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Keratolimbal allotransplant gives hope for complicated cases
In a single procedure, the eye is given both a new reservoir of limbal cells and a transparent cornea.
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UDINE, Italy – Keratolimbal allotransplant can be a viable option in severe cases of corneal damage and limbal deficiency, according to a surgeon here.
“When the limbal damage is extensive, there is no chance that a corneal transplant may be effective. We need to go to the root of the problem and revitalize the limbus. Among the various options, we have chosen keratolimbal transplant, which in a single operation gives the eye both a new reservoir of limbal cells and a transparent cornea,” said Paolo Brusini, MD, at the meeting of the Italian Ophthalmologic Society.
In the eye clinic directed by Dr. Brusini, 11 eyes of 10 patients were treated with this method.
They all had had severe corneal alterations with limbal deficiency, he said. Nine eyes had previously undergone several unsuccessful transplants for herpetic anterior keratouveitis (seven cases), corneal wound (one case) or endophthalmitis (one case). Two eyes had extensive, vascularized corneal leukoma. Visual acuity ranged from hand motion to light perception.
Surgery and after
After a 360° limbal peritomy, a 360° pre-incision was performed at the limbus. A 12.5-mm diameter donor graft was prepared and the recipient cornea was manually removed with surgical knife and scissors.
“When necessary, we performed extracapsular cataract extraction, im-planting an IOL in the sulcus. The donor graft was fixed with single 10-0 nylon sutures,” Dr. Brusini said.
The most common complications of the early postop period were hyphema in seven cases, corneal edema in seven cases and uveal inflammatory reactions in four cases.
“Not particularly severe, and fortunately not long-lasting,” he said.
Patients were treated with mydri-atic agents, antibiotic drops, topical steroids and systemic immunosuppressive therapy.
“We routinely administer full-dose cyclosporine for 6 months, then reduce the quantity for a further 6 months,” Dr. Brusini said.
In the late postop period, secondary glaucoma occurred in five cases, which were treated with medical therapy. Rejection occurred in five cases, three of which were successfully treated with topical steroids.
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Encouraging results
“Taking into account that all these eyes were practically blind and that no other treatment, including corneal transplant, could have been successful, we can be very satisfied with our results,” Dr. Brusini said. “We obtained perfect transparency in six eyes and partial transparency in two eyes. Rejection was irreversible in only two cases. In one unfortunate case, expulsive hemorrhage resulted in bulb phthisis.”
Three cases had a low visual acuity gain of less than 20/400. Two of these eyes had optic atrophy and one had a macular scar, which prevented the eyes from achieving better visual results.
In two eyes, postop visual acuity was between 20/400 and 20/100.
“A modest, but more than acceptable improvement in these eyes. However, we had a rewarding result with three eyes, achieving 20/30 or more,” he said.
One of these cases was a patient with recurrent herpetic keratitis and hand motion visual acuity.
“At 1 week, the patient had a transparent cornea, and at 6 months she was 20/25. Topography showed just a mild residual astigmatism,” Dr. Brusini said.
“But the most astonishing results were obtained with an elderly patient who was blind, not self-sufficient and ill with heart problems and high blood pressure. One eye had been previously operated with disastrous results, as an expulsive hemorrhage had caused bulb phthisis. The other eye had a pemphigoid, which had reduced vision to hand motion.”
Six months after keratolimbal transplant in this eye, the patient achieved visual acuity of nearly 20/20.
“It seemed like a miracle,” he said. “She can now read the first character with a spectacle correction of +3 D, but doesn’t wear glasses for daily tasks. Surgery has greatly changed her life for the better.”
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Not a panacea
Not all cases were successful, Dr. Brusini said. In a patient who had had five previous failures with penetrating keratoplasty for herpetic keratitis and vision limited to hand motion, results were very good just 1 month after surgery.
“He had a perfectly transparent cornea,” he said. “Unfortunately, after 2 months corneal de-epithelialization occurred, resulting in irreversible rejection despite all our attempts.”
He concluded that the procedure is not a panacea in all cases, but is a hope for such patients.
“From our follow-up, which ranges from 6 to 18 months, we can also say that immunosuppressive therapy seems to be effective in preventing rejection, at least in the medium term,” he said.
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For Your Information:
- Paolo Brusini, MD, can be reached at S. Maria Della Misericordia General Hospital, Udine, Italy; (39) 043-480-894; fax: (39) 043-255-2741.