Causticacin severa:

Insuficiencia limbar
completa, leucoma total,
simblfaron e imposibilidad
de autoinjerto limbar.
Dr. Joaqun Salas

Limbal allografting from related live donors for corneal surface

reconstruction
Ophthalmology. 1999 Apr;106(4):822-8

Compares HLA-matched and -unmatched related live donors

PARTICIPANTS: Eight patients (nine eyes) with severe chemical burns (n = 7 eyes) and
Stevens-Johnson syndrome (n = 2 eyes)
INTERVENTION: Recipient eyes were treated with excision of cicatricial tissues .
Transplantation of superior and inferior limbal grafts was performed from related live HLAmatched (n = 7) and -unmatched donors (n = 2). Systemic cyclosporine was not used in
any of the recipients
RESULTS: With a mean observation period of 17.2 months, phenotypically corneal
epithelium, decreased vascularization of the corneal surface, and improved ocular comfort
were seen in seven (77.8%) eyes . In all seven eyes, gradual recurrence of peripheral
corneal vascularization occurred during the follow-up period. Features of graft rejection
developed in three (42.9%) of these seven eyes. In two eyes, limbal transplantation from
HLA-unmatched donors failed to reconstitute the corneal surface. Limbal allograft
transplantation resulted in visual acuity of 20/400 or greater in only two (22.2%) eyes at
last follow-up. Corneal grafts performed 7 and 16 months after successful limbal
transplantation in two eyes developed recurrent epithelial breakdown and superficial
corneal scarring. None of the donor eyes in this study had any complication
CONCLUSION: Transplantation of limbal tissue from related live donors successfully
reconstructs the corneal surface in HLA-matched recipients. Recurrence of vascularization
on long-term follow-up probably results from inadequate stem cell transfer, immunemediated stem cell damage, or both. Limbal allografting is best performed by
transplanting the entire limbus from a cadaveric donor eye with systemic
immunosuppression of the recipient, even if the donor is HLA-compatible

Living related conjunctival limbal allograft for the treatment of

stem cell deficiency.
Ophthalmology. 2001 Jan;108(1):126-33

PARTICIPANTS: Nine living related donors, eight recipients ( 10 eyes) with

Stevens-Johnson syndrome (3 eyes), ectodermal dysplasia (3 eyes), chemical
injury (2 eyes), ocular cicatricial pemphigoid (1 eye), and atopic
keratoconjunctivitis (n = 1)
INTERVENTION: Four clock hours of limbal conjunctival tissue from the best
matched HLA relative donor were transplanted to the recipient eye superiorly
and inferiorly after conjunctival peritomy and removal of conjunctival
pannus. Systemic cyclosporine was administered to all recipients.
RESULTS: Mean follow-up period was 26.2 months. Two highly inflamed eyes
failed to initially epithelialize. The remainder all survived with restoration of
corneal epithelium and reduction of vascularization. Corneal opacification
was reduced (four of eight eyes) and visual improvement was achieved in
seven eyes. All five eyes with pain had an improvement in symptoms.
Allograft rejection occurred in two eyes (25%), and both were treated
successfully. Both eyes had two class I HLA mismatches, and both had an
underlying diagnosis of Stevens-Johnson syndrome. One eye developed a
recurrent epithelial defect and perforated, requiring a penetrating
keratoplasty that remained clear with an intact epithelial surface. The two
initial failures also perforated and required penetrating keratoplasties that
failed. None of the donor eyes had any complications

Allo-limbal transplantation in patients with limbal stem cell

deficiency
Br J Ophthalmol. 1999 Apr;83(4):414-9

6 patients underwent allo-limbal stem cell transplantation. The

primary diagnosis included alkali burn (n = 2), trachoma (n = 1),
chronic rosacea blepharitis and kerato-conjunctivitis (n = 1),
aniridia (n = 1), and Stevens-Johnson syndrome (n = 1). The
limbal rim consisted of peripheral cornea and perilimbal sclera. FK506 was used postoperatively for immunosuppression
Follow up ranged from 3 to 24 months (mean follow up 11.8 (SD
9.3) months). The outcome was considered satisfactory in five of
six cases. The corneal surface was completely epithelialised within
2 weeks, and there was a substantial improvement in vision and
symptoms. One patient had recurrent epithelial defects related to
eyelid abnormalities. No side effects associated with systemic
immunosuppression were noted
Allo-limbal transplantation, with systemic immunosuppression with
FK-506 is useful in reconstruction of the ocular surface with
improvement in vision in patients with severe stem cell deficiency
Descripcion de tecnica en ESTE ARTICULO

Limbal stem cell transplantation from HLAcompatible living donors. Long term observation
Klin Oczna. 2003;105(6):378-83

