Thailand
| | - Kaevalin Lekhanont
- Department of Ophthalmology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand
| | - Rosanun Sikarinkul
- Department of Ophthalmology, Golden Jubilee Medical Center, Mahidol University, Thailand
| | - Sutthicha Matamnan
- Research Division, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chawikan Boonwong
- Research Division, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Warinyupa Pinitpuwadol
- Department of Ophthalmology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ranida Thamphithak
- Department of Ophthalmology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nutchaya Sukon
- Department of Ophthalmology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nutnicha Neti
- Department of Ophthalmology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Shanbhag SS, Tarini S, Kunapuli A, Basu S. Simultaneous surgical management of unilateral limbal stem cell deficiency and symblepharon post chemical burn. BMJ Case Rep 2020; 13:13/12/e237234. [PMID: 33298485 DOI: 10.1136/bcr-2020-237234] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 6-year-old female child presented with severe acute ocular chemical burn in the right eye 2 days after injury with cement. She underwent removal of all foreign bodies from the ocular surface and amniotic membrane transplantation. Three months later, she developed unilateral total limbal stem cell deficiency (LSCD) with symblepharon in two quadrants. Three months after the acute injury, the patient underwent autologous simple limbal epithelial transplant in the right eye with one-clock hour of limbus harvested from the left eye. At the same sitting, she underwent symblepharon release in two quadrants of the right eye with conjunctival autograft harvested from the left eye followed by conjunctival graft suturing to the areas of bare sclera in the right eye. One year after surgery, the patient's visual acuity improved from counting fingers close to face preoperatively to 20/50 (uncorrected) with no recurrence of LSCD or symblepharon.
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Affiliation(s)
- Swapna S Shanbhag
- The Cornea Institute, LV Prasad Eye Institute, Hyderabad, Telangana, India
| | - Shilpa Tarini
- The Cornea Institute, LV Prasad Eye Institute, Hyderabad, Telangana, India
| | - Anuradha Kunapuli
- The Cornea Institute, LV Prasad Eye Institute, Hyderabad, Telangana, India
| | - Sayan Basu
- The Cornea Institute, LV Prasad Eye Institute, Hyderabad, Telangana, India .,Brien Holden Eye Research Centre (BHERC), LV Prasad Eye Institute, Hyderabad, Telangana, India
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Allogenic Simple Limbal Epithelial Transplantation Versus Amniotic Membrane Grafting in the Early Management of Severe-Grade Ocular Chemical Injuries-A Retrospective Comparative Study. Am J Ophthalmol 2020; 217:297-304. [PMID: 32437668 DOI: 10.1016/j.ajo.2020.05.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 05/01/2020] [Accepted: 05/01/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE To compare outcomes of management in the early stage of severe chemical injury (grade 4 and worse; Dua classification) with amniotic membrane grafting (AMG) alone vs allogenic simple limbal epithelial transplantation (alloSLET). DESIGN Retrospective comparative interventional case series. METHODS Retrospective comparative interventional series. Records of patients with severe ocular chemical injury who underwent AMG alone (between 2009 and 2013) vs alloSLET (between 2013 and 2017) were analyzed for grade of injury, time of and interventions for epithelial healing, ocular surface status post healing (grade of symblepharon, and limbal stem cell deficiency [LSCD]), and type of and need for interventions in the chronic stage. RESULTS Among patients presenting in early stage of severe chemical injury, 38 eyes (median age 11 years) managed with AMG alone were compared with 39 eyes (median age 8 years) managed with alloSLET. The mean time of presentation post injury was 33.85 ± 27.5 and 40.6 ± 23.5 days in the AMG and alloSLET group, respectively. The rate of epithelial healing was faster in the alloSLET group and the difference was noted to be statistically significant (odds ratio [OR] 0.966, P = .001). Similarly, the lower occurrence of LSCD (OR 0.137, P = .004) and need for keratoplasty (OR 0.093, P = .003) favored alloSLET over AMG. Final best-corrected visual acuity of >20/200 was achieved in 39.4% and 53.8% in the AMG and alloSLET groups, respectively. CONCLUSION AlloSLET helps in faster epithelialization of the surface, thus reducing the need for subsequent surgeries in the chronic stage and aiding faster visual rehabilitation. The outcomes of alloSLET appear superior to amniotic membrane grafting alone and should be considered in eyes with grade 4 and above (Dua classification) chemical injuries in the early stage.
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Tseng SCG, Chen SY, Mead OG, Tighe S. Niche regulation of limbal epithelial stem cells: HC-HA/PTX3 as surrogate matrix niche. Exp Eye Res 2020; 199:108181. [PMID: 32795525 DOI: 10.1016/j.exer.2020.108181] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 06/15/2020] [Accepted: 07/31/2020] [Indexed: 12/13/2022]
Abstract
Homeostasis of the corneal epithelium is ultimately maintained by stem cells that reside in a specialized microenvironment within the corneal limbus termed palisades of Vogt. This limbal niche nourishes, protects, and regulates quiescence, self-renewal, and fate decision of limbal epithelial stem/progenitor cells (LEPCs) toward corneal epithelial differentiation. This review focuses on our current understanding of the mechanism by which limbal (stromal) niche cells (LNCs) regulate the aforementioned functions of LEPCs. Based on our discovery and characterization of a unique extracellular matrix termed HC-HA/PTX3 (Heavy chain (HC1)-hyaluronan (HA)/pentraxin 3 (PTX3) complex, "-" denotes covalent linkage; "/" denotes non-covalent binding) in the birth tissue, i.e., amniotic membrane and umbilical cord, we put forth a new paradigm that HC-HA/PTX3 serves as a surrogate matrix niche by maintaining the in vivo nuclear Pax6+ neural crest progenitor phenotype to support quiescence and self-renewal but prevent corneal fate decision of LEPCs. This new paradigm helps explain how limbal stem cell deficiency (LSCD) develops in aniridia due to Pax6-haplotype deficiency and further explains why transplantation of HC-HA/PTX3-containing amniotic membrane prevents LSCD in acute chemical burns and Stevens Johnson syndrome, augments the success of autologous LEPCs transplantation in patients suffering from partial or total LSCD, and assists ex vivo expansion (engineering) of a graft containing LEPCs. We thus envisage that this new paradigm based on regenerative matrix HC-HA/PTX3 as a surrogate niche can set a new standard for regenerative medicine in and beyond ophthalmology.
