Transplanted eyes of foreign donors can reinstate the optically activated skin camouflage reactions in bilaterally enucleated salamanders (Ambystoma)

Technical Feasibility of Whole-eye Vascular Composite Allotransplantation: A Systematic Review

There are over 43 million individuals in the world who are blind. As retinal ganglion cells are incapable of regeneration, treatment modalities for this condition are limited. Since first incepted in 1885, whole-eye transplantation (WET) has been proposed as the ultimate cure for blindness. As the field evolves, different aspects of the surgery have been individually explored, including allograft viability, retinal survival, and optic nerve regeneration. Due to the paucity in the WET literature, we aimed to systematically review proposed WET surgical techniques to assess surgical feasibility. Additionally, we hope to identify barriers to future clinical application and potential ethical concerns that could be raised with surgery.

Methods

We conducted a systematic review of PubMed, Embase, Cochrane Library, and Scopus from inception to June 10, 2022, to identify articles pertaining to WET. Data collection included model organisms studied, surgical techniques utilized, and postoperative functional outcomes.

Results

Our results yielded 33 articles, including 14 mammalian and 19 cold-blooded models. In studies performing microvascular anastomosis in mammals, 96% of allografts survived after surgery. With nervous coaptation, 82.9% of retinas had positive electroretinogram signals after surgery, indicating functional retinal cells after transplantation. Results on optic nerve function were inconclusive. Ocular-motor functionality was rarely addressed.

Conclusions

Regarding allograft survival, WET appears feasible with no complications to the recipient recorded in previous literature. Functional restoration is potentially achievable with a demonstrated positive retinal survival in live models. Nevertheless, the potential of optic nerve regeneration remains undetermined.

Whole-eye transplantation: a look into the past and vision for the future

Blindness afflicts ~39 million people worldwide. Retinal ganglion cells are unable to regenerate, making this condition irreversible in many cases. Whole-eye transplantation (WET) provides the opportunity to replace diseased retinal ganglion cells, as well as the entire optical system and surrounding facial tissue, if necessary. Recent success in face transplantation demonstrates that this may be a promising treatment for what has been to this time an incurable condition. An animal model for WET must be established to further enhance our knowledge of nerve regeneration, immunosuppression, and technical aspects of surgery. A systematic review of the literature was performed to evaluate studies describing animal models for WET. Only articles in which the eye was completely enucleated and reimplanted were included. Study methods and results were compared. In the majority of published literature, WET can result in recovery of vision in cold-blooded vertebrates. There are a few instances in which mammalian WET models demonstrate survival of the transplanted tissue following neurovascular anastomosis and the ability to maintain brief electroretinogram activity in the new host. In this study we review in cold-blooded vertebrates and mammalian animal models for WET and discuss prospects for future research for translation to human eye transplantation.

Impediments to eye transplantation: ocular viability following optic-nerve transection or enucleation

Maintenance of ocular viability is one of the major impediments to successful whole-eye transplantation. This review provides a comprehensive understanding of the current literature to help guide future studies in order to overcome this hurdle. A systematic multistage review of published literature was performed. Three specific questions were addressed: (1) Is recovery of visual function following eye transplantation greater in cold-blooded vertebrates when compared with mammals? (2) Is outer retina function following enucleation and reperfusion improved compared with enucleation alone? (3) Following optic-nerve transection, is there a correlation between retinal ganglion cell (RGC) survival and either time after transection or proximity of the transection to the globe? In a majority of the studies performed in the literature, recovery of visual function can occur after whole-eye transplantation in cold-blooded vertebrates. Following enucleation (and reperfusion), outer retinal function is maintained from 4 to 9 h. RGC survival following optic-nerve transection is inversely related to both the time since transection and the proximity of transection to the globe. Lastly, neurotrophins can increase RGC survival following optic-nerve transection. This review of the literature suggests that the use of a donor eye is feasible for whole-eye transplantation.

Tectectomy in the cyclopean salamander

In an Ambystoma larva with both natural eyes removed and one eye grafted atop the head (Cyclops preparation), vision-dependent behavior usually recovers from the enucleation inherent in the operation, but the optically activated skin blanching reaction reappears in a very small number of instances. In the present studies, while the latter trend continued for the conventional Cyclops preparation, tectectomy concurrent with the ectopic eye transplantation resulted in a several-fold increase in the recovery of blanching competency. Some 60 percent of the tectectomized Cyclops animals exhibited the same Hogben-Slome pigmentation indices as larvae with one natural eye intact (controls). As measured planimetrically with an image analyzer, the pigment spots (melanosome containing portions of dermal melanocytes) contracted to the same extent in the blanch-competent Cyclops animals as in controls with a single natural eye.

Anterior decerebration blocks visual habituation in the larval salamander (Ambystoma punctatum)

Amputation of the rostral half of the cerebrum induces a compulsion-like reaction in larval Ambystoma punctatum towards Enchytraeus protected within glass vials. Normal and craniotomized larvae are visually attracted to worm-containing vials, as revealed by time-lapse video taping but, after several unsuccessful attempts to get the prey, habituate and depart. The video tapes revealed that anteriorly decerebrated animals spent as much as 100 of 120 minutes at the worm-containing vial, repeatedly but futilely attacking the glass. The data indicate that the telencephalon plays an active negative role in the salamander larva's visually guided behavior.

Two-eyed versus one-eyed salamanders: does binocularity enhance the optically evoked skin blanching reactions of Ambystoma larvae?

A wide variety of visual functions show increases attributable to binocularity, and the question pursued here was whether a second eye enhances the visually stimulated skin blanching reaction of the larval salamander. Dermal melanin spots (produced by the aggregations of melanosomes within dermal melanophores and which contract or expand to lighten or darken the skin) were measured in eyeless (controls), one-eyed and two-eyed Ambystoma punctatum larvae after chronic adaptation of the subjects to a white background (i.e., stimulus conditions for maximum blanching). The eyeless subjects showed no blanching (thus remained dark) in white cups, and they exhibited melanin spots 7 or 8 times the size of those of the other two groups. All one-eyed or two-eyed subjects exhibited blanching reactions; planometric comparison revealed a significantly larger melanin spot area for one-eyed than for two-eyed animals; i.e., the binocular condition permitted greater contraction of the pigment spots than did the monocular condition. Analytical data compared favorably with independently ascertained pigmentation indices. The results indicate that a second eye quantitatively elevates the blanching maximum of a larval salamander.