11 patients (12 eyes), all with non-ambulatory visual acuity (from light perception to
hand movements)
7 eyes Limbal Stem Cells Deficiency (LSCD) resulted from chemical burn, in 2 eyes from
ocular cicatricial pemphigoid, in one eye from Stevens-Johnson syndrome (SJS). In one
eye congenital LSCD was diagnosed and in another one post-inflammatory LSCD. Mean
follow-up was 16.2 months (from 10 to 32). Among donors prospective class I HLA
matching was performed. Maximal two mismatches were accepted . General
immunosuppressive therapy was switched-on in all subjects. Surgical excision of corneal
pannus with clearing of limbal area was performed. Five clock hours stem cells tissue
grafts from living related donors were harvested and transplanted to the recipient eye.
Three penetrating keratoplasty, one deep lamellar keratoplasty and seven amniotic
membrane transplantations were additionally performed
RESULTS: The graft survival was 83.6% in mean 20.3 months follow-up (from 10 to 32
months). Two cases of graft failure concern eye with SJS and eye with PKP regrafting
after chemical burn. Visual improvement in 7 cases (58.3%), the same visual acuity in 4
cases (33.3%) and deterioration one case (8.3%) were noted. Ambulatory vision in 50%
of patients was achieved. Graft rejection syndrome in four eyes was noticed also when
ideal matching and CsA serum level 220 ng/ml. Two cases were treated with success and
another two grafts failed. No complications in donors eyes were noticed. Impression
cytology in eyes with successful grafts not related to pathological changes
CONCLUSIONS: Lr-CLAL are effective in ocular surface restoration. Living-related donors
are suitable source of stem cells for cultivation in vitro. The prognosis for stem cells
grafting is definitely worse when eyelid anomaly and adhesions exist.

ESTUDIO COMPARATIVO ENTRE TRANSPLANTE DE MEMBRANA

AMNITICA CON Y SIN APLICACIN SIMULTNEA DE
MITOMICINA C EN RECONSTRUCCIN DE FONDO DE SACO
CONJUNTIVAL

Arch Soc Esp Oftalmol 2005; 80: 345-352

Grupo A al cual se le realiz liberacin de simblfaron y
transplante de MA y Grupo B al que adems del transplante se
aplic MMC al 0,02%
Tcnica: El tejido conjuntival cicatrizal fue escindido aplicando
MMC 0,02% por 1 minuto y lavado exhaustivo posterior a la
aplicacin. Se coloc MA cubriendo el defecto (grupo A y B). Las
variables medidas fueron profundidad de saco conjuntival y
movilidad ocular
Grupo A (11 ojos). 7 quemaduras qumicas, 3 simblfaron
traumtico y 1 Stevens-Johnson. En 2 pacientes se obtuvo una
profundidad de fondo de saco de 7 mm o mayor. En 4 pacientes
encontramos una limitacin a la movilidad ocular menor a -1.
Grupo B (12 ojos). 7 quemaduras qumicas, 2 simblfaron
traumtico y 3 Stevens-Johnson. En 9 casos se obtuvo profundidad
de fondo de saco de 7 mm o mayor. En 9 casos la restriccin a la
movilidad se elimin. Los resultados ms pobres en ambos grupos
se obtuvieron en aquellos con trastornos autoinmunes

Role of amniotic membrane graft for ocular chemical and

thermal injuries.
Cornea. 2007 Jan;26(1):21-6

Seventy two eyes of 69 patients were studied of which 24 were

acute cases (median-2 days, range, 1-20 days) and 48 were
chronic cases (median-12.4 months, range, 1.02-95.8 months).
Mean age was 22.4 years (SD +/- 13.34 years) and average follow
up duration was 7.8 months (SD +/- 7.1). Main clinical findings
were symblephara (52.8%), corneal vascularization (51.3%),
conjunctivalization (45.8%), Limbal ischemia (45.8%), Limbal stem
cell deficiency (55.5%) and epithelial defect (48.6%). 18 cases
were due to acid injuries (5 acute, 13 chronic), 52 were due to
alkali (18 acute and 34 chronic) and 2 cases were due to thermal
burns (1 each acute and chronic).
success rate was 87.5% in acute cases and 72.9% in chronic
cases. Indication-wise success rates were 94.3% for epithelial
defect healing, 88.2% for symptomatic relief, 59.7% for ocular
surface reconstruction, and 55% for improving limbal stem cell
function. Success was not achieved in any outcome measure in
1/24 (4.2%) in acute group and 6/48 (12.5%) in chronic group

Changes observed in keratolimbal allograft

Cornea. 2006 May;25(4):377-82

121 KLALs performed in consecutive 85 eyes of 78 patients with

total limbal stem-cell deficiency were analyzed retrospectively.
Mean follow-up period was 46.6 months.
Three types of limbal graft changes classified as epithelial defects,
acute edema, and vascular engorgement were analyzed as
probable signs of immunologic rejection
One or more changes in limbal grafts were observed after 16
KLALs (13.1%). All but 1 eye used systemic and local
immunosuppression using corticosteroid and cyclosporine A, and
most of the changes developed within 3 months postoperatively.
All but 2 eyes developed epithelial breakdown in the central
cornea, and 12 corneas underwent conjunctivalization. The rate of
corneal epithelialization in eyes with limbal graft changes was
significantly worse than those without the changes
Suppression of the immune reaction remains a key to success in
KLAL

