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Surgical rehabilitation following ocular chemical

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ARTICLE in CUTANEOUS AND OCULAR TOXICOLOGY MAY 2013
Impact Factor: 1.12 DOI: 10.3109/15569527.2013.796477 Source: PubMed

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Zuleyha Yalniz-Akkaya

T.C. Salk Bakanl Ankara Eitim ve Arat

T.C. Salk Bakanl Ankara Eitim ve Arat

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Cukurova University

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ISSN: 1556-9527 (print), 1556-9535 (electronic)
Cutan Ocul Toxicol, Early Online: 17
! 2013 Informa Healthcare USA, Inc. DOI: 10.3109/15569527.2013.796477

RESEARCH ARTICLE

Surgical rehabilitation following ocular chemical injury

Ayse Burcu1, Zuleyha Yalniz-Akkaya1, Muhammet Fatih Ozdemir1, Elif Erdem2, Mehmet Mustafa Onat1, and
Firdevs Ornek1
Department of Ophthalmology, MH Ankara Training and Research Hospital, Ankara, Turkey and 2Department of Ophthalmology, Faculty of
Medicine, Cukurova University, Adana, Turkey
Abstract

Keywords

Purpose: The purpose of this study is to evaluate the management of limbal stem cell deficiency
(LSCD) secondary to chemical ocular burns.
Materials and methods: The charts of 48 eyes of 40 patients with grade 2 or higher chemical
injury were evaluated retrospectively. Subjects with follow-up longer than 1 year were
included. Medical treatment, surgical correction of abnormalities of ocular adnexial structures,
limbal stem cell transplantation from patients fellow eye, from living relatives or from cadaveric
donor, amniotic membrane transplantation, conjunctival epitheliectomy, chelation with
ethylenediaminetetraacetic acid and penetrating keratoplasty were the treatment modalities.
Outcome measures were ocular surface stability and corrected distance visual acuity (CDVA).
Failure was defined as the appearance of persistent epithelial defect (nonhealing epithelial
defect for more than 2 weeks) with progressive corneal conjunctivalization/vascularization and
thinning, and also progression of conjunctivalization to the central 6 mm of the cornea in eyes
with subsequent keratoplasty.
Results: The mean age of 31 male and 9 female patients were 32.32  12.6 years. LSCD was
bilateral in 8 cases. The mean follow-up was 77.2  35.1 months. The presentations were in
acute phase in 37.5%, in subacute phase in 32.5% and in chronic phase in 30% of the patients.
Only 13 of 48 (27.1%) eyes obtained sufficient ocular surface stability through medical
treatment; however, only 5 of these eyes achieved CDVA of less than 0.7 logMAR. Limbal stem
cell transplantation was performed in 26 eyes as conjunctival limbal autograft, living-related
conjunctival limbal allograft and keratolimbal allograft or as a combination of these
transplantations. At the last visit, 30 eyes (62.5%) had an intact and stable ocular surface.
Clear cornea was achieved in 11 (78.6%) of 14 eyes with grade 2 injury, in 9 (60%) of 15 eyes
with grade 3 injury, in 5 (50%) of 10 eyes with grade 4 injury, in 1 (16.6%) of 6 eyes with grade 5
injury and in 1 (33.3%) of 3 eyes with grade 6 injury. The CDVA that was 1.66  0.99 logMAR
initially improved to 0.87  0.85 logMAR at the last visit (p50.001).
Conclusion: While patients with low-grade chemical injury seem to benefit quite well from the
medical treatment, amniotic membrane transplantation, limbal graft transplantation and
subsequent keratoplasty; patients with severe injuries seem to be more prone to failure after all
of the available treatment modalities.

