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 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 out- comes of this procedure exclusively in a pediatric popu- lation have not been reported previously. Objective: To report the outcomes of autologous ex vivo cultivated limbal epithelial transplantation (CLET) in pe- diatric patients with LSCD after ocular burns. Design and Setting: A retrospective, interventional case series of patients treated at the L. V. Prasad Eye In- stitute, Hyderabad, India. Participants: Children up to 15 years with LSCD sec- ondary 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 ob- tained from a healthy area of the limbus, the limbal epi- thelial cells were cultured on a denuded human amni- otic membrane substrate using a xeno-free explant culture technique. A monolayer of cultivated epithelial cells along with the amniotic membrane was transplanted on the pa- tient’s affected eye after pannus excision. In cases of fail- ure, the same procedure was repeated. Main Outcomes and Measures: Ocular surface sta- bility and visual improvement were the primary and secondary outcome measures, respectively. Success was defined as a stable corneal epithelium without conjunc- tivalization. Eyes with conjunctivalization and persis- tent 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 com- pletely epithelialized, avascular, and stable ocular sur- faces. At the final visit, 58 eyes (54.2%) had improve- ment in visual acuity of 0.2 or more logMAR units. Conclusions: Autologous CLET was successful in re- storing the ocular surface and improving vision in al- most half of the children blinded by ocular burns. JAMA Ophthalmol. 2013;131(6):731-736. Published online April 4, 2013. doi:10.1001/jamaophthalmol.2013.2308 T HE CORNEAL EPITHELIAL SUR- face is maintained in a trans- parent state by the corneal epithelial stem cells, which are believed to be located at the basal layer of the limbal epithelium. 1,2 Any physical, chemical, thermal, or immu- nologic insult to the limbal region can re- sult in permanent damage to the corneal epithelial stem cells, leading to limbal stem cell deficiency (LSCD). This deficiency re- sults in loss of corneal clarity and a de- crease in vision, often leading to unilat- eral and bilateral corneal blindness. 3 With the advent of different techniques of lim- bal stem cell transplantation, it has be- come possible to treat eyes with blindness due to LSCD. 4-6 There are several ar- ticles 7-13 about the use of conventional and cultured limbal epithelium using various substrates in the treatment of LSCD. How- ever, the patient population includes largely adults, with few pediatric cases. Thus, to our knowledge, the outcomes of this pro- cedure exclusively in a pediatric popula- tion have not been reported previously. It is known that the ocular inflammatory re- sponses to iatrogenic trauma can be more severe in pediatric patients compared with adults, which, in turn, can jeopar- dize the final outcome of the surgical pro- cedure. In this study, we describe the clinical outcomes of autologous ex vivo cultivated limbal epithelial transplanta- tion (CLET) in children with unilateral LSCD after ocular surface burns, using a standardized xeno-free protocol of limbal cell culture. Author Aff Anterior Se Sejpal, Basu Sangwan), Biostatistics Epidemiolo Sreekanth a Stem Cell B (Ms Maddil Sangwan), Ramanamm Care Cente L. V. Prasad School of M University Vemuganti) Hyderabad Author Affiliations: Cornea and Anterior Segment Services (Drs Sejpal, Basu, Ramappa, and Sangwan), Department of Biostatistics and Clinical Epidemiology (Mr Ali), Sreekanth and Sudhakar Ravi Stem Cell Biology Laboratory (Ms Maddileti and Drs Basu and Sangwan), and Jasti V. Ramanamma Children’s Eye Care Center (Dr Kekunnaya) L. V. Prasad Eye Institute, and School of Medical Sciences, University of Hyderabad (Dr Vemuganti) Hyderabad, India. JAMA OPHTHALMOL / VOL 131 (NO. 6), JUNE 2013 WWW.JAMAOPHTH.COM 731 ©2013 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 05/31/2020