Long-Term Outcomes of Allogeneic Ocular Surface Reconstruction: Keratolimbal Allograft (KLAL) Followed by Penetrating Keratoplasty (PK) – ScienceOpen
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      Long-Term Outcomes of Allogeneic Ocular Surface Reconstruction: Keratolimbal Allograft (KLAL) Followed by Penetrating Keratoplasty (PK)

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          Abstract

          Purpose

          Long-term results of the patients with total LSCD, who had undergone keratolimbal allograft (KLAL) for limbal reconstruction followed by penetrating keratoplasty (PK).

          Methods

          The study analyzes surgical treatment of 43 eyes with severe ocular surface disorders. All subjects underwent KLAL to achieve suitable conditions for consecutive PK. Due to failures of primary treatment in 17 eyes (39%), the KLAL was repeated. PK was performed in all the patients at 9-12 months after KLAL. As a retrospective study we analyzed data from the medical records including the preoperative and postoperative best corrected visual acuity, corneal clarity, surgical outcomes and complications, postoperative intraocular pressure, graft rejection, and other comorbidities and complications.

          Results

          The preoperative visual acuity ranged from light perception to 0.01. The final improvement of visual acuity within a gain of one or more lines with the Snellen chart, including the results of successive surgical treatments after PK, was achieved in 23 operated eyes (53%). Early graft rejection was observed in 4 eyes (9%). In 3 eyes, it was manifested as endothelial rejection, and in 1 eye, as combined endothelial and epithelial rejection. PK failure requiring repetitive PK was present in 14 eyes (32%). Phthisis bulbi developed in 6 eyes (14%). Glaucoma or ocular hypertension was reported in 25 eyes (58%). A majority were treated with up to 3 topical agents or referred for trabeculectomy in 3 cases, transscleral cyclophotocoagulation in 2 eyes, and EX-PRESS glaucoma shunt implantation in 3 cases.

          Conclusions

          Successful KLAL carries a high risk of subsequent PK failure. Visual function remains the second aim of treatment; the primary one is to stabilize the surface.

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          Most cited references26

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          Long-term outcome of keratolimbal allograft with or without penetrating keratoplasty for total limbal stem cell deficiency.

          To evaluate the long-term outcome of ocular surface reconstruction, including keratolimbal allograft (KLAL) and amniotic membrane transplantation (AMT) with or without penetrating keratoplasty (PKP), in patients with nonambulatory vision secondary to total limbal stem cell deficiency (LSCD). Retrospective, non-comparative interventional case series. Thirty-nine eyes in 31 consecutive patients with total LSCD, as defined by impression cytology, who had a preoperative best-corrected visual acuity of less than 20/200 and a minimum follow-up of 12 months. Patients were divided into three groups: group 1 (16 eyes) with chemical burns, group 2 (9 eyes) with Stevens-Johnson syndrome (SJS), and group 3 (14 eyes) with other causes of LSCD, including ocular cicatricial pemphigoid, atopic keratoconjunctivitis, and aniridia. All patients underwent KLAL and AMT by one surgeon (SCGT). If needed, PKP was performed at the same surgical setting using tissue from the same donor. Cumulative rates of survival of ambulatory vision (> or = 20/200), survival of KLAL, survival of PKP, and incidence of complications. Fifty-three KLAL with AMT procedures were performed in 39 eyes, of which 23 eyes received simultaneous PKP at the time of the first KLAL. The mean follow-up was 34.0 +/- 21.5 months (range, 12-117.6). The mean period of ambulatory vision was 23.9 +/- 20.9 months (range, 0-104). The overall survival of ambulatory vision was 53.6% at 3 years and 44.6% at 5 years. The survival of ambulatory vision was significantly worse in SJS compared with other causes (67%, 81%, and 92% for groups 1, 2, and 3, respectively; P = 0.06 for group 1 versus 2, P = 0.0008 for group 1 versus 3). KLAL performed alone resulted in higher survival of ambulatory vision at 2 years (86.1% +/- 9.1%) compared with KLAL with PKP (46.9% +/- 10.6%, P = 0.100). The survival of PKP was significantly worse in SJS compared with the other causes (20.0% +/- 17.9% compared with 55.6% +/- 11.7%, respectively, P = 0.028). After 2 years, the survival of the second KLAL was better than that of the first: 68.2% +/- 15.4% compared with 27.3% +/- 13.4%, respectively (P = 0.041). Ambulatory vision for a period of more than 2 years can be achieved by KLAL with or without PKP in eyes with severe ocular surface disorders caused by total LSCD. However, a progressive decline of the visual outcome and graft survival is evident with time. Performing PKP simultaneously with KLAL may be associated with a less favorable outcome. The failure of KLAL is associated with the loss of donor cells in the recipient. Augmentation of ocular surface defense is essential in securing the success of KLAL and PKP. Future modifications of the surgical procedure and of the immune suppressive protocols may improve survival of the allogeneic grafts and the final visual outcome.
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            Therapeutic keratoplasty for advanced suppurative keratitis.

