Korean J Ophthalmol.  2013 Jun;27(3):149-157. 10.3341/kjo.2013.27.3.149.

Autologous Tragal Perichondrium Transplantation: A Novel Approach for the Management of Painful Bullous Keratopathy

• Kim KW
• Chun YS
• Kim JC

• KMID: 1798050
• DOI: http://doi.org/10.3341/kjo.2013.27.3.149

Abstract

PURPOSE
To introduce autologous tragal perichondrium transplantation as a novel surgical modality for the management of intractable symptomatic bullous keratopathy.
METHODS
In three eyes of three patients with painful bullous keratopathy, autologous tragal perichondria were transplanted on the corneal surface with the human amniotic membrane transplanted above. We included an additional three eyes of three patients with painful bullous keratopathy who received amniotic membrane transplantation only to serve as controls. Clinical symptom outcomes were assessed using a visual analogue scale at postsurgical months 1, 3, 5, 7, and 9. In addition, transplanted tragal perichondrium and amniotic membrane complex tissue button obtained from one patient who underwent penetrating keratoplasty was evaluated by immunohistochemical analysis of CD34, vimentin, and alcian blue staining.
RESULTS
All three patients who underwent autologous tragal perichondrium and human amniotic membrane co-transplantation showed improvements in pain and tearing. However, all three patients in the control group experienced aggravation of tearing and no further improvement of pain 3 months after surgery. In addition, one patient in the control group developed premature degradation of the amniotic membrane. Histopathologic and immunohistochemical analysis showed intact surface epithelization and positive CD34, vimentin and alcian blue staining of transplanted tragal perichondria.
CONCLUSIONS
The tragal perichondrium has a high mechanical structural force and high potency due to well-organized epithelization and the presence of mesenchymal stem cells. Autologous tragal perichondrium transplantation may be an effective modality for the management of painful bullous keratopathy.

Keyword

Amniotic membrane transplantation; Bullous keratopathy; Tragal perichondrium transplantation

MeSH Terms

Adult
Aged
Amnion/*transplantation
Corneal Diseases/*pathology/*surgery
Ear Cartilage/*transplantation
Female
Humans
Keratoplasty, Penetrating/*methods
Male
Middle Aged
Transplantation, Autologous
Treatment Outcome

Figure

• 

  Fig. 1 Harvest of autologous tragal perichondrium. (A) Skin incision parallel to the free edge of the tragus. (B) Anterior surface (arrow) of the tragal perichondrium dissected from tragal cartilage. (C) Tragal perichondrium (arrow) to be cut held with forceps. (D) Tagal perichondrium harvested intraoperatively.

• 

  Fig. 2 Visual analogue scales of symptoms (pain and tearing) before and after treatment. (A,B) Symptom improvement continued until postsurgical 9 months in autologous tragal perichondrium + amniotic membrane transplantation group. (C,D) However, in the control group (amniotic membrane transplantation alone), symptom was aggravated after mild improvement in post-surgical early period.

• 

  Fig. 3 Slit lamp photograph of the cornea with bullous keratopathy before (A) and after autologous tragal perichondrium transplantation, followed by corneal tattooing and amniotic membrane transplantation (B). (B) There was an area of epithelial defect (arrow) 2 weeks after surgery. (C,D) After surgery, transplanted autologous tragal perichondrium was well maintained without degradation 5 months after surgery (C), and up to follow-up month 9.

• 

  Fig. 4 Slit lamp photograph of the cornea 6 weeks after amniotic membrane transplantation. (A) Transplanted amniotic membrane degraded in one patient who underwent only amniotic membrane transplantation. (B) Central cornea was ulcerated with fluorescein dye staining.

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  Fig. 5 Clinical appearance before and after autologous tragal perichondrium transplantation in conjunction with corneal tattooing and amniotic membrane transplantation, thereafter penetrating keratoplasty (PKP) in one patient (case 3). (A) Preoperatively, there was central corneal opacity with severe corneal neovascularization. (B) Until post-PKP month 9, there was no graft rejection, maintaining transparency.

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  Fig. 6 Histology of postoperative epithelization underlying transplanted amniotic membrane and autologous tragal perichondrium (×400). Multi-layered generated stratified squamous epithelium was morphologically similar to normal corneal epithelium.

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  Fig. 7 Histology and immunohistochemistry of the transplanted autologous tragal perichondrium. (A) Inner chondrogenic layer of transplanted autologous tragal perichondrium (inside of black rectangle) with hematoxylin and eosin staining (×200). (B) Immunohistochemical staining of vimentin (arrow) and (C) alcian blue staining (arrow head) of the inner chondrogenic layer showed existence of mesenchymal stem cells in transplanted autologous tragal perichondrium (×400).

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  Fig. 8 Immunohistochemical staining of CD34 of the transplanted autologous tragal perichondrium. (A) Formation of vascular structures are shown (arrow) in transplanted autologous tragal perichondrium (×200), and (B) this is supposed to be attributable to CD34-positive endothelial cells (arrow head) in the inner chondrogenic layer (inside of black rectangle in A) (×400).

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