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      Ocular Surface Preparation Before Keratoprosthesis Implantation

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          Abstract

          Introduction

          This study aimed to evaluate the surgical treatment results for conjunctival limbal autograft (CLAU) and keratolimbal allograft (KLAL) in various types of limbal stem cell deficiency (LSCD) etiologies performed in order to achieve a stable ocular surface prior to KPro implantation.

          Methods

          We analyzed the outcomes of the surgical treatment of 43 eyes of 39 patients with LSCD as an initial treatment preparing patients’ ocular surface for KPro implantation. The most common causes were ocular trauma (50.7%), mainly alkali burns (77%); autoimmune causes, mainly ocular cicatricial pemphigoid (OCP; 17.4%); infection (15.9%) including Lyell’s syndrome/Stevens–Johnson syndrome (LS/SJS; 16%). In all 17 eyes operated on with CLAU, this procedure was performed once. Similarly, one uncomplicated KLAL procedure in one eye was performed in 10 women and 19 men. In another one woman and three men, KLAL was performed in both eyes. In one man with Lyell’s syndrome, the KLAL operation was performed three times in one eye. Follow-up was at least 12 months.

          Results

          Visual acuity (VA) improved in 17 eyes (31%) and remained unchanged in 38 eyes (69%). VA improved from light perception to hand movements in three eyes (16%) from the CLAU group of patients and eight eyes (15%) from the KLAL group; VA improved from hand movements to finger counting in two eyes (12%) post CLAU and two eyes (4%) post KLAL operation. The most common complication of surgical treatment was persistent epithelial defect that was refractory to medical treatment in 32 eyes (58%), 5 eyes post CLAU and 27 post KLAL. Corneal conjunctivalization (19%) and neovascularization (29%) were present on the corneal edge of the graft. Symblephara recurred within 3 months in nine eyes (17.3%) after KLAL, including four eyes that had been chemically burned and five eyes with LS/SJS.

          Discussion

          Pretreatment with CLAU or KLAL procedures in severely damaged ocular surfaces allows the ocular surface to be prepared for safe KPro implantation with sufficient tissue surroundings with less conjunctivalization and deeper conjunctival fornices.

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          Most cited references21

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          Limbal autograft transplantation for ocular surface disorders.

          K R Kenyon, S C Tseng (1989)
          Limbal autograft transplantation is presented in 26 consecutive cases comprising both acute and chronic chemical injury (20 cases), thermal burns (2 cases), contact lens-induced keratopathy (3 cases), and ocular surface failure after multiple surgical procedures (1 case), with follow-up ranging from 2 to 45 months (mean, 18 months). The operative technique usually involved transfer of two free grafts of limbal tissue from the uninjured or less injured donor eye to the severely injured recipient eye, the latter having been prepared by limited conjunctival research and superficial dissection of fibrovascular pannus without keratectomy. Clinical results in 21 patients with follow-up of 6 months or more have consistently shown improved visual acuity (17 cases), rapid surface healing (19 cases), stable epithelial adhesion without recurrent erosion or persistent epithelial defect (20 cases), arrest or regression of corneal neovascularization (15 cases), and probable increased success for lamellar or penetrating keratoplasty (8 cases). No intraoperative complications were encountered, and no adverse reactions developed in donor eyes. Impression cytology in selected cases showed restoration of the corneal epithelial phenotype and regression of goblet cells from the recipient cornea. Therefore, limbal autograft transplantation is recommended for treatment of widespread ocular surface damage with loss of limbal epithelial stem cells and, specifically, for chemical or thermal burns, contact lens-induced keratopathy, and selected persistent corneal epithelial defects.
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            Limbal stem cell transplantation: new progresses and challenges.

            H Sheha, Scheffer C G Tseng, Volkhart M-J Li … (2009)
            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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              Global Consensus on the Management of Limbal Stem Cell Deficiency.

              Sophie X. Deng, Friedrich E Kruse, Jose A P Gomes … (2020)
              In recent decades, the medical and surgical treatment of limbal stem cell deficiency (LSCD) has evolved significantly through the incorporation of innovative pharmacological strategies, surgical techniques, bioengineering, and cell therapy. With such a wide variety of options, there is a need to establish a global consensus on the preferred approaches for the medical and surgical treatment of LSCD.
              Article 0 comments Cited 34 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                Beniamin O. Grabarek:
                ORCID: http://orcid.org/0000-0003-1633-7145
                bgrabarek7@gmail.com
                Journal
                Journal ID (nlm-ta): Ophthalmol Ther
                Journal ID (iso-abbrev): Ophthalmol Ther
                Title: Ophthalmology and Therapy
                Publisher: Springer Healthcare (Cheshire )
                ISSN (Print): 2193-8245
                ISSN (Electronic): 2193-6528
                Publication date (Electronic): 22 November 2021
                Publication date PMC-release: 22 November 2021
                Publication date (Print): February 2022
                Volume: 11
                Issue: 1
                Pages: 249-259
                Affiliations
                [1 ]Department of Ophthalmology, Faculty of Medicine in Zabrze, University of Technology in Katowice, 41-800 Zabrze, Poland
                [2 ]Department of Ophthalmology with Paediatric Unit, 5th Regional Hospital in Sosnowiec, 41-200 Sosnowiec, Poland
                [3 ]GRID grid.411728.9, ISNI 0000 0001 2198 0923, Chair and Clinical Department of Ophthalmology, Division of Medical Science in Zabrze, , Medical University of Silesia in Katowice, ; 40-760 Katowice, Poland
                [4 ]Department of Histology, Cytophysiology and Embryology, Faculty of Medicine in Zabrze, University of Technology in Katowice, 41-800 Zabrze, Poland
                Author information
                http://orcid.org/0000-0003-1633-7145
                Article
                Publisher ID: 420
                DOI: 10.1007/s40123-021-00420-8
                PMC ID: 8770772
                PubMed ID: 34811639
                SO-VID: 56c90edd-2cb8-4bf1-9acd-e6e3e54710e3
                Copyright © © The Author(s) 2021
                License:

                Open Access This article is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, which permits any non-commercial use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc/4.0/.

                History
                Date received : 15 August 2021
                Date accepted : 29 October 2021
                Categories
                Subject: Original Research
                Custom metadata
                issue-copyright-statement © The Author(s) 2022

                Keywords: allograft,conjunctival limbal autograft,corneal conjunctivalization,keratoprosthesis,keratolimbal neovascularization
                Data availability:
                Keywords: allograft, conjunctival limbal autograft, corneal conjunctivalization, keratoprosthesis, keratolimbal neovascularization

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