Acid injury, alkali injury, amniotic membrane

transplantation, chemical injury,
keratolimbal transplantation, limbal stem
cell deficiency, limbal stem cell
transplantation, living-related limbal
transplantation

Introduction
Chemical injuries to the eye are common and represent a true
ophthalmic emergency. Proper management in the acute
setting as well as follow-up by an ophthalmologist is crucial
in limiting the adverse effects of ocular tissue damage
secondary to the chemicals. The clinical course after chemical
injury progresses through three distinct phases: acute (07 d);
early repair (721 d) and late repair (421 d)1. The healing
pattern occurring during these phases correlates with the
original degree of limbal stem cell injury and provides
support for subsequent therapeutic decisions. Various ocular

History
Received 20 January 2013
Revised 18 March 2013
Accepted 12 April 2013
Published online 28 May 2013

20
13

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surface transplantation techniques have improved the management and prognosis of severely chemically injured eyes.
Limbal autograft and allograft transplantation can restore
depleted limbal stem cell population, and normal corneal
phenotype can be reestablished27. Similarly, amniotic membrane transplantation can enhance corneal epithelial migration, reduce limbal inflammation and augment the function of
surviving or transplanted limbal stem cells810.
Herein, we seek to investigate treatment approaches
associated with the clinical course and the degree of limbal
deficiency secondary to chemical ocular burns.

Materials and methods

Address for correspondence: Ayse Burcu, Department of Ophthalmology, MH Ankara Training and Research Hospital, Ankara, Turkey.
E-mail: anurozler@yahoo.com.tr

Forty-eight eyes of 40 inpatients with chemical burns of the

cornea and conjunctiva from 1998 to 2010 were reviewed

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A. Burcu et al.

according to the Declaration of Helsinki after the approval of

the institutional board. The hospital inpatient charts were
reviewed to determine the age, sex, elapsed time between the
injury and the clinical application, causes of chemical injury,
place of residence of the patient, initial corrected distance
visual acuity (CDVA), treatment methods, limbal function,
complications of chemical injury, performed operations,
stability of ocular surface, clarity of cornea and final
CDVA. Subjects with follow-up shorter than 1 year were
excluded.
Limbal function was evaluated through one or more of the
following: clinical slit lamp examination with fluorescein
stain to detect conjunctival epithelium over the cornea,
absence of limbal palisades of Vogt, peripheral superficial
neovascularization and corneal impression cytology for the
presence of goblet cells on the corneal surface.
Staging of the injury was done retrospectively, according
to the new classification by Dua et al.11. The extent of limbal
involvement was determined in clock hours, and conjunctival
involvement was estimated by dividing the bulbar and
forniceal conjunctiva into quadrants and determining the
area involved using patients photographs and inpatients
charts.
To prevent corneal exposure, entropion correction, symblepharon lysis and fornix reconstruction have been performed before the limbal stem cell transplantation.
Conjunctivolimbal autograft was performed under general
anesthesia in patients with limbal dysfunction who had
unilateral injury. All fibrotic conjunctival tissue was excised,
and sclera and corneal stroma was exposed. The cryopreserved amniotic membrane has been extended on the denuded
corneal surface and secured using 10-0 nylon sutures (Alcon
Laboratories Inc., Fort Worth, TX) to the limbus and sclera in
some cases. A tissue pair was obtained from the 6 and 12
oclock positions, and the tenon capsule was left intact. A
conjunctival flap of approximately 5  5 mm was excised
from an opposite healthy eye, and adjacent superficial limbal
tissue was also excised using a surgical knife. The grafts were
transferred onto the injured eye at the 6 oclock and 12
oclock limbal areas. A single graft was used in 100 120 in
14 cases. They were secured using 10-0 nylon sutures to the
sclera at the limbal edge and recipient conjunctival edge. At
the end of the surgery, a soft bandage contact lens was placed
to protect the ocular surface. Subconjunctival antibiotics and
corticosteroids were injected. Limbal allograft transplantation
was performed similar to the conventional conjunctivolimbal
autograft in eyes with continuing limbal failure after
conjunctivolimbal autograft or bilateral injured eyes.
Heterologous limbal tissue was obtained from a cadaveric
donor or live relatives without human leukocyte antigen
(HLA) matching. A 360 corneoscleral ring after a conventional 7.5 mm trephination of a cadaveric donor buton was
used in a bilaterally injured patient with total limbal stem cell
deficiency (LSCD). Penetrating keratoplasty (PK) was not
performed simultaneously with limbal stem cell transplantation in any eyes.
Postoperatively, topical ofloxacin 0.3% (Exocin, Allergan
Pharmaceuticals Inc., County Mayo, Ireland) and prednisolone acetate 1% (Pred Forte, Allergan Pharmaceuticals Inc.,
County Mayo, Ireland) or unpreserved dexamethasone 0.1%

