1. HLA-matched Living-related Conjunctival Limbal Allograft for Bilateral Ocular Surface Disorders - Long-term Results - Sérgio Kwitko, Caio Scocco, Samuel Rymer, Diane Marinho, Rodrigo Lindenmeyer Hospital de Clínicas de Porto Alegre Federal University of Rio Grande do Sul - Porto Alegre - Brazil The authors have no financial interest in the subject matter of this poster

2. Lr-CLAL: long term results Visual rehabilitation and stabilization of ocular surface has been reported in a good percentage of cases in the first year after HLA-matched living-related conjunctival limbal allografts (Lr-CLAL) in bilateral ocular surface diseases. Stability of results is, however, still a challenge in these cases, with loss of good initial results over time.Purpose: To evaluate the long-term outcome of HLA-matched Lr-CLAL for bilateral ocular surface disorders.

3. A retrospective interventional case series study of 46 eyes of 36 patients with bilateral surface disorders that underwent HLA-matched Lr-CLAL. All patients had clinical diagnosis of limbal stem cell deficiency due to: Stevens-Johnson syndrome 19 eyes Bilateral alkali burns13 eyes Lyell’s syndrome 6 eyes Ectodermal dysplasia 3 eyes Limbal tumors 2 eyes Multiple pterygium surgeries 2 eyes Eyes were classified according to the classification of Holland, Gomes and Shwartz 22 to analyze and better compare the results Visual acuity (VA), ambulatory vision (VA ≥ 20/200), ocular surface stability, corneal transparency, corneal vascularization and rejection episodes were evaluated and correlated to the disease severity and to HLA compatibility. Lr-CLAL: long term results Methods

4. Donor limbus was obtained from a patient’s relative after Class I and II HLA match. Surgical technique used was the one described by Kenyon and Tseng 7 modified by us 16, that is, only conjuntival limbal was included in the donor, avoiding the peripheral corneal keratectomy and apossible donor limbal deficiency in the future. Corneal keratinization was carefully removed, and limbal allografts were sutured with 10.0 mononylon on the peripheral corneal bed, and with 8.0 vycril on the scleral surface. Lr-CLAL: long term results Methods

5. Donor-recipient HLA-match was identical in 17 pairs (37%), had a 75% match in 4 (8.7%), and had haplo-identity in 25 (54.3%). Corneal transplantation was performed in 12 eyes at least one year after HLA LR-CLAL (26.1%), and systemic immunosuppression in 4 patients (7 eyes) (15.2%). Amniotic membrane transplantation was associated to Lr-CLAL in 12 eyes (26.1%). Autologous serum was used in 9 eyes (19.6%) as part of dry eye treatment. One year after surgery, VA improved in 47.8%, ambulatory vision was achieved in 45.7%, and a stable corneal surface in 80.4% of eyes. At the final follow-up (mean, 51.3 ± 29.6 months), 63.6% of the eyes maintained an improved VA (p=0.50), 76.2% maintained 20/200 or better (p<0.001), and 94.6% still had a stable corneal surface (p=0.009). Limbal graft rejection occurred in 9 eyes (19.6%), 5 in haplo-identical HLA pairs, and 4 in identical HLA pairs (p=0.439). Lr-CLAL: long term results Results

6. Table 1. Preoperative data according to each group, based on classification of of Holland, Gomes and Shwartz GroupNumber of patientsDiagnosis (number of eyes) I a3Post pterygium surgery (1), Limbal papiloma (1), Limbal dysplasia (1) II a4Post pterygium surgery (1), Ectodermal dysplasia (3) I b1Alkali burn (1) II b11Alkali burn (11) I c5Stevens-Johnson syndrome (5) II c15Stevens-Johnson syndrome (9), Lyell syndrome (5), Cicatricial pemphigoid (1)

7. Lr-CLAL: long term results

8. Table 3. Risk of Lr-CLAL (Living-related Conjunctival Limbal Allograft) rejection and HLA recipient-donor compatibility Limbal allograft rejection YesNo Whole group 7 (17.9%)32 (82.1%) 100% HLA compatibility 3 (20%)12 (80%) 50% and 75% HLA compatibility 4 (16.7%)20 (83.3%) p=0.556 (Fisher´s Exact Test)

9. Case : Preop Case : 5 years post Lr-CLAL Case : PreopCase : 9 years post Lr-CLAL

10. Case : Preop Case : 1 year post Lr-CLALCase : 3 years post Lr-CLAL

11. HLA-matched Lr-CLAL can be an adequate method of treatment for bilateral ocular surface disorders, with few complications. Ambulatory vision and surface stability were reduced on long-term results when achieved on first year after surgery, but still with a reasonable percentage of success. No statistical difference on rejection rates between HLA groups was evident. Patients with Stevens-Johnson and Lyell Syndromes had the poorest success rates. Lr-CLAL: long term results Conclusion

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