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Sérgio Kwitko, Caio Scocco, Samuel Rymer, Diane Marinho, Rodrigo Lindenmeyer

HLA-matched Living-related Conjunctival Limbal Allograft for Bilateral Ocular Surface Disorders - Long-term Results -. Sérgio Kwitko, Caio Scocco, Samuel Rymer, Diane Marinho, Rodrigo Lindenmeyer

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Sérgio Kwitko, Caio Scocco, Samuel Rymer, Diane Marinho, Rodrigo Lindenmeyer

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  1. HLA-matched Living-related Conjunctival Limbal Allograft for Bilateral Ocular Surface Disorders- Long-term Results - Sérgio Kwitko, Caio Scocco, Samuel Rymer, Diane Marinho, Rodrigo Lindenmeyer Hospital de Clínicas de Porto AlegreFederal University of Rio Grande do Sul - Porto Alegre - Brazil The authors have no financial interest in the subject matter of this poster

  2. Lr-CLAL: long term results Visual rehabilitation and stabilization of ocular surface has been reported in a good percentage of cases in the first year after HLA-matched living-related conjunctival limbal allografts (Lr-CLAL) in bilateral ocular surface diseases. Stability of results is, however, still a challenge in these cases, with loss of good initial results over time. Purpose: To evaluate the long-term outcome of HLA-matched Lr-CLAL for bilateral ocular surface disorders.

  3. Lr-CLAL: long term results Methods A retrospective interventional case series study of 46 eyes of 36 patients with bilateral surface disorders that underwent HLA-matched Lr-CLAL. All patients had clinical diagnosis of limbal stem cell deficiency due to: • Stevens-Johnson syndrome 19 eyes • Bilateral alkali burns 13 eyes • Lyell’s syndrome 6 eyes • Ectodermal dysplasia 3 eyes • Limbal tumors 2 eyes • Multiple pterygium surgeries 2 eyes Eyes were classified according to the classification of Holland, Gomes and Shwartz22 to analyze and better compare the results Visual acuity (VA), ambulatory vision (VA ≥ 20/200), ocular surface stability, corneal transparency, corneal vascularization and rejection episodes were evaluated and correlated to the disease severity and to HLA compatibility.

  4. Lr-CLAL: long term results Methods Donor limbus was obtained from a patient’s relative after Class I and II HLA match. Surgical technique used was the one described by Kenyon and Tseng7 modified by us16,that is, only conjuntival limbal was included in the donor, avoiding the peripheral corneal keratectomy and apossible donor limbal deficiency in the future. Corneal keratinization was carefully removed, and limbal allografts were sutured with 10.0 mononylon on the peripheral corneal bed, and with 8.0 vycril on the scleral surface.

  5. Lr-CLAL: long term results Results Donor-recipient HLA-match was identical in 17 pairs (37%), had a 75% match in 4 (8.7%), and had haplo-identity in 25 (54.3%). Corneal transplantation was performed in 12 eyes at least one year after HLA LR-CLAL (26.1%), and systemic immunosuppression in 4 patients (7 eyes) (15.2%). Amniotic membrane transplantation was associated to Lr-CLAL in 12 eyes (26.1%). Autologous serum was used in 9 eyes (19.6%) as part of dry eye treatment. One year after surgery, VA improved in 47.8%, ambulatory vision was achieved in 45.7%, and a stable corneal surface in 80.4% of eyes. At the final follow-up (mean, 51.3 ± 29.6 months), 63.6% of the eyes maintained an improved VA (p=0.50), 76.2% maintained 20/200 or better (p<0.001), and 94.6% still had a stable corneal surface (p=0.009). Limbal graft rejection occurred in 9 eyes (19.6%), 5 in haplo-identical HLA pairs, and 4 in identical HLA pairs (p=0.439).

  6. Lr-CLAL: long term results

  7. Lr-CLAL: long term results

  8. Lr-CLAL: long term results

  9. Case : Preop Case : 5 years post Lr-CLAL Case : Preop Case : 9 years post Lr-CLAL

  10. Case : Preop Case : Preop Case : 1 year post Lr-CLAL Case : 3 years post Lr-CLAL

  11. Lr-CLAL: long term results Conclusion • HLA-matched Lr-CLAL can be an adequate method of treatment for bilateral ocular surface disorders, with few complications. • Ambulatory vision and surface stability were reduced on long-term results when achieved on first year after surgery, but still with a reasonable percentage of success. • No statistical difference on rejection rates between HLA groups was evident. • Patients with Stevens-Johnson and Lyell Syndromes had the poorest success rates.