Cutan Ocul Toxicol, Early Online: 17

(Dexasine SE, Laboratoirs Alcon, Kaysersberg, France) were

applied four times a day. Treatment with ofloxacin was
discontinued when epithelization was completed but was
restarted if there was a corneal epithelial defect. Topical
corticosteroid dosage was tapered off in 23 months after
ocular surface became uninflamed. In limbal allograft transplantation, systemic fluocortolone (Ultralan-Oral, Bayer
Turk, Istanbul, Turkey) was added to the previously described
treatment and was tapered from 80 mg/d in 1 month. Systemic
cyclosporine A (Sandimmun-Neoral, Novartis Pharma A.G.,
Basel, Switzerland) starting from 3 mg/kg was used for
approximately 612 months. The blood cyclosporine level
was maintained at 100 ng/ml unless systemic adverse effects
developed. Topical cyclosporine (Restasis 0.05%, Allergan,
East Brunswick, NJ) was applied topically four times a day
for 1 year.
PK and/or cataract surgery were performed in some cases
after ocular surface stability was maintained. When endothelial graft rejection developed, patients were treated with
intensive therapy consisting of hourly instillation of 1%
prednisolone acetate eye drops (tapered to the previous
dosage in 1 months time), a single dose of 500 mg/d
intravenous methylprednisolone and then systemic fluocortolone (tapered from 12 mg/kg body weight/d in 1 month).
Visual acuities, measured using a Snellen chart and
recorded in decimal notation, were converted to the logarithm
of the minimum angle of resolution (logMAR) units for
statistical analysis. Visual acuity of counting fingers was
converted to 2.00 log MAR, and hand motion was converted
to 3.00 log MAR12.
Outcome measures included ocular surface stability, corneal clarity and visual success. Failure was defined as the
appearance of persistent epithelial defect (PED) (nonhealing
epithelial defect for more than 2 weeks) with progressive
corneal conjunctivalization/vascularization and thinning. In
eyes with subsequent keratoplasty, progression of conjunctivalization to the central 6 mm of the cornea, which could be
associated with epithelial disintegrity including PED and
recurrent epithelial erosions, was considered a mark of failure.
Visual success was defined as the improvement in CDVA 1 or
more Snellen lines in the traumatized eye compared with the
initial level, at the end of the follow-up period.

Results
Causes of chemical injuries and demographic characteristics
of patients are shown in Table 1. There were 31 male (77.5%)
and 9 female (22.5%) patients with a mean age of
32.32  12.6 years. The mean follow-up time was
77.2  35.1 months (range, 26186).
Concerning the accidents, 12 (30%) happened at home, 27
(67.5%) occurred at work and one patient (2.5%) who had
bilateral injury suffered from acid attack by her husband. The
interval between the injury and presentation for treatment
varied: 37.5% of the patients presented within the acute phase,
32.5% within the subacute phase and 30% within the chronic
phase of the injury.
Chemical injury-related complications and surgical procedures for the treatment of these complications are presented
in Tables 2 and 3, respectively. Only 13 of 48 (27.1%)

Ocular chemical injury

DOI: 10.3109/15569527.2013.796477

Table 1. Demographic characteristics of patients.

Characteristic

n (%)

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Causative agent
Alkali
Acid
Location of patients at the time of injury
Home
Work
Attack
Age (years)
015
1630
3145
4661
Sex
Male
Female

35 (87.5)
5 (12.5)
12 (30)
27 (67.5)
1 (2.5)
3
18
13
6

(7.5)
(45)
(32.5)
(15)

31 (77.5)
9 (22.5)

Table 2. Ocular complications of chemical eye injuries.

Complications

Corneal scar
PED, corneal ulcer
Symblepharon
Glaucoma
Cataract
Entropion
Corneal perforation

21
13
7
5
6
4
1

52.5
32.5
17.5
10.4
12.5
10
2.5

PED persistent epithelial defect.

