Eyeworld

Cornea Society News – published quarterly by the Cornea Society 8 Managing severe ocular surface disease T his year's Asia Cornea Foun- dation Medalist Lecture at the Asia Cornea Society 5th Bienni- al Scientific Meeting in Seoul, South Korea, was given by Edward Hol- land, MD, Cincinnati, on the topic of "Management of Severe Ocular Surface Disease: Lessons Learned." He first discussed a study looking at patients referred to the Cincinnati Eye Institute. There were 738 eyes of 432 patients diagnosed with limbal stem cell deficiency (LSCD) between 2002 and 2015. Many of these patients received standard keratoplasty, and in all of these patients, the keratoplasty failed. Lesson 1, Dr. Holland said, is do not perform standard keratoplasty with- out a successful ocular surface stem cell transplantation (OSST) for severe con- junctiva deficiency and/or total LSCD. The consequence of doing standard keratoplasty for conjunctival or LSCD is that all keratoplasties eventually fail due to recurrent LSCD or subsequent immunologic rejection. Patients will then be immunologically sensitized to corneal antigens and have a worse prog- nosis for OSST, Dr. Holland said. Lesson 2 is the importance of an ocular surface team. A corneal surgeon cannot take care of these patients alone, he said. At the Cincinnati Eye Institute, they have patterned the team after an organ transplantation program at the University of Cincinnati. Within ophthalmology, the cornea surgeon is the team leader, and also on the team are oculoplastic, retina, and glaucoma specialists. There also needs to be a representative from internal medicine, and Dr. Holland stressed the importance of an expert in organ trans- plant immunosuppression. The drugs used are quite specific and not the same as those used in other medical special- ties such as oncology or rheumatology. A nephrologist managing kidney trans- plants is preferable. Another key part of the team is a transplant coordinator, who oversees patient education and long-term follow-up as these patients take an enormous amount of time, Dr. Holland said. Lesson 3 is to adopt donor and re- cipient screening and immunosuppres- sion (IS) protocols from organ trans- plantation. This could include patient monitoring schedules, new protocols, new agents, and induction therapy. The next lesson Dr. Holland high- lighted was that immunosuppression in OSST is safe. He discussed results from an adverse effects study, which was a retrospective study over the last 10 years with all patients undergoing OSST and receiving concomitant IS from 2000–2007. This study supported 136 patients (225 eyes) with a mean follow-up after OSST of 4.5 years. Of these patients, 76 patients (56%) had no systemic comorbidities at initial presentation. The mean duration of IS was 3.5 years. Additionally, the study found that 105 patients (77.2%) had a stable ocular surface at their last visit, and 37 patients (35.2%) with a stable ocular surface were able to be tapered successfully off IS. The majority of pa- tients remaining on IS were on mono- therapy with Cellcept (Genentech, San Francisco). In terms of adverse events, there were no deaths and no second- ary tumors in this group of patients, although there were three severe events in two patients and 21 minor events in 19 patients. Lesson 5 is that "staged manage- ment" results in better outcomes, and Lesson 6 is to develop a treatment para- digm. "We can achieve good long-term outcomes with OSST for bilateral severe ocular surface disease," Dr. Holland noted in Lesson 7. OSST requires close monitoring and may have significant complications, he said for Lesson 8. Multiple surgeries are often needed. We certainly do see failures, Dr. Holland said. There is also a risk for glaucoma and complications of severe dry eye. A healthy ocular surface is needed for good vision, and immuno- suppression is required. Lesson 9 is to incorporate kerato- prosthesis surgery into the treatment paradigm, and Dr. Holland highlighted some of the advantages and compli- cations associated with the Boston type I KPro. Advantages include that it requires only a single operation, it's technically similar to penetrating keratoplasty (PK) surgery, there is no immunosuppression, no risk of rejec- tion, and a poor ocular surface does not interfere with vision. However, there are complications, Dr. Holland noted in Lesson 10. We can't measure their pressure, he said. They need lifelong, close follow-up and lifelong topical antibiotics. Complications can lead to loss of the eye. "We are cautious about high-risk patients receiving Boston KPros," he said. Ocular surface stem cell transplant has numerous advantages over a KPro in some patients, Dr. Holland said. OSST can be used for severe conjunc- tival disease, offers easy IOP monitor- ing, improves and stabilizes the ocular surface for subsequent keratoplasty, complications result in loss of the surface only and not loss of the eye, and follow-up can be reduced once the surface is stabilized. Dr. Holland's final lesson, Lesson 11, was that it's not which technique is better, but which technique is best indicated for the patient. Both ocular surface transplantation and KPro are successful methods for visual rehabil- itation in patients with severe ocular surface disease, and there are specific indications and complications related to both procedures. Surgeons should become familiar with both procedures and their complication management in order to offer severe ocular surface disease patients the best opportunity for visual recovery, he said. CN Contact information Holland: eholland@holprovision.com Edward Holland, MD

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