Lacrimal Apparatus Procurement in Face Transplantation.

The aesthetic outcome of a well-planned and executed vascularized composite tissue face allotransplant is unquestionable; however, complete functional restoration is necessary. The authors studied the possibility of restoring tear duct function in face transplant recipients. They also examined the technical specifics and feasibility of incorporating a lacrimal drainage apparatus into facial allografting. The authors performed a standardized face vascularized composite allograft on 4 hemi-faces (2 fresh cadavers). On one side of the face, a soft tissue myocutaneous alloflap was raised. They attempted to incorporate the nasolacrimal apparatus into the allograft to develop and describe an efficient harvest method. On the contralateral side, an osteocutaneous alloflap was raised with the midface and mandible. The authors describe 2 techniques to incorporate the lacrimal drainage system. The authors retrieved the graft in a consistent and replicable fashion within conventional alloflap retrieval times. The authors successfully incorporated the entire nasolacrimal drainage system into the conventional soft tissue-only myocutaneous alloflap by transforming it into a modified mini-osteomyocutaneous alloflap. They demonstrated that the contralateral conventional bi-maxillary osteocutaneous alloflap procedure, as an alternative comparative technique, provided another means to restore lacrimal drainage. In conclusion, surgically harvesting the nasolacrimal apparatus is technically feasible in vascularized composite tissue allotransplantation. Before translating this to a clinical setting, further dissections are necessary to explore the technical specifics of how to insert the harvested nasolacrimal apparatus into the recipient to restore a conduit for tear drainage. This study is the first step towards a fully functioning lacrimal drainage system in face transplant recipients.

Cryopreservation and hypothermic storage of lacrimal gland: towards enabling delivery of regenerative medicine therapies for treatment of dry eye syndrome.

Severe dry eye syndrome (DES) can cause painful loss of vision and may result from lacrimal gland dysfunction. Current treatments are palliative, so a causative therapy is desirable. The ability to (cryo)preserve lacrimal gland tissue or epithelial cells would simplify this. Here, lacrimal gland tissue was cryopreserved in 10% dimethylsulphoxide in liquid nitrogen, or stored at 4 °C in culture medium for up to 7 days, and compared with fresh tissue using immunohistochemistry. Cultures were initiated from fresh and stored tissue, and cells characterised in P1 for proliferation (WST-1), colony-forming efficiency (CFE) and secretory capacity (immunocytochemistry and ß-hexosaminidase activity assay). Tissue stored for > 3 days at 4 °C displayed grossly altered tissue architecture when compared with fresh tissue, decreased acinus density and increased caspase-3 activity. Cryopreserved tissue showed less obvious signs of damage without caspase-3 activation. Storage at 4 °C and cryopreservation delayed epithelial outgrowth compared with that from fresh tissue initially (p  < â€…0.05) but, by day 9, all explants showed comparable outgrowth (~90%), except tissue stored at 4 °C for 3 or 7 days (p  < â€…0.05 compared with fresh tissue). Epithelial cell yields per explant were similar from fresh and stored tissue, apart from tissue stored at 4 °C for 7 days (p  < â€…0.01). In P1, epithelial cells from fresh and stored tissue were largely equivalent in terms of: proliferation; CFE (~21%); Rab3D, HexA and lysozyme expression; mucin production; and ß-hexosaminidase activity. These data demonstrate that cryo(preservation) of lacrimal gland tissue and cells is possible, which may enable use of autologous cells in regenerative medicine approaches to treating DES. Copyright © 2016 John Wiley & Sons, Ltd.

Mucosal and lacrimal flaps for endonasal dacryocystorhinostomy: a systematic review.

BACKGROUND: Historically dacryocystorhinostomy (DCR) has been performed externally with very good outcomes. Current literature shows comparable success rates between endonasal and external approaches. A common reason for the failure of a DCR is the reclosure of the nasolacrimal stoma by granulation tissue and synechiae. OBJECTIVE OF REVIEW: A systematic review and critical evaluation of the evidence relating to the preservation of nasal mucosal flaps in DCR surgery. TYPE OF REVIEW AND EVALUATION METHOD: A systematic review using the consort guidance for review of randomised control trials. SEARCH STRATEGY: A search of the following evidence-based medicine databases was performed: Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness, Cochrane Central Register of Controlled Trials, Ovid, Medline, EMBASE and PubMed. The search was limited to English language articles, and the following key words were used: Endonasal, Endoscopic, Dacryocystorhinostomy, DCR, Mucosal Flaps, between years 1970 and 2015. RESULTS: The best available evidence was level 1B, comprising two randomised control trials and three comparative studies included in the review. The main outcome measures used were lacrimal irrigation and absence of epiphora. Two of the studies demonstrated a statistically significant benefit of mucosal sparing either with nasal mucosal flaps or with lacrimal flaps. More debridement was needed, and granulation tissue was also seen in the groups without mucosal preservation. There was no difference in surgical complications between a mucosal and non-mucosal-sparing technique. CONCLUSIONS: The overall quality of current evidence is poor, and there does however appear to be a trend towards improved outcomes and reduced granulation in groups where nasal mucosal and lacrimal flaps were preserved, but this is not clear-cut. There was no evidence of increased complication rates with mucosal-sparing techniques. We recommend that until further good quality research is available we should be performing a mucosal-sparing technique when performing DCR routinely.

