April 29, 2025
3 min learn
Key takeaways:
- Dwelling-related conjunctival limbal allograft permits for tissue typing and reduces rejection.
- The specialist staff wants to incorporate a transplant coordinator.
LOS ANGELES — Dwelling-related conjunctival limbal allograft ought to be first-line remedy for limbal stem cell deficiency, Edward J. Holland, MD, mentioned throughout Cornea Day on the American Society of Cataract and Refractive Surgical procedure assembly.
Holland, a professor of ophthalmology on the College of Cincinnati and director of cornea and exterior illness on the Cincinnati Eye Institute, offered the inaugural Holland Lecture, the primary named lecture for the subspecialty day.
Penetrating keratoplasty is the commonest surgical procedure carried out for whole limbal deficiency; nonetheless, it’s by no means profitable, he mentioned.
Holland carried out a 22-year chart overview in his apply, discovering almost 1,600 eyes with limbal stem cell deficiency that have been improperly managed and referred to his apply. Diagnoses have been delayed or incorrect, or the fallacious therapy was administered.
The procedures that failed included PK, superficial keratectomy and amniotic membrane transplantation, Boston KPro and easy limbal epithelial transplantation.
“There have been two sufferers I noticed in 1 week that helped me resolve to vary my course of how I wished to guide the schooling,” Holland mentioned.
One was a 65-year-old with aniridia, whole limbal deficiency, extreme glaucoma and 13 failed PKs. The opposite was a 45-year-old with Stevens-Johnson syndrome, symblepharon, irritation, whole limbal deficiency, an enucleated left eye, and 7 failed PKs in the precise eye and 7 failed PKs within the left eye.
“When do you say perhaps we should always do one thing totally different?” Holland requested.
Repeated, failed PKs may cause further problems resembling irritation, glaucoma, cataract and retinal detachment, he mentioned.
“Our normal procedures now are a living-related conjunctival limbal allograft with a tissue-matched donor,” Holland mentioned, “and one we did quite a bit at first, keratolimbal allograft with a deceased donor. Within the worst eyes, we mix these with what we termed the ‘Cincinnati Process.’ … We thought we might stop rejection, however we didn’t do it proper; then we lastly went to the staff that invented transplant rejection administration, and that’s the renal staff.”
Holland mentioned collaboration is important for achievement, with the cornea surgeon because the quarterback.
With the Cincinnati Process, “You want a staff of specialists: cornea, glaucoma, retina, oculoplastics,” he mentioned. “It’s essential to be all in on the preoperative screening, the protocols, the testing of donors, and it’s essential to have a renal specialist that will help you with these tough decisions, like who’s the perfect donor. The lacking individual that ties the entire thing collectively is the transplant coordinator that the renal staff at all times has.
“These sufferers are very sophisticated,” Holland continued. “Many cellphone calls, unwanted side effects of medicines, different appointments. A corneal surgeon can’t do it; the corneal surgeon’s workplace individuals can’t do it. Any individual must be devoted. That’s what renal does, and that’s what we do.”
Holland mentioned living-related conjunctival limbal allograft (LR-CLAL) permits for tissue typing and reduces rejection.
“Plus, if we’re managing conjunctival illness, we’d like conjunctiva, not simply limbus,” he mentioned. “That is our process of alternative. … We’re getting conjunctival stem cells; we’re getting goblet cells. It turns these eyes into a greater ocular floor.”
He famous {that a} keratolimbal allograft has a 71% success fee, whereas LR-CLAL with a great match has an 88% success fee.
“The success fee with [LR-CLAL] has actually modified the sport,” Holland mentioned. “We’re so assured that we are able to observe these sufferers fastidiously, we began doing kids. … We’ve achieved over 25 kids with systemic immunosuppression. We get long-term success.”
The surgical procedure is difficult, reimbursement is “horrible,” sufferers require loads of time, and “surgeons don’t need to function on regular eyes as a result of we maintain propagating a worry that taking cells from a traditional eye will make it go blind,” he mentioned.
“We are able to all do that. You simply should companion with the precise individuals. … I feel this ought to be first-line remedy.”
Sources/Disclosures
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Holland EJ. Going through the challenges of managing extreme ocular floor illness. Introduced at: American Society of Cataract and Refractive Surgical procedure assembly; April 25-28, 2025; Los Angeles.
Disclosures:
Holland stories having monetary disclosures for Alcon and Aurion Biotech.
