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

HLA-matched Living-related Conjunctival Limbal Allograft HLA-matched Living-related Conjunctival Limbal Allograft for Bilateral Ocular Surface Disordersfor Bilateral Ocular Surface Disorders

- Long-term Results -- 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

Lr-CLAL: long term resultsLr-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:Purpose:To evaluate the long-term outcome of HLA-matched Lr-CLAL for bilateral ocular surface disorders.

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.


MethodsMethods

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.


MethodsMethods

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).


ResultsResults


Table 1. Preoperative data according to each group, based on classification of of Holland, Gomes and Shwartz

Group Number of patients Diagnosis (number of eyes)

I a 3 Post pterygium surgery (1), Limbal papiloma (1), Limbal dysplasia (1)

II a 4 Post pterygium surgery (1), Ectodermal dysplasia (3)

I b 1 Alkali burn (1)

II b 11 Alkali burn (11)

I c 5 Stevens-Johnson syndrome (5)

II c 15 Stevens-Johnson syndrome (9), Lyell syndrome (5), Cicatricial pemphigoid (1)


Visual acuity Observations Follow-up

Group Case number Diagnosis Age Donor-recipient Pre-0p 1 year post-op Final 1 year post-op Final (months)HLA compatibility

I a 1 Post pterygium surgery 61 100% HM 20/100 CF YES YES AMT, REJ 362 Limbal papiloma 65 50% 20/400 20/30 20/30 YES YES REJ 243 Epithelial dysplasia 80 50% 20/100 20/60 20/60 YES YES 24

II a 1 Post pterygium surgery 45 75% 20/400 20/400 HM YES YES PKP 482 Ectodermal dysplasia 12 50% CF CF 20/400 YES YES PKP 853 Ectodermal dysplasia 14 50% CF CF 20/200 YES YES 614 Ectodermal dysplasia 67 100% HM HM HM YES YES 49

I b 1 Alkali burn 13 100% CF 20/20 20/20 YES YES 18

II b 1 Alkali burn 27 50% LP LP LP NO NO 262 Alkali burn 39 100% CF CF CF YES YES 253 Alkali burn 32 50% CF 20/80 20/200 YES YES PKP 384 Alkali burn 33 100% HM HM HM YES YES PKP 495 Alkali burn 48 100% 20/200 20/60 20/60 YES YES PKP 966 Alkali burn 47 50% 20/40 20/40 20/40 YES YES 727 Alkali burn 45 50% 20/100 20/60 20/60 YES YES 1208 Alkali burn 33 100% CF 20/60 20/30 YES YES PKP 1219 Alkali burn 33 100% CF 20/60 20/30 YES YES PKP 120

10 Alkali burn 27 50% CF CF CF YES YES 3711 Alkali burn 40 50% 20/200 20/200 CF NO YES AMT 38

I c 1 Stevens-Johnson 33 50% 20/400 20/80 20/100 YES YES REJ 262 Stevens-Johnson 36 75% HM CF CF YES YES 383 Stevens-Johnson 13 50% 20/100 20/60 20/60 YES YES 254 Stevens-Johnson 30 100% LP LP LP YES YES 195 Stevens-Johnson 34 50% 20/200 20/100 20/100 YES NO 25

II c 1 Stevens-Johnson 30 50% 20/80 20/80 20/80 NO YES AMT, REJ 262 Stevens-Johnson 32 100% CF CF CF YES YES 243 Stevens-Johnson 48 100% CF HM HM YES YES 184 Stevens-Johnson 18 50% HM HM NLP NO YES 505 Stevens-Johnson 8 50% HM HM CF YES NO AMT 846 Stevens-Johnson 34 50% CF HM HM NO NO PKP, REJ 367 Stevens-Johnson 13 100% HM CF HM YES YES AMT 508 Stevens-Johnson 13 100% CF 20/200 CF NO YES 489 Lyell 23 100% HM 20/100 20/60 YES YES REJ 84

10 Cicatricial pemphigoid 86 50% LP LP LP YES YES 1811 Lyell 23 100% HM 20/200 20/40 YES YES REJ 8412 Lyell 24 50% CF CF 20/100 YES YES AMT 3713 Stevens-Johnson 2 50% HM 20/100 20/200 YES YES 7214 Lyell 25 75% 20/200 CF CF YES YES AMT 3715 Lyell 25 75% 20/200 CF CF YES YES 36

HM= hand motion; CF= count fingers; LP= light perception; AMT= amniotic membrane transplantation; PKP = penetrating keratoplasty; IMMUN= systemic immunosuppression; REJ= limbal allograft rejection

Surface stability

Table 2. Pre and post-operative data according to each group


Table 3. Risk of Lr-CLAL (Living-related Conjunctival Limbal Allograft) rejection and HLA recipient-donor compatibility

Limbal allograft rejection

Yes No

Whole group 7 (17.9%) 32 (82.1%)

100% HLA compatibility 3 (20%) 12 (80%)

50% and 75% HLA compatibility 4 (16.7%) 20 (83.3%)

p=0.556 (Fisher´s Exact Test)

Case : Preop Case : 5 years post Lr-CLAL

Case : Preop Case : 9 years post Lr-CLAL

Case : Preop Case : Preop

Case : 1 year post Lr-CLAL Case : 3 years post Lr-CLAL

• 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.


ConclusionConclusion

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

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