Causticacin severa: Insuficiencia limbar completa, leucoma total, simblfaron e imposibilidad de autoinjerto limbar.Dr. Joaqun Salas

Limbal allografting from related live donors for corneal surface reconstructionOphthalmology. 1999 Apr;106(4):822-8 Compares HLA-matched and -unmatched related live donors PARTICIPANTS: Eight patients (nine eyes) with severe chemical burns (n = 7 eyes) and Stevens-Johnson syndrome (n = 2 eyes) INTERVENTION: Recipient eyes were treated with excision of cicatricial tissues. Transplantation of superior and inferior limbal grafts was performed from related live HLA-matched (n = 7) and -unmatched donors (n = 2). Systemic cyclosporine was not used in any of the recipients RESULTS: With a mean observation period of 17.2 months, phenotypically corneal epithelium, decreased vascularization of the corneal surface, and improved ocular comfort were seen in seven (77.8%) eyes. In all seven eyes, gradual recurrence of peripheral corneal vascularization occurred during the follow-up period. Features of graft rejection developed in three (42.9%) of these seven eyes. In two eyes, limbal transplantation from HLA-unmatched donors failed to reconstitute the corneal surface. Limbal allograft transplantation resulted in visual acuity of 20/400 or greater in only two (22.2%) eyes at last follow-up. Corneal grafts performed 7 and 16 months after successful limbal transplantation in two eyes developed recurrent epithelial breakdown and superficial corneal scarring. None of the donor eyes in this study had any complication CONCLUSION: Transplantation of limbal tissue from related live donors successfully reconstructs the corneal surface in HLA-matched recipients. Recurrence of vascularization on long-term follow-up probably results from inadequate stem cell transfer, immune-mediated stem cell damage, or both. Limbal allografting is best performed by transplanting the entire limbus from a cadaveric donor eye with systemic immunosuppression of the recipient, even if the donor is HLA-compatible

Living related conjunctival limbal allograft for the treatment of stem cell deficiency.Ophthalmology. 2001 Jan;108(1):126-33 PARTICIPANTS: Nine living related donors, eight recipients (10 eyes) with Stevens-Johnson syndrome (3 eyes), ectodermal dysplasia (3 eyes), chemical injury (2 eyes), ocular cicatricial pemphigoid (1 eye), and atopic keratoconjunctivitis (n = 1) INTERVENTION: Four clock hours of limbal conjunctival tissue from the best matched HLA relative donor were transplanted to the recipient eye superiorly and inferiorly after conjunctival peritomy and removal of conjunctival pannus. Systemic cyclosporine was administered to all recipients. RESULTS: Mean follow-up period was 26.2 months. Two highly inflamed eyes failed to initially epithelialize. The remainder all survived with restoration of corneal epithelium and reduction of vascularization. Corneal opacification was reduced (four of eight eyes) and visual improvement was achieved in seven eyes. All five eyes with pain had an improvement in symptoms. Allograft rejection occurred in two eyes (25%), and both were treated successfully. Both eyes had two class I HLA mismatches, and both had an underlying diagnosis of Stevens-Johnson syndrome. One eye developed a recurrent epithelial defect and perforated, requiring a penetrating keratoplasty that remained clear with an intact epithelial surface. The two initial failures also perforated and required penetrating keratoplasties that failed. None of the donor eyes had any complications

Allo-limbal transplantation in patients with limbal stem cell deficiency Br J Ophthalmol. 1999 Apr;83(4):414-9 6 patients underwent allo-limbal stem cell transplantation. The primary diagnosis included alkali burn (n = 2), trachoma (n = 1), chronic rosacea blepharitis and kerato-conjunctivitis (n = 1), aniridia (n = 1), and Stevens-Johnson syndrome (n = 1). The limbal rim consisted of peripheral cornea and perilimbal sclera. FK-506 was used postoperatively for immunosuppression Follow up ranged from 3 to 24 months (mean follow up 11.8 (SD 9.3) months). The outcome was considered satisfactory in five of six cases. The corneal surface was completely epithelialised within 2 weeks, and there was a substantial improvement in vision and symptoms. One patient had recurrent epithelial defects related to eyelid abnormalities. No side effects associated with systemic immunosuppression were noted Allo-limbal transplantation, with systemic immunosuppression with FK-506 is useful in reconstruction of the ocular surface with improvement in vision in patients with severe stem cell deficiency Descripcion de tecnica en ESTE ARTICULO

