34 EyeWorld Asia Pacific | June 2024 at 84 months) compared to eyes without OSD (78% at 84 months). Aravena et al. found that eyes undergoing a KPro implantation for failed keratoplasty had a retention failure rate of 0.052/ year while eyes with SJS, chemical injury, and MMP had retention failure rates of 0.299/year, 0.094/year, and 0.147/year.13 We have published our poor KPro results for total LSCD patients: 2.4% developed endophthalmitis with devastating visual consequences (vision decreased to light perception in 2 of 3 eyes), and 16% encountered melt-related complications. In addition, 47% of patients lost vision due to glaucoma in just 32 months follow up.14 Due to our poor results, we stopped offering and performing primary KPros in this patient population unless there is a contraindication for OSSTx. Obstacles in adoption of OSSTx with SI There are many reasons why corneal surgeons have not embraced OSSTx with SI. First, corneal specialists fear managing or don’t want to manage systemic immunosuppression, despite the fact that a safe and acceptable treatment with immunosuppression is well published and demonstrates long-term efficacy of maintaining a stable ocular surface.3-5 This fear on the part of the clinician is often communicated to the patient. There appears to be a misunderstanding by corneal surgeons regarding the safety of SI even with appropriate monitoring. Corneal surgeons may not be aware of the literature supporting the safety of this approach or feel comfortable enough to follow these protocols. Cornea is the only transplant specialty that does not employ the principles of systemic immunosuppression, which are not needed for routine keratoplasty but are beneficial in high-risk keratoplasty (i.e., prior graft rejection, stromal neovascularization) in addition to OSSTx.15 We have used SI on more than 1,000 patients and have seen minimal severe adverse events (rare cardiovascular disease and one secondary malignancy) and no deaths. We have published on our use of these medications and the protocol to adopt the principles of SI from organ transplantation experts, notably nephrology (Cincinnati protocol).3,5 Partnering with renal transplant specialists on preoperative screening, tissue typing of donors, SI level monitoring, and management of medication side effects has provided a treatment paradigm for corneal surgeons to use SI safely and effectively to achieve excellent outcomes for our patients. Recommendations In our goal to achieve better outcomes in patients with severe OSD with LSCD, we want to encourage our cornea colleagues to recognize this issue at an individual, corneal service, departmental, and societal level. From our experience, LSCD is the leading cause of untreated corneal blindness in the U.S. It has been more than 30 years since the techniques of OSSTx with SI have been introduced. The surgical techniques have improved, valuable preoperative screening has been applied, and the SI medications are safer and more effective. Yet we have not seen a significant change in corneal surgeons’ behavior. Given the small number of clinicians performing these procedures, we need to acknowledge the scope and severity of this problem. These patients have a terrible quality of life due to blindness and chronic ocular pain. As a community, we must do better and offer safe and effective OSSTx. We do not expect every corneal surgeon to perform OSSTx with SI. However, we think major ophthalmology centers should build programs, and groups of corneal surgeons should collaborate to create regional centers to make this treatment more accessible to help this population with the biggest unmet need in our field. About the Physicians Albert Cheung, MD | Virginia Eye Consultants, Norfolk, Virginia | acheung@cvphealth.com Edward Holland, MD | Professor of Ophthalmology, University of Cincinnati, Cincinnati, Ohio | eholland@holprovision.com References 1. Holland EJ. Epithelial transplantation for the management of severe ocular surface disease. Trans Am Ophthalmol Soc. 1996;94:677–743. 2. Croasdale CR, et al. Keratolimbal allograft: recommendations for tissue procurement and preparation by eye banks, and standard surgical technique. Cornea. 1999;18:52– 58. 3. Holland EJ, et al. Systemic immunosuppression in ocular surface stem cell transplantation: results of a 10-year experience. Cornea. 2012;31:655–661. 4. Movahedan A, et al. Long-term outcomes of ocular surface stem cell allograft transplantation. Am J Ophthalmol. 2017;184:97–107. 5. Cheung AY, et al. Cincinnati protocol for preoperative screening and donor selection for ocular surface stem cell transplantation. Cornea. 2018;37:1192–1197. 6. Cheung AY, et al. Clinical outcomes of allogeneic ocular surface stem cell transplantation in pediatric patients. Cornea. 2021;40:54–60. 7. Orphanet. Limbal stem cell deficiency. www.orpha.net. Accessed October 15, 2022. 8. Cheung AY, et al. Limbal stem cell deficiency: demographics and clinical characteristics of a large retrospective series at a single tertiary referral center. Cornea. 2021;40:1525–1531. 9. Tugal-Tutkun I, et al. Penetrating keratoplasty in cicatrizing conjunctival diseases. Ophthalmology. 1995;102:576–585. 10. Sepsakos L, et al. Outcomes of keratoplasty after ocular surface stem cell transplantation. Cornea. 2017;36:1025–1030. 11. Sangwan VS. Limbal stem cells in health and disease. Biosci Rep. 2001;21:385–405. 12. Srikumaran D, et al. Long-term outcomes of Boston type 1 keratoprosthesis implantation: a retrospective multicenter cohort. Ophthalmology. 2014;121:2159– 2164. 13. Aravena C, Yu F, Aldave AJ. Long-term visual outcomes, complications, and retention of the Boston type I keratoprosthesis. Cornea. 2018;37:3-10. 14. Chan CC, et al. Incidence, risk factors, and surgical management of Boston type 1 keratoprothesis corneal melts, leaks, and extrusions. Cornea. 2016;35:1049–1056 15. Azam AM, et al. Immunosuppressive therapy for high-risk corneal transplant. Curr Ophthalmol Rep. 2022; 10:114–129. This article originally appeared in the March 2024 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. Relevant Disclosures Cheung: None Holland: None CORNEA
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