Patients need to receive treatment for any present ocular surface comorbidities before undergoing surgery for limbal stem cell deficiency (LSCD), The International Limbal Stem Cell Deficiency Working Group wrote in its global consensus report of a systematic approach for the disease’s therapy in Cornea. The group analyzed treatment options and determined criteria that LSCD treatment options need to meet to be part of the consensus.
While no topical or oral medication can directly replenish limbal stem cells (LSC), treating patients’ ocular surface comorbidities can help restore any residual LSCs and aid in the survival of any transplanted LSCs, according to investigators. They recommended a 4-step process of optimizing the ocular surface to manage LSCD with ocular surface comorbidity prior to surgery:
1. Treat any abnormalities present in the eyelids and or conjunctiva, which often calls for a multi-disciplinary approach to treatment.
2. Control ocular surface inflammation using treatments such as anti-inflammatory drugs or adjuvant therapies, such as amniotic membrane transplantation.
3. Restore the tear film function with treatments such as preservative-free lubricants, punctal occlusion, blood-based eye drops and, in severe cases of dry eye disease, lateral or medial canthoplasty or tarsorrhaphy or salivary gland transplantation. Management of meibomian gland dysfunction with treatments such as localized lid hygiene, warm compresses, eyelid scrubs, topical, and systemic anti-inflammatory treatments.
4. Maintain the ocular surface epithelium homeostasis. Vitamin A, blood-based eye drops, and therapeutic contact lenses can be helpful treatments.
Surgery is often necessary when LSCD has significantly compromised vision, and the surgical interventions that are most appropriate depend on the severity of the disease. For patients with unilateral or bilateral stages I and IIA LSCD, surgical interventions short of LSC transplantation can aid in the reepithelization of the central corneal surface, or preferentially replace the central visual axis of the cornea with existing or remaining corneal phenotypic epithelium. These interventions include, sequential sectorial conjunctival epitheliectomy (a treatment for partial LSCD) and amniotic membrane transplantation.
Patients in stages IIB and III may require LSC transplantation options include autologous transplantation procedures and, in some bilateral cases,keratoprosthesis or cultivated oral mucosal epithelial transplantation (COMET)
The authors also recommended ophthalmologists involve corneal specialists with expertise in LSCD in the treatment of the disease.
Calcineurin blockers and antimetabolites can help minimize use of systemic corticosteroids after surgery, and valganciclovir and trimethoprim/sufamethoxazole can be used for infection prophylaxis against cytomegalovirus and Pneumocystis jirovecii.
A scleral contact lens is the preferred option for visual rehabilitation after transplantation, but procedures such as optical penetrating keratoplasty or deep anterior lamella keratoplasty may also be useful in some cases. Intraocular pressure should be monitored as glaucoma is a comorbidity of postsurgical treatment of LSCD.
The authors said further research is being done to investigate the use of mesenchymal stem cells, small molecules, growth factors, microRNAs, residual LSCs by ex vivo cultivation, oral mucosa epithelial cells, adipose tissue-derived mesenchymal stem cells, embryonic stem cells, and induced pluripotent stem cells for treatment of LSCD.
Deng S, Kruse F, Gomes J, et al. Global consensus on the management of limbal stem cell deficiency. Cornea. 2020;39(10):1291-1302. doi: 10.1097/ICO.0000000000002358