Regenerative surgery of the cornea: Myth or reality?

Alió, J.L.; Alió del Barrio, J.

doi:10.1016/j.oftale.2023.02.007

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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "425" "paginaFinal" => "426" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J.L. Alió, J. Alió del Barrio" "autores" => array:2 [ 0 => array:4 [ "nombre" => "J.L." "apellidos" => "Alió" "email" => array:1 [ 0 => "jlalio@vissum.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J." "apellidos" => "Alió del Barrio" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Catedrático de Oftalmología, Universidad Miguel Hernández, Elche, Alicante, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Profesor Asociado, Universidad Miguel Hernández, Elche, Alicante, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Cirugía regenerativa de la córnea: ¿mito o realidad?" ] ] "textoCompleto" => "Corneal transplantation (keratoplasty), performed in its different modalities, nowadays offers enormous improvements in surgical technique and anatomical results with respect to the past of this technique. Despite the undoubted progress made, both penetrating keratoplasty and lamellar keratoplasty, particularly anterior lamellar keratoplasty, have limitations in terms of long-term results that merit reflection.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> The analysis of both single-centre<a class="elsevierStyleCrossRef" href="#bib0010">2</a> and multicentre studies carried out in Spain from the OFTARED Thematic Network of Ophthalmological Research,<a class="elsevierStyleCrossRef" href="#bib0015">3</a> as well as a systematic analysis at a global level,<a class="elsevierStyleCrossRef" href="#bib0005">1</a> makes evident the limitations that their results still offer and therefore the need to take a step further with regard to the use of human tissue for keratoplasty, which is also limited in its execution by the availability of human donor tissue, which is always scarce and costly.It is therefore necessary to evolve towards more modern therapeutic models that are less subject to complications and more biologically controllable than methods of replacement with human donor corneal tissue. Today we are beginning to glimpse the possibility of replacing diseased corneal tissue with tissues generated by the patient himself, without immunogenic potential, and which can be manipulated even at a technological level to provide them with refractive value. The era of corneal regenerative surgery has undoubtedly begun.Taking into account the anatomical structure of the cornea, regenerative surgery of the ocular surface is key to ensure that the corneal tissue remains stable and transparent. In this sense, studies by various authors, including those of the IOBA group in our country,<a class="elsevierStyleCrossRefs" href="#bib0020">4,5</a> clearly indicate that, with the currently existing limitations, it is possible to obtain regeneration of the corneal surface and conjunctiva to provide healthy homeostasis for those patients who have a corneal disease with deterioration of the ocular surface, such as aniridia, as well as those in whom there is a loss of corneal limbal cell competence, with subsequent corneal opacification.<a class="elsevierStyleCrossRef" href="#bib0025">5</a>Regenerative replacement of the corneal stroma has undergone great progress in recent years thanks to the publication of the results of pioneering international studies carried out by authors from our country,<a class="elsevierStyleCrossRefs" href="#bib0030">6,7</a> which have demonstrated the possibility of using human acellular tissue with multipotent mesenchymal cells of adipose origin which, implanted into the corneal stroma, allow the biological revitalisation of this tissue as well as an increase in its thickness. This therapy, which also replaces opaque corneal tissue with new transparent tissue, opens up an immense number of possibilities for the treatment of corneal blindness caused by stromal problems, particularly corneal degenerative dystrophies, among which keratoconus stands out. The incorporation of stromal lenticule carving techniques, obtaining special shapes to compensate for corneal deformities and even providing these lenticules with a calculated optical power, can profoundly change the use of these regenerated tissues, also providing them with an adequate dioptric potential.<a class="elsevierStyleCrossRef" href="#bib0040">8</a>3D and 5D printing techniques, the use of xenogeneic tissue and the possibility of having cell banks that make it unnecessary to obtain cells from the patient himself by invasive methods will open up an enormous potential of possibilities, and would initiate the progressive replacement of corneal tissue replacement techniques with human donor tissue by others in which tissue regeneration achieves the restoration of corneal transparency and the patient’s vision.Finally, the posterior corneal plane, endothelial-descematic, offers possibilities for replacement by cultured corneal endothelial cells from cell banks, as has already been demonstrated by studies in Japan,<a class="elsevierStyleCrossRef" href="#bib0045">9</a> and also in our country. The concept of being able to inject cells into the anterior chamber that can adhere to the posterior corneal plane of the cornea is extremely attractive, but even more so is the possibility of implanting cell sheets already colonised by endothelial or even mesothelial cells of extraocular origin<a class="elsevierStyleCrossRef" href="#bib0050">10</a> that allow the restoration of corneal transparency affected by chronic endothelial failure.What lies ahead? Undoubtedly, first of all, the consolidation of these regeneration techniques for both surface and stromal and corneal endothelial regeneration. The final development of a cornea regenerated in all its layers from pluripotent cells, the obtaining of a true corneal organoid, a true tissue obtained from pluripotent cells that, duly manipulated, will allow us to obtain a structure that successfully replaces the entire cornea or some of its parts, is a myth that is achievable in the near future, which will mean the consolidation and widespread application of these techniques as an alternative to the current keratoplasty.It is very likely that we will see in the next 10–20 years the application of these new techniques, which will represent a new scale in corneal surgery. There is no doubt that in 20 years’ time many of the current corneal transplants will not be necessary because these techniques will achieve the restoration of corneal transparency with far fewer side effects, greater control and fewer application limitations than current corneal transplants.Conflict of interestNo conflicts of interest were declared by the authors." 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Archivos de la Sociedad Española de Oftalmología is the official journal of the Ophthalmology Society of Spain, that has over 4,000 members. It gives priority to the publication of basic, translational and clinic research including reviews, original articles, short communications, editorials, letters to the editor and clinic practice guides related to Ophthalmology and its subspecialties. A small section of the journal is reserved for the most relevant papers presented at the annual Congress of the Society. All manuscripts considered for publication are reviewed by expert examiner peers (double blind). The journal is published monthly and even though its official language is Spanish all articles are translated into English to increase the dissemination of scientific information. At present, Archivos is the only Spanish language Ophthalmology journal indexed in PubMed/MEDLINE in addition to other prestigious international databases such as Scopus.

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