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Viestenz A, Kesper C, Hammer T, Heinzelmann J, Foja S, Viestenz A. ALT (allogeneic limbal transplantation): a new surgical technique for limbal stem cell deficiency. Int Ophthalmol 2022; 42:3749-3762. [PMID: 35984558 PMCID: PMC9617846 DOI: 10.1007/s10792-022-02373-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 05/27/2022] [Indexed: 11/26/2022]
Abstract
Purpose Limbal stem cell deficiency (LSCD) is a rare but extremely relevant disease of the eye. LSCD patients often require a variety of surgical procedures, including keratoplasty in some cases. However, the outcome of these surgeries, including opacification and revascularization, is often frustrating due to LSCD relapse. Methods We developed a new surgical technique for the treatment of LSCD in which partial allogenic limbal transplantation (ALT) is carried out as part of penetrating keratoplasty (PK). After the PK, 1–8 slices from the limbal tissue of the donor graft are prepared and placed under the double running sutures attaching the corneal graft. This procedure was performed on 14 patients with LSCD, caused by severe ocular burn in 5 cases and by infection in 9. Between one and eight limbal transplants were used depending on the extension of the LSCD. Results All 14 patients showed stable or increased visual acuity after the ALT surgery compared to their preoperative visual acuity. All of the grafts were integrated into the superficial corneal layers without progression of corneal vascularization beyond the limbal grafts. The median follow-up period was 12 months on average. Conclusion The ALT method seems to be a promising surgical procedure for the treatment of patients with LSCD. It can be properly carried out in the context of keratoplasty and does not require a separate donor tissue. The ALT grafts may offer the possibility of constructing a new limbal region, resulting in stable or even increased visual acuity and the absence of corneal vascularization.
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Affiliation(s)
- Anja Viestenz
- Department of Ophthalmology, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, Ernst-Grube Straße 40, 06120, Halle, Germany.
| | - Christiane Kesper
- Department of Ophthalmology, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, Ernst-Grube Straße 40, 06120, Halle, Germany
| | - Thomas Hammer
- Department of Ophthalmology, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, Ernst-Grube Straße 40, 06120, Halle, Germany
| | - Joana Heinzelmann
- Department of Ophthalmology, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, Ernst-Grube Straße 40, 06120, Halle, Germany
| | - Sabine Foja
- Department of Ophthalmology, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, Ernst-Grube Straße 40, 06120, Halle, Germany
| | - Arne Viestenz
- Department of Ophthalmology, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, Ernst-Grube Straße 40, 06120, Halle, Germany
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Amin S, Jalilian E, Katz E, Frank C, Yazdanpanah G, Guaiquil VH, Rosenblatt MI, Djalilian AR. The Limbal Niche and Regenerative Strategies. Vision (Basel) 2021; 5:vision5040043. [PMID: 34698278 PMCID: PMC8544688 DOI: 10.3390/vision5040043] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 08/27/2021] [Accepted: 09/16/2021] [Indexed: 12/17/2022] Open
Abstract
The protective function and transparency provided by the corneal epithelium are dependent on and maintained by the regenerative capacity of limbal epithelial stem cells (LESCs). These LESCs are supported by the limbal niche, a specialized microenvironment consisting of cellular and non-cellular components. Disruption of the limbal niche, primarily from injuries or inflammatory processes, can negatively impact the regenerative ability of LESCs. Limbal stem cell deficiency (LSCD) directly hampers the regenerative ability of the corneal epithelium and allows the conjunctival epithelium to invade the cornea, which results in severe visual impairment. Treatment involves restoring the LESC population and functionality; however, few clinically practiced therapies currently exist. This review outlines the current understanding of the limbal niche, its pathology and the emerging approaches targeted at restoring the limbal niche. Most emerging approaches are in developmental phases but show promise for treating LSCD and accelerating corneal regeneration. Specifically, we examine cell-based therapies, bio-active extracellular matrices and soluble factor therapies in considerable depth.
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Affiliation(s)
- Sohil Amin
- Department of Ophthalmology and Visual Sciences, University of Illinois Chicago, Chicago, IL 60612, USA; (S.A.); (E.J.); (E.K.); (C.F.); (G.Y.); (V.H.G.); (M.I.R.)
| | - Elmira Jalilian
- Department of Ophthalmology and Visual Sciences, University of Illinois Chicago, Chicago, IL 60612, USA; (S.A.); (E.J.); (E.K.); (C.F.); (G.Y.); (V.H.G.); (M.I.R.)
| | - Eitan Katz
- Department of Ophthalmology and Visual Sciences, University of Illinois Chicago, Chicago, IL 60612, USA; (S.A.); (E.J.); (E.K.); (C.F.); (G.Y.); (V.H.G.); (M.I.R.)
| | - Charlie Frank
- Department of Ophthalmology and Visual Sciences, University of Illinois Chicago, Chicago, IL 60612, USA; (S.A.); (E.J.); (E.K.); (C.F.); (G.Y.); (V.H.G.); (M.I.R.)
| | - Ghasem Yazdanpanah
- Department of Ophthalmology and Visual Sciences, University of Illinois Chicago, Chicago, IL 60612, USA; (S.A.); (E.J.); (E.K.); (C.F.); (G.Y.); (V.H.G.); (M.I.R.)