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Affiliation(s)
- Scheffer C G Tseng
- Research & Development Department, TissueTech, Inc., Miami, FL, 33126, USA; Ocular Surface Center and Ocular Surface Research & Education Foundation, Miami, FL, 33126, USA.
| | - Szu-Yu Chen
- Research & Development Department, TissueTech, Inc., Miami, FL, 33126, USA
| | - Olivia G Mead
- Research & Development Department, TissueTech, Inc., Miami, FL, 33126, USA
| | - Sean Tighe
- Research & Development Department, TissueTech, Inc., Miami, FL, 33126, USA; Department of Biochemistry and Molecular Biology, University of Miami Miller School of Medicine, Miami, FL, 33136, USA; Department of Ophthalmology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, 33199, USA
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Ozer MD, Altınkurt E, Yilmaz YC, Gedik AC, Alparslan N. The Surgical Outcomes of Limbal Allograft Transplantation in Eyes Having Limbal Stem Cell Deficiency. J Curr Ophthalmol 2020; 32:132-141. [PMID: 32775793 PMCID: PMC7337021 DOI: 10.4103/joco.joco_91_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 12/08/2019] [Accepted: 12/23/2019] [Indexed: 12/15/2022] Open
Abstract
Purpose: To report the limbal allograft transplantation and penetrating keratoplasty (PK) results in limbal stem cell deficiency (LSCD)-developed eyes because of chemical or thermal injury. Methods: Medical records of 18 eyes of 14 patients who had undergone keratolimbal allograft (KLAL) or living-related conjunctival limbal allograft (lr-CLAL) with or without PK and followed up at least 1 year postoperatively were evaluated retrospectively. The preoperative LSCD grade was noted in all patients. Rejection incidents, recurrence of LSCD, and corneal graft clarity along with a visual improvement during the follow-up were noted. The complications rate due to surgery or injury itself, for instance, glaucoma and cataract, were evaluated. The limbal allograft tissue survival analysis and corneal allograft survival analysis were done to reveal the differences in both the procedures. The existence of normal corneal epithelium and improvement in visual acuity were accepted as the surgical success criteria. Results: In the limbal allograft transplantation group, the survival rates of the allograft tissue were 65 ± 10.7% at 1 year and 36.6 ± 11.4% at 3 years in lr-CLAL and 66.7 ± 15.7% at 12 months and 53.3 ± 17.3% at 18 months in KLAL-transplanted eyes. The survival rate of corneal allograft at the 5th postoperative year was lower in the simultaneous procedure compared to the staged procedure, but it was not statistically significant (25.7 ± 25.8% vs. 62.5 ± 17.1%, P = 0.75). The ambulatory vision was achieved in 10 eyes (56%) after a mean follow-up time of 93.8 ± 37.8 months. The visual acuity level has increased in 12 eyes (67%) in which the limbal allograft transplantation was applied. The ambulatory visual acuity level was achieved (≤1.0 logMar [20/200]) in 10 eyes (56%). In addition, two or more Snellen lines’ gain in the best corrected visual acuity was observed in 12 eyes of 18 (67%) at the last follow-up, and there was not any significant difference between the KLAL and lr-CLAL. Conclusions: Ocular surface integrity was longer in KLAL than in lr-CLAL transplantation, but it was not statistically significant. The staged procedure was more convenient than the simultaneous procedure in terms of corneal allograft clarity maintenance in limbal allograft-employed eyes.
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Affiliation(s)
- Muhammet Derda Ozer
- Department of Ophthalmology, Medical Faculty, Van Yuzuncu Yil University, Van, Turkey
| | - Emre Altınkurt
- Department of Ophthalmology, Istanbul Faculty of Medicine, Istanbul University, İstanbul, Turkey
| | | | - Ali Ceyhun Gedik
- Department of Ophthalmology, Luleburgaz State Hospital, Kirklareli, Turkey
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Ozer MD, Altinkurt E, Alparslan N. The long-term surgical outcomes of conjunctival-limbal autograft procedure with or without penetrating keratoplasty in eyes with unilateral limbal stem cell deficiency. Taiwan J Ophthalmol 2020; 10:22-28. [PMID: 32309120 PMCID: PMC7158933 DOI: 10.4103/tjo.tjo_55_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 07/21/2019] [Indexed: 12/15/2022] Open
Abstract
AIM: The aim of the study is to report the results of conjunctival-limbal autograft (CLAU) transplantation and penetrating keratoplasty (PK) in eyes with limbal stem cell deficiency (LSCD) due to chemical or thermal injury. METHODS: Thirty-one eyes of the 31 patients, who had unilateral LSCD due to chemical or thermal injury, were included in the study. Bilaterally affected cases and LSCD due to Steven-Johnson syndrome and mucous membrane pemphigoid were excluded from the study. All patients underwent a complete ophthalmologic examination. The surgical procedures, postoperative complications, ocular surface status, and visual outcomes were noted. RESULTS: In the CLAU group, regular corneal epithelium and ambulatory vision (≤1.0 logarithm of the minimum angle of resolution [20/200]) were achieved in 81% of eyes, including 22 eyes (71%) that were assessed after a mean follow-up period of 58 months, respectively. The 5-year survival rate of corneal allograft was 33%, 4 ± 13.9 in the CLAU applied eyes. In addition, the corneal graft clarity maintenance rate was found to be higher in patients having ≥12 months duration between CLAU and PK, which is statistically significant (62% vs. 23%, P = 0.046). CONCLUSION: Waiting at least 1 year after CLAU transplantation to perform PK increases corneal clarity. Eyelid problems, even if the eyelids were reconstructed properly, remain a major risk factor for the development of the epithelial disorder in the early and late postoperative period in CLAU applied eyes.
