CLINICAL SCIENCE Long-Term Ocular Surface Stability in Conjunctival Limbal Autograft Donor Eyes Albert Y. Cheung, MD,*† Enrica Sarnicola, MD,*†‡ and Edward J. Holland, MD*† (OSST) procedures can provide healthy limbal stem cells Purpose: fi – To investigate the incidence of limbal stem cell de ciency and conjunctiva to rehabilitate a damaged ocular surface.2 8 (LSCD) in donor eyes after conjunctival limbal autograft (CLAU). Conjunctival limbal autograft (CLAU) is a technique that ; Methods: An observational retrospective review was performed on transplants a portion (typically 3to6clockhours)ofthe all patients who underwent CLAU alone, combined keratolimbal healthy stem cells from an unaffected eye to the contralat- allograft with CLAU (“Modified Cincinnati Procedure”), or com- eral affected eye in individuals affected by unilateral LSCD.6 bined living-related conjunctival limbal allograft (lr-CLAL) with 7 $ Cultivated limbal epithelial transplantation (CLET) CLAU having 6 months of follow-up after surgery. The outcome 8 measures were best-corrected visual acuity (BCVA) and ocular and simple limbal epithelial transplantation (SLET) provide surface status. ex vivo and in vivo expansion of stem cells, respectively, to repopulate the ocular surface. In contrast to CLET and SLET, Results: The inclusion criteria were fulfilled by 45 patients. Of CLAU is ideal for rehabilitating severe unilateral LSCD these, 26 patients underwent CLAU, 18 underwent combined requiring combined conjunctival limbal transplantation and keratolimbal allograft/CLAU, and 1 underwent combined lr- for reconstruction of the ocular surface. Proponents of CLET CLAL/CLAU. Mean age at the time of surgery was 39.6 years. and SLET have raised concerns regarding the potential Mean logMAR preoperative BCVA was 20.08. There were no iatrogenic damage of CLAU to the healthy donor eye.8,9 operative complications. The mean follow-up duration after To date, there remains a paucity of data on the long- surgery was 48.3 months (range 8.3–181.5 mo). At last follow- term effects of CLAU on donor eyes. In this study, we up, all eyes maintained a stable ocular surface, and mean logMAR investigate the incidence of LSCD in donor eyes after CLAU. BCVA was 20.05. Conclusions: With the advent of newer ocular surface trans- plantation methods, there has been concern that CLAU carries the METHODS theoretical risk of inducing LSCD. Our long-term clinical results A retrospective chart review was performed on all following donor eyes after CLAU demonstrate no signs of LSCD. patients with LSCD who required surgical management between May 2000 and July 2016 at the Cincinnati Eye Key Words: donor, conjunctival limbal autograft, limbal stem cell Institute. This study was conducted according to a protocol deficiency, ocular surface stem cell transplantation approved by the University of Cincinnati Institutional (Cornea 2017;36:1031–1035) Review Board (Cincinnati, OH). The protocol and methods usedalsocompliedwiththestandardssetforthbythe Declaration of Helsinki. The inclusion criteria comprised 1) imbal stem cell deficiency (LSCD) occurs when the all patients who underwent CLAU surgery alone or com- Llimbal stem cells are destroyed or become dysfunctional, bined with another OSST procedure 2) with a minimum of leading to the hallmark characteristic of corneal conjunctiv- 6-month follow-up. The parameters assessed included alization with invasion of conjunctival goblet cells onto the demographics, presenting diagnosis and clinical features, corneal surface.1 Ocular surface stem cell transplantation preoperative and postoperative Snellen best-corrected visual acuities (BCVAs) of the donor eye, intraoperative and postoperative complications of the donor eye, and ocular Received for publication March 19, 2017; revision received April 24, 2017; surface stability of the donor eye at last follow-up. If care accepted April 25, 2017. Published online ahead of print June 21, 2017. had been transferred to a local corneal specialist, the most From the *Cincinnati Eye Institute, Cincinnati, OH; †University of Cincinnati, recent records were requested. A stable ocular surface was ‡ Department of Ophthalmology, Cincinnati, OH; and Department of defined as intact corneal epithelium devoid of conjunctival- Medicine Surgery and Neuroscience, University of Siena, Siena, Italy. fl E. J. Holland has consulted for Alcon Laboratories, Allergan, Bausch & ization or in ammation. An improved ocular surface was Lomb, Kala Pharmaceuticals, Mati Pharmaceuticals, Omeros, PRN, RPS, defined as an eye with signs of partial failure with areas of Senju Pharmaceuticals, Shire, TearLab, and TearScience. The remaining healthy corneal epithelium and areas of abnormal epithe- authors have no funding or conflicts of interest to disclose. lium, late fluorescein staining, or conjunctival epithelium Reprints: Edward J. Holland, MD, Cincinnati Eye Institute, 580 South Loop fi Rd, Suite 200, Edgewood, KY 41017 (e-mail: Eholland@holprovision. over the cornea. Ocular surface failure was de ned as com). recurrent diffuse late staining, conjunctivalization, or per- Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. sistent epithelial defects despite all treatment measures. Cornea Volume 36, Number 9, September 2017 www.corneajrnl.com | 1031 Copyright Ó 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Cheung et al Cornea Volume 36, Number 9, September 2017 Statistical analysis was performed using a 2-tailed t test with included on the CLAU. The donor sites are closed with P , 0.05 considered statistically significant. 