En Bloc Keratolimbal Allograft and Central Lamellar Keratoplasty: A Novel Surgical Technique in Chronic and Delayed-Onset Mustard Gas Keratopathy
Mohammadreza Arzaghi1 , Kiana Hassanpour1 , Farid Karimian1 *, Zahra Karjou1
- Ophthalmic Research Center, Research Institute for Ophthalmology and Vision Science, Shahid Beheshti University of Medical Sciences, Tehran, Iran
Abstract: This study introduces a novel surgical technique, the "en bloc procedure," combining 270-degree keratolimbal allograft with Central lamellar keratoplasty (KLAL+CLK), for managing severe limbal stem cell deficiency (LSCD) secondary to chronic and delayed-onset mustard gas keratopathy (MGK). The purpose is to investigate the long-term outcomes and potential benefits of this innovative approach.
Methods: Besides the introduction of the surgical technique, a retrospective interventional case series was conducted at a tertiary referral center in Tehran, Iran, spanning from 2002 to 2019. Thirteen eyes of 13 male patients with chronic and delayed-onset MGK underwent the en bloc KLAL and central lamellar keratoplasty procedure. During the procedure, 270-degree limbal area 2mm from the limbus was marked. The incision was started from the superior quadrants. Lamellar dissection was performed using a crescent blade and later a blunt dissector. One fresh whole globe with appropriate intact 360-degree conjunctiva was used to prepare the same-shaped donor tissue. The ocular surface integrity and best-corrected visual acuity were the clinical outcomes.
Results: After an average follow-up of 87.6 ± 49.8 months, surgical success was achieved in 12 out of 13 patients (92.3%), characterized by an integrated ocular surface without epitheliopathy and a clear central cornea. Preoperative best-corrected visual acuity (BCVA) improved from 1.07 ± 0.24 (20/250) logMAR to 0.63 ± 0.30 (20/80) logMAR. In total, one patient experienced an immune rejection episode in the KLAL, and two patients experienced a corneal rejection episode, all of which were successfully managed with aggressive immunosuppression. None of the patients required anti-glaucoma medication during the follow-up period.
Conclusion: The “en bloc KLAL+CLK” with combining 270-degree KLAL with central lamellar keratoplasty offers promising long-term outcomes in the management of chronic and delayed-onset MGK associated with severe LSCD. This approach demonstrates improved surgical complexity, reduced antigenic load, and anatomical alignment, resulting in successful integration of the ocular surface and improved visual acuity.