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Affiliation(s)
- Muhammet Derda Ozer
- Department of Ophthalmology, Medical Faculty, Van Yuzuncu Yil University, Tuşba, Van 65080, Turkey
| | - Emre Altinkurt
- Department of Ophthalmology, Istanbul Faculty of Medicine, Istanbul University, Fatih, Istanbul 34000, Turkey
| | - Nilufer Alparslan
- Department of Ophthalmology, Istanbul Faculty of Medicine, Istanbul University, Fatih, Istanbul 34000, Turkey
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Long-term outcomes of conjunctival limbal autograft in patients with unilateral total limbal stem cell deficiency. Ocul Surf 2019; 17:670-674. [PMID: 31499235 DOI: 10.1016/j.jtos.2019.09.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 08/29/2019] [Accepted: 09/05/2019] [Indexed: 11/22/2022]
Abstract
PURPOSE To investigate the long-term clinical outcomes of conjunctival limbal autograft (CLAU) in patients with unilateral total limbal stem cell deficiency (LSCD). METHODS In this retrospective interventional case series, the medical charts of patients with unilateral total LSCD were reviewed. Patients who underwent CLAU and no other allograft ocular stem cell transplantation with a minimum follow-up of 1 year were included. Main outcome measures were ocular surface stability, best-corrected visual acuity (BCVA), and postoperative complications. RESULTS 27 eyes fulfilled the inclusion criteria with a mean follow-up period of 49.8 ± 36.6 months (4.15 years; range 12-186.72 months; 1-15.56 years). Ocular surface stability was achieved in 77.8% (n = 21) of eyes at last follow-up, while 22.2% (n = 6) developed partial surface failure. Optical penetrating or deep lamellar anterior keratoplasty was performed in 44.45% (n = 12). BCVA improved from 1.42 ± 0.95 mean LogMAR (equivalent to 20/400) preoperatively to 0.53 ± 0.47 mean LogMAR (equivalent to 20/70) at last follow-up (p < 0.001). BCVA ≥20/40 was achieved in 44.45% (n = 12) at last follow-up. Microbial keratitis occurred in 14.81% (n = 4). Ocular hypertension secondary to corticosteroid use developed in 25.9% (7/27) eyes. There were no other complications in the donor or recipient eyes. CONCLUSIONS CLAU can provide long-term ocular surface stability and successful visual outcomes in patients with unilateral LSCD.
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Bizrah M, Yusuf A, Ahmad S. An update on chemical eye burns. Eye (Lond) 2019; 33:1362-1377. [PMID: 31086244 PMCID: PMC7002428 DOI: 10.1038/s41433-019-0456-5] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 02/06/2019] [Accepted: 04/02/2019] [Indexed: 01/20/2023] Open
Abstract
Ocular chemical injuries vary in severity, with the more severe end of the spectrum having profound visual consequences and medicolegal implications. Grading of ocular injuries is critical for determining acute treatment and visual prognosis. Poor immediate management results in more challenging treatment of acute disease. Similarly, poorly controlled acute disease results in more treatment-resistant chronic ocular disease. Despite several decades of research and public health initiatives, simple and effective interventions such as wearing protective eyewear and immediate irrigation of eyes remain as key challenges. Education and prevention are therefore important public health messages. Hurdles in the acute management of disease include poor evidence-base for commonly used treatments (e.g. based on experimental animal studies), reduced treatment adherence rates and high clinic non-attendance rates. The evolution of treatment strategies, particularly limbal stem cell transplantation, has revolutionised the visual and cosmetic outcomes in chronic phases of disease. It is therefore increasingly important to consider tertiary referral for patients with limbal stem cell failure or vision-limiting corneal scarring.
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Affiliation(s)
- Mukhtar Bizrah
- Imperial College Healthcare NHS Trust, Western Eye Hospital, 153-173 Marylebone Road, London, NW1 5QH, UK.
| | - Ammar Yusuf
- UCL Institute of Ophthalmology, 11-43 Bath Street, London, EC1V 9EL, UK
| | - Sajjad Ahmad
- Moorfields Eye Hospital NHS Foundation Trust, 162 City Road, London, EC1V 2PD, UK
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Shukla S, Shanbhag SS, Tavakkoli F, Varma S, Singh V, Basu S. Limbal Epithelial and Mesenchymal Stem Cell Therapy for Corneal Regeneration. Curr Eye Res 2019; 45:265-277. [DOI: 10.1080/02713683.2019.1639765] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Sachin Shukla
- Center for Ocular Regeneration (CORE), L V Prasad Eye Institute, Hyderabad, India
| | - Swapna S Shanbhag
- Tej Kohli Cornea Institute, L V Prasad Eye Institute, Hyderabad, India
| | - Fatemeh Tavakkoli
- Center for Ocular Regeneration (CORE), L V Prasad Eye Institute, Hyderabad, India
| | - Shobhit Varma
- Tej Kohli Cornea Institute, L V Prasad Eye Institute, Hyderabad, India
| | - Vivek Singh
- Center for Ocular Regeneration (CORE), L V Prasad Eye Institute, Hyderabad, India
| | - Sayan Basu
- Center for Ocular Regeneration (CORE), L V Prasad Eye Institute, Hyderabad, India
- Tej Kohli Cornea Institute, L V Prasad Eye Institute, Hyderabad, India
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Shanbhag SS, Nikpoor N, Rao Donthineni P, Singh V, Chodosh J, Basu S. Autologous limbal stem cell transplantation: a systematic review of clinical outcomes with different surgical techniques. Br J Ophthalmol 2019; 104:247-253. [PMID: 31118185 DOI: 10.1136/bjophthalmol-2019-314081] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 04/09/2019] [Accepted: 04/22/2019] [Indexed: 12/13/2022]
Abstract
PURPOSE To conduct a systematic review on outcomes of three different techniques of autologous limbal stem cell transplantation (LSCT): conjunctival-limbal autografting (CLAu), cultivated limbal epithelial transplantation (CLET) and simple limbal epithelial transplantation (SLET), in unilateral limbal stem cell deficiency (LSCD). METHODS Literature searches were conducted in MEDLINE (Ovid), Embase, Web of Science and Cochrane Central Register. Standard systematic review methodology was followed using Meta-analysis of Observational Studies in Epidemiology guidelines. Studies with a sample size of more than 10 eyes were included. The primary outcome measure of efficacy was restoration of a completely epithelised, stable and avascular corneal surface (anatomical success). The secondary outcome measure of efficacy was improvement in best-corrected visual acuity of two-lines or greater (functional success). RESULTS The review identified 22 non-comparative case series, which included 1023 eyes. Ocular burns were the major (88%) indication for surgery. Overall, at a median postoperative follow-up of 1.75 years, autologous LSCT for unilateral LSCD showed anatomical and functional success rates of 69% and 60%, respectively, without any serious adverse events in the donor eye. The follow-up duration and indications for surgery were comparable across all groups (p>0.05). The anatomical and functional success rates of SLET (78%; 68.6%) and CLAu (81%; 74.4%) were comparable, and significantly better than those of CLET (61.4%; 53%; p=0.0048). CONCLUSION Autologous LSCT is a safe and effective treatment for unilateral LSCD. In the absence of randomised controlled trials, existing evidence clearly suggests that clinical outcomes are better with SLET and CLAu as compared with CLET.
