Eyeworld

EW CORNEA 124 March 2018 by Maxine Lipner EyeWorld Senior Contributing Writer sity of Cincinnati who co-manage his patients. "Our ocular surface transplant patients are managed just like organ transplant patients," Dr. Holland said. "This level of systemic immunosuppression is required for success because unlike routine ker- atoplasty, ocular surface transplant tissue is highly vascularized and thus at risk for rejection." Dr. Holland pointed out that "no surgeon would diagnose kidney failure and perform a kidney trans- plant without immunosuppression and expect it to work." Why would anyone expect a vascularized tissue with a rejection rate higher than kidney transplant to work without systemic immunosuppression? "If you're going to do stem cell trans- plant, you have to understand the best practices of immunosuppres- sion, which is very complicated," Dr. Holland said. "We co-manage our patients with a nephrologist who manages kidney transplants, and we think that is the ideal per- son on your management team if you're going to do these cases." It is Dr. Holland's hope that practitioners come away from the study forewarned about inadequate- ly treating these patients and the repercussions. "The take-home mes- sage is don't perform DALK or PK in a patient with total limbal deficien- cy," he said, adding that it's better to do nothing than to perform a transplant destined to fail. Dr. Holland encouraged corneal surgeons to actively get involved in the management of these patients. "There are not enough surgeons in- volved with these patients," he said. "They are the most complicated cornea patients we take care of, and we need more surgeons doing ocular surface stem cell transplants." EW Reference 1. Sepsakos L, et al. Outcomes of keratoplasty after ocular surface stem cell transplantation. Cornea. 2017;36:1025–1030. Editors' note: Dr. Holland has no financial interests related to his comments. Contact information Holland: eholland@holprovision.com success rate in the other group was zero. This absolute failure rate is because the underlying problem was never addressed, he explained. "The primary reason why these patients have opaque corneas is because they don't have a source of corneal epithelium," he said. "All donor corneas will have their epithelium slough over time and if the recipient does not have viable limbal stem cells, conjunctivalization of the do- nor cornea occurs, leading to surface failure and ultimately rejection." The resultant failed keratoplasty may also lead to a more challeng- ing immunologic situation in the future. "The limbal deficiency will 100% of the time affect the new graft; the ocular surface will fail, and it will bring in inflammatory cells, neovascularization, and lead to rejection," Dr. Holland said. "The patient is now immunologically compromised because he or she has rejected donor tissue." In perform- ing a PK or DALK without first doing an ocular surface stem cell transplant, they've put the patient through an operation that won't work and made it immunologically more challenging to address limbal deficiency in future keratoplasty, Dr. Holland said. Clinical perspective "We showed that these are some of the most challenging patients," Dr. Holland said. The approach need- ed here should be two-pronged. It is possible to get good results in these patients if the limbal stem cell deficiency is appropriately managed first with an ocular surface stem cell transplant, he said, stressing that it then becomes a question of provid- ing adequate immunosuppression. "The second management mis- take we see is patients who undergo stem cell transplants but receive minimal or short-term immuno- suppression. Inadequate immuno- suppression is the main cause of limbal stem cell transplant failure," Dr. Holland said. "It's critical that if you're going to manage these patients, you understand the proper role of immunosuppression and you work with people who understand that as well." He works with the renal transplant team at the Univer- see how the long-term outcomes of those who had an effective ocular surface stem cell transplant fared compared to those who had not received this. Dr. Holland took his group of patients who had received successful ocular stem cell trans- plants but who still had corneal opacity requiring a keratoplasty and examined how they stacked up against another group of pa- tients he had inherited from other practitioners. This second group had undergone keratoplasty elsewhere without having their limbal defi- ciency dealt with first, Dr. Holland noted. Studying graft survival The outcomes were clear cut. "Our group of patients had a reason- able survival rate of 92% at year 1, 77% at year 2, and 62% at year 3," Dr. Holland said, adding that the What this can mean for successful outcomes F or patients with severe ocu- lar surface disease undergo- ing keratoplasty, outcomes can hinge on whether or not an underlying limbal deficiency is recognized and ad- dressed first, according to Edward Holland, MD, professor of ophthal- mology, University of Cincinnati, and director of cornea, Cincinnati Eye Institute. "It's our experience that a keratoplasty (PK or DALK) in total limbal deficiency will fail 100% of the time," Dr. Holland said. In a study published in the journal Cornea, investigators honed in on the success of patients here. 1 Investigators in this retrospec- tive review of 102 eyes that had undergone PK or DALK wanted to Keratoplasty and ocular surface stem cell transplantation PreOp Va = HM PostOp Va = 20/30 PreOp Va = HM PostOp Va = 20/25 Keratolimbal allograft for severe ocular disease Source: Edward Holland, MD Research highlight

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