P49-A103 Allogeneic limbo-DALK: a novel surgical technique for patients with corneal stromal disease and limbal stem cell deficiency

PURPOSE

To describe a novel corneal surgical technique combining Deep Anterior Lamellar Keratoplasty (DALK) with grafting of allogeneic limbal stem cells (limbo-DALK) as treatment for eyes with corneal stromal pathology and limbal stem cell deficiency (LSCD).

METHODS

This is a series of six Limbo-DALKs in five eyes of five patients. One patient received a second limbo-DALK after graft failure following the first procedure. Two of the donor corneae were HLA matched. Clinical records of included patients were reviewed retrospectively. All patients had been diagnosed with LSCD due to various pathologies. Analysed data included demographic data, diagnoses and clinical history, graft visualization and thickness measurements by anterior segment OCT, visual acuity and epithelial status. Follow-up visits were 6 weeks and 3, 6, 9, 12 and 18 months postoperatively with final suture removal at 18 months and further follow-up examinations twice yearly thereafter.

RESULTS

Two grafts showed total epithelial closure after 2 days, two after 14 days. In one eye, full closure of corneal epithelium did not occur after the first limbo-DALK, but could be achieved one month after second limbo-DALK. No endothelial graft rejection was seen.

CONCLUSION

Based on data from this pilot series, limbo-DALK seems to be a novel viable surgical approach for eyes with severe LSCD and stromal corneal pathology.

Corneal Hydrops - Aetiology and Advanced Therapeutic Strategies

Acute hydrops refers to sudden corneal edema caused by rupture of Descemet's membrane (DM) - often in progressive keratectasia. It leads to a sudden decrease in visual acuity, pain, and foreign body sensation as well as an increased glare sensation. Acute hydrops usually heals with scarring within months, but complications such as corneal perforation, infectious keratitis, and corneal vascularization may occur. The prevalence in keratoconus patients is 2.6 to 2.8%. Risk factors include keratoconjunctivitis vernalis, atopic dermatitis, high keratometry, male gender, and eye rubbing. Keratoplasty should be avoided in the acute phase. The prognosis of the graft is reduced, and after scar healing of the hydrops, wearing contact lenses or glasses may be possible again. Conservative therapy alone with lubricants and hyperosmolar eye drops, prophylactic antibiotic eye drops to prevent superinfection, and topical steroids was long considered the only possible form of treatment. However, healing under conservative therapy takes an average of over 100 days. In the meantime, there are different surgical strategies that rapidly shorten the healing and thus the recovery phase of the patients to a few days. If the DM is detached without tension, a simple injection of gas into the anterior chamber can already lead to reattachment and thus to almost immediate deswelling of the cornea. If the DM is under tension, predescemetal sutures combined with a gas injection into the anterior chamber can flatten the cornea and reattach the DM. Mini-Descemet membrane endothelial keratoplasty (mini-DMEK) allows for sutureless closure of the DM defect by transplantation of a small (< 5 mm) graft. In cases of particularly large DM tears and very pronounced hydrops, suture loosening and relapse may occur after the placement of predescemetal sutures. Mini-DMEK can then lead to permanent healing, but in contrast to simple corneal sutures, it is usually performed under general anesthesia and by aid of intraoperative optical coherence tomography. The very good results with regard to the rapid healing prove that surgical therapy makes sense in the vast majority of patients with acute hydrops and should be initiated quickly.

Blood-Aqueous Barrier Disruption in Penetrating and Posterior Lamellar Keratoplasty: Implications for Clinical Outcome

BACKGROUND

The blood-aqueous barrier (BAB) separates immunoprivileged tissue of the eye from the blood circulation. Disruption of the BAB is therefore a risk factor for rejection after keratoplasty.

PURPOSE

The present work provides a review of the work of our group and others on BAB disruption in penetrating and posterior lamellar keratoplasty and its implications for clinical outcome.

METHODS

A PubMed literature search was performed to generate a review paper.

RESULTS

Laser flare photometry provides an objective and reproducible method to assess the integrity of the BAB. Studies of the flare after penetrating and posterior lamellar keratoplasty demonstrate a mostly regressive disruption of the BAB in the postoperative course, which is influenced in extent and duration by multiple factors. Persistently elevated flare values or an increase in flare after initial postoperative regeneration may indicate an increased risk of rejection.

DISCUSSION

In case of persistent or recurrent elevated flare values after keratoplasty, intensified (local) immunosuppression may potentially be useful. This could become important in the future, especially for the monitoring of patients after high-risk keratoplasty. Whether an increase of the laser flare is a reliable early indicator of an impending immune reaction after penetrating or posterior lamellar keratoplasty has to be shown in prospective studies.