- Richard and Loan Hill Department of Bioengineering, University of Illinois Chicago, Chicago, IL 60612, USA
| | - Victor H. Guaiquil
- Department of Ophthalmology and Visual Sciences, University of Illinois Chicago, Chicago, IL 60612, USA; (S.A.); (E.J.); (E.K.); (C.F.); (G.Y.); (V.H.G.); (M.I.R.)
| | - Mark I. Rosenblatt
- Department of Ophthalmology and Visual Sciences, University of Illinois Chicago, Chicago, IL 60612, USA; (S.A.); (E.J.); (E.K.); (C.F.); (G.Y.); (V.H.G.); (M.I.R.)
| | - Ali R. Djalilian
- Department of Ophthalmology and Visual Sciences, University of Illinois Chicago, Chicago, IL 60612, USA; (S.A.); (E.J.); (E.K.); (C.F.); (G.Y.); (V.H.G.); (M.I.R.)
- Correspondence:
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Sakimoto T, Sakimoto A, Yamagami S. Autologous transplantation of conjunctiva by modifying simple limbal epithelial transplantation for limbal stem cell deficiency. Jpn J Ophthalmol 2019; 64:54-61. [PMID: 31760516 DOI: 10.1007/s10384-019-00701-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 10/31/2019] [Indexed: 11/28/2022]
Abstract
PURPOSE As a treatment to replace regenerative medicine to treat limbal stem cell deficiency (LSCD), we performed 4 consecutive cases of autologous transplantation of conjunctival explants by modifying simple limbal epithelial transplantation (SLET). STUDY DESIGN Single-center case series. METHODS Four patients with LSCD were enrolled in this study. After resection of scar tissue with neovascularization from the ocular surface, human amniotic membrane (AM) was placed over the bare ocular surface. The bulbar conjunctiva of the operated eye was dissected at the temporal superior fornix, divided into small pieces, and transplanted onto AM with fibrin glue. Keratoplasty was performed simultaneously or few months after surgery. RESULTS Epithelialization was achieved in all patients. Best-corrected visual acuity was improved in all patients. CONCLUSION This is the first report of ocular surface reconstruction using autologous conjunctival epithelial transplants from the affected eye. Transplantation by modifying SLET effectively restored a clear corneal surface with minimal neovascularization in 4 patients with LSCD. Autologous conjunctival transplants combined with AM transplantation could be a practical option for treating bilateral LSCD in patients without symblepharon or severe keratinization.
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Affiliation(s)
- Tohru Sakimoto
- Division of Ophthalmology, Department of Visual Sciences, Nihon University School of Medicine, 30-1 Oyaguchi Kamimachi, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Akira Sakimoto
- Division of Ophthalmology, Department of Visual Sciences, Nihon University School of Medicine, 30-1 Oyaguchi Kamimachi, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Satoru Yamagami
- Division of Ophthalmology, Department of Visual Sciences, Nihon University School of Medicine, 30-1 Oyaguchi Kamimachi, Itabashi-ku, Tokyo, 173-8610, Japan.
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Yazdanpanah G, Jabbehdari S, Djalilian AR. Emerging Approaches for Ocular Surface Regeneration. CURRENT OPHTHALMOLOGY REPORTS 2019; 7:1-10. [PMID: 31275736 DOI: 10.1007/s40135-019-00193-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Purpose of review In this manuscript, the recent advancements and novel approaches for regeneration of the ocular surface are summarized. Recent findings Following severe injuries, persistent inflammation can alter the rehabilitative capability of the ocular surface environment. Limbal stem cell deficiency (LSCD) is one of the most characterized ocular surface disorders mediated by deficiency and/or dysfunction of the limbal epithelial stem cells (LESCs) located in the limbal niche. Currently, the most advanced approach for revitalizing the ocular surface and limbal niche is based on transplantation of limbal tissues harboring LESCs. Emerging approaches have focused on restoring the ocular surface microenvironment using (1) cell-based therapies including cells with capabilities to support the LESCs and modulate the inflammation, e.g., mesenchymal stem cells (MSCs), (2) bio-active extracellular matrices from decellularized tissues, and/or purified/synthetic molecules to regenerate the microenvironment structure, and (3) soluble cytokine/growth factor cocktails to revive the signaling pathways. Summary Ocular surface/limbal environment revitalization provide promising approaches for regeneration of the ocular surface.
