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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 1  |  Page : 9-13

A new surgical technique for severe ocular surface burns: Full ocular surface transplantation


1 Department of Ophthalmology, School of Medicine, Gazi University, Ankara, Turkey
2 Department of Ophthalmology, School of Medicine, Yildirim Beyazit University, Ankara, Turkey
3 Department of Ophthalmology, School of Medicine, Kastamonu University, Kastamonu, Turkey
4 Department of Medical Biology, School of Medicine, Hacettepe University, Ankara, Turkey

Date of Submission07-Jun-2020
Date of Acceptance17-Jun-2021
Date of Web Publication07-Jan-2022

Correspondence Address:
Dr. Erdem Yuksel
Kastamonu Universitesi, Kuzeykent Mahallesi Orgeneral Atilla Ates Pasa Cad. No: 19, 37150, Kuzeykent/KASTAMONU
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_1854_20

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  Abstract 


To describe a new surgical technique for severe ocular surface burn. A 46-year-old man suffering from bilateral sequelae of chemical injury had “allograft limbal, conjunctival, and corneal transplantation” combined with amniotic membrane transplantation and symblepharon ring implantation. The patient received mycophenolate mofetil and tacrolimus for systemic immunosuppression therapy. No intraoperative or postoperative complications were noted. After the 24 months follow-up period, the cornea was clear, and visual acuity increased from hand movement to 20/400. Allograft limbo-conjunctival-corneal transplantation (full ocular surface transplantation) might be a seminal and life-saving procedure for selected cases with severe bilateral ocular surface burn.

Keywords: Corneal transplantation, ocular surface burns


How to cite this article:
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

How to cite this URL:
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 [serial online] 2022 [cited 2022 Jan 21];2:9-13. Available from: https://www.ijoreports.in/text.asp?2022/2/1/9/334917



An ocular chemical burn is common eye emergencies. They cause extensive damage in almost all anterior segment structures, particularly in the ocular surface epithelium, limbal stem cells, cornea, and conjunctiva, and in turn, they frequently lead to blindness. In these cases, the main goal of therapy is to restore normal ocular surface anatomy, maintain corneal clarity and normal lid position, and control of glaucoma. The late reparative phase and sequelae of the high-grade ocular burn are the most challenging steps to manage since massive corneal scarring frequently develops, and multiple surgical interventions might also be required.[1] Although ocular surface reconstruction procedures such as auto/allo-limbal stem cell grafting, amniotic membrane transplantation, kerato-limbal or corneoscleral allograft, and keratoprosthesis are proposed as the hope for these patients, there still does not exist an exhaustive surgical method addressing all the problems in a single operation.[2] Based on this fact, this case report aims to present a novel technique to improve the prognosis of patients with severe chemical injuries.


  Case Report Top


A 46-year-old man with severe bilateral ocular chemical burn was presented to our cornea service. He had had an unfortunate accident, exposition to hydrochloride acid spillage in 2010, and complained of poor vision and was dependent on others as he could not walk or feed independently.

In an initial examination, 3 months after the accident, his right eye had become phthisical, and he had no light perception on the right eye. He had cataract surgery on his left eye at a different medical center before presented to our service. He could count fingers only from 1 m on his left eye. Left cornea was completely edematous, and limbus was 360° necrotic [Figure 1]a. The topical and systemic treatments were planned; however, the patient did not follow the clinical appointments for the following 2 years. Two years after the accident, the patient presented with opaque and vascularized left cornea without discernible iris detail, and symblepharon at the inferior and superior fornix [Figure 1]b. He could only feel hand movement on the left eye. The left eye's intraocular pressure (IOP) was 28 mm Hg, and B-scan ultrasonography images did not show distinct retinal pathology.
Figure 1: (a) Total corneal edema and 360° necrotic limbus (at 3. Month) (b) Total vascularized opacity of cornea and symblepharon at inferior and superior fornix (at 2. year)

