|Year : 2022 | Volume
| Issue : 2 | Page : 638-639
The ever changing face of ocular surface reconstruction
Anahita Kate1, Sayan Basu2
1 The Cornea Institute, KVC Campus, LV Prasad Eye Institute, Vijayawada, Andhra Pradesh, India
2 The Cornea Institute, KAR Campus; Prof. Brien Holden Eye Research Centre (BHERC), LV Prasad Eye Institute, Hyderabad, Telangana, India
|Date of Web Publication||13-Apr-2022|
Prof. Brien Holden Eye Research Centre (BHERC), LV Prasad Eye Institute, Hyderabad, Telangana
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kate A, Basu S. The ever changing face of ocular surface reconstruction. Indian J Ophthalmol Case Rep 2022;2:638-9
Ocular chemical burns (OCBs) constitute a chronic ocular disease entity with serious visual morbidity. The management of the sequelae that ensue from OCBs often requires a multi-pronged surgical approach of different structures of the eye. This is carried out with the ultimate goal of reestablishing a healthy ocular surface and visually rehabilitating the patient. These surgeries are usually performed sequentially with the correction of adnexal pathologies being done prior to limbal stem cell transplants (LSCTs) and keratoplasties. In cases with bilateral involvement, the LSCTs are allogeneic, necessitating systemic immunosuppression. Keratoprosthesis (KPro) is the procedure of choice when multiple interventions are not feasible or if the patient is not a suitable candidate for immunosuppressive therapy. However, these ocular implants are fraught with severe complications such as extrusion, secondary glaucoma, endophthalmitis, and sterile melts.
The decision to perform a corneal transplant in an eye with limbal stem cell deficiency (LSCD) must be taken after a careful and comprehensive clinical examination. In several cases, the assessment of the density of the corneal scarring is challenging because of the dense superficial pannus that obscures the view of the deeper layers. The infrared image of the cornea that accompanies an optical coherence tomography (OCT) scan often provides a clue regarding the degree of scarring, and if the anterior chamber details are discernible, then performing an LSCT in isolation may provide adequate visual regain. Additionally, the fact that the scar undergoes remodeling following an LSCT and may decrease in density must also be considered before committing to a keratoplasty. Furthermore, many of these cases obtain a good functional vision with rigid contact lenses after the LSCT corrects the epithelial tissues.
The mere presence of a symblepharon is not an indication of its release. The procedure is usually performed to enable placement of a scleral contact lens or if the fibrosis is inducing significant ptosis or lagophthalmos. Once excised, there are several sources from where the donor graft can be harvested for surface reconstruction. An autologous conjunctival graft is preferred in unilateral cases, whereas in bilateral conjunctival cicatrization, the bare area can be covered with an amniotic membrane, oral mucous membrane, or allogeneic conjunctival graft.
In the report by Akata et al., a “full ocular surface transplantation” has been described wherein a conjunctival allograft with a large sclerokeratoplasty was performed. Following the procedure, the patient received intensive immunosuppression, and at the end of the 2-year follow up, the graft clarity was maintained on a monotherapy of oral mycophenolate mofetil. The authors proffer the single-stage procedure to be a viable alternative to KPros in bilateral OCBs. However, larger series would be required to establish the true efficacy of the procedure. Moreover, the final visual acuity in the reported case was 20/400, which is lower than the reported 90% of cases who have a vision of better than 20/200 with KPros for LSCD due to OCBs. Also, combining a keratoplasty with LSCT increases the risk of rejection of the corneal transplant probably due to the increased manipulation, and in cases of allogeneic LSCT, the additional antigenic load. In view of this risk, performing a lamellar keratoplasty when feasible is recommended.
Thus, the management of severe OCBs, especially in cases with bilateral affliction of the disease, involves a complex decision-making process with a comprehensive clinical examination and ancillary investigative tools if needed. Although a one-step procedure is convenient and has had good results in this particular report, the constantly evolving nature of the disease and its response to treatment must be considered when planning extensive simultaneous procedures.
| References|| |
Basu S, Serna-Ojeda JC, Senthil S, Pappuru RR, Bagga B, Sangwan V. The Aurolab Keratoprosthesis (KPro) versus the Boston Type I Kpro: 5-year Clinical Outcomes in 134 Cases of Bilateral Corneal Blindness. Am J Ophthalmol 2019;205:175-83.
Kate A, Basu S. Mini-conjunctival autograft combined with deep anterior lamellar keratoplasty for chronic sequelae of severe unilateral chemical burn: A case report. Int J Surg Case Rep 2021;88:106508.
Shanbhag SS, Patel CN, Goyal R, Donthineni PR, Singh V, Basu S. Simple limbal epithelial transplantation (SLET): Review of indications, surgical technique, mechanism, outcomes, limitations, and impact. Indian J Ophthalmol. 2019;67:1265-77.
Akata F, Akcam HT, Yuksel E, Yaylacioglu F. A new surgical technique for severe ocular surface burns: Full ocular surface transplantation. Indian J Ophthalmol Case Rep 2022;2:9-13. [Full text]
Shanbhag SS, Saeed HN, Paschalis EI, Chodosh J. Boston keratoprosthesis type 1 for limbal stem cell deficiency after severe chemical corneal injury: A systematic review. Ocul Surf 2018;16:272-81.
Basu S, Mohamed A, Chaurasia S, Sejpal K, Vemuganti GK, Sangwan VS. Clinical outcomes of penetrating keratoplasty after autologous cultivated limbal epithelial transplantation for ocular surface burns. Am J Ophthalmol 2011;152:917-24.e1.