Ocular surface reconstruction for thermal burns caused by

fireworks
Cornea. 2006 Feb;25(2):139-45

Six eyes, chronic stage of thermal injury, and all had total limbal
stem cell dysfunction and subsequent conjunctival fibrosis. They
had limbal stem cell transplantation (1 had an allograft and 5 had
autograft transplantation) combined with AMT to restore vision.
Mitomycin C was used in 1 eye intraoperatively
Mean follow-up period of 36 months (range, 5-87 months), marked
reduction of fibrosis was noted in all eyes. At last examination, the
corneal surface was covered by corneal-phenotype epithelium in 4
eyes, and the remaining 2 eyes had conjunctivalization. The
cornea was optically clear in 3 eyes, with corrected visual acuity of
20/100 in these 3 eyes. Both eyes that developed
conjunctivalization had massive fibrosis preoperatively and severe
eyelid deformities
Limbal stem cell transplantation combined with AMT enable some
success in cosmetic and visual outcome. Management of eyelid
abnormalities and ocular surface fibrosis seemed to be a key to
success in visual rehabilitation.

Survival analysis of conjunctival limbal grafts and amniotic

membrane transplantation in eyes with total limbal stem cell
deficiency
Am J Ophthalmol. 2005 Aug;140(2):223-30

Thirty-three eyes of 31 patients with total LSCD that

underwent conjunctival limbal grafts and AMT
Ten eyes (30%) underwent conjunctival limbal autograft and
23 (70%) underwent conjunctival limbal allograft from living
HLA-matched donor. Graft survival was seen in 13 eyes
(40%) at 1 year and in 11 eyes (33.3%) at 2 years, with a
cumulative survival of 33% after a mean follow-up time of
33 months. Increase in postoperative visual acuity was
observed in 20 eyes (60.6%) during this period. Marked
impact on graft survival was observed for patients with
Stevens-Johnson syndrome, dry eye, keratinization, eyelid
abnormalities, and allogeneic conjunctival limbal
transplantation (independently of HLA compatibility) (P < .
05). Preoperative dry eye was the most important
prognostic parameter for surgical outcome (P < .001).

Severe limbal deficiency treated by combined limbal allograft

and amniotic membrane transplantation
Arch Soc Esp Oftalmol. 2005 Jul;80(7):405-12

14 eyes with severe limbal deficiency, treated with LT

combined with AMT (LT + AMT). We studied the morphology of
the limbocorneal epithelium and stroma by impression
cytology and limbal biopsy
Visual acuity showed a mean improvement of 0.4 at 24
months of follow-up. Corneal clarity and loss of
neovascularization were markedly improved after 3 and 6
months, respectively. We did not find corneal
conjuntivalization on cytology performed 6 months after
surgery, except in a patient with chemical burn. Cytology and
limbal biopsy performed nine months after surgery showed an
epithelium and limbocorneal stroma near to normality
CONCLUSIONS: LT + AMT is a very effective procedure for
restoring the ocular surface integrity in patients with severe
limbal deficiency. This combination improves the outcomes
obtained with LT alone.

Transplantation of cultivated autologous oral mucosal

epithelial cells in patients with severe ocular surface disorders
British Journal of Ophthalmology 2004;88:1280-1284

Methods: The eyes (n = 6) of four patients with StevensJohnson syndrome (three eyes) or chemical burns (three eyes)
were studied. Autologous oral epithelial cells, grown for 23
weeks on a denuded amniotic membrane carrier in the presence
of 3T3 fibroblasts, were air lifted. The resultant sheet was
transplanted onto the damaged eye, and acceptance of the
sheet by the corneal surface was confirmed 48 hours after
surgery. The success of ocular surface reconstruction, graft
survival, changes in visual acuity, and postoperative
complications were assessed and the quality of the cultivated
oral epithelial sheet was evaluated histologically.
Results: At 48 hours after transplant, the entire corneal surface
of all six eyes was free of epithelial defects indicating complete
survival of the transplanted oral epithelium. Visual acuity was
improved in all eyes. During follow up (mean 13.8 (SD 2.9)
months), the corneal surface remained stable, although all eyes
manifested mild peripheral neovascularisation.

Propuesta:

1.-Reparar simblfaron con MA

2.-Aloinjerto limbar de familiar con mejor
compatibilidad HLA + MA, bajo
inmunosupresin
3.-Queratoplastia penetrante
4.-Evaluar nueva MA +/- SA
5.-Qx Catarata?
Recordar que es ciruga de rescate