 Great we have dr. Betz presenting on limbo stem cell deficiency and some new techniques It's everyone's favorite topic Hope you're all excited as me So this is mainly a case presentation with just kind of a review on limbo stem cell transplants and then this Newish procedure that we just started doing here. So we had a patient his chief complaint He was referred to dr. Mifflin for vision very fuzzy in his left out of his left eye His history he he was in prison and he had some kind of scalding water slash chemical burn There back in 2005 he was actually seen here a couple months later and had a amnioc membrane transplant tarsaur ify Tell because he had a persistent epithelial defect and then he was lost fall for a long time and Came back in kind of late spring 2016 saw oculoplastics and he had secretricial Entropion of his left upper lid with a significant tracheosis. So that was repaired And they were sent to cornea So he was interested in the limbo stem cell transplant Here's his past medical history diabetes depression bipolar disorder. It's had some other surgeries former smoker not now and then his Meds he was on valley psychovir because there was some concern that maybe he'd had HSV at one point But nothing really out sticking out there I examined 20 30 is right. I left eye terrible vision as you can see But no RAPD and his IOP was pretty good It was a difficult view into the back of his eye But we could tell his retina was healthy and then he had a totally Conjunctivalized if I could pronounce that cornea with some superficial deep vessels and then it looked like his Kind of had a normal appearing limb is slash nasal corneal epithelium In that eye, but mainly it was pretty bad and I have a photo. It's not great But yeah, and you can't even tell right here. My picture is better, but he does have a kind of hazy cornea You can tell on on my computer that it's you know kind of has this opaque whitish appearance So we you know we talked to him a lot about different procedures But just before we go into that I wanted to kind of just quick review on limbo stem cell deficiency it's difficult to Measure limbo epithelium stem cells fact you can't as far as I know doctor Dr. Manlis may have some thoughts on that but as far as you know, no one's ever seen them We think they're there. There's like these indirect markers of limbo stem cell deficiency Mainly what does the cornea appearance look like there's lots of palisades of vote and then you get this peripheral corneal neovascularization There are a lot of people looking at objective ways to measure this And in the theory behind the pathogenesis is that you have this limb it this limbo stem cell population or cell population that acts as a barrier to The conjuctiva from overtaking cornea epithelium and lots of these cell populations You when you lose them you lose this barrier function, but also there's some kind of cells there that help regenerate the the cornea epithelium And like I said about diagnosis, it's mainly clinical and there's a big there's a meta-analysis that came out in late last year and they looked at 40 different studies that had to do with limbo stem cell deficiency and 36 of the 40 mainly use clinical diagnosis as their main diagnostic criteria There's also impression cytology where you can take an impression of the cornea and see presence of goblet cells Which normally shouldn't be in cornea epithelium, and then there's some newer things like cytokeratin markers, which aren't have it really panned out And then confocal microscopy, which also, you know is not It's mainly a clinical diagnosis. That's my point with my little star right here non-surgical treatment is Basically if this is an acute injury you want to protect the cornea until it scars over essentially No one will do you shouldn't be doing surgical things when the cornea is acutely inflamed or there's in cute epithelial defect because there's an Increased risk for failure of the surgeries So aggressive lubrication you try to decrease ocular surface inflammation And then when you're getting ready to think about surgery you want to correct any lid abnormalities so that you set yourself up for the best success And that's kind of what happened in this case the gentleman came we knew as lit it was going to be an issue He had that taken care of by our oculoplastic service, and then he came to us So traditional surgical treatment can be broken up into two different categories You have a carotolimbol allograft so from a donor or you have an autograph or from a fellow I So the allograft is probably more common because it seems to be the most common reason to do this is aniridia Which they don't have good stem cells on either I also Steven's John's syndrome I'll go sick atricial Pemphagoid and then chemical or thermal injuries Ed Holland and Cincinnati is like the big guy who does is he does about 80 to 90 percent of all The limbo stem cell transplants in the country so most of the data I'm going to show in the next few slides is from him, but the most common procedure is called a carotolimbol allograft And you take a cadaver eye, and you take the the limbis and part of the cornea and you transplant it to the affected Eye or eyes this can be combined with a penetrating carotoplasty Which especially like the aniridic patients sometimes need when you do a combat procedure the failure rate is a lot higher and The main problem is rejection and this is not like a coronary transplant You need some hardcore immunosuppression, which you can see right here. This is the Cincinnati protocol, which is kind of standardized and As an ophthalmologist like I look at that list, and I I personally feel uncomfortable Managing all this because on average your patient is on immunosuppression for three to five years And I was talking to at Holland's fellow a few months ago And he said that they first recommended three years and now they're recommending at minimum five years of treatment And so there's this protocol like you know you you hit them really hard for a while And then at a first year you kind of start tapering stuff And so that's the reason why this is Everyone sends their