Table 3. Surgical procedures for complications of chemical eye injuries.
Surgery

Limbal transplantation
CLAU
CLAU lrCLAL
lrCLAL
CLAU KLAL
KLAL
Amniotic membrane transplantation
PK
Symblepharon release
Cataract surgery
Epitheliectomy
Chelation with EDTA
Evisceration
Glaucoma drainage device
Tenonplasty

26
16
4
3
1
2
14
13
7
6
3
3
2
2
1

54.2
33.3
8.3
6.3
2.1
4.2
29.1
27.1
14.6
12.5
6.3
6.3
4.2
4.2
2.1

CLAU conjunctival limbal autograft, EDTA ethylenediaminetetraacetic acid, KLAL keratolimbal allograft, lrCLAL living-related
conjunctival limbal allograft, PK penetrating keratopalsty.

eyes obtained sufficient ocular surface stability through

medical treatment; however, only 5 of these eyes achieved
CDVA of less than 0.7 logMAR. Thirty-five eyes (73%)
underwent at least one surgery. Combined or recurrent
surgical treatments were necessary in 24 eyes (50%).
Amniotic membrane transplantation (14 eyes, 22 transplantations), chelation with ethylenediaminetetraacetic acid
(3 eyes), conjunctival epitheliectomy after limbal transplantation (3 eyes), tenoplasty (1 eye), entropion reconstruction (4
eyes) and fornix reconstruction for symblepharon (7 eyes)
were the additional surgical procedures for obtaining sufficient ocular surface stability.

LSCD was bilateral in 8 and unilateral in 20 patients.

Patients representing 10 eyes refused to have limbal stem cell
transplantation. Limbal stem cell transplantation was performed in 26 eyes: 16 conjunctival limbal autograft (CLAU),
4 CLAU and living-related conjunctival limbal allograft
(lrCLAL), 3 lrCLAL, 1 CLAU and keratolimbal allograft
(KLAL) and 2 KLAL. Some case examples are presented in
Figures 1 and 2. Limbal deficiency persisted in 2 of 16 CLAU
eyes, which had grade 4 injury. Vascularized leukoma
developed in these 2 eyes. Limbal deficiency recurred in 2
eyes after PK, which was performed following the achievement of ocular stability with limbal transplantation. Ocular
surface stability was not achieved in 1 of 4 eyes which
underwent both CLAU and lrCLAL, which had a grade 5
injury. Three patients with bilateral injury achieved acceptable CDVA and ocular surface stability following lrCLAL.
Ocular surface stability was not achieved in a patient with
bilateral injury (grade 5 and grade 6) following the
keratolimbal allograft. At the last visit, 30 eyes (62.5%) had
an intact and stable ocular surface. We did not have any case
with pseudopterygium formation and partial stem cell deficiency at the donor site.
Fifteen PKs were performed in 13 eyes at least 6 months
after limbal transplantation (19.9  12.4 months). The procedure was repeated in two eyes because of graft failure.
Corneal endothelial graft rejection was observed in 7 eyes, 2 of
which failed despite therapy. Five eyes experienced graft
failure because of recurrence of LSCD after PK. Sectoral
conjunctivalization/vascularization appeared slowly over the
graft, which extended to the visual axis in 4 of them, and
evisceration was performed in one eye because of PED-related
corneal melting which aggravated after cataract surgery. At the
final visit, 6 eyes had clear grafts with sufficient CDVA.
The patient who suffered from bilateral acid attack
underwent left evisceration due to total limbal ischemia and
extensive corneal melting at the early stage.
For visual rehabilitation, cataract extraction and intraocular lens implantation were performed in 6 eyes. Intraocular
pressure was controlled medically in 3 eyes and by implantation of Ahmed glaucoma valve in 2 eyes. One of these
patients had Ahmed glaucoma valve 83 months after chemical
injury and is continuing on double antiglaucoma medication
therapy. The other patient had Ahmed glaucoma valve 19
months after chemical injury and had glaucoma control
without medication.
Clear cornea was achieved in 11 (78.6%) of 14 eyes with
grade 2 injury, in 9 (60%) of 15 eyes with grade 3 injury, in 5
(50%) of 10 eyes with grade 4 injury, in 1 (16.6%) of 6 eyes
with grade 5 injury and in 1 (33.3%) of 3 eyes with grade 6
injury clear cornea was achieved. The mean initial CDVA was
1.66  0.99 logMAR. Nine eyes (18.8%) had 0.7 logMAR or
less initial visual acuity. The mean CDVA was 0.87  0.85
logMAR at the last visit. There was statistical difference
between the initial and last CDVAs (p50.001). At the end of
the study, 0.7 logMAR or less CDVA was obtained in 27 eyes
(56.3%) (Table 4). The cause of limbal deficiency was found
to have a major effect on the final visual outcome in 16 eyes,
endothelial rejection in 2 eyes and mild central localized haze
in 1 eye. Clinical characteristics of the patients are detailed in
the Supplemental Table.

