Central corneolimbal transplantation under systemic ciclosporin A cover for severe limbal stem cell insufficiency

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Abstract
Severe stem cell deficiencies uniformly lead to superficial conjunctivalization of corneal grafts with subsequent functional failure. We sought better long-term results by transplanting central corneolimbal grafts and simultaneously protecting the graft and its stem cells from immunological destruction by means of systemic administration of ciclosporin A. In an ongoing pilot study, up to April 1995 20 eyes with stem cell dysfunctions of various etiology (e.g. chemical burn, ocular pseudopemphigoid, congenital aniridia) received eccentrically trephined fresh corneal grafts of 7.7-10.0 mm diameter. About one third of the circumference of the grafts contained limbal area. The mean age of the patients was 46.2 years (range 9-84 years). All patients received systemic ciclosporin A for at least 12 months. At present, the mean follow-up period is 9.6 months (mean 1-20.6 months). Fourteen of 20 grafts (70%) have remained clear so far. Reasons for six graft failures were surface disorders in four eyes, immune reactions in one eye and surface disorders in combination with immune reactions in another eye. Ten of 20 grafts (50%) experienced severe surface disorders. In six eyes surface disorders were coincident with endothelial immune reactions, in four eyes they were not. In four of 20 grafts (20%) conjunctivalization was observed in front of the transplanted limbal area; in seven of 20 grafts (35%) conjunctivalization occurred only distant from the transplanted limbal stem cells. Our method of central corneolimbal transplantation with simultaneous protection of the transplanted stem cell population from immunological destruction by means of systemic ciclosporin A has been successful for 14 eyes with severe stem cell deficiencies up to 20.6 months postoperatively. This new treatment principle promises - for the first time - long-term rehabilitation for a majority of eyes with severe limbal stem cell deficiencies.