8 a case of rejection in a patient with turner's syndrome and submitted to deep lamellar keratoplast

TRANSPLANTAT OF LIMBAL STEM CELLS IN PATIENT WITH AKALI BURN: OUR EXPERIENCE L. Mele MD*, M.G. Iorio MD*, D. Capobianco MD°, M. Bifani MD*. *Department of Ophthalmology, Second University of Naples ° ASL NA1 Centro - PSI Napoli Est – UOSD di Oculistica -

Marco Giovanni Iorio MD.

Luigi Mele MD.

Dipartimento multidisciplinare di Medico Chirurgiche ed Odontoiatriche

Oculista Dipartimento multidisciplinare di Medico Chirurgiche ed Odontoiatriche

Scienze

Scienze

Seconda Università degli Studi di Napoli

Seconda Università degli Studi di Napoli

Decio Capobianco MD.

Mario Bifani MD.

Oculista

Oculista

ASL NA1 Centro - PSI Napoli Est – UOSD di Oculistica

Dipartimento multidisciplinare di Medico Chirurgiche ed Odontoiatriche Seconda Università degli Studi di Napoli

Scienze

Abstract Purpose and materials: The aim of the present work is to report our experience in transplantation of limbal stem cells grafting in a 26 years old patient with a history of alkali burn in his left eye.

Method: After demonstrating of a limbal stem cells deficiency in the patient, a portion of tissue from his right eye sclera-corneal ring was collected and placed in culture medium for the multiplication of stem cells. It was subsequently carried out the grafting of the magnified tissue in his left eye. Patient was submitted to a follow-up at 6 and 10 months and then to the practice of penetrating keratoplasty.

Results: Six months after treatment the flap appeared transparent and the suture present and tight.

normal to acupressure. On physical examination in ODX: outbuildings healthy, specular and transparent cornea, anterior chamber depth, pupil eucyclic, in situ and transparent crystalline lens, vitreous and fundus limits for age. Osn showed a diffuse conjunctival and perikeratic hyperemia, a total corneal conjunctivization with widespread neovascularization. ( fig 1.)

The examination with fluorescein highlighted epithelial defects, recurrent ulcers spread.

Anterior chamber, lens and fundus were not explored because of the opacity of the anterior structures.

Metods First, the patient was subjected to an examination of impression cytology.

Conclusions: Limbal transplantation represents a new and efficient therapeutic solution. In the case of a severe limbal deficiency the only stem cells graft is not sufficient to restore the corneal transparency, so we recommend to perform subsequently a penetrating keratoplasty.

This method was able to demonstrate the presence of goblet cells corneal epithelium, a sign of conjunctivization, caused by deficiency of limbal stem cells. It was possible to detect, in addition, high expression of CK19 (fig. 2), which indicates the presence of conjunctival epithelial cells in the corneal tissue district where it should be expressed only CK3.

TEXT

Subsequently it was decided to biopsy in ODX through the following phases (Fig. 3-4):

Patient We selected a 26 year old male patient, abs, came to our observation with significant pain symptoms, tearing, photophobia, mild blepharospasm and severe reduction of visual acuity in the left eye.

Alkali burn by referring to history dating back to the year 2002, already subjected twice to pannectomy followed by apposition of amniotic membrane.

The visual situation was characterized by a UCVA in ODX of 10/10 and a UCVA motu manu in Osn. Tonometry (applanation technique) was 16 mmHg in ODX, while it was not detectable in Osn, but it appeared

Topical anesthesia with 0.4% oxibuprocaine • para-bulbar anesthesia with 2% Carbocaine after opening the conjunctiva at the limbus • Pick biopsy of the size of 2mm x 2mm with a depth of 200 microns at 12 sclero corneal ring • Sending the levy to the "Foundation Eye Bank of Veneto" where it was placed in a culture medium prepared in such a way as to create the ideal conditions for the proliferation of limbal stem cells.

