Nancy Hemphill, ELS, FAAO , 2025-04-29 18:00:00
April 29, 2025
3 min read
Key takeaways:
- Living-related conjunctival limbal allograft allows for tissue typing and reduces rejection.
- The specialist team needs to include a transplant coordinator.
LOS ANGELES — Living-related conjunctival limbal allograft should be first-line therapy for limbal stem cell deficiency, Edward J. Holland, MD, said during Cornea Day at the American Society of Cataract and Refractive Surgery meeting.
Holland, a professor of ophthalmology at the University of Cincinnati and director of cornea and external disease at the Cincinnati Eye Institute, presented the inaugural Holland Lecture, the first named lecture for the subspecialty day.
Image: Nancy Hemphill
Penetrating keratoplasty is the most common surgery performed for total limbal deficiency; however, it is never successful, he said.
Holland conducted a 22-year chart review in his practice, finding nearly 1,600 eyes with limbal stem cell deficiency that were improperly managed and referred to his practice. Diagnoses were delayed or incorrect, or the wrong treatment was administered.
The procedures that failed included PK, superficial keratectomy and amniotic membrane transplantation, Boston KPro and simple limbal epithelial transplantation.
“There were two patients I saw in 1 week that helped me decide to change my course of how I wanted to lead the education,” Holland said.
One was a 65-year-old with aniridia, total limbal deficiency, severe glaucoma and 13 failed PKs. The other was a 45-year-old with Stevens-Johnson syndrome, symblepharon, inflammation, total limbal deficiency, an enucleated left eye, and seven failed PKs in the right eye and seven failed PKs in the left eye.
“When do you say maybe we should do something different?” Holland asked.
Repeated, failed PKs can cause additional complications such as inflammation, glaucoma, cataract and retinal detachment, he said.
“Our standard procedures now are a living-related conjunctival limbal allograft with a tissue-matched donor,” Holland said, “and one we did a lot in the beginning, keratolimbal allograft with a deceased donor. In the worst eyes, we combine these with what we termed the ‘Cincinnati Procedure.’ … We thought we could prevent rejection, but we didn’t do it right; then we finally went to the team that invented transplant rejection management, and that’s the renal team.”
Holland said collaboration is critical for success, with the cornea surgeon as the quarterback.
With the Cincinnati Procedure, “You need a team of specialists: cornea, glaucoma, retina, oculoplastics,” he said. “You need to be all in on the preoperative screening, the protocols, the testing of donors, and you need to have a renal specialist to help you with those difficult choices, like who’s the best donor. The missing person that ties the whole thing together is the transplant coordinator that the renal team always has.
“These patients are very complicated,” Holland continued. “Many phone calls, side effects of medications, other appointments. A corneal surgeon can’t do it; the corneal surgeon’s office people can’t do it. Somebody has to be dedicated. That’s what renal does, and that’s what we do.”
Holland said living-related conjunctival limbal allograft (LR-CLAL) allows for tissue typing and reduces rejection.
“Plus, if we’re managing conjunctival disease, we need conjunctiva, not just limbus,” he said. “This is our procedure of choice. … We’re getting conjunctival stem cells; we’re getting goblet cells. It turns these eyes into a better ocular surface.”
He noted that a keratolimbal allograft has a 71% success rate, while LR-CLAL with a good match has an 88% success rate.
“The success rate with [LR-CLAL] has really changed the game,” Holland said. “We’re so confident that we can follow these patients carefully, we started doing children. … We’ve done over 25 children with systemic immunosuppression. We get long-term success.”
The surgery is challenging, reimbursement is “terrible,” patients require a lot of time, and “surgeons don’t want to operate on normal eyes because we keep propagating a fear that taking cells from a normal eye will make it go blind,” he said.
“We can all do this. You just have to partner with the right people. … I think this should be first-line therapy.”
Sources/Disclosures
Collapse
Holland EJ. Facing the challenges of managing severe ocular surface disease. Presented at: American Society of Cataract and Refractive Surgery meeting; April 25-28, 2025; Los Angeles.
Disclosures:
Holland reports having financial disclosures for Alcon and Aurion Biotech.
