Publication Exclusive: Surgeons detail steps for simple limbal epithelial transplantation

In 1964, Jose Barraquer described a surgical technique for limbal stem cell deficiency, or LSCD. The paramount finding of extensive LSCD is conjunctival transgression across the corneal-conjunctival border and the limbus and onto the cornea, resulting in vascularization, chronic inflammation, persistent epithelial defects and recurrent erosions, which uninterrupted can progress to corneal opacity and transform to a skin-like corneal surface with corneal blindness. These border “policemen” between the corneal and conjunctival territories are largely accepted as the limbal stem cells that are believed to be housed within the radial fibrovascular ridges, the limbal palisades of Vogt.

With all the global research in this field, there is no definite marker at the present time for limbal stem cells. Compromise of limbal stem cells up to a certain extent, namely, partial or sectoral LSCD, can be corrected by the remaining stem cells. However, more extensive or total LSCD results in the inevitable transformation of the clear cornea toward an opaque cornea and potential loss of vision.

Management strategies depend on the following key questions:

1. Unilateral or bilateral LSCD?

2. Extent of damage — mild or extensive?

3. Is there active inflammation, or is the eye quiescent?

4. Is there enough tear function, and is lid function normal or abnormal?

Ocular surface stabilization is a must before undertaking surgical intervention for LSCD. Transplanted tissue may be conjunctival limbal autograft, keratolimbal or mucosal; it may be autologous in unilateral LSCD, and allogenic, namely, cadaveric or living related, in bilateral LSCD or cell culture-assisted techniques. Partial LSCD in a quiet eye with good tear and normal lid functions may be successfully treated with only conjunctival scraping and amniotic membrane transplantation. For extensive unilateral LSCD, autologous keratolimbal grafts from the opposite healthy eye, without systemic immunosuppression, and for more extensive bilateral LSCD, allogenic keratolimbal grafts, with systemic immunosuppression, are usually the treatment approaches. Primary penetrating keratoplasty will usually fail in LSCD. Tissue-sparing surgical techniques involve ex vivo or in vivo limbal stem cell expansion procedures.

In this column, Drs. Palioura, Atallah, Karp and Amescua describe how they perform the newly reported simple limbal epithelial transplantation (SLET) technique for unilateral LSCD. This is an in vivo limbal stem cell expansion technique.

Click here to read the full publication exclusive, Surgical Maneuvers, published in Ocular Surgery News U.S. Edition, August 10, 2016.