•

Once we got an "amplified" tissue grafting has been practiced in Osn:

The surgical technique included: • • • • •

para-bulbar anesthesia with 0.5% Marcaine limbal peritomy Pannectomy Engaging the tissue "amplified" in limbo-scleral zone 12 hours occlusive bandage with suministracion of antibiotics and anti-inflammatory topical.

Once we got an "amplified" tissue grafting has been practiced in Osn( Fig. 5).

Six months after, the objective picture showed a corneal enlightenment and an almost total absence of perikeratic injection, which denoted a valid grafting (Fig. 6).

Ten months after, during which the objective situation seemed at rest, with illuminated cornea, we proceeded performing a penetrating keratoplasty suture with separate stitches (fig 7).

Results At 6 months after keratoplasty, during which the post-operative course was normal, the flap appeared be transparent and suture was present and tight. The IOP by applanation technique was 14mmHg. Ophthalmoscopy of the posterior segment would not show notable pathologies. The BCVA was 8/10b (Fig. 8).

Conclusions Limbus transplantation today is a new therapeutic certainty with a high percentage of success. Careful preoperative evaluation and adequate postoperative care, improve the long-term success and allow standardization of the technique, making reproducible result.

Generally in case of severe limbal deficiency, it is difficult that only the expanded graft of epithelial cells is sufficient to restore a perfect corneal transparency, so in these cases it is almost always advised to follow the surgery by penetrating keratoplasty which has the advantage to obtain an adequate visual rehabilitation.

Bibliography 1. Ramachandran C, Basu S, Sangwan VS, Balasubramanian D. Concise Review: The Coming of Age of Stem Cell Treatment for Corneal Surface Damage. Cells Transl Med. 2014 Sep 9.

2. Zhou Q, Liu XY, Ruan YX, Wang L, Jiang MM, Wu J, Chen J. Construction of corneal epithelium with human amniotic epithelial cells and repair of limbal deficiency in rabbit models. Hum Cell. 2014 Aug 19.

3. Eslani M, Baradaran-Rafii A, Movahedan A, Djalilian AR. The ocular surface chemical burns. J Ophthalmol. 2014;2014:196827 4. Amescua G, Atallah M, Nikpoor N, Galor A, Perez VL. Modified simple limbal epithelial transplantation using cryopreserved amniotic membrane for unilateral limbal stem cell deficiency.

Int Ophthalmol. 2014 Jun 5 5. Barreiro TP, Santos MS, Vieira AC, de Nadai Barros J, Hazarbassanov RM, Gomes JÁ. Comparative study of conjunctival limbal transplantation not associated with the use of amniotic membrane transplantation for treatment of total limbal deficiency secondary to chemical injury. Cornea.

2014 Jul;33(7):716-20 6. Bu P, Vin AP, Sethupathi P, Ambrecht LA, Zhai Y, Nikolic N, Qiao L, Bouchard CS. Effects of activated omental cells on rat limbal corneal

alkali injury. Exp Eye Res. 2014 Apr;121:143-6.

7. Vazirani J, Basu S, Kenia H, Ali MH, Kacham S, Mariappan I, Sangwan .Unilateral partial limbal stem cell deficiency: contralateral versus ipsilateral autologous cultivated limbal epithelial transplantation. Am J Ophthalmol. 2014 Mar;157(3):58490.e1-2.

8. Yin JQ, Liu WQ, Liu C, Zhang YH, Hua JL, Liu WS, Dou ZY, Lei AM. Reconstruction of damaged corneal epithelium using Venus-labeled limbal epithelial stem cells and tracking of surviving donor cells. Exp Eye Res. 2013 Oct;115:246-54

Fig. 1: Diffuse conjunctival and perikeratic hyperemia, a total corneal conjunctivization with widespread neovascularization.

Fig. 2: High expression of CK19

Fig. 3: surgical phase

IMAGES

Fig.4: surgical phase

Fig. 5: amplified tissue grafting

Fig. 6: Absence of perikeratic injection

Fig. 7: Penetrating keratoplasty

Fig. 8: Six months after penetrating keratoplasty