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Affiliation(s)
- Swapna S Shanbhag
- Tej Kohli Cornea Institute, LV Prasad Eye Institute, Hyderabad, India
| | - Neda Nikpoor
- Byers Eye Institute, Stanford University, Stanford, California, USA
| | | | - Vivek Singh
- Center for Ocular Regeneration (CORE), LV Prasad Eye Institute, Hyderabad, India
| | - James Chodosh
- Cornea and Refractive Surgery Service, MEEI, Boston, Massachusetts, USA
| | - Sayan Basu
- Center for Ocular Regeneration (CORE), LV Prasad Eye Institute, Hyderabad, India
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Abstract
PURPOSE To investigate the incidence of limbal stem cell deficiency (LSCD) in donor eyes after conjunctival limbal autograft (CLAU). METHODS An observational retrospective review was performed on all patients who underwent CLAU alone, combined keratolimbal allograft with CLAU ("Modified Cincinnati Procedure"), or combined living-related conjunctival limbal allograft (lr-CLAL) with CLAU having ≥6 months of follow-up after surgery. The outcome measures were best-corrected visual acuity (BCVA) and ocular surface status. RESULTS The inclusion criteria were fulfilled by 45 patients. Of these, 26 patients underwent CLAU, 18 underwent combined keratolimbal allograft/CLAU, and 1 underwent combined lr-CLAL/CLAU. Mean age at the time of surgery was 39.6 years. Mean logMAR preoperative BCVA was -0.08. There were no operative complications. The mean follow-up duration after surgery was 48.3 months (range 8.3-181.5 mo). At last follow-up, all eyes maintained a stable ocular surface, and mean logMAR BCVA was -0.05. CONCLUSIONS With the advent of newer ocular surface transplantation methods, there has been concern that CLAU carries the theoretical risk of inducing LSCD. Our long-term clinical results following donor eyes after CLAU demonstrate no signs of LSCD.
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Singh G, Singh Bhinder H. Evaluation of Therapeutic Deep Anterior Lamellar Keratoplasty in Acute Ocular Chemical Burns. Eur J Ophthalmol 2018; 18:517-28. [DOI: 10.1177/112067210801800403] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- G. Singh
- Guru Gobind Singh International, Eye Research and Cure Centre, New Delhi - India
- Ex Prof. M.A.M. College and Associated Guru Nanak Eye Centre, New Delhi - India
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Kocaba V, Damour O, Auxenfans C, Burillon C. [Limbal stem cell deficiency management. A review]. J Fr Ophtalmol 2016; 39:791-803. [PMID: 27742136 DOI: 10.1016/j.jfo.2016.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 08/02/2016] [Accepted: 08/23/2016] [Indexed: 11/16/2022]
Abstract
Limbal stem cell deficiency is predominantly caused by severe eye burns resulting in a decreased or a complete ablation of the regenerative potential of these stem cells. The inability to reconstruct the corneal epithelium further leads conjunctivalization of the gimbal-epithelial barrier. These abnormalities collectively result in the progressive opacification of the cornea responsible for blindness that is driven by chronic corneal ulceration and neovascularization. The underlying pathology of the cornea affects the homeostasis of the neighboring conjunctiva, eyelids, and tear film. Therefore, the ocular reconstruction to treat limbal stem cell deficiency is quite prolonged and involves a continued treatment plan. The management of limbal stem cell deficiency has undergone a multitude of changes over the past several decades. The understanding of limbal anatomy and physiology, as well as therapeutic advances in the stem cell field have propelled the development of new treatments offering new hope to severely disabled patients. Cultivated limbal epithelial and oral mucosal epithelial transplantations are therefore viable alternatives that could be utilized for the treatment of limbal stem cell deficiency.
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Affiliation(s)
- V Kocaba
- Cornea Center of Excellence, Harvard Medical School, Schepens Eye Research Institute, 20, Staniford Street, Boston, 02114-MA, États-Unis; Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, 243, Charles Street, Boston, 02114-MA, États-Unis; Banque de cornée de Lyon, pavillon I, hôpital Edouard-Herriot, hospices civils de Lyon, 5, place d'Arsonval, 69003 Lyon, France; Service d'ophtalmologie, pavillon C, hôpital Edouard-Herriot, 5, place d'Arsonval, 69003 Lyon, France; Université Claude-Bernard Lyon-I, 43, boulevard du 11-Novembre-1918, 69100 Villeurbanne, France.
| | - O Damour
- Banque de cornée de Lyon, pavillon I, hôpital Edouard-Herriot, hospices civils de Lyon, 5, place d'Arsonval, 69003 Lyon, France
| | - C Auxenfans
- Banque de cornée de Lyon, pavillon I, hôpital Edouard-Herriot, hospices civils de Lyon, 5, place d'Arsonval, 69003 Lyon, France
| | - C Burillon
- Banque de cornée de Lyon, pavillon I, hôpital Edouard-Herriot, hospices civils de Lyon, 5, place d'Arsonval, 69003 Lyon, France; Service d'ophtalmologie, pavillon C, hôpital Edouard-Herriot, 5, place d'Arsonval, 69003 Lyon, France; Université Claude-Bernard Lyon-I, 43, boulevard du 11-Novembre-1918, 69100 Villeurbanne, France
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Iyer G, Srinivasan B, Agarwal S, Tarigopula A. Outcome of allo simple limbal epithelial transplantation (alloSLET) in the early stage of ocular chemical injury. Br J Ophthalmol 2016; 101:828-833. [DOI: 10.1136/bjophthalmol-2016-309045] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 07/20/2016] [Accepted: 09/04/2016] [Indexed: 11/03/2022]
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Fasolo A, Pedrotti E, Passilongo M, Marchini G, Monterosso C, Zampini R, Bohm E, Birattari F, Franch A, Barbaro V, Bertolin M, Breda C, Di Iorio E, Ferrari B, Ferrari S, Meneguzzi M, Ponzin D. Safety outcomes and long-term effectiveness of ex vivo autologous cultured limbal epithelial transplantation for limbal stem cell deficiency. Br J Ophthalmol 2016; 101:640-649. [DOI: 10.1136/bjophthalmol-2015-308272] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 07/11/2016] [Accepted: 07/30/2016] [Indexed: 11/03/2022]
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Vazirani J, Ali MH, Sharma N, Gupta N, Mittal V, Atallah M, Amescua G, Chowdhury T, Abdala-Figuerola A, Ramirez-Miranda A, Navas A, Graue-Hernández EO, Chodosh J. Autologous simple limbal epithelial transplantation for unilateral limbal stem cell deficiency: multicentre results. Br J Ophthalmol 2016; 100:1416-20. [DOI: 10.1136/bjophthalmol-2015-307348] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 01/03/2016] [Indexed: 11/03/2022]
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Long-Term Outcomes of Cultivated Limbal Epithelial Transplantation: Evaluation and Comparison of Results in Children and Adults. BIOMED RESEARCH INTERNATIONAL 2015; 2015:480983. [PMID: 26770973 PMCID: PMC4681831 DOI: 10.1155/2015/480983] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 10/25/2015] [Accepted: 11/04/2015] [Indexed: 11/17/2022]
Abstract
PURPOSE To compare the long-term clinical outcomes of cultivated limbal epithelial transplantation (CLET) in children and adults with limbal stem cell deficiency. DESIGN Retrospective case series. METHODS Case records of patients with limbal stem cell deficiency (LSCD) who underwent CLET from April 2004 to December 2014 were studied. Outcome measures were compared in terms of anatomical success and visual improvement. Parameters for total anatomical success were avascular, epithelized, and clinically stable corneal surface without conjunctivalization, whereas partial anatomical success was considered when mild vascularization (sparing centre of cornea) and mild conjunctivalization were noted along with complete epithelization. RESULTS A total of 62 cases underwent the CLET procedure: 38 (61.3%) were children and 24 (38.7%) were adults. Patients with unilateral LSCD (33 children and 21 adults) had autografts and those with bilateral LSCD (5 children and 3 adults) had allografts. Amongst the 54 autografts partial and total anatomical success were noted in 21.2% and 66.6% children, respectively, and 19.0% and 80.9% in adults, respectively (p value 0.23). Visual improvement of 1 line and ≥2 lines was seen in 57.5% and 21.2% children, respectively, and 38% and 38% in adults, respectively (p value 0.31). CONCLUSION Cultivated limbal epithelial transplantation gives good long-term results in patients with LSCD and the outcomes are comparable in children and adults.