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A. Burcu et al.

Cutan Ocul Toxicol, Early Online: 17

Figure 1. Patients with grade-3 alkali burn. Upper row (Patient 31, left eye): (a) The LSCD of the superior quadrant after 8 months. (b) Superior
quadrant after 2 days following 120 conjunctivolimbal autograft. (c) Vascularization after 11 months of the inferonasal quadrant. (d) Inferonasal
quadrant after epitheliectomy. Middle row (Patient 38, right eye): (e) Subacute phase. (f) Vascularization at the nasal quadrant 10 months after chelation
with ethylenediaminetetraacetic acid and twice amniotic membrane transplantation. (g) Seven days after 120 conjunctivolimbal autograft to nasal
quadrant. (h) Fourteen months following conjunctivolimbal autograft. Lower row (Patient 5, left eye): (j) Eleven months after injury. (k and l) Livingrelated conjunctivolimbal allograft (lrCLAL) to superior and inferior quadrant from mother. (m) Forty-six months after lrCLAL with CDVA of 0.4
logMAR.

Discussion
The management of chemical burns is contingent upon the
time elapsed from the injury. Treatment requires medical and
surgical interventions that correlate with the extent of damage
for maximal visual rehabilitation (1). Conventional medical
management alone may not always be sufficient in grade 2
and above injuries. Surgical treatments can be required in
order to promote ocular surface healing and to restore ocular
surface stability, corneal clarity and visual acuity. Medical
treatment was sufficient in 13 of 48 patients (27.1%) to obtain
ocular surface stability, but only 7 of these eyes gained
sufficient CDVA in our study group, which consisted of grade
2 and above injured patients.
Ocular burns may destroy the limbus, causing LSCD.
In such cases, the corneal surface is invaded by bulbar
conjunctival cells. This process leads to chronic inflammation, scarring and vascularization of the corneal stroma1,13.
The corneal surface can be reconstructed by debridement of
conjunctival epithelium with14,15 or without16 transplantation
of cryopreserved amniotic membrane for eyes with partial
LSCD. Dua et al.16 reported that removal of the conjunctival
epithelium from the cornea (sequential-sector conjunctival
epitheliectomy) allowed cells of the corneal epithelial
phenotype to cover the denuded area, alleviating symptoms
and improving visual acuity. Therefore, it is not always
necessary to undertake partial limbal or stem cell transplantation to restore the corneal surface in patients with partial
stem cell deficiency16. However, the pathologic entity tends

to involve the stroma in partial stem cell deficiency with a

fibrovascular pannus covering the cornea; thus limbal transplant may be required17. Conjunctival epitheliectomy was
performed as an additional surgery to restore the corneal
surface in 3 eyes after the limbal transplantation in our study.
In severe ocular surface burns, corneal transparency is lost
because of total damage to the limbal stem cells1,13.
Keratoplasty restores transparency temporarily, but eventually
the conjunctival cells begin to invade and resurface the graft.
The only way to prevent this invasion is to restore the limbus.
Stem cell transplantation has been shown to be effective in the
treatment of LSCD2,13,17,18. For patients with unilateral
limbal deficiency, the contralateral uninjured eye can provide
healthy limbal tissue for limbal autograft transplantation2,17.
Although limbal autografting provides excellent results in
unilateral cases2,18,19, ocular surface reconstruction is challenging in patients with bilateral limbal deficiency5. For
patients with severe bilateral limbal deficiency, only heterologous limbal tissue can be used for keratolimbal allograft
transplantation, which can be obtained from cadaveric donors
or from living-related donors4,5,7,2023. More limbal tissue and
stem cells can be obtained from a cadaveric donor to restore
the barrier to the entire limbus7. Unfortunately, the graft
rejection rate is high in allograft transplantation, and longterm systemic immunosuppressive treatment is required for
these patients7,20. Theoretically, limbal allograft transplantation from an HLA antigen-matched living-related donor is a
means to achieve long-term graft survival7,20. Moreover, graft
rejection can occur even in eyes with limbal allograft

