Born Compatible: A Twin-To-Twin Simple Limbal Epithelial Transplantation In Severe Chemical Injury

To report a successful surgical outcome of a two-phase surgical treatment for severe bilateral chemical burn with complete corneal decompensation. Endothelial failure was originally treated with Descemet membrane endothelial keratoplasty, followed by a simple limbal epithelial transplantation from a monozygotic twin for the limbal stem cell deficiency.

Department of Ophthalmology, University Hospital Brussels, Brussels, Belgium 

A 46-year old man with a history of bilateral chemical burn, initially treated with bilateral amniotic membrane (AM) transplant and a symblepharon ring, followed by a superficial keratectomy and a Descemet membrane endothelial keratoplasty (DMEK) for the left eye 4 months after. Two rebubblings were performed 1 and 3 weeks postoperatively. In 2022, he undergone a DMEK for the right eye, followed by a rebbubling 7 days after the procedure. In the following years, patient developed a bilateral limbal stem cell deficiency. Due to the bilateral character of the disease, a simple limbal epithelial transplantation (SLET) was performed using the stem cells from his monozygotic twin brother. After the complete conjunctival periotomy with removal of conjunctival overgrowth, a single layer of AM was placed over cornea using fibrin glue. Limbal graft taken from the patient’s twin was cut into smaller fragments, distributed in the mid-periphery of the cornea and glued to the AM. Conjunctiva was advanced to the limbal edge using Vicryl 8-0 single sutures and the bandage contact lens was placed. Postoperatively, patient was using topical tobramycin/dexamethasone, and oral methylprednisolone and moxifloxacin for 3 weeks. Four months after, his vision improved to 0.1 using pinhole, without signs of corneal conjunctivalization. Apart from old deep stromal neovascularizations, corneal transparency was improved, with visible remnants of the stem cell biopsies.

To our knowledge, this is the second report of a SLET taken from a monozygotic twin for a severe bilateral chemical burn, with a successful surgical outcome four months postoperatively. Positive results of the syngeneic SLET might be supported by better corneal homeostasis enabled by the previously performed DMEK, suggesting the combination of these procedures as a possible treatment option for severe corneal chemical injuries, in suitable scenarios.