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de Araujo AL, Gomes JP. Corneal stem cells and tissue engineering: Current advances and future perspectives. World J Stem Cells 2015; 7:806-814. [PMID: 26131311 PMCID: PMC4478627 DOI: 10.4252/wjsc.v7.i5.806] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 01/05/2015] [Accepted: 04/20/2015] [Indexed: 02/06/2023] Open
Abstract
Major advances are currently being made in regenerative medicine for cornea. Stem cell-based therapies represent a novel strategy that may substitute conventional corneal transplantation, albeit there are many challenges ahead given the singularities of each cellular layer of the cornea. This review recapitulates the current data on corneal epithelial stem cells, corneal stromal stem cells and corneal endothelial cell progenitors. Corneal limbal autografts containing epithelial stem cells have been transplanted in humans for more than 20 years with great successful rates, and researchers now focus on ex vivo cultures and other cell lineages to transplant to the ocular surface. A small population of cells in the corneal endothelium was recently reported to have self-renewal capacity, although they do not proliferate in vivo. Two main obstacles have hindered endothelial cell transplantation to date: culture protocols and cell delivery methods to the posterior cornea in vivo. Human corneal stromal stem cells have been identified shortly after the recognition of precursors of endothelial cells. Stromal stem cells may have the potential to provide a direct cell-based therapeutic approach when injected to corneal scars. Furthermore, they exhibit the ability to deposit organized connective tissue in vitro and may be useful in corneal stroma engineering in the future. Recent advances and future perspectives in the field are discussed.
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Baradaran-Rafii A, Akbari M, Shirzadeh E, Shams M. Single block conjunctival limbal autograft for unilateral total limbal stem cell deficiency. J Ophthalmic Vis Res 2015; 10:90-2. [PMID: 26005561 PMCID: PMC4424727 DOI: 10.4103/2008-322x.156132] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 03/17/2015] [Indexed: 11/14/2022] Open
Affiliation(s)
- Alireza Baradaran-Rafii
- Ocular Tissue Engineering Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mitra Akbari
- Ophthalmic Research Center, Guilan University of Medical Sciences, Guilan, Iran
| | - Ebrahim Shirzadeh
- Depatrment of Ophthalmology, Sabzevar University of Medical Sciences, Sabzevar, Iran
| | - Majid Shams
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Sotozono C, Inatomi T, Nakamura T, Koizumi N, Yokoi N, Ueta M, Matsuyama K, Kaneda H, Fukushima M, Kinoshita S. Cultivated oral mucosal epithelial transplantation for persistent epithelial defect in severe ocular surface diseases with acute inflammatory activity. Acta Ophthalmol 2014; 92:e447-53. [PMID: 24835597 PMCID: PMC4329382 DOI: 10.1111/aos.12397] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 02/22/2014] [Indexed: 12/15/2022]
Abstract
Purpose To assess the clinical efficacy of cultivated oral mucosal epithelial transplantation (COMET) for the treatment of persistent epithelial defect (PED). Methods We treated 10 eyes of nine patients with PED (Stevens–Johnson syndrome: three eyes; thermal/chemical injury: five eyes; ocular cicatricial pemphigoid: two eyes) with COMET at Kyoto Prefectural University of Medicine, Kyoto, Japan from 2002 to 2008. Results Preoperatively, PED existed on over more than 50% of the corneal surface in seven eyes. Severe ocular surface inflammation with fibrovascular tissue surrounded the PED in all 10 eyes. At 24-weeks postoperative, PED had improved in all cases except 1 in which the patient was unable to return to the hospital (95% CI, 55.5–99.7; Wilcoxon signed-rank test, p = 0.0078). The preoperative median of logarithmic minimum angle of resolution was 1.85 (range 0.15–2.70), and 1.85, 1.85, and 1.52 at the 4th, 12th, and 24th postoperative week, respectively. The mean total preoperative ocular surface grading score was 7.0 (range 4–17). At 4 and 12 weeks postoperative, the total ocular surface grading score had improved significantly (p = 0.0020, p = 0.0078), and at 24 weeks postoperative, it was 3.0 (range 2–12, p = 0.0234). During the follow-up period (median 23.3 months, range 5.6–39.7 months), no recurrence of PED was observed in any eye, and long-term ocular surface stability was obtained. Conclusion COMET enabled complete epithelialization of PED and stabilization of the ocular surface in patients with severe ocular surface disease, thus preventing end-stage cicatrization and vision loss at a later stage.