Ocular chemical injury

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DOI: 10.3109/15569527.2013.796477

Figure 2. Upper row (Patient 18, right eye, grade 4 injury): (a) PK after 32 months of 120 conjunctivolimbal autograft (CLAU). (b) Limbal deficiency
18 months after PK. (c) Twenty-two months following 120 keratolimbal allograft to inferior quadrant. Middle row (Patient 37, right eye, grade 4
injury): (d) 18 months following the injury. (e) PK after (15 months) 120 superior living-related conjunctivolimbal allograft (lrCLAL). (f) Following
phacoemulsification and Ahmed glaucoma valve (AGV) implantation (49 months after AGV and lrCLAL). Lower row (Patient 3, right eye, grade 5
injury): (g) 9 months after the injury. (h) Two weeks after CLAU to superior quadrant. (j) One month after PK (the time between CLAU and PK was
52 weeks).
Table 4. Degree of chemical eye injuries and distribution of patients according to visual acuities.
Number of patients according to
VAs at presentation (logMAR) (n 48)
Injury grade
Grade
Grade
Grade
Grade
Grade
Total

2
3
4
5
6

Number of patients according to

VA at final visit (logMAR) (n 46)a

00.3
n

0.40.7
n

0.81.3
n

41.3
n

00.3
n

0.40.7
n

0.81.3
n

41.3
n

5
1

2
1

4
5

1
10

3
8
10
6
2
29

10
5
2
1

18

1
4
3

1
9

1
2
1

2
4
4
4
1
15

Two eyes were eviscerated.

transplantation from HLA antigen-matched living-related

donors4. Previous studies have shown that long-term efficacy
of limbal allograft transplantation from living-related donors
is low in eyes with severe total limbal deficiency4,22. Limbal
allograft transplantation from living-related donors is a good
option for individuals with bilateral partial stem cell deficiency. Even if graft rejection after living-related limbal
allograft transplantation resulted in stem cell dropout, the
amount of residual stem cells was able to sustain sufficient
epithelial cell repopulation3.
The recipients ocular status may influence overall limbal
graft survival. Limbal ischemia and severe inflammation may

be major prognostic indicators of early graft failure4,5,22.

In our case series, all of the recipient eyes were stable late
stage chemical burns, and most patients underwent prior
surgical procedures to correct ocular structure abnormalities.
All patients received systemic corticosteroids before and after
limbal allografting to combat inflammation.
The extent of associated conjunctival injury has been
considered as another prognostic factor. In eyes with total
loss of limbal and corneal epithelium, the presence of any
surviving conjunctival epithelium is a favorable prognostic
indicator when compared to eyes with total conjunctival
epithelial injury. Epithelization of the cornea by the

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A. Burcu et al.

Cutan Ocul Toxicol, Early Online: 17

Figure 3. (Patient 4, left eye after grade 6 acid injury). (a) Twenty-one months after the injury. (b) Three months after 60 autograft to inferior and
superior quadrants. (c) Vascularization at the inferonasal quadrant following allograft from brother to nasal and temporal quadrants. (d) Eleven months
after epitheliectomy to inferonasal quadrant.

conjunctival epithelium is better than no epithelial cover.

