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Variations in the technique for autologous limbal transplantation
Variaciones en la técnica del trasplante limbar autólogo
B. Mataix
, A. Alcántara, M. Caro, J. Montero, B. Ponte, E. Rodríguez de la Rúa
Corresponding author
Sección de Superficie Ocular y Córnea, Servicio de Oftalmología, Hospital Universitario Virgen Macarena, Sevilla, Spain
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Mataix, A. Alcántara, M. Caro, J. Montero, B. Ponte, E. Rodríguez de la Rúa" "autores" => array:6 [ 0 => array:4 [ "nombre" => "B." "apellidos" => "Mataix" "email" => array:1 [ 0 => "b1mataix@yahoo.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Alcántara" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Caro" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "Montero" ] 4 => array:2 [ "nombre" => "B." "apellidos" => "Ponte" ] 5 => array:2 [ "nombre" => "E." "apellidos" => "Rodríguez de la Rúa" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Sección de Superficie Ocular y Córnea, Servicio de Oftalmología, Hospital Universitario Virgen Macarena, Sevilla, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Variaciones en la técnica del trasplante limbar autólogo" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 622 "Ancho" => 1400 "Tamanyo" => 156450 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Persistent limbar insufficiency after the first heterologous limbar transplant. (A) 360° neovascularization with thin and uneven epithelium covering the corneal surface in the upper temporal quadrant and conjunctivalization of the rest of the surface. (B) Late fluorescein staining.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The corneal surface epithelium is produced by a population of self-renewable cells derived from germinal or stem cells located in the sclerocorneal limbus, at the level of the Vogt palisades.</p><p id="par0010" class="elsevierStylePara elsevierViewall">When said cells lose their function, limbar insufficiency (LI) arises. The key sign of LI is corneal conjunctivalization, the most significant clinical expression being persistent epithelial defect.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In complete unilateral LI, the autologous transplant of two 60° corneoconjunctival segments (2<span class="elsevierStyleHsp" style=""></span>h) taken from the contralateral eye with or without amniotic membrane transplant (AMT), is one of the main therapeutic strategies.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> Even though variations of the classic technique has been described, there is some controversy about the necessary size of the grafts.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The present article reports 2 cases in which the corneal surface was restored with a single segment and AMT. In one it was necessary to perform sequential conjunctival epitheliectomies in the post-surgery period.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Clinic cases</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Clinic case report 1</span><p id="par0025" class="elsevierStylePara elsevierViewall">Female, 21, who visited due to loss of vision, photophobia and recurring red eye after suffering caustication 2 years before in both eyes.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Impression cytology showed epithelial cells with a moderate-severe grade of metaplasia, as well as observing very altered goblet cells. Clinic and impressions cytology led to the diagnostic of full LI.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Due to the caustication antecedent also involving the right eye, heterologous transplant of 2 limbar (corneoconjunctival) segments were placed at 6 and 12 o’clock together with the AMT.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Post-surgery, 2 complications were observed: on the one hand, acute rejection which did not respond to the medical treatment, and on the other an excessively thick inferior segment, for which reason it was explanted.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Due to the persistence of signs and symptoms (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) an autologous transplant of a single 60° graft was performed in the inferior limbus together with the AMT. Persistent postoperative neovascularization was treated with cauterization using thin needle and intra-stromal corneal injections of bevacizumab (Avastin, Genetech, San Francisco, CA).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">After the second intervention, even though significant stromal fibrosis remained, the patient exhibited clear improvements of symptoms and signs. A smooth and even epithelial surface was obtained with normal stains, which remains normal after 2 years follow-up (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Clinic case report 2</span><p id="par0055" class="elsevierStylePara elsevierViewall">Female, 48, referred with LI diagnostic. Ocular antecedents included prolonged contact lens use and persistent epithelial defect. AMT had been performed without success. The patient referred intense photophobia and epiphora.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Autologous transplant with a 90° segment was performed together with AMT (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Postoperatively, progressive re-epithelialization occurred with an epithelium having corneal characteristics. At 2 months, re-epithelialization was completed except in the corneal periphery where neovascularization and conjunctivalization persisted and were treated with sequential sectoral epitheliectomies (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">After 18 months follow-up, the surface presented stable epithelium with diminished subepithelial fibrosis and neovascularization.</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">Traditionally, autologous limbus transplant is performed on the basis of two 60° segments,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> although the potential of provoking LI in the donor eye has given rise to considering the needs to diminish the size of the necessary graft.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">In what concerns total LI conditions, there is only one successfully treated case with a single 60° segment.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> Moldovan et al. required a segment between 90 and 100° together with AMT. Smaller sizes were insufficient.