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Affiliation(s)
- Chie Sotozono
- Department of Ophthalmology Kyoto Prefectural University of Medicine Kyoto Japan
| | - Tsutomu Inatomi
- Department of Ophthalmology Kyoto Prefectural University of Medicine Kyoto Japan
| | - Takahiro Nakamura
- Department of Ophthalmology Kyoto Prefectural University of Medicine Kyoto Japan
- Research Center for Inflammation and Regenerative Medicine Faculty of Life and Medical Sciences Doshisha University Kyoto Japan
| | - Noriko Koizumi
- Department of Ophthalmology Kyoto Prefectural University of Medicine Kyoto Japan
- Department of Biomedical Engineering Faculty of Life and Medical Sciences Doshisha University Kyoto Japan
| | - Norihiko Yokoi
- Department of Ophthalmology Kyoto Prefectural University of Medicine Kyoto Japan
| | - Mayumi Ueta
- Department of Ophthalmology Kyoto Prefectural University of Medicine Kyoto Japan
- Research Center for Inflammation and Regenerative Medicine Faculty of Life and Medical Sciences Doshisha University Kyoto Japan
| | - Kotone Matsuyama
- Translational Research Informatics Center Foundation for Biomedical Research and Innovation Kobe Japan
| | - Hideaki Kaneda
- Translational Research Informatics Center Foundation for Biomedical Research and Innovation Kobe Japan
| | - Masanori Fukushima
- Translational Research Informatics Center Foundation for Biomedical Research and Innovation Kobe Japan
| | - Shigeru Kinoshita
- Department of Ophthalmology Kyoto Prefectural University of Medicine Kyoto Japan
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Sangwan VS, Jain R, Basu S, Bagadi AB, Sureka S, Mariappan I, Macneil S. Transforming ocular surface stem cell research into successful clinical practice. Indian J Ophthalmol 2014; 62:29-40. [PMID: 24492499 PMCID: PMC3955067 DOI: 10.4103/0301-4738.126173] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
It has only been a quarter of a century since the discovery of adult stem cells at the human corneo-scleral limbus. These limbal stem cells are responsible for generating a constant and unending supply of corneal epithelial cells throughout life, thus maintaining a stable and uniformly refractive corneal surface. Establishing this hitherto unknown association between ocular surface disease and limbal dysfunction helped usher in therapeutic approaches that successfully addressed blinding conditions such as ocular burns, which were previously considered incurable. Subsequent advances in ocular surface biology through basic science research have translated into innovations that have made the surgical technique of limbal stem cell transplantation simpler and more predictable. This review recapitulates the basic biology of the limbus and the rationale and principles of limbal stem cell transplantation in ocular surface disease. An evidence-based algorithm is presented, which is tailored to clinical considerations such as laterality of affliction, severity of limbal damage and concurrent need for other procedures. Additionally, novel findings in the form of factors influencing the survival and function of limbal stem cells after transplantation and the possibility of substituting limbal cells with epithelial stem cells of other lineages is also discussed. Finally this review focuses on the future directions in which both basic science and clinical research in this field is headed.
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Affiliation(s)
- Virender S Sangwan
- Clinical Trial Center, Dr. Paul Dubord Chair in Cornea, L V Prasad Eye Institute, Hyderabad, Andhra Pradesh, India
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He H, Yiu SC. Stem cell-based therapy for treating limbal stem cells deficiency: A review of different strategies. Saudi J Ophthalmol 2014; 28:188-94. [PMID: 25278795 DOI: 10.1016/j.sjopt.2014.06.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Revised: 06/16/2014] [Accepted: 06/16/2014] [Indexed: 12/13/2022] Open
Abstract
The self renewal capability of limbal epithelial stem (LEST) cells is fundamental to the maintenance and healing of corneal epithelium. Limbal stem cell deficiency (LSCD), due to dysfunction or loss of LEST cells, therefore presents as persistent epithelial defects, corneal vascularization, conjunctivalization etc. Stem cell-based therapy, in its simplest form - limbal autograft, has been used successfully for more than a decade. For bilateral LSCD, similar approaches with limbal allografts have been unsuccessful largely due to strong immune rejection. Therefore, as an alternate strategy for treating bilateral LSCD, ex vivo expansion of the remaining LEST cells or autologous stem cells sourced from other potential sites is being explored. Different culture systems (with and without xenobiotic supplements) using substrates like amniotic membrane or fibrin gels have been used successfully for ex vivo LEST cell maintenance and reproduction by imitating the stem cell niche. This paper is organized into sections reviewing the LEST cells, LSCD and various stem cell-based approaches for treating LSCD and discussing future direction and challenges.
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Affiliation(s)
- Hong He
- The Wilmer Eye Institute, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Samuel C Yiu
- The Wilmer Eye Institute, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
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Subramaniam SV, Sejpal K, Fatima A, Gaddipati S, Vemuganti GK, Sangwan VS. Coculture of autologous limbal and conjunctival epithelial cells to treat severe ocular surface disorders: long-term survival analysis. Indian J Ophthalmol 2014; 61:202-7. [PMID: 23552358 PMCID: PMC3730502 DOI: 10.4103/0301-4738.99840] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Cultivated limbal epithelium for reconstruction of corneal surface is a well-established procedure; however, it is not adequate for damage which also extensively involves the conjunctiva. In severe cases of ocular surface damage that warrant additional conjunctival transplantation apart from cultivated limbal stem cell transplantation, we describe the long-term survival of a novel method of cocultivating autologous limbal and conjunctival epithelium on a single substrate. MATERIALS AND METHODS Forty eyes of 39 patients with severe limbal stem cell deficiency and conjunctival scarring or symblepharon underwent transplantation of autologous cocultivated epithelium on human amniotic membrane. A ring barrier was used to segregate the central limbal and peripheral conjunctival epithelia in vitro. Patients were followed up at regular intervals to assess stability of the ocular surface, defined by absence of conjunctivalization into the central 4 mm of the cornea and absence of diffuse fluorescein staining. Penetrating keratoplasty (PKP) was subsequently performed, where indicated, in patients with surface stability. RESULTS The cumulative survival probability was 60% at 1 year and 45% at 4 years by Kaplan-Meier analysis (mean follow-up duration: 33 ± 29 months, range: 1-87 months). Best-corrected visual acuity improved to greater than 20/200 in 38% eyes at the last follow-up, compared with 5% eyes before surgery. Immunohistochemistry in five of the corneal buttons excised for PKP showed an epithelial phenotype similar to cornea in all five. CONCLUSIONS Synchronous use of cultured limbal and conjunctival epithelium offers a feasible alternative and a simpler one-step surgical approach to treat severe ocular surface disorders involving limbus and conjunctiva.
