Himanshu Matalia, MD1,2 Arokiaraj Vincent, MSc2 D Kamesh, MSc2 Early results of ex vivo cultivated autologous limbal epithelium transplantation for limbal stem cell deficiency Himanshu Matalia, MD1,2 Arokiaraj Vincent, MSc2 D Kamesh, MSc2 Cornea & Refractive Services, Narayana Nethralaya Narayana Nethralaya Stem Cell Research Laboratory Narayana Nethralaya Narayana Health City Super Specialty Eye Hospital & Post Graduate Institute of Ophthalmology Bangalore - INDIA Authors have no financial interest Poster 610

Limbal Stem Cell Defiency (LSCD) Clinical Features of LSCD Loss of palisades of Vogt Kinoshita S et al JpJ Clin Ophth 1986 Tseng SC et al OCNA 1990 Conjunctivalization Stippled appearance with fluorescein Dua HS Am J Ophthalmol 1990 Huang AJ IOVS 1991 Ch. Inflammation Recurrent epi. break down

Algorithm for LSCD Unilateral Disease Bilateral Disease Establish Diagnosis of Stem cells deficiency (Clinical features & Impression Cytology) Unilateral Disease Bilateral Disease Focal or Partial Total Deficiency KLAL Lr-CLAL Cultured live-related limbal allograft AMT CLAG Debridment Cadaveric kerato-limbal allograft (KLAL) Live-related conjunctivo limbal allograft (Lr-CLAL) Cultured limbal auto graft (best option ) Outcome not very encouraging

Cultivated Autologous Limbal Epithelium Transplantation (CALET) Most recent technique Best for unilateral LSCD Autologous cells, no immune suppression required No risk at donor site Repeatable Limitations Availability of the tissue culture facility Long-term outcome awaited Pellegrini et al Lancet 1997; 349: 900-993 Tsai RJ, Li LM, Chen JK. N Engl J Med 2000;343(2):86-93 Schwab et al Cornea 2000;19(4):421-6 Koizumi et al IOVS 2002;43(7):2114-21

Purpose To describe the early results of our technique of ex vivo cultivated autologous limbal epithelial transplantation (CALET) for limbal stem cell deficiency (LSCD).

Methods Prospective, non-randomized interventional case series 14 eyes of 14 consecutive patient with LSCD underwent CALET from October 2008-October 2009. Primary outcome measures: Successful ocular surface reconstruction: stable ocular surface Best corrected visual acuity (BCVA) Secondary outcome measures: Complications

Culture technique Limbal biopsy Amniotic membrane Unique from others* Normal limbal epithelium from contra lateral normal eye or normal area of same eye 2 x 2 mm (One clock hour) of normal limbal with cornea epithelium Amniotic membrane De-epithelialized, processed & preserved amniotic membrane used as substrate / carrier Unique from others* Monolayer only No air lifting, no fibroblast feeder Culture duration: 10-14 days Human Corneal Epithelium medium *Sangwan VS, Matalia HP et al Arch Ophthalmol 2005

Surgical technique One drop 1:1000 epinephrine on pannus to reduce bleeding (chemical cauterization) Pannus resection done Conjunctival peri-ectomy (2 mm) was done Cauterization of bleeders done Ex vivo cultivated autologous limbal epithelium grown over human amnotic membrane (HAM) was spread over the ocular surface HAM was secured to the eye with fibrin glue (Tisseal) and 8-0 Vicryl Bandage contact lens applied at the end

Results From July 2008 14 eyes of 14 patients underwent CALET Female: Male - Etiology of LSCD: Chemical injury 10 eyes (72%) 8 of these 10 were lime injury 7 eyes (50%): Previous history of AMT Follow up: Mean 9 months Mean duration of culture: 174.40 days

Results Clinical Outcome Visual acuity improvement Complications Preop Clinical Outcome Success: 12 (85.7), 95% CI 67.4-100 Failure: 2 (14.3%), 95%CI: 0-32.6 Visual acuity improvement Preop visual acuity: 0.20  0.38 Postop visual acuity: 0.38 0.41 (p=0.018) Complications Microbial keratitis: 2 Repeat transplants: 2 Repeat limbal biopsy: 2 HM+ PR accurate Postop 20/4020/25P

Results Visual acuity improvement Preop visual acuity: 20/100 Postop visual acuity: 20/50 (p=0.018)

Conclusions Cultivated autologous limbal epithelial transplantation (CALET) could successfully restore the ocular surface in cases with LSCD.