An Evidence–Based Review of Surgical Interventions for Limbal Stem Cell Deficiency

Abstract

Abstract: : Purpose:To assess quality of reporting in the world literature on surgical management of limbal stem cell deficiency (LSCD). Methods: All studies published in the English language concerning surgical intervention for limbal stem cell deficiency were identified using MEDLINE, EMBASE, Science citation index, Biosis, and The Cochrane Library. Only studies evaluating 15 eyes or greater were included. All animal and scientific studies, reviews, and conference abstracts were excluded. A data extraction form was used to collate data on study design, numbers, diagnoses, follow up, surgical intervention and clinical outcome. The main clinical outcome was improvement in vision of at least two lines of Snellen visual acuity. A strength of evidence rating was given according to The American Academy of Ophthalmology's guidelines. GradeIrepresents well conducted randomised controled trials, II substantial evidence lacking level I evidence, and III consensus of expert opinion or small retrospective case series. A grading of A to C reflected importance of intervention to clinical outcome. A is very important, B moderately important and C not critical to clinical outcome. Results:1017 studies were identified in the preliminary search. All abstracts were reviewed, of which 44 were deemed suitable for further evaluation. All 44 original articles were reviewed with 18 satisfying our inclusion criteria. These 18 publications were assessed in detail using the data extraction form mentioned earlier.There were no randomised controled trials. All 18 studies were non comparitive case series. 14 papers looked at intervention for total LSCD, 2 at partial and total LSCD, with only one paper assessing partial LSCD only. It was unclear in one paper what severity of LSCD was being looked at. 14/18 (78%) of studies were graded as IIIC. 4/18 (22%) were graded at IIIB. Two of the IIIB studies were assessing management of unilateral total LSCD. One study used conjuctival limbal autograft and concomitant deep lamellar keratoplasty, whilst the other used ex–vivo expanded autologous limbal sytem cell transplantation. One IIIB study used amniotic membrane transplantation alone for partial LSCD with good outcomes. The final IIIB study used keratolimbal allograft and amniotic membrane transplantation with systemic immunosupression. Conclusions: The overall quality of reporting was poor. No clear recommendations can be made on the surgical treatment of partial or total limbal stem cell deficiency. Multicentered well designed randomised controled trials are required to provide the evidence–base for clinical recommendations.

Keywords: cornea: epithelium