            To determine indications, therapeutic success, and corneal transplantation techniques for advanced medically uncontrolled infectious keratitis.
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              Long-term outcomes of keratolimbal allograft for the treatment of severe ocular surface disorders.

              To investigate the long-term outcome of keratolimbal allograft (KLAL) for the treatment of severe ocular surface disorders. Retrospective, noncomparative case series. Twenty patients (23 eyes) with severe ocular surface disorders. Thirty-three KLAL procedures were performed. Ten patients (10 eyes) underwent KLAL in combination with other surgical procedures. Oral or topical cyclosporine or both were used after surgery in 15 patients to prevent allograft rejection. Reconstruction of the ocular surface with restoration of phenotypic corneal epithelium, reduction of corneal vascularization and conjunctivalization, decreased pain, and visual improvement. The mean follow-up was 60 months (range, 15-96 months). Eight eyes (24.2%) never reepithelialized and were considered primary failures. The remaining 25 grafts initially restored a phenotypic corneal epithelium, but at last follow-up only 7 (21.2%) were stable. Graft survival rate was 54.4% at 1 year, 33.3% at 2 years, and 27.3% at 3 years. Visual acuity improved or was unchanged in 19 eyes (82.6%) and decreased in 4 eyes (17.4%). Seventeen corneal transplantations (3 lamellar keratoplasties and 14 penetrating keratoplasties) were performed either in combination with or after a KLAL. All three lamellar keratoplasties were successful, whereas 13 of the 14 penetrating keratoplasties failed. Cyclosporine was used initially in high-risk recipients and later in all recipients. Allograft rejection episodes occurred in 13 KLAL procedures of 11 eyes (39.4%) and were more common in patients treated with cyclosporine compared with the untreated group (87.5% vs. 22.2%). Graft survival was longer in the cyclosporine-treated group compared with the untreated group. Keratolimbal allograft is useful in ocular surface reconstruction and restores phenotypic corneal epithelium. Graft survival rate, however, decreases dramatically over a 2-year period. Long-term use of cyclosporine appears to prolong graft survival but does not prevent acute allograft rejections.
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                Author and article information

                Contributors
                Journal
                J Ophthalmol
                J Ophthalmol
                JOPH
                Journal of Ophthalmology
                Hindawi
                2090-004X
                2090-0058
                2020
                14 April 2020
                : 2020
                : 5189179
                Affiliations
                1Department of Ophthalmology with Pediatric Unit, St Barbara 5th Regional Hospital, Trauma Centre, Medykow Square 1, 41200 Sosnowiec, Poland
                2Chair and Clinical Department of Ophthalmology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Panewnicka 65 Str., 40760 Katowice, Poland
                3Department of Ophthalmology, District Railway Hospital, Panewnicka 65, 40-760 Katowice, Poland
                4Department of Biophysics and Molecular Physics, A. Chelkowski Institute of Physics, Silesian Center for Education and Interdisciplinary Research, University of Silesia, 41-500 Chorzów, 75 Pułku Piechoty 1A, Poland
                Author notes

                Academic Editor: Michele Figus

                Author information
                https://orcid.org/0000-0001-9737-5391
                https://orcid.org/0000-0002-8768-1691
                https://orcid.org/0000-0002-0520-9589
                https://orcid.org/0000-0002-6707-5790
                https://orcid.org/0000-0003-4405-8020
                Article
                10.1155/2020/5189179
                7178497
                8288578f-a790-46bf-838c-e009b92565d0
                Copyright © 2020 Katarzyna Krysik et al.

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 3 November 2019
                : 20 February 2020
                : 4 March 2020
                Categories
                Research Article

                Ophthalmology & Optometry
                Ophthalmology & Optometry

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