Conjunctivalization of the cornea protects against progressive melting and perforation allows the eye to settle and
provides the opportunity to carry out restorative procedures
at a future date. One such example is shown in Figure 3.
In this patient, total conjunctivalization of the cornea was
developed at the early stage. Conjunctival autograft and
allograft from his brother were performed at the stable late
stage. Stable ocular surface was obtained, and 0.7 logMAR
CDVA with mild central localized haze was achieved over
5 years. Similar examples have been reported in the
literature2,24.
After conjunctival limbal autografting, donor eyes rarely
developed LSCD18,20,25. To avoid possible LSCD at the donor
eye, less than one clock hour donor limbal tissue can be
cultivated and expanded ex vivo into a transplantable epithelial sheet26. Both techniques are effective in the long-term
restoration of the damaged ocular surface in eyes with
LSCD2,18,20,25,27, but sophisticated laboratory support is
required in cultivated limbal epithelial transplantation
(CLET), and the surgeons preference is often limited by
economic and logistic factors28. Mini-CLAU is the new
technique in which smaller, single two-clock-hour-long
lenticules are used to treat total LCSD19. It remains unclear
how small the size of limbal graft is sufficient to restore the
corneal surface with total LSCD. Rao et al. successfully used
1 CLAU of 60 90 for treating eyes with partial LSCD but
found it insufficient to treat 2 eyes with total LSCD29.
Moldovan et al. found that 1 CLAU of 90 or 100 could
restore eyes with total LSCD, but that of 80 was unsuccessful30. Kheirkhah et al. showed that successful reconstruction
of a corneal surface with total LSCD can be achieved by using
only one 60 (i.e. 2 clock hours), graft together with amniotic

membrane transplantation as both a permanent graft and a

temporary patch19.
Unfortunately, since we do not have the necessary laboratory equipment, we did not have the opportunity to use CLET
for our patients. We preferred 100 120 single or double 60
transplants depending on the extent and the localization of
limbal deficiency. CLAU was successful in 14 of 16 eyes.
LSCD persisted and vascularized leukoma developed in two
eyes with grade 4 injury; these patients did not accept further
surgical intervention. Limbal deficiency recurred in 2 of
14 eyes following PK. The ocular stability was not achieved in
1 of 4 eyes with grade 5 injury, which underwent both CLAU
and lrCLAL. Sufficient CDVA and ocular surface stability
was achieved after allograft transplantation from living
relatives without tissue compatibility testing in 3 eyes with
grade 3 injury. Keratolimbal allograft was unsuccessful in
bilateral case with grade 5 and grade 6 injury. In our series all
the unsuccessful cases had severe injury.
Improvement in corneal clarity and CDVA as a result of
successful limbal transplantation may obviate the need for a
PK. However, in cases where there is significant stromal
scarring, a corneal graft is necessary to visually rehabilitate
the patient31,32. The two-stage approach of allogenic32,33 and
autologous limbal epithelial transplantation31 followed by PK
successfully restores ocular surface stability and vision in eyes
with chronic ocular burns. There are no existing guidelines
regarding the relative timing of the two transplantations.
Basu et al. have shown that the ocular surface stabilized at
approximately 6 weeks in eyes following two-stage surgery,
so the timing of PK thereafter did not have any effect on the
corneal allograft survival31.
Extensive corneal stromal vascularization predisposes
these eyes to a higher risk of corneal allograft failure34.

Ocular chemical injury

DOI: 10.3109/15569527.2013.796477

Seven of 13 eyes that underwent PK experienced at least one

rejection episode and sequential endothelial failure developed
in two eyes despite the aggressive immunosupressive and
antiinflammatory treatment.
CDVA of 0.7 logMAR or less was achieved in 27 (56.3%)
eyes at the last visit. The grade of limbal deficiency was
found to have a major effect on the final visual outcome.
We observed that patients with severe initial injury ultimately
had unfavorable visual outcomes.

11.
12.
13.
14.

15.

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For personal use only.

Conclusion
In conclusion, patients with low-grade chemical injury seem
to benefit quite well from the medical treatment, amniotic
membrane transplantation, limbal graft transplantation and
subsequent keratoplasty. However, patients with severe
injuries seem to be more prone to failure after all of the
available treatment modalities.

Acknowledgements
The manuscript was edited for language correction (www.
editavenue.com, file number: EA 462234493). This study was
partially presented orally at the 44th National Congress of the
Turkish Ophthalmology Society in October 2011.
Declaration of interest
The authors have not used any sources of public or private
financial support.
The authors have no conflicts of interest relevant to the
subject matter or materials discussed in the manuscript.

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