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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 1  |  Issue : 1  |  Page : 100-102

Novel approach of autologous simple limbal epithelial transplantation (autoSLET) in eyes with acute unilateral severe ocular chemical injury


1 Jain Eye Hospital and LASER Centre, Delhi, India
2 The Cornea Institute, LV Prasad Eye Institute, Hyderabad, Telangana, India

Date of Submission21-Apr-2020
Date of Acceptance22-Jul-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Dr. Rajat Jain
Jain Eye Hospital and LASER Centre, AG-152, Shalimar Bagh, New Delhi - 110 088
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_1083_20

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  Abstract 


A 19-year-old boy was presented 4 days after left eye acute chuna injury grade 4 (Dua). BCVA was finger counting 1 m, limbal ischemia, ground glass cornea, and corneal epithelial defect involving adjacent conjunctiva. Autologous contralateral simple limbal epithelial transplantation (SLET) was performed. Complete ocular surface epithelization was noted at day 21. At 8-months follow-up, there was a stable ocular surface with 20/20p BCVA. AutoSLET achieves rapid epithelialization in severe chemical injuries thereby preventing adverse effects of delayed epithelial healing avoiding the need for visual rehabilitative procedures later. Larger case series with longer follow-up is required.

Keywords: Autologous, autoSLET, ocular chemical injury, simple limbal epithelial transplantation, simple limbal epithelial transplantation


How to cite this article:
Jain R, Mohan N, Basu S. Novel approach of autologous simple limbal epithelial transplantation (autoSLET) in eyes with acute unilateral severe ocular chemical injury. Indian J Ophthalmol Case Rep 2021;1:100-2

How to cite this URL:
Jain R, Mohan N, Basu S. Novel approach of autologous simple limbal epithelial transplantation (autoSLET) in eyes with acute unilateral severe ocular chemical injury. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Feb 27];1:100-2. Available from: https://www.ijoreports.in/text.asp?2021/1/1/100/305473



Amniotic membrane transplantation (AMT) is the current standard of care for grade 4–6 (Dua Classification) acute ocular chemical injury.[1] However, a recently published Cochrane review showed that complete ocular surface epithelization happened only in around 6% eyes each with medical treatment alone or in conjunction with AMT.[2] Another study concluded that long-term debilitated vision remained poor and most patients required visual rehabilitative procedures postoperatively.[3] Allogenic stem cell transplant in acute injury has been introduced which leads to early ocular surface epithelization. However, the gradual failure of the allo-explants noted in most patients required repeat autologous limbal stem cell transplant (LSCT) later.[4]

Autologous simple limbal epithelial transplantation (autoSLET) has been hypothesized to be avoided in acute chemical injury as explants would eventually fail and the precious limbal tissue would be wasted.[4] We propose that autologous LSCT performed in acute chemical injury leads to early, stable, and sustained ocular surface epithelization. To our knowledge, this is the first report of such a procedure done in the acute stage of ocular chemical injuries.


  Case Report Top


A 19-year-old boy presented 4 days after left eye ocular “chuna” injury. At presentation, best-corrected visual acuity (BCVA) was finger counting at 1 m. The patient had normal eyelids, inflamed conjunctival surface with limbal ischemia from 1–8 clock hour, ground-glass appearance of the cornea with a corneal epithelial defect, and corneal haze. The anterior chamber details were hazy [Figure 1]a. Fluorescein staining revealed a large central epithelial defect measuring 7 × 8 mm extending on the adjacent sclera. The conjunctival epithelial defect was noted inferiorly extending from 2–8 clock hours [Figure 2]a and [Figure 2]f. Anterior chamber details were hazy. Lens appeared clear. Intraocular pressure measured digitally was normal. The Ultrasound B-scan of the posterior segment was normal. The right eye was normal with an unaided visual acuity of 20/20.
Figure 1: Composite of images showing surgical steps: (a) preoperative clinical image showing grade 4 chemical injury with limbal ischemia, necrotic conjunctiva, and diffuse corneal edema; (b) conjunctival peritomy begun 3 mm from the limbus and (c) continued 360 all around; (d) appearance after peritomy, minimal cautery done for small bleeders; (e) amniotic membrane secured with glue; (f) limbal biopsy cut into multiple explants and spread on the ocular surface; (g) bandage contact lens applied; (h) central temporary tarsorrhaphy done

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Figure 2: Diffuse slit-lamp (Top row) and fluorescein stained images (Bottom row) of the prototype case preoperatively (a and f), at day 14 (b and g), at 27 (c and h), day 45 (d and i) and was maintained at day 240 (e and j)

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AutoSLET was done as per the surgical steps earlier described.[4] A 1-clock hour limbal biopsy was harvested from contralateral eye. The injured eye was then subjected to a 360° peritomy about 3 mm away from the limbus. The remaining epithelium on the corneal surface was scraped off with a 15 number surgical blade. The bare ocular surface was then covered with human-derived amniotic membrane graft (AMG) which was secured with fibrin glue (TISSEEL Kit from Baxter AG, Vienna, Austria). A limbal biopsy was divided into >12 small pieces, distributed over the ocular surface in described pattern[5] and secured using fibrin glue. The bandage contact lens was applied and central, temporary, suture tarsorrhaphy was performed using 4-0 silk suture [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d, [Figure 1]e, [Figure 1]f, [Figure 1]g, [Figure 1]h.