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Donor tissue preparation

The donor was a 20-year-old man who had no systemic illness, and the cause of death was a traffic accident. The limbo-conjunctival-corneal graft was harvested in a morgue situation. Following 50% povidone–iodine installation on the eye for sterilization, a lid speculum was inserted. First, the conjunctiva was separated from Tenon's capsule and dissected to the fornix at all quadrants. Then, a 360° scleral incision was performed 2 mm behind the limbus using a 15° keratome knife, and donor tissues were removed [Figure 2]a, [Figure 2]b and [Figure 3]a, [Figure 3]b. The extracted donor tissues were preserved within the corneal storage medium (Eusol-C, Dextran Corneal Storage Media, Al.Chi.Mi.A, Padova, Italy) for about 48 h until the day of transplantation.
Figure 2: (a) Conjunctiva was collected over cornea after separation from Tenon's capsule and dissection from fornix at all quadrants. (b) The globe after donor tissues were totally removed

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Figure 3: (a) The globe before harvested. (b) Conjunctiva over the cornea and scleral incision 2 mm behind the limbus

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Recipient bed preparation

Since the eye had massive conjunctival synechia, high IOP, and severe corneal conjunctivalization, the recipient bed was initially prepared for the combined transplantation procedure. For this purpose, a 360° transscleral diode laser cyclophotocoagulation, amnion membrane transplantation, and symblepharon ring implantation were performed. After 1 month, IOP reduced to 16 mmHg (without any medication), and the eye stabilized concerning corneal vascularization and symblepharon. The full ocular surface transplantation was planned at six months after host bed preparation.

Surgical technique

Before the operation, all risks were explained to the patient, and full informed consent was obtained. Surgery was performed under general anesthesia by an experienced corneal surgeon (F.A.). Initially, the adherent conjunctival tissues were separated from the limbus using forceps and scissors [Figure 4]a. The fully opaque and vascularized cornea was then extracted circumferentially according to the donor corneal button size [Figure 4]b. At this point, unexpectedly, we faced a thick membrane that covered the intraocular lens. The membrane dissection was followed by anterior vitrectomy (with pars plana approach), and the hydrophilic acrylic material intraocular lens was removed; the intact posterior capsule had been left. Afterward, the sizeable corneal donor button was sutured with interrupted 10-0 nylon sutures (16 separate sutures) [Figure 4]c. Finally, donor conjunctiva sutured circumferentially to the recipient conjunctiva with the help of 8-0 Vicryl sutures [Figure 4]d. Following successful completion of suturing, a Seidel test was performed to check for any leakage, and then a bandage contact lens (0 diopters, 14.2 mm CIBA Vision: Novartis, Duluth, GA, USA) and a symblepharon ring were applied [Figure 4]e. The operation was finished after temporal blepharorraphy [[Figure 4]f and Video 1][Additional file 1]. Thus, all the necessary surgeries were performed at one sitting.
Figure 4: (a) The globe after removing adherent conjunctival tissues from the Cornea. (b) The opaque and vascularized cornea after extracted circumferentially. (c) The suturing of large corneal donor button with interrupted 10-0 nylon sutures. (d) The suturing of donor conjunctiva to the recipient conjunctiva with 8-0 Vicryl sutures. At the end of surgery, (e) Symblepharon ring and (f) temporal blepharorrhaphy were applied

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Medical therapy

Postoperative topical treatment included a combination of antibiotics for 1 month (Vigamox®, ALCON), steroids for 3 months (Maxidex®, ALCON), topical cyclosporine A 0.05% for 3 months (Restasis®, ALLERGAN), and nonpreservative artificial tears (Refresh®, ALLERGAN) for 6 months. The oral immunosuppressive regimen is determined preoperatively by the Gazi University Transplantation Team.