Effect of subconjunctival lacrimal gland transplantation in a rabbit dry eye model.

PURPOSE: The main and accessory lacrimal glands are involved in reflex and basal secretion of tears, respectively, with the glandular tissue anatomy being similar for both glands. We transplanted part of the main lacrimal gland under the palpebral conjunctiva in a rabbit dry eye model and assessed the therapeutic effect of this procedure. METHODS: In New Zealand White rabbits, the greater superficial petrosal nerve was cut unilaterally under a microscope. The other eye served as a normal control. For transplantation, approximately 0.07 g of the main lacrimal gland was harvested from the normal side, labeled with octadecylindocarbocyanine, and transplanted under the palpebral conjunctivae of both eyes. At 1 week and 1 month after the transplantation, the eyes were observed, and the Schirmer tear test and histological examination of the palpebral conjunctiva were performed. RESULTS: On the denervated side, tear flow, measured by the Schirmer tear test, recovered at 1 month after the transplantation of the main lacrimal gland compared with that before transplantation. The contralateral control side showed no changes. On the denervated side, the fluorescein score significantly improved at 1 month after transplantation compared with that before transplantation (P < 0.005), whereas the rose bengal score showed no difference. Histological examination revealed that octadecylindocarbocyanine-labeled transplanted main lacrimal gland tissue was present under the palpebral conjunctiva. CONCLUSIONS: These results suggest that the partial transplantation of the main lacrimal gland may be effective for treatment of dry eyes.

Morphological features of the porcine lacrimal gland and its compatibility for human lacrimal gland xenografting.

In this study, we present first data concerning the anatomical structure, blood supply and location of the lacrimal gland of the pig. Our data indicate that the porcine lacrimal gland may serve as a potential xenograft candidate in humans or as an animal model for engineering of a bioartificial lacrimal gland tissue construct for clinical application. For this purpose, we used different macroscopic preparation techniques and digital reconstruction of the histological gland morphology to gain new insights and important information concerning the feasibility of a lacrimal gland transplantation from pig to humans in general. Our results show that the lacrimal gland of the pig reveals a lot of morphological similarities to the analogous human lacrimal gland and thus might be regarded as a xenograft in the future. This is true for a similar anatomical location within the orbit as well as for the feeding artery supply to the organ. Functional differences concerning the composition of the tear fluid, due to a different secretory unit distribution within the gland tissue will, however, be a challenge in future investigations.

Safety and immunomodulatory effects of allogeneic canine adipose-derived mesenchymal stromal cells transplanted into the region of the lacrimal gland, the gland of the third eyelid and the knee joint.

BACKGROUND AIMS: Mesenchymal stromal cells (MSCs) have been extensively studied as a cellular therapeutic for various pathologic conditions. However, there remains a paucity of data regarding regional and systemic safety of MSC transplantations, particularly with multiple deliveries of allogeneic cells. The purpose of this study was to investigate the safety and systemic immunomodulatory effects of repeated local delivery of allogeneic MSCs into the region of the lacrimal gland, the gland of the third eyelid and the knee joint in dogs. METHODS: Allogeneic adipose tissue-derived canine MSCs were delivered to the regions of the lacrimal gland and the third eyelid gland as well as in the knee joints of six healthy laboratory beagles as follows: six times with 1-week intervals for delivery to the lacrimal gland and the third eyelid gland regions and three to four times with 1- to 2-week intervals for intra-articular transplantations. Dogs were sequentially evaluated by clinical examination. At the conclusion of the study, dogs were humanely euthanized, and a complete gross and histopathologic examination of all organ systems was performed. Mixed leukocyte reactions were also performed before the first transplantation and after the final transplantation. RESULTS: Clinical and pathologic examinations found no severe consequences after repeated MSC transplantations. Results of mixed leukocyte reactions demonstrated suppression of T-cell proliferation after MSC transplantations. CONCLUSIONS: This is the first study to demonstrate regional and systemic safety and systemic immunomodulatory effects of repeated local delivery of allogeneic MSCs in vivo.

'Punctal switch' grafting for the treatment of dry eyes: our experience.

We evaluated the efficacy and safety of 'punctal switch' grafting, a proposed new technique for permanent punctal occlusion. We prospectively evaluated the results and complications in 22 patients (5 males and 17 females) who underwent the procedure in our department over a period of 3 years. Patients' ages ranged from 41 to 81 years. The average follow-up was 12.8 months. Subjective and clinical improvement was documented in 91% of the cases with a low rate of recanalization (9%). Only 1 patient developed epiphora postoperatively, and the operation has been successfully reversed in that case. There were no serious complications. As a conclusion, punctal switch grafting is an effective technique for permanent punctal occlusion. The complication rate is low, recanalization is rare and the occlusion can be reversed if symptomatic epiphora develops.

