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CCP

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ocular surface reconstruction with SLET under guarded prognosis, chemical injury

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CCP

  1. 1. CASE PRESENTATION Moderator: Dr. Suhas Haldipurkar Dr. Abhishek Hoshing
  2. 2. History  11 year old, female  Complaints of redness, pain, watering LE: 4 years  Diminution of vision in LE: 4 years  History of chemical injury (lime/”chuna”) 4 years ago
  3. 3. History  Primary treatment post chemical injury taken at other hospital  Amniotic membrane grafting done somewhere else  Opinion sought at our hospital in Feb, 2015  Was advised ocular surface reconstruction with SLET under guarded prognosis
  4. 4. Chemical injury in Paediatric population – How are they different?  Pose a greater threat  Delay in timely diagnosis  Difficulty in adequate management  Additional risk of AMBLYOPIA!!
  5. 5. • Age group 0-5 years: most commonly affected (68% patients were 1-3 yrs old) • “Chuna”/ Lime: most common offending agent (Grade 4 injuries and 68% eyes had final median BCVA of 1/60) • One third patients did NOT receive irrigation at time of injury • Delay in presentation (70.2% presented after 1 month of injury)
  6. 6. Examination  General Examination : WNL  Ocular Examination : Visual Acuity RIGHT EYE LEFT EYE Distance 6/6 HM, PR accurate Near N6 -
  7. 7. Ocular Examination RIGHT EYE LEFT EYE Lids and adnexa WNL WNL Conjunctiva WNL Good limbal tissue Superiorly anterior insertion of conjunctiva Described in the diagram Cornea Clear Described in the diagram Sclera Normal Visible sclera is normal AC Well formed, quiet PACD = ½ CT No view Iris Normal No view Pupil RRR, 3 mm No RAPD No view Lens Clear No view Fundus WNL No view
  8. 8. LE: Diagram representing the clinical findings
  9. 9. DIAGNOSIS LE: TOTAL LIMBAL STEM CELL DEFECIENCY WITH SYMBLEPHARON WITH PROBABLE CORNEAL SCAR AND CATARACT
  10. 10. Defined stem cells, by virtue of their functional attributes, as “undifferentiated cells” capable of (a) proliferation, (b) self maintainence, (c) producing a large number of differentiated, functional progeny, (d) regenerating the tissue after injury, and (e) a flexibility in the use of these options
  11. 11. Corneal Stem cells  Located exclusively in the Limbal basal epithelium  Why the limbus only?  Central corneal epithelium transparent  basal cells devoid of pigment highly susceptible to solar damage.  Basal cells in the limbal region do not have this constraint; they are heavily pigmented and, thus, are well protected.  Transparency of cornea dictates a smooth epithelial- stromal junction  minimal anchorage  renders epithelium susceptible to physical shearing.  In contrast, limbal epithelium is very resistant to shearing forces and displays a highly undulating epithelial-stromal junction.
  12. 12. What causes limbal stem cell damage?  Primary limbal stem cell deficiency (1° LSCD)  Absence of identifiable external factors  Insufficient environment to support the cells  Aniridia, erythroderma, multiple endocrine deficiency, neurotrophic keratopathy, peripheral inflammmation  Secondary limbal stem cell deficiency (2° LSCD)  Presence of destructive external factors  Chemical & thermal injuries, cicatrizing inflammmations  CL wear, multiple ocular surgeries
  13. 13. How to diagnose LSCD? CONJUNCTIVALISATION VASCULARIZATION CHRONIC INFLAMMATION TRIAD
  14. 14. DIAGNOSIS LE: TOTAL LIMBAL STEM CELL DEFECIENCY WITH SYMBLEPHARON WITH PROBABLE CORNEAL SCAR AND CATARACT
  15. 15.  What next??  What are the options available??  To consider surgery or not??  What is the visual prognosis??
  16. 16. Procedure Abrv Donor Tx tissue Conjunctival Transplantation - Conjunctival autograft - Cadaveric conjunctival allograft - Living –related conjunctival allograft CAU c-CAL Lr-CAL Fellow Cadaver Living relative Conjunctiva Conjunctiva Conjunctiva Limbal Transplantation - Conjunctival Limbal autograft - Cadaveric limbal allograft - Living –related limbal allograft - Keratolimbal allograft CLAU CCLAL LrCLAL KLAL Fellow Cadaver Living relative Cadaver Limbus/Conj Limbus/Conj Limbus/Conj Limbus/ Cornea Cultured stem cell transplantation - Cultured limbal autotransplant - Cultured cadaveric limbal allotransplant - Cultured living related limbal allotranspllant Cu –LAU Cu-CLAL Cu – LrLAL Fellow Cadaver Living relative Limbus Limbus Limbus Proposed modified classification for Epithelial Transplantation procedures for Ocular surface disease
  17. 17. UNILATERAL LSCD PARTIAL TOTAL Observation Mechanical Debridement Amniotic membrane Ipsilateral translocation CLAU Cu- LAU Lr – CLAL (One eyed) BILATERAL LSCD KLAL Lr - CLAL KLAL Lr - CLAL Cu - LrLAL PARTIAL TOTAL CLAU: Conjunctival limbal autograft; KLAL: Keratolimbal allograft; Lr-CLAL: Living related conjunctival allograft; Cu – LAU: Cultured limbal autograft; Cu – LAL: Cultured limbal allograft FLOW DIAGRAM FOR MANAGING LSCD
  18. 18. CLET
  19. 19. COMET
  20. 20. Comparison of SLET with existing techniques of autologous limbal transplantation for treatment of unilateral limbal stem cell deficiency
  21. 21. So what did we do?  PLAN : OS – Symblepharon release + Conjunctival autograft + Simple limbal epithelial transplant +/- Penetrating keratoplasty under GA and guarded visual prognosis Why not CLAU/ Cu – LAU? 1. CLAU: Two lenticules, 3 clock hours each of limbus & conjunctiva harvested Problem: Rare reports of Donor LSCD 2. Cu – LAU: Culture of limbal stem cells Problem: Ex vivo cultivation expensive and unnecessary
  22. 22. Post operative course Day of surgery : 29 June ‘15 30 June 15 POD 1 • Vn : CF 2mts • Predforte 8t/d • Moxiflox 4t/d 06 July 15 POD 7 • Vn : CF 2 mts • Predforte 1 week Tapering 6/4/3 • Combigan BD 20 July 15 POD 21 • Vn : CF 2 mts • Predforte 3/2/1 tapering • Combigan BD
  23. 23. Post operative course Day of surgery : 29 June ‘15 21 Aug 15 POW 8 • Vn : CF 3 mts • RGP fitting • OD patching 2 hours/day 10 Sept 15 POW 10 • Vn : 6/60 • Good diffuse fit of RGP • Predforte OD • Ccombigan BD 9 Oct 15 POW 14 • Vn : CF 2 mts • Combigan BD • Dispense new CL
  24. 24. TAKE HOME MESSAGE  Paediatric chemical injuries – fairly common clinical scenario, needs aggressive treatment  SLET is a simple and cost effective procedure for management of LSCD  Multi-faceted approach towards visual rehabilitation  Never give up on a patient!
  25. 25. THANK YOU

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