30 EyeWorld Asia Pacific | June 2024 Aniridic keratopathy and total limbal stem cell deficiency— preoperative photo of the left eye. to treat patients with limbal stem cell deficiency and said he wouldn’t generally recommend this option. That leaves stem cell transplantation, of which there are several options. One is transplanting from one eye to the other. In the case of a unilateral chemical burn, for example, you could do that, Dr. Jeng said. If conditions permit with the unaffected eye, then you can take either four small clock hour blocks from the other eye and move to the diseased eye or you could do simple limbal epithelial transplant (SLET). “While I personally haven’t had success with [SLET], others definitely have,” he said. The second option is a living, related donor, which is very similar to using cells from a cadaveric donor. Use of cadaveric donors, described by Edward Holland, MD, and his group, requires systemic immunosuppression for a year, Dr. Jeng said. “I think that a lot of ophthalmologists are uncomfortable with that, and if you don’t do it right, you either have a failure of surgery or you could make the patient very sick. He added that ophthalmologists alone should not be managing these transplant medications. These are at the level of a kidney or heart transplant, he said, so you need to have the infrastructure with a transplant team that’s in place. He noted that Dr. Holland’s Cincinnati Protocol has this infrastructure. “I’ve had a few patients ask about that [option], and we have sent them to Cincinnati to do it because we don’t have an infrastructure set up for it,” Dr. Jeng said, adding that one other obstacle is that he really doesn’t see the surgical volume necessary to set up a program like this. Dr. Jeng said that he has personally used this technique. “But I felt that I didn’t do a high enough volume that makes me the best person to do this,” he said. “It makes sense, but we need to make sure any center set up has the appropriate volume to serve the patients.” In terms of surgeons being trained to treat limbal stem cell deficiency or dysfunction, Dr. Jeng said he believes new fellows are well versed in when someone needs a scleral lens, and they’re probably trained in KPros, as well. They are most likely not trained in stem cell transplants because many centers don’t do them, he said, emphasizing that the surgery itself is not the difficult thing, but it’s managing the patients postoperatively. Sophie Deng, MD, PhD Dr. Deng sees patients for limbal stem cell deficiency very frequently in her practice. “We have established a center for limbal stem cell deficiency (LSCD), so we get referrals from the region and sometimes from across the country,” she said, adding that she often sees several of these cases per week. She said the first step, even before treatment, is to stage the disease. She uses live imaging to evaluate the stem cell function in these eyes. “We do the anterior segment OCT first to look at the epithelial thickness in these eyes to make sure we don’t misdiagnose the stem cell deficiency,” she said. “Subsequently, we will perform in vivo confocal microscopy on these eyes to look at the microstructure of limbus and cornea.” We came up with a formula to quantify the stem cell function, she said. “After we’ve done all [this] testing, then we determine the stage of LSCD,” she said. “Based on the severity of the LSCD, we treat the patients accordingly.” Often, Dr. Deng said these patients have other comorbidities, such as ocular surface inflammation, dry eye disease, or eyelid abnormalities. In many of these eyes, their stem cell function improves as a result of removing the insulting agents, she said. As a majority of eyes with LSCD still have residual LSCs, once the health of the ocular Aniridic keratopathy and total limbal stem cell deficiency— preoperative photo of the right eye. Aniridic keratopathy and total limbal stem cell deficiency—right eye 15 year postoperative after a keratolimbal allograft. Aniridic keratopathy and total limbal stem cell deficiency— left eye 14 years postoperative after keratolimbal allograft. Source (all): Edward Holland, MD CORNEA
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