Accordingly, intravenous methylprednisolone was administered as 250 mg every 6 h for 3 days, followed by oral prednisone (1 mg/kg/day) for 10 days. A quick oral tapering followed the steroid regimen. Other systemic immunosuppressive agents consisted of tacrolimus (4 mg twice a day – the blood level was 9.4 ng/mL) and mycophenolate (500 mg four times a day). A prophylactic dose of trimethoprim–sulfamethoxazole was also prescribed. Tacrolimus dosing was tapered off 2 mg quarterly; the total duration of tacrolimus was 1 year. The blood level of tacrolimus was 7.3, 4.3, 1.7, and 1.1 ng/mL, respectively, before each tapering off. The patient was maintained on mycophenolate mofetil as monotherapy (tapered to 500 mg two times a day 3 months after the surgery and kept on the same dose) throughout the follow-up period by controlling systemic side effects.

Outcome data

The cornea reepithelialized within 1 week postoperatively. The visual acuity improved from hand movement to 20/125 (Snellen-at 3 month visit) after surgery [Figure 5]a and [Figure 5]b. The epimacular membrane was observed on the fundus examination. During the follow-up period for 24 months, no rejection episodes occurred. The visual acuity was 20/400 at the last visit (at the second-year visit). The IOP was stable throughout the follow-up; any high IOP had been detected (The IOP was 15, 18, 13, and 16 mmHg at third months, sixth months, first year, and second year, respectively). No adverse effects due to systemic immunosuppression, and no ocular complication were observed.
Figure 5: The cornea and ocular surface (a) at 3 months visit (b) at first-year visit

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  Discussion Top


As generally accepted, recovery of an ocular burn is attributed to two critical factors: the causative agent and the extent of the damage.[1] Since acid substances block further ocular penetration through tissue protein precipitation, which in turn provides a physiological barrier, they are less harmful than alkaline agents.[1] Based on this fact, our case had the edge over alkaline injured eyes. However, an advanced grade of ocular burn made it remain as a challenging case.

The extent of the damage is crucial in determining the prognosis and treatment plan of ocular surface burns. Therefore, it should be evaluated separately as to whether the presence of corneal and conjunctival damage increased IOP, limbal ischemia, cataract formation, and the density of corneal opacification.[3] Since the existence of the limbal stem cell deficiency may lead to opacification and neovascularization of the cornea, it can cause severe corneal epithelial damage and trigger conjunctival epithelial loss. Extensive conjunctival scarring leading to symblepharon and loss of conjunctival goblet cells as a result of ocular surface inflammation can cause dry eye as well. The presence of cataract formation and uncontrolled glaucoma are the additional vital issues that complicate the surgical intervention and postoperative care. Therefore, the high grade of ocular burn increases the chance of poor visual prognosis. In this context, our case was one of the most unfortunate scenarios among all eye injuries.

In the medical literature, high-grade ocular burns are characterized by resistance to conventional therapy, and treatment options are quite limited in bilateral cases.[4] In those eyes, not only ocular surface rehabilitation but also visual improvement is required. Living-related conjunctival limbal allograft (CLAL) and kerato-limbal allograft (KLAL) are promising options for those eyes in terms of ocular surface rehabilitation. Moreover, along with the Cincinnati procedure,[5] which was described in 2011, combined CLAL+KLAL, the likelihood of success has further increased in bilateral cases. Yet, unintentionally, a healthy eye may be compromised when harvesting the living-related donor tissue, and there is the need to wait for a particular time for the corneal rehabilitation. Concerning keratoplasty, there is no doubt that it is the first-line treatment option for corneal rehabilitation and visual improvement. But it is often more technically challenging in patients who had undergone stem cell transplantation previously because even minor manipulations in keratoplasty technique may be harmful to earlier transplanted tissues, which may decrease the long-term success. Additionally, keratoplasty can be performed in the third month after limbal stem cell grafting at earliest, and this recovery period delays visual rehabilitation.