Limbal stem cell transplantation from HLA-compatible living donors. Long term observationKlin Oczna. 2003;105(6):378-83 11 patients (12 eyes), all with non-ambulatory visual acuity (from light perception to hand movements) 7 eyes Limbal Stem Cells Deficiency (LSCD) resulted from chemical burn, in 2 eyes from ocular cicatricial pemphigoid, in one eye from Stevens-Johnson syndrome (SJS). In one eye congenital LSCD was diagnosed and in another one post-inflammatory LSCD. Mean follow-up was 16.2 months (from 10 to 32). Among donors prospective class I HLA matching was performed. Maximal two mismatches were accepted. General immunosuppressive therapy was switched-on in all subjects. Surgical excision of corneal pannus with clearing of limbal area was performed. Five clock hours stem cells tissue grafts from living related donors were harvested and transplanted to the recipient eye. Three penetrating keratoplasty, one deep lamellar keratoplasty and seven amniotic membrane transplantations were additionally performed RESULTS: The graft survival was 83.6% in mean 20.3 months follow-up (from 10 to 32 months). Two cases of graft failure concern eye with SJS and eye with PKP regrafting after chemical burn. Visual improvement in 7 cases (58.3%), the same visual acuity in 4 cases (33.3%) and deterioration one case (8.3%) were noted. Ambulatory vision in 50% of patients was achieved. Graft rejection syndrome in four eyes was noticed also when ideal matching and CsA serum level 220 ng/ml. Two cases were treated with success and another two grafts failed. No complications in donors eyes were noticed. Impression cytology in eyes with successful grafts not related to pathological changes CONCLUSIONS: Lr-CLAL are effective in ocular surface restoration. Living-related donors are suitable source of stem cells for cultivation in vitro. The prognosis for stem cells grafting is definitely worse when eyelid anomaly and adhesions exist.

ESTUDIO COMPARATIVO ENTRE TRANSPLANTE DE MEMBRANA AMNITICA CON Y SIN APLICACIN SIMULTNEA DE MITOMICINA C EN RECONSTRUCCIN DE FONDO DE SACO CONJUNTIVAL Arch Soc Esp Oftalmol 2005; 80: 345-352 Grupo A al cual se le realiz liberacin de simblfaron y transplante de MA y Grupo B al que adems del transplante se aplic MMC al 0,02% Tcnica: El tejido conjuntival cicatrizal fue escindido aplicando MMC 0,02% por 1 minuto y lavado exhaustivo posterior a la aplicacin. Se coloc MA cubriendo el defecto (grupo A y B). Las variables medidas fueron profundidad de saco conjuntival y movilidad ocular Grupo A (11 ojos). 7 quemaduras qumicas, 3 simblfaron traumtico y 1 Stevens-Johnson. En 2 pacientes se obtuvo una profundidad de fondo de saco de 7 mm o mayor. En 4 pacientes encontramos una limitacin a la movilidad ocular menor a -1. Grupo B (12 ojos). 7 quemaduras qumicas, 2 simblfaron traumtico y 3 Stevens-Johnson. En 9 casos se obtuvo profundidad de fondo de saco de 7 mm o mayor. En 9 casos la restriccin a la movilidad se elimin. Los resultados ms pobres en ambos grupos se obtuvieron en aquellos con trastornos autoinmunes

Role of amniotic membrane graft for ocular chemical and thermal injuries. Cornea. 2007 Jan;26(1):21-6 Seventy two eyes of 69 patients were studied of which 24 were acute cases (median-2 days, range, 1-20 days) and 48 were chronic cases (median-12.4 months, range, 1.02-95.8 months). Mean age was 22.4 years (SD +/- 13.34 years) and average follow up duration was 7.8 months (SD +/- 7.1). Main clinical findings were symblephara (52.8%), corneal vascularization (51.3%), conjunctivalization (45.8%), Limbal ischemia (45.8%), Limbal stem cell deficiency (55.5%) and epithelial defect (48.6%). 18 cases were due to acid injuries (5 acute, 13 chronic), 52 were due to alkali (18 acute and 34 chronic) and 2 cases were due to thermal burns (1 each acute and chronic). success rate was 87.5% in acute cases and 72.9% in chronic cases. Indication-wise success rates were 94.3% for epithelial defect healing, 88.2% for symptomatic relief, 59.7% for ocular surface reconstruction, and 55% for improving limbal stem cell function. Success was not achieved in any outcome measure in 1/24 (4.2%) in acute group and 6/48 (12.5%) in chronic group

Changes observed in keratolimbal allograft Cornea. 2006 May;25(4):377-82 121 KLALs performed in consecutive 85 eyes of 78 patients with total limbal stem-cell deficiency were analyzed retrospectively. Mean follow-up period was 46.6 months. Three types of limbal graft changes classified as epithelial defects, acute edema, and vascular engorgement were analyzed as probable signs of immunologic rejection One or more changes in limbal grafts were observed after 16 KLALs (13.1%). All but 1 eye used systemic and local immunosuppression using corticosteroid and cyclosporine A, and most of the changes developed within 3 months postoperatively. All but 2 eyes developed epithelial breakdown in the central cornea, and 12 corneas underwent conjunctivalization. The rate of corneal epithelialization in eyes with limbal graft changes was significantly worse than those without the changes Suppression of the immune reaction remains a key to success in KLAL

