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Clinical Sciences |

Cultivated Limbal Epithelial Transplantation in Children With Ocular Surface Burns

Kunjal Sejpal, FRCS; Mohammed Hasnat Ali, MBA; Savitri Maddileti, MSc; Sayan Basu, MS; Muralidhar Ramappa, MS; Ramesh Kekunnaya, FRCS; Geeta K. Vemuganti, MD; Virender S. Sangwan, MS
JAMA Ophthalmol. 2013;131(6):731-736. doi:10.1001/jamaophthalmol.2013.2308.
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Importance Although several reports are available on the use of conventional and cultured limbal epithelium using various substrates in the treatment of limbal stem cell deficiency (LSCD), the patient populations studied have been largely adults. Thus, to our knowledge, the outcomes of this procedure exclusively in a pediatric population have not been reported previously.

Objective To report the outcomes of autologous ex vivo cultivated limbal epithelial transplantation (CLET) in pediatric patients with LSCD after ocular burns.

Design and Setting A retrospective, interventional case series of patients treated at the L. V. Prasad Eye Institute, Hyderabad, India.

Participants Children up to 15 years with LSCD secondary to chemical or thermal injury who underwent CLET from April 1, 2001, through June 31, 2010, with a follow-up of at least 1 year, were included in the study.

Intervention After a limbal biopsy specimen obtained from a healthy area of the limbus, the limbal epithelial cells were cultured on a denuded human amniotic membrane substrate using a xeno-free explant culture technique. A monolayer of cultivated epithelial cells along with the amniotic membrane was transplanted on the patient's affected eye after pannus excision. In cases of failure, the same procedure was repeated.

Main Outcomes and Measures Ocular surface stability and visual improvement were the primary and secondary outcome measures, respectively. Success was defined as a stable corneal epithelium without conjunctivalization. Eyes with conjunctivalization and persistent epithelial defects were classified as failures.

Results Of the 107 eyes of 107 patients included in this study, 73 eyes (68.2%) underwent 1 and 34 eyes (31.8%) underwent 2 autologous CLET procedures. At a mean follow-up of 3.4 years, 50 eyes (46.7%) achieved completely epithelialized, avascular, and stable ocular surfaces. At the final visit, 58 eyes (54.2%) had improvement in visual acuity of 0.2 or more logMAR units.

Conclusions Autologous CLET was successful in restoring the ocular surface and improving vision in almost half of the children blinded by ocular burns.

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Figures

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Figure 1. Kaplan-Meier survival plots of cumulative probability of survival of cultivated limbal epithelial transplantation (CLET) in eyes undergoing early surgery (≤4 months after chemical injury) vs late surgery (>4 months).

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Figure 2. Clinical photographs of eyes after alkali injury. A-D, Eyes with total limbal stem cell deficiency and corneal stromal scarring. E-H, Same eyes after cultivated limbal epithelial transplantation (CLET). E, Left eye of an 8-year-old boy 2 years postoperatively showing a stable corneal surface, minimal stromal scarring, and a best-corrected visual acuity (BCVA) of 20/50. F, Left eye of a 5-year-old boy 2 years postoperatively with a clear graft and BCVA of 20/50. G, Right eye of a 9-year-old girl 5 years postoperatively with a failed CLET and lamellar keratoplasty, followed by repeat CLET and subsequent lamellar keratoplasty, showing a stable corneal surface with a BCVA of 20/200. H, Left eye of a 5-year-old boy 6 years postoperatively showing recurrence of conjunctivalization (failure) with residual scarring.

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