The second treatment option for patients with bilateral corneal failure secondary to chemical burn is keratoprosthesis.[6] Osteo-odonto-keratoprosthesis (OOKP) is a method in which the tooth root taken from patients himself is used to support an optical cylinder and has resulted in improved visual results in patients with end-stage corneal failure not amendable to penetrating keratoplasty. However, OOKP is a complex surgery requiring a multidisciplinary approach and includes several challenges such as uncontrolled glaucoma, retinal detachment, resorption/extrusion of the OOKP lamina, and aesthetic issues.[7] Although Boston keratoprosthesis (Kpro) type 1 might be a good surgical alternative in those eyes and decrease the necessity of systemic immunosuppression treatment, it has several postoperative complications including retro-prosthetic membrane, elevated IOP, corneal melting, infectious keratitis/endophthalmitis, retinal detachment, and vitreous hemorrhage.[8] Alternatively, because of the high cost of Boston KPro, Auro KPro has been used in ocular surface disorders with end-stage corneal blindness.[8] Unfortunately, postoperative complications are still remaining.[8] Furthermore, both KPro types are artificial materials and admittedly can never be a 100% alternative for natural human texture.

To combine all advantages and eliminate all disadvantages of previously described techniques mentioned in the literature, we described allograft limbo-conjunctival-corneal transplantation. In the current technique, not only limbal cells but also goblet cells that provide wetting of ocular surface were transplanted, and this was the crucial factor in increasing the success of our patient. Moreover, to our knowledge, the term “Full Ocular Surface Transplantation” is pronounced for the first time as well.

In undesirable situations, there may be a high tissue rejection expectancy rate in our technique. However, the whole graft-maintained aliveness after 24 months of follow-up period with intense and continuous immunosuppression.


  Conclusion Top


In conclusion, albeit it is a unique case experience, we have a hunch that allograft limbo-conjunctival-corneal transplantation with continuous immunosuppression treatment might expand horizons and be new hope for blindness caused by end-stage ocular surface diseases in selected cases.

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.
Maskati QB, Maskati BT. Management of chemical injuries of the eye. Indian J Ophthalmol 2017;65:35-40.  Back to cited text no. 1
    
2.
Nita M, Strzałka-Mrozik B, Grzybowski A, Romaniuk W, Mazurek U. Ophthalmic transplantology: Anterior segment of the eye - part I. Med Sci Monit 2012;18:RA64-72.  Back to cited text no. 2
    
3.
Barreiro TP, Santos MS, Vieira AC, de Nadai Barros J, Hazarbassanov RM, Gomes JÁ. Comparative study of conjunctival limbal transplantation not associated with the use of amniotic membrane transplantation for treatment of total limbal deficiency secondary to chemical injury. Cornea 2014;33:716-20.  Back to cited text no. 3
    
4.
Burcu A, Yalniz-Akkaya Z, Ozdemir MF, Erdem E, Onat MM, Ornek F. Surgical rehabilitation following ocular chemical injury. Cutan Ocul Toxicol 2014;33:42-8.  Back to cited text no. 4
    
5.
Biber JM, Skeens HM, Neff KD, Holland EJ. The cincinnati procedure: Technique and outcomes of combined living-related conjunctival limbal allografts and keratolimbal allografts in severe ocular surface failure. Cornea 2011;30:765-71.  Back to cited text no. 5
    
6.
Yaghouti F, Nouri M, Abad JC, Power WJ, Doane MG, Dohlman CH. Keratoprosthesis: Preoperative prognostic categories. Cornea 2001;20:19-23.  Back to cited text no. 6
    
7.
Wong HS, Then KY, Ramli R. Osteo-odonto-keratoprosthesis for end-stage cornea blindness. Med J Malaysia 2011;66:369-70.  Back to cited text no. 7
    
8.
Shanbhag SS, Senthil S, Mohamed A, Basu S. Outcomes of the Boston type 1 and the Aurolab keratoprosthesis in eyes with limbal stem cell deficiency. Br J Ophthalmol 2021;105:473-8.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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