Ocular allergy modulation to hi-dose antigen sensitization is a Treg-dependent process

A reproducible method to inhibit allergic immune responses is accomplished with hi-dose Ag sensitization, via intraperitoneal (IP) injection. However, the role of CD4+ CD25+ FoxP3+ T regulatory cells (Treg) in this process is unknown, as is whether such modulation extends to ocular allergy. We therefore determined herein whether hi-dose sensitization modulates ocular allergy, and whether CD4+ CD25+ FoxP3+ Treg are involved. C57BL/6 mice were IP sensitized via low-dose (100 µg) versus hi-dose (1000 µg) ovalbumin (OVA), in aluminum hydroxide (1 mg) and pertussis-toxin (300 ng). Other mice received anti-CD25 Ab (PC61) to ablate Treg during sensitization. In another experiment, Treg from hi-dose sensitized mice were adoptively transferred into low-dose sensitized mice. Once daily OVA challenges were administered. Clinical signs, IgE, T cell cytokines, and eosinophils were assessed. Data revealed that hi-dose, but not low-dose, sensitization led to allergy modulation, indicated by decreased clinical signs, serum IgE levels, Th2 recall responses, and eosinophil recruitment. T cells from hi-dose sensitized mice showed a robust increase in TGF-b production, and Treg from these mice were able to efficiently suppress effector T cell proliferation in vitro. In addition, in vivo Treg ablation in hi-dose sensitized mice revoked allergy modulation. Lastly, Treg from hi-dose sensitized mice were able to adoptively transfer allergy modulation to their low-dose sensitized counterparts. Collectively, these findings indicate that modulation to hi-dose sensitization, which is extended to ocular allergy, occurs in a Treg-dependent manner. In addition, our data suggest that hi-dose sensitization may henceforth facilitate the further examination of CD4+ CD25+ FoxP3+ Treg in allergic disease.

Blocking CCR7 at the ocular surface impairs the pathogenic contribution of dendritic cells in allergic conjunctivitis

CCR7 plays a key role in mobilizing tissue dendritic cells (DCs) to the lymphoid compartment for consequent elicitation of adaptive immunity. Interfering with CCR7 function therapeutically would therefore be anticipated to inhibit the progression of atopic conditions, for example, allergic conjunctivitis (AC). However, the CCR7-CCL19/CCL21 system in the ocular surface is poorly understood as is the precise role of DCs in AC immunopathogenesis. T cells from ovalbumin (OVA)-primed mice were adoptively transferred into wild-type (WT) hosts. Exogenous WT (eGFP(+)) versus CCR7(-/-) DCs were engrafted subconjunctivally (SCJ), and hosts were challenged with OVA (Texas-Red+) eye drops. AC immunopathogenesis was evaluated via clinical examinations, infiltration of mast cells and eosinophils, Th2 reactivity, and serum IgE levels. AC was also assessed in actively immunized mice challenged with OVA eye drops containing 1% anti-CCR7 antibody or isotype control. In eye-draining lymph nodes (LNs), OVA(+) SCJ engrafted WT DCs conferred upregulated CCR7 and caused augmentation of clinical signs. This result was corroborated by increased conjunctival infiltration, Th2 cytokines in LNs, and serum OVA-specific IgE. Strikingly, this was completely reversed with SCJ engrafted CCR7(-/-) DCs in all parameters tested. Furthermore, topical antibody blockade of CCR7 in actively immunized mice significantly inhibited AC. Ocular surface DCs via CCR7 expression contribute to the immunopathogenesis of AC, thereby allowing significant inhibition of this experimental condition via topical CCR7 antibody blockade.

Dendritic cells elicit allergic immune responses in a CCR7-dependent fashion (103.10)

DCs are key in mounting allergic immunity by mobilizing from allergen exposed sites to lymphoid tissues for T cell activation. However, whether the CCR7-CCL19/21 axis promotes DC mobilization and Th2 responses in allergy is incompletely understood. We thus sought to determine if CCR7 expression by DCs promotes allergy. Allergic conjunctivitis (AC) was evaluated in wild-type (WT) mice immunized via adoptive transfer with OVA/Alum-primed (WT) T cells. Mice were injected subconjunctivally (SCJ) with exogenous WT or CCR7 KO DCs (or PBS), and immediately instilled with OVA-loaded eye drops to induce AC. Clinical signs were scored biomicroscopically, and sera were sampled for OVA-specific IgE analysis. T cells were isolated for cytokine analyses to in vitro recall stimulation. Lastly, leukocytosis of collagenase-digested conjunctival cells was FACS analyzed. Upregulated CCR7 expression was confirmed of SCJ injected WT DCs found in lymph nodes of immunized mice following instillation of PE-OVA eye drops. Mice with WT DCs showed significant augmentation of clinical signs relative to sham controls. This was corroborated by a 2-fold increase in mast cell and eosinophil infiltration, 4-fold increase in IL-13 and IL-4, and an 8-fold increase in IgE (p&lt;0.05). Strikingly, this augmentation was completely reversed in hosts with CCR7 KO DCs, and this abrogation was consistently seen in all parameters. Thus, our study suggests that DCs promote allergic immunity in a CCR7-dependent fashion.