Outcomes and Complications of Limbal Stem Cell Allograft Transplantation: A Report by the American Academy of Ophthalmology

Jennifer Y Li; Maria S Cortina; Mark A Greiner; Anthony N Kuo; Darby D Miller; Roni M Shtein; Peter B Veldman; Jia Yin; Stephen J Kim; Joanne F Shen

doi:10.1016/j.ophtha.2024.02.018

Outcomes and Complications of Limbal Stem Cell Allograft Transplantation: A Report by the American Academy of Ophthalmology

Ophthalmology. 2024 Apr 27:S0161-6420(24)00157-X. doi: 10.1016/j.ophtha.2024.02.018. Online ahead of print.

Authors

Jennifer Y Li¹, Maria S Cortina², Mark A Greiner³, Anthony N Kuo⁴, Darby D Miller⁵, Roni M Shtein⁶, Peter B Veldman⁷, Jia Yin⁸, Stephen J Kim⁹, Joanne F Shen¹⁰

Affiliations

¹ UC Davis Eye Center, University of California, Davis, California.
² Department of Ophthalmology and Visual Science, University of Illinois College of Medicine, Chicago, Illinois.
³ Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa, Iowa City, Iowa.
⁴ Department of Ophthalmology, Duke University School of Medicine, Durham, North Carolina.
⁵ Department of Ophthalmology, Mayo Clinic, Jacksonville, Florida.
⁶ Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, Michigan.
⁷ Department of Ophthalmology & Visual Science, The University of Chicago, Chicago, Illinois.
⁸ Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts.
⁹ Department of Ophthalmology, Vanderbilt University School of Medicine, Nashville, Tennessee.
¹⁰ Department of Ophthalmology, Mayo Clinic, Scottsdale, Arizona.

PMID: 38678469
DOI: 10.1016/j.ophtha.2024.02.018

Abstract

Purpose: To review the published literature on the safety and outcomes of keratolimbal allograft (KLAL) transplantation and living-related conjunctival limbal allograft (lr-CLAL) transplantation for bilateral severe/total limbal stem cell deficiency (LSCD).

Methods: Literature searches were last conducted in the PubMed database in February 2023 and were limited to the English language. They yielded 523 citations; 76 were reviewed in full text, and 21 met the inclusion criteria. Two studies were rated level II, and the remaining 19 studies were rated level III. There were no level I studies.

Results: After KLAL surgery, best-corrected visual acuity (BCVA) improved in 42% to 92% of eyes at final follow-up (range, 12-95 months). The BCVA was unchanged in 17% to 39% of eyes and decreased in 8% to 29% of eyes. Two of 14 studies that evaluated the results of KLAL reported a notable decline in visual acuity over time postoperatively. Survival of KLAL was variable, ranging from 21% to 90% at last follow-up (range, 12-95 months) and decreased over time. For patients undergoing lr-CLAL surgery, BCVA improved in 31% to 100% of eyes at final follow-up (range, 16-49 months). Of the 9 studies evaluating lr-CLAL, 4 reported BCVA unchanged in 30% to 39% of patients, and 3 reported a decline in BCVA in 8% to 10% of patients. The survival rate of lr-CLAL ranged from 50% to 100% at final follow-up (range, 16-49 months). The most common complications were postoperative elevation of intraocular pressure, persistent epithelial defects, and acute allograft immune rejections.

Conclusions: Given limited options for patients with bilateral LSCD, both KLAL and lr-CLAL are viable choices that may provide improvement of vision and ocular surface findings. The studies trend toward a lower rejection rate and graft failure with lr-CLAL. However, the level and duration of immunosuppression vary widely between the studies and may impact allograft rejections and long-term graft survival. Complications related to immunosuppression are minimal. Repeat surgery may be needed to maintain a viable ocular surface. Reasonable long-term success can be achieved with both KLAL and lr-CLAL with appropriate systemic immunosuppression.

Financial disclosure(s): Proprietary or commercial disclosure may be found after the references.

Keywords: conjunctival limbal autograft; keratolimbal allografts; limbal stem cell deficiency disease; living related conjunctival allograft; stem cell transplantation.