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Affiliation(s)
- Sandhya V Subramaniam
- Cornea and Anterior Segment Services; Sudhakar and Sreekanth Ravi Stem Cell Biology Laboratory, C-TRACER, Hyderabad Eye Research Foundation, L V Prasad Eye Institute, Hyderabad, India
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Burcu A, Yalniz-Akkaya Z, Ozdemir MF, Erdem E, Onat MM, Ornek F. Surgical rehabilitation following ocular chemical injury. Cutan Ocul Toxicol 2013; 33:42-8. [PMID: 23713679 DOI: 10.3109/15569527.2013.796477] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE The purpose of this study is to evaluate the management of limbal stem cell deficiency (LSCD) secondary to chemical ocular burns. MATERIALS AND METHODS The charts of 48 eyes of 40 patients with grade 2 or higher chemical injury were evaluated retrospectively. Subjects with follow-up longer than 1 year were included. Medical treatment, surgical correction of abnormalities of ocular adnexial structures, limbal stem cell transplantation from patient's fellow eye, from living relatives or from cadaveric donor, amniotic membrane transplantation, conjunctival epitheliectomy, chelation with ethylenediaminetetraacetic acid and penetrating keratoplasty were the treatment modalities. Outcome measures were ocular surface stability and corrected distance visual acuity (CDVA). Failure was defined as the appearance of persistent epithelial defect (nonhealing epithelial defect for more than 2 weeks) with progressive corneal conjunctivalization/vascularization and thinning, and also progression of conjunctivalization to the central 6 mm of the cornea in eyes with subsequent keratoplasty. RESULTS The mean age of 31 male and 9 female patients were 32.32 ± 12.6 years. LSCD was bilateral in 8 cases. The mean follow-up was 77.2 ± 35.1 months. The presentations were in acute phase in 37.5%, in subacute phase in 32.5% and in chronic phase in 30% of the patients. Only 13 of 48 (27.1%) eyes obtained sufficient ocular surface stability through medical treatment; however, only 5 of these eyes achieved CDVA of less than 0.7 logMAR. Limbal stem cell transplantation was performed in 26 eyes as conjunctival limbal autograft, living-related conjunctival limbal allograft and keratolimbal allograft or as a combination of these transplantations. At the last visit, 30 eyes (62.5%) had an intact and stable ocular surface. Clear cornea was achieved in 11 (78.6%) of 14 eyes with grade 2 injury, in 9 (60%) of 15 eyes with grade 3 injury, in 5 (50%) of 10 eyes with grade 4 injury, in 1 (16.6%) of 6 eyes with grade 5 injury and in 1 (33.3%) of 3 eyes with grade 6 injury. The CDVA that was 1.66 ± 0.99 logMAR initially improved to 0.87 ± 0.85 logMAR at the last visit (p < 0.001). CONCLUSION While patients with low-grade chemical injury seem to benefit quite well from the medical treatment, amniotic membrane transplantation, limbal graft transplantation and subsequent keratoplasty; patients with severe injuries seem to be more prone to failure after all of the available treatment modalities.
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Affiliation(s)
- Ayse Burcu
- Department of Ophthalmology, MH Ankara Training and Research Hospital , Ankara , Turkey and
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Regenerative Therapies for the Ocular Surface. Regen Med 2013. [DOI: 10.1007/978-94-007-5690-8_29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Abstract
The cornea, the clear window at the front of the eye, transmits light to the retina to enable vision. The corneal surface is renewed by stem cells located at the peripheral limbal region. These cells can be destroyed by a number of factors, including chemical burns, infections, and autoimmune diseases, which result in limbal stem cell deficiency (LSCD), a condition that can lead to blindness. Established therapy for LSCD based on ex vivo expanded limbal epithelial cells is currently at a stage of refinement. Therapy for LSCD is also rapidly evolving to include alternative cell types and clinical approaches as treatment modalities. In the present perspectives chapter, strategies to treat LSCD are discussed and advances in this important field of regenerative medicine are highlighted.
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Affiliation(s)
- Tor Paaske Utheim
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
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36
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37
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Eslani M, Baradaran-Rafii A, Ahmad S. Cultivated Limbal and Oral Mucosal Epithelial Transplantation. Semin Ophthalmol 2012; 27:80-93. [DOI: 10.3109/08820538.2012.680641] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Vemuganti GK, Sangwan VS, Mariappan I, Balasubramanian D. Regenerative Therapies for the Ocular Surface. Regen Med 2011. [DOI: 10.1007/978-90-481-9075-1_26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Miri A, Al-Deiri B, Dua HS. Long-term Outcomes of Autolimbal and Allolimbal Transplants. Ophthalmology 2010; 117:1207-13. [PMID: 20163866 DOI: 10.1016/j.ophtha.2009.10.028] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2009] [Revised: 10/13/2009] [Accepted: 10/13/2009] [Indexed: 11/28/2022] Open
Affiliation(s)
- Ammar Miri
- Division of Ophthalmology and Visual Sciences, University of Nottingham, England
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Affiliation(s)
- Harminder S Dua
- Division of Ophthalmology and Visual Sciences, University of Nottingham, Nottingham NG7 2UH, England, UK.
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Ram J, Sukhija J, Behera D, Gupta A. Ocular and Systemic Morbidity Profile in Mass Formic Acid Injuries. Ophthalmic Surg Lasers Imaging Retina 2010; 41:123-7. [DOI: 10.3928/15428877-20091230-22] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2009] [Indexed: 11/20/2022]
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Vemuganti GK, Fatima A, Madhira SL, Basti S, Sangwan VS. Chapter 5 Limbal Stem Cells. INTERNATIONAL REVIEW OF CELL AND MOLECULAR BIOLOGY 2009; 275:133-81. [DOI: 10.1016/s1937-6448(09)75005-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Abstract
Patients with limbal stem cell deficiency (LSCD) suffer from photophobia and a severe loss of vision uncorrectable by conventional PKP. This literature review shows that new strategies can be formulated for treating LSCD. Early cryopreserved amniotic membrane transplantation (AMT) as a temporary biological bandage with sutures or with sutureless ProKera in the acute stage of chemical burn and Stevens-Johnson syndrome prevents the occurrence of LSCD by preserving and expanding the remaining limbal epithelial stem cells. Similarly, remaining limbal stem cells can also be expanded in corneal surfaces with partial or nearly total LSCD if corneal pannus is removed and AMT is performed as a graft with or without sutures by the use of fibrin glue. Moreover, AMT as a temporary bandage and a graft using fibrin glue can also facilitate corneal surface reconstruction by reducing the size of a conjunctival limbal autograft (CLAU) to one 60 degrees graft for unilateral total LSCD as well as promote the success of a keratolimbal allograft (KLAL) for bilateral total LSCD. The latter success is further dictated by effective systemic immunosuppression and by measures to restore the ocular surface defenses, suppress conjunctival inflammation, and correct cicatricial complications so that a stable tear film can be maintained before surgery. This review also summarizes recent findings and outlines future challenges that we need to overcome in squamous metaplasia, that is, another major type of ocular surface failure.