Ocular surface reconstruction for thermal burns caused by fireworks Cornea. 2006 Feb;25(2):139-45 Six eyes, chronic stage of thermal injury, and all had total limbal stem cell dysfunction and subsequent conjunctival fibrosis. They had limbal stem cell transplantation (1 had an allograft and 5 had autograft transplantation) combined with AMT to restore vision. Mitomycin C was used in 1 eye intraoperatively Mean follow-up period of 36 months (range, 5-87 months), marked reduction of fibrosis was noted in all eyes. At last examination, the corneal surface was covered by corneal-phenotype epithelium in 4 eyes, and the remaining 2 eyes had conjunctivalization. The cornea was optically clear in 3 eyes, with corrected visual acuity of 20/100 in these 3 eyes. Both eyes that developed conjunctivalization had massive fibrosis preoperatively and severe eyelid deformities Limbal stem cell transplantation combined with AMT enable some success in cosmetic and visual outcome. Management of eyelid abnormalities and ocular surface fibrosis seemed to be a key to success in visual rehabilitation.

Survival analysis of conjunctival limbal grafts and amniotic membrane transplantation in eyes with total limbal stem cell deficiency Am J Ophthalmol. 2005 Aug;140(2):223-30 Thirty-three eyes of 31 patients with total LSCD that underwent conjunctival limbal grafts and AMT Ten eyes (30%) underwent conjunctival limbal autograft and 23 (70%) underwent conjunctival limbal allograft from living HLA-matched donor. Graft survival was seen in 13 eyes (40%) at 1 year and in 11 eyes (33.3%) at 2 years, with a cumulative survival of 33% after a mean follow-up time of 33 months. Increase in postoperative visual acuity was observed in 20 eyes (60.6%) during this period. Marked impact on graft survival was observed for patients with Stevens-Johnson syndrome, dry eye, keratinization, eyelid abnormalities, and allogeneic conjunctival limbal transplantation (independently of HLA compatibility) (P < .05). Preoperative dry eye was the most important prognostic parameter for surgical outcome (P < .001).

Severe limbal deficiency treated by combined limbal allograft and amniotic membrane transplantationArch Soc Esp Oftalmol. 2005 Jul;80(7):405-12 14 eyes with severe limbal deficiency, treated with LT combined with AMT (LT + AMT). We studied the morphology of the limbocorneal epithelium and stroma by impression cytology and limbal biopsy Visual acuity showed a mean improvement of 0.4 at 24 months of follow-up. Corneal clarity and loss of neovascularization were markedly improved after 3 and 6 months, respectively. We did not find corneal conjuntivalization on cytology performed 6 months after surgery, except in a patient with chemical burn. Cytology and limbal biopsy performed nine months after surgery showed an epithelium and limbocorneal stroma near to normality CONCLUSIONS: LT + AMT is a very effective procedure for restoring the ocular surface integrity in patients with severe limbal deficiency. This combination improves the outcomes obtained with LT alone.

Transplantation of cultivated autologous oral mucosal epithelial cells in patients with severe ocular surface disorders British Journal of Ophthalmology 2004;88:1280-1284

Methods: The eyes (n = 6) of four patients with Stevens-Johnson syndrome (three eyes) or chemical burns (three eyes) were studied. Autologous oral epithelial cells, grown for 23 weeks on a denuded amniotic membrane carrier in the presence of 3T3 fibroblasts, were air lifted. The resultant sheet was transplanted onto the damaged eye, and acceptance of the sheet by the corneal surface was confirmed 48 hours after surgery. The success of ocular surface reconstruction, graft survival, changes in visual acuity, and postoperative complications were assessed and the quality of the cultivated oral epithelial sheet was evaluated histologically. Results: At 48 hours after transplant, the entire corneal surface of all six eyes was free of epithelial defects indicating complete survival of the transplanted oral epithelium. Visual acuity was improved in all eyes. During follow up (mean 13.8 (SD 2.9) months), the corneal surface remained stable, although all eyes manifested mild peripheral neovascularisation.

Propuesta:1.-Reparar simblfaron con MA2.-Aloinjerto limbar de familiar con mejor compatibilidad HLA + MA, bajo inmunosupresin3.-Queratoplastia penetrante4.-Evaluar nueva MA +/- SA5.-Qx Catarata?

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