ocular surface reconstruction with SLET under guarded prognosis, chemical injury

1. CASE PRESENTATION
Moderator: Dr. Suhas Haldipurkar
Dr. Abhishek Hoshing

2. History
 11 year old, female
 Complaints of redness, pain, watering LE: 4 years
 Diminution of vision in LE: 4 years
 History of chemical injury (lime/”chuna”) 4 years ago

3. History
 Primary treatment post chemical injury taken at other
hospital
 Amniotic membrane grafting done somewhere else
 Opinion sought at our hospital in Feb, 2015
 Was advised ocular surface reconstruction with SLET
under guarded prognosis

4. Chemical injury in Paediatric
population – How are they
different?
 Pose a greater threat
 Delay in timely diagnosis
 Difficulty in adequate management
 Additional risk of AMBLYOPIA!!

5. • Age group 0-5 years: most commonly affected (68%
patients were 1-3 yrs old)
• “Chuna”/ Lime: most common offending agent (Grade 4
injuries and 68% eyes had final median BCVA of 1/60)
• One third patients did NOT receive irrigation at time of
injury
• Delay in presentation (70.2% presented after 1 month of
injury)

6. Examination
 General Examination : WNL
 Ocular Examination :
Visual Acuity RIGHT EYE LEFT EYE
Distance 6/6 HM, PR accurate
Near N6 -

7. Ocular Examination
RIGHT EYE LEFT EYE
Lids and adnexa WNL WNL
Conjunctiva WNL
Good limbal tissue
Superiorly anterior
insertion of conjunctiva
Described in the diagram
Cornea Clear Described in the diagram
Sclera Normal Visible sclera is normal
AC Well formed, quiet
PACD = ½ CT
No view
Iris Normal No view
Pupil RRR, 3 mm
No RAPD
No view
Lens Clear No view
Fundus WNL No view

8. LE: Diagram representing the clinical findings

10. DIAGNOSIS
LE: TOTAL LIMBAL STEM CELL DEFECIENCY
WITH SYMBLEPHARON WITH PROBABLE
CORNEAL SCAR AND CATARACT

11. Defined stem cells, by virtue of their functional attributes, as
“undifferentiated cells” capable of
(a) proliferation,
(b) self maintainence,
(c) producing a large number of differentiated, functional
progeny,
(d) regenerating the tissue after injury, and
(e) a flexibility in the use of these options

12. Corneal Stem cells
 Located exclusively in the Limbal basal epithelium
 Why the limbus only?
 Central corneal epithelium transparent  basal cells
devoid of pigment highly susceptible to solar damage.
 Basal cells in the limbal region do not have this constraint;
they are heavily pigmented and, thus, are well protected.
 Transparency of cornea dictates a smooth epithelial-
stromal junction  minimal anchorage  renders
epithelium susceptible to physical shearing.
 In contrast, limbal epithelium is very resistant to shearing
forces and displays a highly undulating epithelial-stromal
junction.

13. What causes limbal stem cell
damage?
 Primary limbal stem cell deficiency (1° LSCD)
 Absence of identifiable external factors
 Insufficient environment to support the cells
 Aniridia, erythroderma, multiple endocrine deficiency,
neurotrophic keratopathy, peripheral inflammmation
 Secondary limbal stem cell deficiency (2° LSCD)
 Presence of destructive external factors
 Chemical & thermal injuries, cicatrizing inflammmations
 CL wear, multiple ocular surgeries

14. How to diagnose LSCD?
CONJUNCTIVALISATION VASCULARIZATION
CHRONIC
INFLAMMATION
TRIAD

15. DIAGNOSIS
LE: TOTAL LIMBAL STEM CELL DEFECIENCY
WITH SYMBLEPHARON WITH PROBABLE
CORNEAL SCAR AND CATARACT

16.  What next??
 What are the options available??
 To consider surgery or not??
 What is the visual prognosis??

17. Procedure Abrv Donor Tx tissue
Conjunctival Transplantation
- Conjunctival autograft
- Cadaveric conjunctival allograft
- Living –related conjunctival allograft
CAU
c-CAL
Lr-CAL
Fellow
Cadaver
Living relative
Conjunctiva
Conjunctiva
Conjunctiva
Limbal Transplantation
- Conjunctival Limbal autograft
- Cadaveric limbal allograft
- Living –related limbal allograft
- Keratolimbal allograft
CLAU
CCLAL
LrCLAL
KLAL
Fellow
Cadaver
Living relative
Cadaver
Limbus/Conj
Limbus/Conj
Limbus/Conj
Limbus/
Cornea
Cultured stem cell transplantation
- Cultured limbal autotransplant
- Cultured cadaveric limbal allotransplant
- Cultured living related limbal
allotranspllant
Cu –LAU
Cu-CLAL
Cu –
LrLAL
Fellow
Cadaver
Living relative
Limbus
Limbus
Limbus
Proposed modified classification for Epithelial
Transplantation procedures for Ocular surface disease

18. UNILATERAL LSCD
PARTIAL TOTAL
Observation
Mechanical
Debridement
Amniotic
membrane
Ipsilateral
translocation
CLAU
Cu- LAU
Lr – CLAL
(One eyed)
BILATERAL LSCD
KLAL
Lr - CLAL
KLAL
Lr - CLAL
Cu - LrLAL
PARTIAL TOTAL
CLAU: Conjunctival limbal autograft; KLAL: Keratolimbal allograft;
Lr-CLAL: Living related conjunctival allograft; Cu – LAU: Cultured
limbal autograft; Cu – LAL: Cultured limbal allograft
FLOW DIAGRAM FOR MANAGING LSCD

19. CLET

20. COMET

22. Comparison of SLET with existing techniques
of autologous limbal transplantation for treatment of
unilateral limbal stem cell deficiency

23. So what did we do?
 PLAN : OS – Symblepharon release + Conjunctival
autograft + Simple limbal epithelial transplant +/-
Penetrating keratoplasty under GA and guarded visual
prognosis
Why not CLAU/ Cu – LAU?
1. CLAU: Two lenticules, 3 clock hours each of limbus & conjunctiva
harvested
Problem: Rare reports of Donor LSCD
2. Cu – LAU: Culture of limbal stem cells
Problem: Ex vivo cultivation expensive and unnecessary

24. Post operative course
Day of surgery : 29 June ‘15
30 June 15
POD 1
• Vn : CF 2mts
• Predforte 8t/d
• Moxiflox 4t/d
06 July 15
POD 7
• Vn : CF 2 mts
• Predforte 1
week Tapering
6/4/3
• Combigan BD
20 July 15
POD 21
• Vn : CF 2 mts
• Predforte 3/2/1
tapering
• Combigan BD

25. Post operative course
Day of surgery : 29 June ‘15
21 Aug 15
POW 8
• Vn : CF 3 mts
• RGP fitting
• OD patching 2
hours/day
10 Sept 15
POW 10
• Vn : 6/60
• Good diffuse fit
of RGP
• Predforte OD
• Ccombigan BD
9 Oct 15
POW 14
• Vn : CF 2 mts
• Combigan BD
• Dispense new CL

27. TAKE HOME MESSAGE
 Paediatric chemical injuries – fairly common clinical
scenario, needs aggressive treatment
 SLET is a simple and cost effective procedure for
management of LSCD
 Multi-faceted approach towards visual rehabilitation
 Never give up on a patient!

28. THANK YOU