Simple limbal epithelial transplantation (SLET): a novel surgical technique for the treatment of unilateral limbal stem cell deficiency

Abstract

This study describes a novel surgical technique of limbal transplantation, which combines the benefits of existing techniques while avoiding their difficulties. Six patients with unilateral and total limbal stem cell deficiency following ocular surface burns underwent a single-stage procedure. A 2 × 2 mm strip of donor limbal tissue was obtained from the healthy eye and divided into eight to ten small pieces. After surgical preparation of the recipient ocular surface, these tiny limbal transplants were distributed evenly over an amniotic membrane placed on the cornea. After surgery, a completely epithelialised, avascular and stable corneal surface was seen in all recipient eyes by 6 weeks, and this was maintained at a mean ± SD follow-up of 9.2 ± 1.9 months. Visual acuity improved from worse than 20/200 in all recipient eyes before surgery to 20/60 or better in four (66.6%) eyes, while none of the donor eyes developed any complications. This technique requires less donor tissue than previously used for conventional autografting and does not need a specialist laboratory for cell expansion. Although long-term results are awaited, this simple limbal epithelial transplantation promises to be an easy and effective technique for treating unilateral limbal stem cell deficiency following ocular burns.

Concise Review: The Coming of Age of Stem Cell Treatment for Corneal Surface Damage

“…In a clinical trial conducted on six patients, a stable, epithelialized, and avascular ocular surface was observed within 6 weeks after surgery. A 11-month follow-up of the patients showed restoration of a stable epithelial surface plus considerable improvement in the visual acuity of all patients and no complications [21]. This work was replicated by another group in four patients, and similar outcomes were found in terms of visual improvement and stable ocular surface regeneration [22].…”

“…As shown in Figure 3, SLET is a one-step surgical procedure in which a limbal biopsy of 2 3 2 mm is obtained from the healthy eye, chopped into small pieces, stuck to the hAM using fibrin glue, and then placed on the prepared recipient cornea [21]. The growth of cells occurs in situ instead of in a laboratory.…”

“…Expenses incurred in CLET include clean-room facilities, nutrient medium, and trained personnel for the culture of the cells. Simple limbal epithelial transplantation (SLET) is a surgical technique that has been introduced to reduce the cost of treatment for LSCD without compromising the visual outcomes [21].…”

Evaluation of the AlgerBrush II rotating burr as a tool for inducing ocular surface failure in the New Zealand White rabbit

“…Subsequently, this species has been used to examine the efficacy of epithelial tissue transplants for the treatment of LSCD (Schwab, 1999). Refinements of this technology over the last two decades have led to the establishment of methods for the treatment of LSCD in several clinics around the world (Harkin et al, 2013;Pellegrini et al, 1997;Sangwan et al, 2012;Schwab, 1999;Shimazaki et al, 2002;Shortt et al, 2007;Zakaria et al, 2010). While there are significant variations in methodology, each treatment strategy is ultimately built around the engraftment of epithelial progenitor cells to replace those lost through disease and trauma.…”

“…In other words, it may well be possible to mimic the effects of seeding of small epithelial clusters akin to the recent innovation of seeding small fragments of autologous limbus for the treatment of LSCD (i.e. simple limbal epithelial transplant or SLET (Sangwan et al, 2012)). Whatever the explanation, since traces of keratin 3 positive cells were sporadically observed in all completely wounded animals (R1 to R3), we must conclude that the level of epithelial cell removal achieved using the Algerbrush II is less than 100%.…”