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  • AAO OTAC Cornea and Anterior Segment Disorders Panel, Hoskins Center for Quality Eye Care
    Cornea/External Disease


    A Report by the American Academy of Ophthalmology Ophthalmic Technology Assessment Committee Cornea and Anterior Segment Disorders Panel

    Jennifer Y. Li, MD;1 Maria S. Cortina, MD;2 Mark A. Greiner, MD,3 Anthony N. Kuo, MD;4 Darby D. Miller, MD, MPH;5 Roni M. Shtein, MD, MS;6 Peter B. Veldman, MD;7Jia Yin, MD, PhD, MPH;8 Stephen J. Kim, MD;9 Joanne F. Shen, MD10

    Ophthalmology, In Press © 2024 by the American Academy of Ophthalmology. Click here for free access to the OTA.

    Purpose: To review the published literature on the safety and outcomes of keratolimbal allograft (KLAL) transplantation and living-related conjunctival limbal allograft (lr-CLAL) transplantation for bilateral severe/total limbal stem cell deficiency (LSCD).

    Methods: Literature searches were last conducted in the PubMed database in February 2023 and were limited to the English language. They yielded 523 citations; 76 were reviewed in full text, and 21 met the inclusion criteria. Two studies were rated level II, and the remaining 19 studies were rated level III. There were no level I studies.

    Results: After KLAL surgery, best-corrected visual acuity (BCVA) improved in 42% to 92% of eyes at final follow-up (range, 12–95 months). The BCVA was unchanged in 17% to 39% of eyes and decreased in 8% to 29% of eyes. Two of 14 studies that evaluated the results of KLAL reported a notable decline in visual acuity over time postoperatively. Survival of KLAL was variable, ranging from 21% to 90% at last follow-up (range, 12–95 months) and decreased over time. For patients undergoing lr-CLAL surgery, BCVA improved in 31% to 100% of eyes at final follow-up (range, 16–49 months). Of the 9 studies evaluating lr-CLAL, 4 reported BCVA unchanged in 30% to 39% of patients, and 3 reported a decline in BCVA in 8% to 10% of patients. The survival rate of lr-CLAL ranged from 50% to 100% at final follow-up (range, 16–49 months). The most common complications were postoperative elevation of intraocular pressure, persistent epithelial defects, and acute allograft immune rejections.

    Conclusions: Given limited options for patients with bilateral LSCD, both KLAL and lr-CLAL are viable choices that may provide improvement of vision and ocular surface findings. The studies trend toward a lower rejection rate and graft failure with lr-CLAL. However, the level and duration of immunosuppression vary widely between the studies and may impact allograft rejections and long-term graft survival. Complications related to immunosuppression are minimal. Repeat surgery may be needed to maintain a viable ocular surface. Reasonable long-term success can be achieved with both KLAL and lr-CLAL with appropriate systemic immunosuppression.

    1UC Davis Eye Center, University of California, Davis, California
    2Associate Professor of Ophthalmology, Department of Ophthalmology and Visual Science, University of Illinois College of Medicine, Chicago, Illinois 
    3Department of Ophthalmology and Visual Sciences, Carver College of Medicine and Institute for Vision Research, University of Iowa, Iowa City, Iowa 
    4Duke Eye Center, Duke University Medical Center, Durham, North Carolina
    5Department of Ophthalmology, Mayo Clinic, Jacksonville, Florida 
    6Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, Michigan 
    7Department of Ophthalmology & Visual Sciences, The University of Chicago, Chicago, Illinois 
    8Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts 
    9Department of Ophthalmology, Vanderbilt University School of Medicine, Nashville, Tennessee 
    10Department of Ophthalmology, Mayo Clinic, Scottsdale, Arizona