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">In the present 2 cases, the authors partially attribute success to the AMT with conjunctival suture (after 360° peritomy). The therapeutic usefulness of amniotic membrane is due to its mechanical and mainly biological properties.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a> It comprises numerous growth factors and performs as a substrate, promoting epithelial cell migration and adhesion. Although traditionally the amniotic membrane has been sutured over the conjunctiva, when placing the edges thereof over the membrane produces conjunctival epithelial cell growth over the membrane and not over the corneal surface.</p><p id="par0090" class="elsevierStylePara elsevierViewall">In some cases, as in the second clinic case reported herein, despite achieving normal epithelialization of the visual axis and the majority of the surface, some peripheral conjunctivalization tufts may remain, which can be treated with sequential conjunctival epitheliectomies without requiring the implant of a second graft.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Even though the results obtained cannot be extrapolated for treating all patients, the use of a single 60–90° segment together with AMT could be an option to be considered in cases where the donor eye comprises the risk of developing LI.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflict of interests</span><p id="par0100" class="elsevierStylePara elsevierViewall">No conflict of interests was declared by the authors.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres733565" "titulo" => "Abstract" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec737393" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres733566" "titulo" => "Resumen" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "abst0015" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec737394" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Clinic cases" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Clinic case report 1" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Clinic case report 2" ] ] ] 6 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interests" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-03-14" "fechaAceptado" => "2016-03-18" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec737393" "palabras" => array:5 [ 0 => "Limbal stem cell deficiency" 1 => "Amniotic membrane" 2 => "Limbal autograft" 3 => "Sequential sectoral conjunctival epitheliectomy" 4 => "Corneal epithelium" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec737394" "palabras" => array:5 [ 0 => "Insuficiencia limbar" 1 => "Membrana amniótica" 2 => "Trasplante limbar autógeno" 3 => "Epiteliectomía conjuntival sectorial secuencial" 4 => "Epitelio corneal" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To present the results on the use of a single block limbal autograft, combined with amniotic membrane transplantation and sectoral sequential postoperative epitheliectomy of the conjunctiva in 2 patients with unilateral total limbal stem cell deficiency.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conclusions</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A single block limbal autograft combined with amniotic membrane transplantation may be sufficient to restore a stable corneal surface, but sometimes sequential sectoral conjunctival epitheliectomy may be required to treat anomalous epithelial remnants.</p></span>" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Objetivo</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Presentar los resultados del uso de un único segmento de autoinjerto limbar combinado con trasplante de membrana amniótica y epiteliectomías conjuntivales sectoriales secuenciales postoperatorias en 2 pacientes con insuficiencia límbica unilateral total.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Un solo segmento de autoinjerto limbal junto con el trasplante de membrana amniótica puede ser suficiente para restaurar una superficie corneal estable, siendo en ocasiones necesario realizar en el postoperatorio epiteliectomías conjuntivales secuenciales en zonas remanentes de epitelio anómalo.</p></span>" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "abst0015" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Mataix B, Alcántara A, Caro M, Montero J, Ponte B, Rodríguez de la Rúa E. Variaciones en la técnica del trasplante limbar autólogo. Arch Soc Esp Oftalmol. 2016;91:501–504.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 622 "Ancho" => 1400 "Tamanyo" => 156450 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Persistent limbar insufficiency after the first heterologous limbar transplant. (A) 360° neovascularization with thin and uneven epithelium covering the corneal surface in the upper temporal quadrant and conjunctivalization of the rest of the surface. (B) Late fluorescein staining.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 508 "Ancho" => 1801 "Tamanyo" => 105109 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Clinic case report 1. (A) Surface normalization after autologous transplant. The epithelium is even and smooth although significant stromal fibrosis persists. (B) Fluorescein staining. (C) Diminished neovascularization after cauterization and injection of interest stromal bevacizumab.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 622 "Ancho" => 1400 "Tamanyo" => 145189 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Second patient surgery details. (A) Autologous corneoconjunctival segment sutured to the upper limbus. (B) Positioning of the conjunctiva above the amniotic membrane.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 531 "Ancho" => 1400 "Tamanyo" => 91455 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Clinic case report 2. (A) Corneal surface after autologous and amniotic membrane transplant, showing central stromal fibrosis and normal surface epithelialization excepts in the periphery (arrows). (B) Complete re-epithelialization after sequential sectoral conjunctival epitheliectomies.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Postoperative complications of conjunctival limbal autograft surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A. Baradaran-Rafii" 1 => "M. Eslani" 2 => "H. Jamali" 3 => "F. Karimian" 4 => "U.A. Tailor" 5 => "A.R. 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