patients to dr. Holland is because he has he employs a nephrologist who hosts managed their immunosuppression Which is kind of the big thing So we we dr. Mythland does these here and so we manage our own patients Which has been a good learning experience about tachyrolimus and celsa for me So there is a ten-year outcome on this care to limbo alligraf procedure that came out a couple years ago They had 220 22 eyes of 158 patients with an average follow-up is 62 months and 80% of these were this care to limbo alligraf The other 20% were a combination of other things you can actually take The limbo stem cells from a living relative of the patient if they have you know if it's like a chemical thermal burn and that has a higher success rate than the cadaver eye donor and they'll do some Combinations if there's like a unilateral stem cell deficiency from a burn you can take a combination of Cells from the patient's eye and a living relative and do all these kind of combination things so that you can increase your cancer success But essentially what we do here is if we need to do this we do a donor eye. So this K-Law procedure 31 at within this population of patients 31% of the eyes that had rejection had rejection and only 36% of those were had a stable ocular surface without epithelial defects At their final follow-up compared to a 71% of eyes that didn't have rejection had a stable ocular surface a follow-up So rejection is a big thing and and which is why we're going to be talking about the procedure We are going to go over today The limbo alligraf the traditional way of doing that You have to have a good eye as you take six clock hours of limbo tissue from a donor eye and you transplant it to the other eye In India and for reasons that are probably obvious because we have an FDA You cannot we can't do this cultivated limbo stem cell transplant Which seems as have a high success rate, but essentially they take a small population about a clock hour of limbo stem cells They X of Evo they grow this into a sheet of stem cells and they transplanted to the affected eye and it seems to work really well Out of this idea came the simple limbo epithelial transplant from saying one he's kind of the he was he also helped Start this cultivated limbo stem cell transplant, but he's really championed this Started doing it back in 2010 and basically it's the same thing you take about a clock hour of the limbis You cut it into eight to 12 small pieces And you glue those to the anionic membrane that's been glued to the recipient eye And then you just let it sit and the stem cells grow and it will repopulate the corneal epithelium And it seemed when I first saw this last year. I like that seems too easy and crazy, but it works They only four-year outcomes This was published in 2016, but it's from 2010 to 2014 125 eyes 76% of Eyes had a stable ocular surface at their final follow-up things that they found the increase the risk for failure for this procedure Is if you combined the trans the limbo stem cell transplant with any other procedure like a PK? They did find though if you waited a while the PK had a higher success Rate than if you did a combination procedure So we did this on our patient because there's other I was totally fine and I have a little video so Essentially we there there have been some groups in the US who've been doing this and published the results and we kind of use Baskin-Palmer's approach the biggest issue that People found is that the limbo stem the the cells tend to slough off of the cornea So we took our little sample here this I we did in our top of the donor I we use topical anesthesia and so we did that little sub-conjunctile anesthesia But essentially you make a little pritomy and It's only five minute video, but Jump ahead we used it. We used a a diamond knife to kind of cut out a two by two millimeter section Didn't end up quite two by two millimeter. It was Probably a little bit longer than two millimeters along the limb is a little shorter in the Radial axis but use the diamond knife to kind of cut partial thickness into the cornea and then we have this section of cells and After I cut it out, we just let it sit in a some bss and then we're prepared to his other eye But you can really see his eye here. It's pretty scarred. So, you know, we talked to him and this Patient has history being in prison not very reliable. He lives like in three or four hours away in Idaho So we're really concerned about doing the cadaver I Transmit because you have to be in a lot of immunosuppression takes a lot of follow-up a lot of lab work So we're like, let's do this and if we need to do another procedure after to help with your visual Rehabilitation we can do that but we use a grease Harborblade and to try to get as much of the neovascularization off of the cornea He had some deeper vessels, which you'll see in some follow-up pictures and we'll probably end up needing a cornea transplant, but We did a diamond burn and then and then you know little cotterie and then the Baskin-Palmer method is basically It's like a dealt you sandwich the limbo stem cells in an AMT in AMT bread So this is our bottom piece of our sandwich here and we we fixated it The edges of it with some tenon nylon sutures, and then we glued this piece to the surface of the cornea So there's my sutures pulling this back we're gonna put some To seal glue on the cornea Yeah, we sutured it. Yeah, they recommend doing a big career to me and then wrapping the The the layer of AMT that is going to be on top of the cornea Kind of underneath the pretty me edges So I tried to do these kind of deeper sutures and then we smoothed it out Make sure it was fixated and then the Baskin-Palmer method is also you do these four Tenon nylon fixation sutures at the limb is just so that the amniotic membrane stays in place It's just like extra precaution Because we really didn't want this to we didn't want our stem cells to Fall off so there's our section and basically we tried to I think we cut it into eight pieces This is my only non sped up part of the video here just this first cut, but essentially you can see See I'll skip ahead. You