10-0 nylon sutures, and a large-diameter (16.0 or 18.0 mm) bandage contact lens (Kontur, Hercules, CA) is placed over the eye. The harvested CLAU tissue is then fixated into the Operative Procedure respective 12- and 6-o’clock positions at the limbal edge of Details of the surgical technique for CLAU6 (Fig. 1) the recipient eye with 10-0 nylon sutures and tissue glue. and combined keratolimbal allograft (KLAL) with CLAU For the Modified Cincinnati Procedure, the CLAU pro- (“Modified Cincinnati Procedure”)10 have previously been cedure is augmented by also securing KLAL segments to described, and the surgical techniques implemented for the 3- and 9-o’clock positions of the recipient eye.10 There eyes in this study do not differ significantly. Importantly, it was 1 eye that underwent combined living-related con- should be noted that approximately 2 clock hours in the junctival limbal allograft (lr-CLAL) with CLAU. Here, the limbal circumference (;6to6.25mm)atboth12-and6- CLAU procedure is augmented instead by securing 2 lr- o’clock positions with corresponding conjunctiva [dissec- CLAL segments to the 3- and 9-o’clock positions of the tion carried ;5mm(inferior)–8 mm (superior) posteriorly] recipient eye. The lr-CLAL donor tissue is harvested in are excised. Calipers are used to ensure that the extent of a manner identical to that of CLAU donor tissue but in an tissue to be harvested is always less than half the circum- eye of a living relative. Living relatives undergo ABO ference (ie. ,6 clock hours). Blunt dissection is performed blood typing, human leukocyte antigen typing, crossmatch- to a point 1 mm anteriorly beyond the limbus and periph- ing, and panel reactive antibody testing to identify the best- eral corneal vasculature to ensure that limbal stem cells are matched relative. Acceptable donor relatives had to be FIGURE 1. Intraoperative photo- graphs demonstrating the CLAU procedure. Two clock hours in the limbal circumference (;6 to 6.25 mm) at both 12- and 6-o’clock po- sitions are measured and marked (A). The conjunctiva is elevated with balance salt solution on a 30-guage needle (black arrow, B). Blunt dis- section is performed to a point 1 mm anteriorly beyond the limbus and peripheral corneal vasculature (C). The CLAU segment is excised (D). The donor sites are closed with 10- 0 nylon sutures (E). The harvested CLAU tissue is then fixated to the respective 12- and 6-o’clock posi- tions (black arrows) at the limbal edge of the recipient eye with 10- 0 nylon sutures and tissue glue (F). 1032 | www.corneajrnl.com Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. Copyright Ó 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Cornea Volume 36, Number 9, September 2017 Conjunctival Limbal Autograft Donor Eyes viable ABO blood donors and have a negative crossmatch developed. There were 2 eyes with a history of amblyopia with the recipient; the fewer the human leukocyte antigen and 1 eye with a remote history of contact lens wear for 6 mismatches between a recipient–donor pair, the better years. All other donor eyes were healthy eyes without contact the match. lens wear. There were no intraoperative complications in the donor eyes. In the early postoperative period, there was 1 eye that developed a delle at both CLAU sites, which resolved Follow-up Care quickly with conservative therapy, 2 eyes that demonstrated Postoperatively, the donor eye is administered a top- mild conjunctival thinning at a CLAU site, and 1 eye that ical corticosteroid (prednisolone 1% or difluprednate developed a small pyogenic granuloma over the conjunctival 0.05%) and fluoroquinolone (moxifloxacin 0.5% or levo- CLAU site (this resolved with topical corticosteroids). floxacin 0.5%). Once the conjunctiva has reepithelialized Before OSST, the mean BCVA for donor eyes was (typically within 1 wk), the bandage contact lens and 20/24 (91.1% $ 20/40). At last follow-up, mean BCVA for fluoroquinolone are discontinued, whereas the corticoste- donor eyes was 20/22 (93.3% $ 20/40). There was no roid is tapered over 1 month. statistically significant difference between preoperative BCVA and BCVA at last follow-up (P =0.12).Atlast follow-up, all donor eyes maintained a stable ocular surface RESULTS (100%) and clear corneas (except for the prephthisical/ During the 15-year retrospective study period, 51 phthisical eye, which has since developed band keratop- patients were referred for LSCD and underwent a CLAU athy) without any late staining, neovascularization, or procedure (alone or combined with other OSST) by a single conjunctivalization (Fig.