Lacrimal canalicular transplantation with composite eyelid graft.

PURPOSE: To describe a new surgical approach for secondary repair of canalicular lacerations using a full-thickness en bloc eyelid transplantation. METHODS: This a single case report of full-thickness en bloc eyelid transplantation. The patient presented with symptomatic epiphora several years after traumatic laceration of the left lower canalicular system. The canalicular system of the right upper eyelid, including the punctum and a section of the canaliculus, was resected and transplanted to repair a dysfunctional left lower eyelid. The primary outcome measure was the functionality of the transplanted canalicular system. RESULTS: The transplanted lacrimal system was patent by irrigation at multiple visits postoperatively. In addition, the patient was asymptomatic and was pleased with the cosmetic result. CONCLUSION: This is the first reported case of successful canalicular transplantation. Although a single case report, the authors anticipate future success with this technique.

Transplantation of newborn lacrimal gland cells in a rat model of reduced tear secretion.

BACKGROUND: Decreased lacrimal gland output may cause dry eye syndrome. Using a rat model, we examined the feasibility of transplanting lacrimal gland cells from newborns. OBJECTIVES: To restore lacrimal gland function in eyes with compromised tear production. METHODS: A model of dry eye in adult rats was developed by unilateral surgical removal of the main lacrimal gland. Tear secretion in both eyes was then assessed by masked Schirmer's test. Lacrimal gland tissue from newborn rats was transplanted into the fibrous connective tissue in which the lacrimal gland had been embedded. Masked Schirmer's test was repeated 4, 8 and 12 weeks after transplantation. RESULTS: Schirmer's test performed in 13 rats 10 days after unilateral lacrimal gland excision revealed significantly less wetting on the side with excised gland compared with the normal side (P < 0.003). The lack of secreting cells on the operated side was verified histologically. The reduction in tear secretion on the operated side remained significant for 8 weeks on average. In the six rats with transplanted lacrimal gland tissue however, there were no differences in tear reduction between the two eyes at 4, 8 or 12 weeks after the operation (P = 0.81, 0.56 and 0.8, respectively). CONCLUSIONS: Transplantation of lacrimal gland tissue from newborn rats effectively restored eye wetting in this new model. Further research is needed to evaluate this new approach for treating lacrimal gland dysfunction. Using this model might also facilitate evaluation of potential clinical treatments for dry eyes.

Sjögren syndrome.

Sjögren syndrome is a chronic systemic disease characterized by polyglandular tissue destruction leading to keratoconjunctivitis sicca (KCS) and xerostomia. Patients with primary Sjögren syndrome show evidence of KCS and xerostomia, whereas patients with secondary Sjögren syndrome suffer from KCS, xerostomia, and an autoimmune disease, most commonly rheumatoid arthritis. Certain factors cause autoimmune dysregulation leading to destruction of the acinar cells and ductal epithelia with subsequent dry eyes and dry mouth. Activated lymphocytes in patients with autoimmune diseases appear to have selective homing into the lacrimal and salivary glands leading to tissue damage. Understanding the factors involved in the immune dysregulation may improve our diagnostic and therapeutic approaches in Sjögren syndrome. Current therapeutic measures include means to increase secretion, relieve symptoms, and repair damage of the ocular surface.

[Partial canaliculus transplantation--further results]. / Die partielle Canaliculustransplantation, weitere Ergebnisse.

Partial canaliculus transplantation is a suitable method of substituting the canaliculus when the nasal lower lid region has been damaged by tumor. Two cases are described, illustrating that the area of indication may be extended to substitution surgery of parts of the canaliculus next to the lacrimal sac and that, analogously to complete lid transplantation, the method can be combined with sliding plasty. During the observation period, which lasted for 17 to 20 months, the partial canaliculus transplantations followed up proved to be patent.

[Partial canaliculus transplantation (author's transl)]. / Die partielle Canaliculustransplantation.

In some cases of palpebral tumors, causing epiphora by canalicular obstruction, surgical reconstruction of the lacrimal system is necessary . The defect of the nasal part of the lower lid is closed by transplantation of the nasal part of the upper lid of the other eye, including a part of the canaliculus. Three patients suffering from basaliomas in the region of the lower canaliculus were treated by this method. Good cosmetic and functional results were achieved.

Naso-lacrimal by-pass surgery. An easier approach.

An easier method of naso-lacrimal by-pass surgery is described in which a large anterior mucosal flap is fashioned from the lacrimal sac and the nasal mucosa. The short posterior lacrimal mucosal flap is completely excised. Particular operative, and postoperative techniques. Over 95 per cent of the 46 eyes in this series of 45 patients no longer have epiphora.