know we just held it and Cut it into small pieces as we can And then you can see here. There's our I think we had ten actually ten around the limbis the trickiest part of this procedure was Getting a small enough amount of the to seal Because they have it, you know, there's a thick portion and then a thin portion and It's really hard to get a teeny teeny drop of the thin portion, but we tried to individually glue every piece We probably waited ten minutes for those pieces to at least ten minutes for them to Stick down and we're not mobile and then we then we did our anti-salanchin We sewed this piece to I think we use six fixation sutures to the the conjuctiva And then So we did I the The basement membrane side was opposed to the stem cells on both sides on both sides. Yeah So after this is was fixated We put a contour 16 I think with this was actually 18 millimeter contact lens over the eye and then we were extra OCD and we did a tarsophie because we did not want this to fail And that's kind of what the the Baskin-Palmer method is all about is having success Benny Jane who's he's a chairman of Maryland. He was at UCSF for a long time. He had a case He he had a discussion I think it was in Inet a couple months ago and talked about how he's done three cases and two failed because when they took the contact lens out at two Weeks the stem cells came with them So that was the whole reason for us doing all this extra stuff including the tarsophie So two weeks after the procedure we removed the tarsophie a Visual Q. You're still really bad with some photos This is actually the staining is intact amniotic membrane You can see our little fixation sutures here, but there's actually intact epithelium superiorly and you can actually see that little section of limbis right here And here's another another photo, but you can appreciate some of these little stem cell Populations right there, and then there's some staining no IP defect that we could tell at that time So we we put them on antibiotic and prednisolone four times a day until we saw him again at a month So one month IP was good vision still count fingers, but andic membrane was gone You can see the stem cell populations Right here there. They are a little bit elevated, but he didn't have an epithelial defect So it seemed to work for the purpose that we wanted it You can't appreciate he has like I said these deep more deep stromal vessels he's developed a cataract over the last couple years and so Um Frightly further treatment, I think Dr. Mifflin's plan was way to while see if he needs cataract surgery. Maybe consider a Penetrating care to plastic if needed after he had cataract surgery There is some in the long-term outcomes people have reported that those stem cell islands tend to Smooth out and kind of disappear over time And so we're hoping that you know, this is a viable procedure It's minimally invasive when you compare it to the other things that are done You're really taking a small amount of stem cells from the donor eye So it spares more tissue You got to have the right candidate. Most of these people are going to be unilateral chemical or thermal burns And then once again higher failure rate when you combine this with a penetrating care to plastic So if this guy has one down the road, hopefully we can wait a year and help be set up for better success So we took the tarsography and took the contact out at two weeks Which is what people had recommended who had done these things before so when you're taking the actual Yeah, we did I set my diamond blade at 250 microns. So it's you know, pretty thin Yeah, and ideally you want to orient it so that the The the anatomic orientation is correct I can tell you after you cutting those pieces really smarts really hard to tell so we did the best we could But it seemed to work So it you know, this is a nice option could instead, you know, like I said the traditional methods you take six clock hours of Limbs from the donor eye and those people end up doing had end up having you know, you can tell that their limb is has been altered quite a bit But you know, I think this will probably be if this ends up panning out This will be our kind of go-to method for a unilateral burn for somebody who wants surgical a surgical intervention You said it's hard for us to tell exactly what are the stem cells and what aren't and so Do these transplanted stem cells we make more stem cells and then differentiated into the normal The field or once they differentiate is that it when you run out of Stem cells to keep that service under control. I don't think we have the answer to that question I mean, that's an area that another guy's investment armor looking into trying to find out if you can see if these stem cells are regenerating Most stem cells Mm-hmm. I think that's the key thing keeping these surface of the eyes of these transplants Dr. Bezel These I believe a lot of everything I've read it's regulation about taking those cells and then Culturing them outside the eye and in a lab and I think mainly it's regulation. That's that's everything. I've read So I don't know. I don't know of any group in the US. That's actually tried to do it Yeah, they recommend one of the large diameter the brand's contour And you can get 16 millimeter to 20 millimeter Contact lenses, which are really big. So I believe that was an 18 millimeter one and they just recommended just so that there's less Movement of the contact lens if you close close the eye with a tar swerve V Dr. Tell were you done dr. Patel Yeah Yeah, the success rates about you know, the best success rate is about 80% and that's with that culture cultivated limbo stem cells I mean to your point it would surprise me if we could do because of regulations I mean there was just a group in Florida that does Yes stem cells and basically the heart of stem cells from your fat and then they injected it in eyes and blinded three eyes and so Clearly, I'm not saying that yes, that's a good idea. So why not do this? But you know that they're using as long as you're using your own stem cells It really seems like their avenues to do this type of thing Well, thank you