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Limbal stem cell transplantation: new progresses and challenges. EYE (LONDON, ENGLAND) 2008. [PMID: 19098704 DOI: 10.1038/eye] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Patients with limbal stem cell deficiency (LSCD) suffer from photophobia and a severe loss of vision uncorrectable by conventional PKP. This literature review shows that new strategies can be formulated for treating LSCD. Early cryopreserved amniotic membrane transplantation (AMT) as a temporary biological bandage with sutures or with sutureless ProKera in the acute stage of chemical burn and Stevens-Johnson syndrome prevents the occurrence of LSCD by preserving and expanding the remaining limbal epithelial stem cells. Similarly, remaining limbal stem cells can also be expanded in corneal surfaces with partial or nearly total LSCD if corneal pannus is removed and AMT is performed as a graft with or without sutures by the use of fibrin glue. Moreover, AMT as a temporary bandage and a graft using fibrin glue can also facilitate corneal surface reconstruction by reducing the size of a conjunctival limbal autograft (CLAU) to one 60 degrees graft for unilateral total LSCD as well as promote the success of a keratolimbal allograft (KLAL) for bilateral total LSCD. The latter success is further dictated by effective systemic immunosuppression and by measures to restore the ocular surface defenses, suppress conjunctival inflammation, and correct cicatricial complications so that a stable tear film can be maintained before surgery. This review also summarizes recent findings and outlines future challenges that we need to overcome in squamous metaplasia, that is, another major type of ocular surface failure.
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Shi W, Gao H, Wang T, Xie L. Combined penetrating keratoplasty and keratolimbal allograft transplantation in comparison with corneoscleral transplantation in the treatment of severe eye burns. Clin Exp Ophthalmol 2008; 36:501-7. [DOI: 10.1111/j.1442-9071.2008.01802.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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A systematic literature review of surgical interventions for limbal stem cell deficiency in humans. Am J Ophthalmol 2008; 146:251-259. [PMID: 18486098 DOI: 10.1016/j.ajo.2008.03.018] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2007] [Revised: 03/11/2008] [Accepted: 03/13/2008] [Indexed: 11/23/2022]
Abstract
PURPOSE To evaluate the relative benefits and to identify any adverse effects of surgical interventions for limbal stem cell deficiency (LSCD). DESIGN Systematic literature review. METHODS We searched the following electronic databases from January 1, 1989 through September 30, 2006: MEDLINE, EMBASE, Science citation index, BIOSIS, and the Cochrane Library. In addition, reference lists were scanned to identify any additional reports. The quality of published reports was assessed using standard methods. The main outcome measure was improvement in vision of at least two Snellen lines of best-corrected visual acuity (BCVA). Data on adverse outcomes also were collected. RESULTS Twenty-six studies met the inclusion criteria. There were no randomized controlled studies. All 26 studies were either prospective or retrospective case series. For bilateral severe LSCD, keratolimbal allograft was the most common intervention with systemic immunosuppression. Other interventions included eccentric penetrating keratolimbal allografts and cultivated autologous oral mucosal epithelial grafts. An improvement in BCVA of two lines or more was reported in 31% to 67% of eyes. For unilateral severe LSCD, the most common surgical intervention was contralateral conjunctival limbal autograft, with 35% to 88% of eyes gaining an improvement in BCVA of two lines or more. The only study evaluating partial LSCD showed an improvement in BCVA of two lines or more in 39% of eyes. CONCLUSIONS Studies to date have not provided strong evidence to guide clinical practice on which surgery is most beneficial to treat various types of LSCD. Standardized data collection in a multicenter LSCD register is suggested.
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Abstract
PURPOSE To report the results of one 60 degrees conjunctival limbal autograft (CLAU) combined with amniotic membrane (AM) transplantation for an eye with total limbal stem cell deficiency (LSCD). METHODS One eye of a patient with chronic total LSCD and symblepharon caused by chemical burn was subjected to symblepharon lysis, removal of pannus from corneal surface, AM transplantation to cover the conjunctival and corneal surfaces as a permanent graft, one 60 degrees CLAU to the superior limbal area, and insertion of ProKera as a temporary AM patch to cover the CLAU. RESULTS After surgery, corneal epithelialization over the AM was evident adjacent to the CLAU on day 6, progressed to pass the horizontal midline by day 11, and was completed by day 18. During a follow-up of 1 year, the corneal surface remained stable and smooth, and the stroma considerably regained clarity with regression of midstromal vascularization. The best-corrected visual acuity improved from 20/400 to 20/50. The conjunctival inflammation completely resolved, and the fornices were deep. CONCLUSIONS One 60 degrees CLAU combined with AM transplantation as both a permanent graft and a temporary patch can restore the entire corneal surface in an eye with total LSCD caused by chemical burn.
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Majo F, Barrandon Y, Othenin-Girard P, Toublanc M, Hoang-Xuan T. [Corneal epithelial diseases related to limbal stem cell deficiency]. J Fr Ophtalmol 2006; 29:1060-9. [PMID: 17115001 DOI: 10.1016/s0181-5512(06)73901-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Treatment of corneal epithelial diseases induced by limbal stem cell deficiency is an important challenge in ocular surface reconstruction. Since the 1990s, corneal stem cells have been localized in the limbus. This new concept completely changed the way we consider ocular surface reconstruction, with new diseases now found to be isolated in the ocular surface. Limbus insufficiency syndromes are specific depending on their origin (congenital or acquired), their expression (unilateral or bilateral, partial or total), their progression (acute or chronic), and the mechanism involved (burn, infection, chronic inflammation, etc.). Some of these diseases are local diseases and others are systemic diseases. Clinically, limbus insufficiency is a switch of the normal corneal epithelial phenotype (expression of a specific keratin, avascularity, and transparency of the corneal matrix) in an opaque and fibrovascularized cornea. In terms of cellular biology, a phenotype is a terminal expression of a cell differentiation process. This process is the outcome of the interaction between the genome of a cell or a group of cells with their microenvironment. In limbus insufficiency, epithelial cells and corneal matrix are destroyed, and it is the destruction of these two components that leads to limbus insufficiency syndrome.
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Affiliation(s)
- F Majo
- Hôpital Bichat-Claude Bernard, et Fondation Ophtalmologique A. de Rothschild, Paris, France
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Mittal V, Sangwan VS, Fernandes M, Thomas R. Survival analysis of conjunctival limbal grafts and amniotic membrane transplantation in eyes with total limbal stem cell deficiency. Am J Ophthalmol 2006; 141:599-600; author reply 600. [PMID: 16490530 DOI: 10.1016/j.ajo.2005.11.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2005] [Revised: 10/27/2005] [Accepted: 11/18/2005] [Indexed: 11/17/2022]
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