  12. References • Thoft RA. Conjunctival transplantation. Arch Ophthalmol 1977; 95: 1425-7. • Kinoshita S, Friend J, Thoft RA. Biphasic cell proliferation in transdifferentiaton of conjunctival to corneal epithelium in rabbits. Invest Ophthalmol Vis Sci 1983; 24: 1008-14. • Tseng SC, Tsai RJ. Limbal transplantation for ocular surface reconstruction - a review. Fortschr Ophthalmol 1991; 88: 236-42. • Dua HS. The conjunctiva in corneal epithelial wound healing. Br J Ophthalmol 1998; 82: 1407-11. • Pellegrini G, Traverso CE, Franzi AT, et al. Long-term restoration of damaged corneal surfaces with autologous cultivated corneal epithelium. Lancet 1997; 349: 990-3. • Chiou AG, Florakis GJ, Kazim M. Management of conjunctival cicatrizing diseases and severe ocular surface dysfunction. Surv Ophthalmol 1998; 43: 19-46. • Kenyon KR, Tseng SCG. Limbal autograft transplantation for ocular surface disorders. Ophthalmology 1989; 96: 706-23. • Tsubota K, Toda I, Saito H, et al. Reconstruction of the corneal epithelium by limbal allograft transplantation for severe ocular surface disorders. Ophthalmology 1995; 102:1486-96. • Basti S, Mathur U. Unusual intermediate-term outcome in three cases of limbal autograft transplantation. Ophthalmology 1999; 106: 958-63. • Thoft RA. Keratoepithelioplasty. Am J Ophthalmol 1984; 97: 1-6. • Weise RA, Mannios MJ, Vastine DW, et al. Conjunctival transplantation: autologous and homologous grafts. Arch Ophthalmol 1985; 103: 1736-40. • Tsubota K, Satake Y, Kaido M, et al. Treatment of severe ocular-surface disorders with corneal epithelial stem-cell transplantation. New Engl J Med 1999:340-1697-1703. • Tseng SCG, Chen JJY, Huang AJW, et al. Classification of conjunctival surgeries for corneal diseases based on stem cell concept. Ophthalmol Clin North Am 1990; 3:595-610. • Tsai RJF, Tseng SCG. Human allograft limbal transplantation for cornea surface reconstruction. Cornea 1994; 13:389-400. • Holland EJ, Djalilian AR, and Schwartz GS. Management of aniridic keratopathy with keratolimbal allograft: a limbal stem cell transplantation technique. Ophthalmologt 2003; 100:125-130. • Kwitko S, Marinho D, Barcaro S, et al. Allograft conjunctival transplantation for bilateral ocular surface disorders. Ophthalmology 1995; 102: 1020-5. • Tan DTH, Ficker LA, Buckley RJ. Limbal transplantation. Ophthalmology 1996; 103:29-36. • Rao SK, Rajagopal R, Sitalakshmi G, et al. Limbal allografting from related live donors for corneal surface reconstruction. Ophthalmology 1999; 106:822-8. • Daya SM, Ilari FA. Living related conjunctival limbal allograft for the treatment of stem cell deficiency. Ophthalmology 2001; 108:126-33. • Ilari L, Daya SM. Long-term outcomes of keratolimbal allograft for the treatment of severe ocular surface disorders. Ophthalmology 2002; 109:1278-84. • Solomon A, Ellies P, Anderson DF, et al. Long-term outcome of keratolimbal allograft with or without penetrating keratoplasty for total limbal stem cell deficiency. Ophthalmology 2002; 109:1159-66. • Holland EJ, Gomes JA, Shwartz GS. Preoperative staging of disease severity. In: Holland ES, Mannis MJ, eds. Ocular Surface Disease: Medical and Surgical Management. New York: Springer-Verlag, 2001: 149-57. • Holland EJ, Shwartz GS. The evolution of ocular surface transplantation. In: Holland ES, Mannis MJ, eds. Ocular Surface Disease: Medical and Surgical Manegement. New York: Springer-Verlag, 2001: 149-57. • Sloper CML, Powell RJ, Dua HS. Tacrolimus (FK506) in the management of high-risk corneal and limbal grafts. Ophthalmology 2001;108:1838-44. • Kim JC, Tseng SCG. Transplantation of preserved human amniotic membrane for surface reconstruction in severely damaged rabbit corneas. Cornea 1995; 14:473-84. • Amos DB, Pool P, Grier J. HLA typing. In: Rose NR, Friedman H, eds. Manual of Clinical Immunology, 2nd ed. Washington, DC: American Society for Microbiology, 1980:978-86. • Tsai RJF, Sun TT, Tseng SCG. Comparison of limbal and conjunctival autograft transplantation in corneal surface reconstruction in rabbits. Ophthalmology 1990;97:446-455. • Farah M, Marinho DR, Kwitko S, et al. Corneal epithelial healing in rabbit eyes with partial corneal and conjunctival limbal deficiency. Inv Ophthalmol Vis Sci (suppl) 1998; 3:84. • Rymer S, Burnier M, Marinho D, et al. Conjunctival and corneal-conjunctival limbal autologous transplantation in the treatment of alkali burn in rabbits. Arq Bras Oftalmol 2002; 65:161-70.

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