Early results of ex vivo cultivated autologous limbal

epithelium transplantation for limbal stem cell deficiency

Himanshu Matalia, MD1,2

Arokiaraj Vincent, MSc2

D Kamesh, MSc2

Authors have no financial interest Poster 610

1. Cornea & Refractive Services, Narayana Nethralaya2. Narayana Nethralaya Stem Cell Research Laboratory

Narayana NethralayaNarayana Health City

Super Specialty Eye Hospital & Post Graduate Institute of Ophthalmology

Bangalore - INDIA

Clinical Features of LSCD Loss of palisades of Vogt

Kinoshita S et al JpJ Clin Ophth 1986

Tseng SC et al OCNA 1990

Conjunctivalization

Stippled appearance with

fluorescein

Dua HS Am J Ophthalmol 1990

Huang AJ IOVS 1991

Ch. Inflammation

Recurrent epi. break down

Limbal Stem Cell Defiency (LSCD)

Algorithm for LSCD

Establish Diagnosis of Stem cells deficiency(Clinical features & Impression Cytology)

Unilateral Disease Bilateral Disease

Focal or Partial

Total Deficiency

AMT CLAG Debridment

Cadaveric kerato-limbal allograft (KLAL) Live-related conjunctivo limbal allograft (Lr-CLAL)

Cultured limbal auto graft (best option )

KLAL Lr-CLAL Cultured live-related

limbal allograft

Outcome not very encouraging

Cultivated Autologous Limbal Epithelium Transplantation (CALET)

Most recent technique Best for unilateral LSCD Autologous cells, no immune suppression required No risk at donor site RepeatableLimitations Availability of the tissue culture facility Long-term outcome awaited

Pellegrini et al Lancet 1997; 349: 900-993 Tsai RJ, Li LM, Chen JK. N Engl J Med 2000;343(2):86-93Schwab et al Cornea 2000;19(4):421-6Koizumi et al IOVS 2002;43(7):2114-21

Purpose

• To describe the early results of our technique of ex vivo cultivated autologous limbal epithelial transplantation (CALET) for limbal stem cell deficiency (LSCD).

Methods

• Prospective, non-randomized interventional case series

• 14 eyes of 14 consecutive patient with LSCD underwent CALET from October

2008-October 2009.

• Primary outcome measures:

– Successful ocular surface reconstruction: stable ocular surface

– Best corrected visual acuity (BCVA)

• Secondary outcome measures:

– Complications

Culture technique Limbal biopsy

Normal limbal epithelium from contra lateral normal eye or normal area of same eye

2 x 2 mm (One clock hour) of normal limbal with cornea epithelium

Amniotic membrane De-epithelialized, processed &

preserved amniotic membrane used as substrate / carrier

Unique from others*

Monolayer only

No air lifting, no fibroblast feeder

Culture duration: 10-14 days

Human Corneal Epithelium medium

*Sangwan VS, Matalia HP et al Arch Ophthalmol 2005

Surgical technique• One drop 1:1000 epinephrine on pannus to reduce bleeding

(chemical cauterization)

• Pannus resection done

• Conjunctival peri-ectomy (2 mm) was done

• Cauterization of bleeders done

• Ex vivo cultivated autologous limbal epithelium grown over human

amnotic membrane (HAM) was spread over the ocular surface

• HAM was secured to the eye with fibrin glue (Tisseal) and 8-0 Vicryl

• Bandage contact lens applied at the end

Results

From July 2008

14 eyes of 14 patients underwent CALET

Female: Male -

Etiology of LSCD:

− Chemical injury 10 eyes (72%)

− 8 of these 10 were lime injury

7 eyes (50%): Previous history of AMT

Follow up: Mean 9 months

Mean duration of culture: 174.40 days

20/4020/4020/25P20/25P

PreopPreop

PostopPostop

Results

HM+ PR accurateHM+ PR accurate

Clinical OutcomeSuccess: 12 (85.7), 95% CI 67.4-100

Failure: 2 (14.3%), 95%CI: 0-32.6

Visual acuity improvementPreop visual acuity: 0.20 0.38

Postop visual acuity: 0.38 0.41 (p=0.018)

ComplicationsMicrobial keratitis: 2

Repeat transplants: 2

Repeat limbal biopsy: 2

Results

Visual acuity improvementPreop visual acuity: 20/100

Postop visual acuity: 20/50 (p=0.018)

Conclusions

• Cultivated autologous limbal epithelial

transplantation (CALET) could successfully

restore the ocular surface in cases with LSCD.