Eyeworld Daily News

EW SHOW DAILY 10 Friday, April 17, 2015 by Lauren Lipuma EyeWorld Staff Writer works well, and we should follow that," he said. What Dr. Holland would like to see in the next decade of ocular surface transplantation is safer, more efficacious immunosuppression protocols, reduced or non-antigenic donor tissues, and improvements in CLET protocols. Culturing limbal stem cells needs to be more afford- able, he said, and conjunctival stem cells need to be included in the culture. The best and final solution for LSCD, however, is culturing the patient's own pluripotent bone marrow stem cells and differenti- ating them into cornea limbal and epithelial cells, Dr. Holland said. Using the patient's own cells will eliminate the need for finding a suitable donor and the problem of rejection, and Dr. Holland hopes to see this become a reality in the near future. EW Editors' note: Dr. Holland has finan- cial interests with Alcon (Fort Worth, Texas), Bausch + Lomb (Bridgewater, N.J.), Kala Pharmaceuticals (Waltham, Mass.), Mati Therapeutics (Austin, Texas), Rapid Pathogen Screening (Sarasota, Fla.), Senju Pharmaceutical (Osaka, Japan), TearLab (San Diego), and TearScience (Morrisville, N.C.). procedure. This method involves harvesting epithelial stem cells from a fellow eye, relative, or cadaver, cul- turing the cells in vitro, and trans- planting them to a diseased cornea. Managing LSCD today and in the future Graft rejection is the leading cause of ocular surface transplant failure for both LR-CLAL and KLAL proce- dures, Dr. Holland said. Surprisingly, the biggest obstacle to success in these procedures is not the tech- nique, he said, but the mindset of the physicians. "If I think of the one thing that is an obstacle to successful protocols, it's not the surgery—it's that most corneal surgeons won't embrace systemic immunosuppression," he said. "You wouldn't see a kidney transplant surgeon putting a patient on CellCept [mycophenolic mofetil, Genentech, South San Francisco] for 6 months and expecting them to do well, but yet [in ophthalmology] we continue to see that." Dr. Holland advocates for strict adherence to organ transplantation immunosuppression protocols, including using individualized im- munosuppression regimens based on recipient risk factors. "We've learned from organ transplantation what "For unilateral disease, we certainly look to the conjunctival limbal autograft as the procedure of choice," Dr. Holland said. "It eliminates our biggest problem in tissue grafts in the ocular surface—it eliminates rejection." Patients with bilateral disease represent the biggest challenge in managing LSCD, Dr. Holland said. For these patients, physicians moved on to keratolimbal allograft (KLAL) procedures using cadaveric donor tissues, and in 1995, doctors per- formed the first living-related con- junctival limbal allograft (LR-CLAL) procedures, using donor tissue from a living relative. The success of these proce- dures was largely dependent upon a change in thinking that occurred among eye banks in the mid-1990s, Dr. Holland said. "Eye banks were totally focused on the endotheli- um and were not harvesting tissue and saving the limbus," he said. "In fact, they were taught to take all the conjunctival cells off. So it was a whole change in thinking of harvesting tissue to harvest tissue for both epithelial disease and endothe- lial disease, and today, that is what is done." Advances in cell culture tech- niques have led to the use of cul- tured limbal epithelial cell trans- plantation (CLET) as an alternative D uring Thursday after- noon's "Ocular Surface Disease" session, Edward J. Holland, MD, Cin- cinnati, presented the keynote lecture, "Limbal Stem Cell Deficiency: A Historical Perspective; Past, Present, and Future." Dr. Holland described how management of limbal stem cell deficiency (LSCD) has changed dramatically over the last several decades as physicians have gained a deeper understanding of the anat- omy and physiology of the limbus. Jose Barraquer, MD, pioneered the first ocular surface transplantation techniques, describing an autograft procedure for superficial burns at the first World Cornea Congress in 1964. Dr. Barraquer described "epi- thelial limbus, conjunctivocorneal [cells] taken from the other eye." The ocular surface transplantation technique didn't take off, however, until the 1970s and 1980s, when cornea specialists began to under- stand the location and function of limbal stem cells and the critical role of the conjunctiva in ocular surface disease and LSCD. Physicians began to use limbal stem cell transplantation clinically in the late 1980s and early 1990s, starting with autografts from the fellow eye in unilateral disease—a technique that is still in use today. The past, present, and future of limbal stem cell transplantation According to Dr. Holland, the biggest obstacle to success in ocular surface transplantation is that most corneal surgeons won't embrace systemic immunosuppression. 'Ocular Surface Disease' I n addition to Dr. Holland's keynote address, "Limbal Stem Cell Deficiency: A Historical Perspective; Past, Present, and Future," these physicians spoke on the following topics: • Minas T. Coroneo, MD, MS, MSc, FRACS, New South Wales, Australia, spoke on "Restoring Glamour in Pterygium Surgery." • Richard S. Davidson, MD, Aurora, Colo., spoke on "New Diagnostic Approaches for Ocular Surface Disease." • Beatrice Cochener, MD, PhD, Brest Cedex, France, spoke on "New Therapeutic Strategies for Tear-Deficient and Evaporative Dry-Eye Disease." • Wendy W. Lee, MD, PhD, Miami, spoke on "Protecting the Corneal Realm: Eyelid Disorders and the Cornea." • Carol Karp, MD, Miami, spoke on "Ocular Surface Squamous Neoplasia: Novel Diagnostic/Treatment Options." • Mark J. Mannis, MD, Sacramento, Calif., spoke on "Systemic Features of Ocular Surface Disease." • José A.P. Gomes, MD, PhD, São Paulo, Brazil, spoke on "Challenges and Advances for Ocular Surface Reconstruction in Bilateral Limbal Stem Cell Deficiency." EW

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