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• W2151757927 abstract "Despite the many sound fundamental principles applied and described by Rao et al1Rao S.K. Rajagopal R. Sitalakshmi G. Padmanabhan P. Limbal allografting from related live donors for corneal surface reconstruction.Ophthalmology. 1999; 106: 822-828Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar regarding limbal allografting from related live donors for corneal surface reconstruction, corneal diseases with limbal stem cell deficiency remain some of the most challenging clinical problems.2Tseng S.C.G. Prabhasawat P. Barton K. et al.Amniotic membrane transplantation with or without limbal allografts for corneal surface reconstruction in patients with limbal stem cell deficiency.Arch Ophthalmol. 1998; 116: 431-441Crossref PubMed Scopus (625) Google Scholar Although successful epithelialization of the ocular surface was achieved in 77.8%, peripheral vascularization recurred in all eyes. Many unanswered questions still remain, and the best management plan in such difficult cases is controversial. Combining penetrating keratoplasty (PKP) with limbal transplantation (ALT) was favored by the authors with certain possible advantages detailed.1Rao S.K. Rajagopal R. Sitalakshmi G. Padmanabhan P. Limbal allografting from related live donors for corneal surface reconstruction.Ophthalmology. 1999; 106: 822-828Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar This approach is not supported by previous reported experience of an increase in significant complications when ALT and PKP were performed with the same donor corneoscleral button.2Tseng S.C.G. Prabhasawat P. Barton K. et al.Amniotic membrane transplantation with or without limbal allografts for corneal surface reconstruction in patients with limbal stem cell deficiency.Arch Ophthalmol. 1998; 116: 431-441Crossref PubMed Scopus (625) Google Scholar The total reaction incited by a combined procedure in such a hostile host environment may not be conducive for graft survival. A prospective, comparative study on the safety and efficacy of the two different approaches seems warranted. Cadaveric allografts combining with immunosuppression have been recommended as the best option by the authors, as well as some others.1Rao S.K. Rajagopal R. Sitalakshmi G. Padmanabhan P. Limbal allografting from related live donors for corneal surface reconstruction.Ophthalmology. 1999; 106: 822-828Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar, 3Shimazaki J. Yang H.Y. Tsubota K. Amniotic membrane transplantation for ocular surface reconstruction in patients with chemical and thermal burns.Ophthalmology. 1997; 104: 2068-2076Abstract Full Text PDF PubMed Scopus (412) Google Scholar However, the dosage, agent, and duration of immunosuppression for optimal results remain to be defined.4Hill J.C. Systemic cyclosporine in high-risk keratoplasty. Short- versus long-term therapy.Ophthalmology. 1994; 101: 128-133Abstract Full Text PDF PubMed Scopus (135) Google Scholar Many different regimes have been adopted, and patients are likely to require indefinite immunosuppression.2Tseng S.C.G. Prabhasawat P. Barton K. et al.Amniotic membrane transplantation with or without limbal allografts for corneal surface reconstruction in patients with limbal stem cell deficiency.Arch Ophthalmol. 1998; 116: 431-441Crossref PubMed Scopus (625) Google Scholar, 5Theng J.T.S. Tan D.T.H. Combined penetrating keratoplasty and limbal allograft transplantation for severe corneal burns.Ophthalmic Surg Lasers. 1997; 28: 765-768Crossref PubMed Google Scholar, 6Tsubota K. Toda I. Saito H. et al.Reconstruction of the corneal epithelium by limbal allograft transplantation for severe ocular surface disorders.Ophthalmology. 1995; 102: 1486-1496Abstract Full Text PDF PubMed Scopus (247) Google Scholar The ideal ALT transplant is probably an HLA well-matched entire cadaveric limbus, thereby providing a generous source of stem cells with no donor complications and reduced rejection risks. Such grafts would only be available from a very large eyebank that would be expensive to set up and maintain. Patients awaiting PKP and/or ALT can wait for a best-matched donor, because unlike other organ transplants, anterior surface conditions are not life threatening. Until the expression of major histocompatibility complex antigens by limbal stem cells and the definition of a good match are clearly worked out, the objective for HLA-matching is probably not to obviate the need for immunosuppression, but rather to promote the chances of survival in such cases, and hopefully, less immunosuppression will be required. Although the factors governing limbal stem cell function are still poorly understood, the recipient environment should be optimized to promote the donor tissue survival. Amniotic membrane appears to be a good substrate for ALT in several reports.2Tseng S.C.G. Prabhasawat P. Barton K. et al.Amniotic membrane transplantation with or without limbal allografts for corneal surface reconstruction in patients with limbal stem cell deficiency.Arch Ophthalmol. 1998; 116: 431-441Crossref PubMed Scopus (625) Google Scholar, 3Shimazaki J. Yang H.Y. Tsubota K. Amniotic membrane transplantation for ocular surface reconstruction in patients with chemical and thermal burns.Ophthalmology. 1997; 104: 2068-2076Abstract Full Text PDF PubMed Scopus (412) Google Scholar In summary, we believe in the importance of a holistic approach in managing such difficult cases. Not only do we aim to prevent ALT death, it is also vital to promote graft survival by providing the best possible environment. We propose, whenever possible, to use HLA well-matched donor tissues. The use of live-related donor tissue without HLA matching is not recommended.1Rao S.K. Rajagopal R. Sitalakshmi G. Padmanabhan P. Limbal allografting from related live donors for corneal surface reconstruction.Ophthalmology. 1999; 106: 822-828Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar For live donors, we recommend the combined approach of transplanting a 6 to 8 clock hours HLA matched donor limbal stem cell to the recipient bed, which is then covered by an amniotic membrane. Whereas for cadaveric donors, the transplant of the entire cadaveric limbus is recommended. In either case, until more information about the prevention and control of the ALT rejection is available, long-term use of topical and systemic immunosuppression appears to be necessary." @default.
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