Journal of Stem Cells and Regenerative Medicine (Jan 2009)
Ocular Surface Reconstruction: Recent Innovations
Abstract
The ocular surface is exceptionally rich in complexity and functionality. Severe ocular surface disorders/conditions, such as chemical or thermal injuries, Stevens-Johnson syndrome (SJS), ocular cicatricial pemphigoid, neurotrophic keratopathy, chronic limbitis, and severe microbial keratitis cause significant morbidities and even corneal blindness. Hypofunction may be caused by Aniridia, Neurotrophy, Endocrine, Pterygium and Chronic limbitis Approximately 6000 patients are seen in Ocular Surface Clinic every year; almost 80% have some form of dry eyes. About 125 new patients of Stevens Johnson Syndrome are seen in a year of which approximately 25% may benefit from Cultured Epithelial Transplant and 75 new patients of thermal/chemical injury in a year of which almost 80% will benefit from Stem Cell Transplantation. Of the 128 severe vernal keratoconjunctivitis which were seen in the ocular surface clinic, 10% require stem cell transplantation. Nearly 30 new cases of Ocular cicatrical pemphigoid every year are seen and they may need stem cell transplantation. In addition, several patients with persistent epithelial defects may benefit from limbal stem cell transplantation to alleviate, maintain conjunctivalization regression and corneal avascularity limbal deficiency, and restore vision. Even if granted that this statistics is for a single large ophthalmic hospital, for a large country as India with 1.1 billion populations, the number of patients requiring corneal stem cell transplantation is enormous. Stem cells in the palisades of Vogt participate in regeneration and preservation of corneal transparency and avascularity. The diminished regenerative capacity seen in LSCD is characterized by persistent epithelial defects, erosion and ulceration, conjunctivalization and neovascularization, and chronic inflammation. Standard corneal transplantation for restoration of corneal clarity and avascularity is a contraindication in the surgical management protocol of LSCD patients. Autologous limbal transplantation Despite its success, its utility is limited. the requirement for a sizable limbal donation; up to 30-40% must be harvested from the contralateral donor eye and its harvest may theoretically harm the structural integrity, cause subclinical LSCD or cryptogenic changes in the donor eye. Ex vivo expansion and cultivation techniques for autologous limbal stem cells are being actively investigated. , the use of human AM for ocular surface regeneration (OSR) and as a growth support substrate for ex vivo expansion of autologous corneal equivalent epithelial cells and their successful OSR in animal cornea model, as well as human, was reported. The conventional cultivation methods for corneal epithelial tissues for clinical transplantation applications involve utilization of xenobiotic materials such as fetal bovine serum (FBS) and murine-derived feeder cells. FBS-free culture systems have been developed to reduce the risk of zoonotic infection, but these have the disadvantage of reduced efficacy for cell propagation. it must be emphasized that AMT is not a substitution for LSCT and AMT should not be performed when true LSCD exists because AM only provides a supportive matrix for the limbal stem cells to migrate, proliferate and restore the corneal surface. There are several disadvantages of AMT and LSCT technique. This delicate procedure requires technical skill for the preparation of AM with attached corneal epithelial cells and surgical dexterity to manipulate the AM onto the ocular surface.A rabbit model for transplantation of cultivated corneal limbal stem cells onto corneal stem cell deficient animals was developed & its results are very encouraging for similar studies in human corneal surface reconstruction. Our investigations indicated that Ex vivo cultivation of human corneal limbal stem cells (HCLSC) occurred with ease in the thermoresponsive biodegradable gel - “Mebiol Gel”. The growth rate within Mebiol Gel varied from 8 - 10 days to develop a monolayer formation with all the HCLT from different eye donors five - six times more than HCLSC multiplying on human amniotic membrane & the cultivated cells were identifiable as Corneal stem cells, Transient amplifying cells, Pluripotent cells and Mature corneal epithelial cells. Cells cultivated within Mebiol Gel can be used for Therapeutic purposes with a distinct possibility of avoiding a human tissue in the form of human amniotic membrane. The rabbit model study can be replicated in human corneal surface reconstruction with corneal limbal stem cells cultivated in Mebiol Gel to CLCD patients.