He was prescribed a combination of moxifloxacin 0.5% and prednisolone acetate 1% eye drops and CMC 0.5% eye drops in both eyes. The steroid drops were then tapered in 6 weeks and CMC 0.5% eye drops were continued for 3 months. The patient was examined every third day till tarsorrhaphy was opened at a 2-weeks follow-up. Subsequently, the patient was examined every third day till 1-month post-op and then monthly thereafter for 6 months. The first post-op clinical assessment done on day 14 revealed near the epithelized ocular surface with AMG induced corneal haze, 3 × 4 mm epithelial defect [Figure 2]b and [Figure 2]g. Complete ocular surface epithelization was seen on day 21. ([Figure 2]c and [Figure 2]h taken on day 27 post-op) At day 45 post-op, he had 20/40p BCVA with a stable ocular surface [Figure 2]d and [Figure 2]i. There was no evidence of symblepharon formation of corneal melt. The ocular surface stabilized further and at 8 months, the patient had 20/20p BCVA [Figure 2]e and [Figure 2]j.


  Discussion Top


Long-term complications of ocular surface chemical injury include persistent epithelial defects, corneal melting, perforation, and visual limitation due to partial/total LSCD.[6] Allogenic stem cell transplantation in acute chemical injury cases was published where the authors found early epithelization and a significant decrease in such complications. While many of the deleterious effects were eliminated, visual rehabilitation remained problematic due to the failure of allogenic explants in the long-term. Patients also required systemic immunosuppression. Eventually, explants in 1/3 cases failed.[4] Herein, lies the concept of using autologous stem cells. In principle, they do not reject and should provide sustained ocular surface support. Further, alloSLET when performed in chronic LSCD carries some risk of failure even with immunosuppression, therefore, autoSLET saves patients, particularly children, from the risk of side-effects of immunosuppression and long-term failure.[7] It is, however, feared that it might lead to wastage of precious limbal tissue required to form the ocular surface in the future.

The management of acute chemical injury starts with a thorough ocular surface wash, mechanical removal of all chuna particles by eversion and double-eversion of the upper lids, and initiation of intensive medical management. Besides, in this case, autologous limbal stem cells were used for ocular surface epithelization which was seen in 21 days and was maintained for 8 months. No subsequent ocular reconstructive procedures were required. The patient attained a stable and good vision. No donor site deficiency/complications were noted. It is, however, pertinent to note that autoSLET was performed as this was a unilateral chemical injury. The author's state that autoSLET best be avoided in cases of bilateral chemical injury.

Though long-term results are awaited, we hypothesize that once autologous explants have sustained the acute phase of an injury, they should remain functionally viable in the long-term[8] with a higher potential success rate than allogenic explants.


  Conclusion Top


AutoSLET is useful to achieve rapid epithelialization in severe chemical injuries thereby preventing adverse effects of delayed epithelial healing. Larger case series with varying severity of the ocular injury and longer follow-up are, however, required.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sharma N, Kaur M, Agarwal T, Sangwan VS, Vajpayee RB. Treatment of acute ocular chemical burns. Sur Ophthalmol 2018;63:214-35.  Back to cited text no. 1
    
2.
Clare G, Suleman H, Bunce C, Dua H. Amniotic membrane transplantation for acute ocular burns.Cochrane Database Syst Rev 2012;:CD009379.  Back to cited text no. 2
    
3.
Westekemper H, Figueiredo FC, Siah WF, Wagner N, Steuhl KP, Meller D. Clinical outcomes of amniotic membrane transplantation inthe management of acute ocularchemical injury. Br J Ophthalmol 2017;101:103-7.  Back to cited text no. 3
    
4.
Iyer G, Srinivasan B, Agarwal S, Tarigopula A. Outcome of allo simple limbal epithelial transplantation (alloSLET) in early stage of ocular chemical injury.Br J Ophthalmol 2017;101:828-33.  Back to cited text no. 4
    
5.
Mittal V, Jain R, Mittal R. Ocular surface epithelialization pattern after simple limbal epithelial transplantation: An in vivo observational study. Cornea 2015;34:1227-32.  Back to cited text no. 5
    
6.
Yin J, Jurkunas U. Limbal stem cell transplantation and complications. Semin Ophthalmol 2018;33:134-41.  Back to cited text no. 6
    
7.
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.  Back to cited text no. 7
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8.
Basu S, Sureka SP, Shanbhag SS, Kethiri AR, Singh V, Sangwan VS. Simple limbal epithelial transplantation: Long-term clinical outcomes in 125 cases of unilateral chronic ocular surface burns. Ophthalmology 2016;123:1000-10.  Back to cited text no. 8
    


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