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Affiliation(s)
- Ghasem Yazdanpanah
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Sayena Jabbehdari
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Ali R Djalilian
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, Illinois, USA
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Le Q, Deng SX. The application of human amniotic membrane in the surgical management of limbal stem cell deficiency. Ocul Surf 2019; 17:221-229. [PMID: 30633967 DOI: 10.1016/j.jtos.2019.01.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 11/12/2018] [Accepted: 01/07/2019] [Indexed: 12/31/2022]
Abstract
The application of human amniotic membrane (AM) has a wide spectrum of indications in the treatment of ocular surface disorders. Transplantation of AM has been incorporated routinely as a component of ocular surface reconstruction in a variety of ocular pathologies. The application of human AM can be combined with nearly all types of limbal transplantation in treating limbal stem cell deficiency (LSCD). AM provides support and possible protection to the transplanted limbal tissues and limbal stem cells owing to its mechanical and biological properties, and these properties are thought to enhance the success rate of LSC transplantation. This paper reviews the current literature on the applications of AM in the surgical management of LSCD and summarizes the outcome of different surgical approaches. The current literature contains mostly low-level evidences in supporting the role of AM. The efficacy of AM in LSC transplantation needs to be confirmed by randomized controlled clinical trials.
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Affiliation(s)
- Qihua Le
- Stein Eye Institute, Cornea Division, David Geffen School of Medicine, University of California, Los Angeles, USA; Department of Ophthalmology, Eye & ENT Hospital of Fudan University, Shanghai 200031, China
| | - Sophie X Deng
- Stein Eye Institute, Cornea Division, David Geffen School of Medicine, University of California, Los Angeles, USA.
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Strategies for reconstructing the limbal stem cell niche. Ocul Surf 2019; 17:230-240. [PMID: 30633966 DOI: 10.1016/j.jtos.2019.01.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 10/21/2018] [Accepted: 01/07/2019] [Indexed: 12/19/2022]
Abstract
The epithelial cell layer that covers the surface of the cornea provides a protective barrier while maintaining corneal transparency. The rapid and effective turnover of these epithelial cells depends, in part, on the limbal epithelial stem cells (LESCs) located in a specialized microenvironment known as the limbal niche. Many disorders affecting the regeneration of the corneal epithelium are related to deficiency and/or dysfunction of LESCs and the limbal niche. Current approaches for regenerating the corneal epithelium following significant injuries such as burns and inflammatory attacks are primarily aimed at repopulating the LESCs. This review summarizes and assesses the clinical feasibility and efficacy of current and emerging approaches for reconstruction of the limbal niche. In particular, the application of mesenchymal stem cells along with appropriate biological scaffolds appear to be promising strategies for long-term revitalization of the limbal niche.
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Feeder Cells Free Rabbit Oral Mucosa Epithelial Cell Sheet Engineering. Tissue Eng Regen Med 2018; 15:321-332. [PMID: 30603557 DOI: 10.1007/s13770-017-0108-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 12/11/2017] [Accepted: 12/15/2017] [Indexed: 12/24/2022] Open
Abstract
The optimal cell culture method of autologous oral mucosal epithelial cell sheet is not well established for a safe transplantation on to the patients' ocular surface. Animal serum and 3T3 mouse feeder cells are currently being used to stimulate the growth of the epithelial cells. However, the use of animal compounds can have potential side effects for the patient after transplantation of the engineered cell sheet. In the present study, we focused on engineering a rabbit oral mucosal epithelial cell sheet without 3T3 mouse feeder cells using a mix of Dulbecco's Modified Eagle Medium/Bronchial Epithelial Cell Growth Medium culture media (DMEM/BEGM). Autologous oral mucosal epithelial cell sheets, engineered with DMEM/BEGM feeder cell free culture media, were compared to those cultured in presence of serum and feeder cells. Using a DMEM/BEGM mix culture media, feeder cell free culture condition, autologous oral mucosal epithelial cells reached confluence and formed a multilayered sheet. The phenotype of engineered cell sheets cultured with DMEM/BEGM were characterized and compared to those cultured with serum and feeder. Hematoxylin and eosin staining showed the formation of a similar stratified multilayer cell sheets, in both culture conditions. The expression of deltaN-p63, ABCG2, PCNA, E-cadherin, Beta-catenin, CK3, CK4, CK13, Muc5AC, was similar in both culture conditions. We demonstrated that rabbit autologous oral mucosal epithelial cell sheet can be engineered, in feeder cell free conditions. The use of the DMEM/BEGM culture media to engineer culture autologous oral mucosa epithelial cell sheet will help to identify key factors involved in the growth and differentiation of oral mucosal epithelial cells.
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Dhamodaran K, Subramani M, Matalia H, Jayadev C, Shetty R, Das D. One for all: A standardized protocol for ex vivo culture of limbal, conjunctival and oral mucosal epithelial cells into corneal lineage. Cytotherapy 2016; 18:546-61. [DOI: 10.1016/j.jcyt.2016.01.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Revised: 12/27/2015] [Accepted: 01/03/2016] [Indexed: 12/18/2022]
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