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Biomedical subjects

R Sundmacher

Publications and source records attributed to R Sundmacher.

At least 19 recordsLinked to original sources
PubMed1998

Prophylactic argon laser coagulation for rhegmatogenous retinal detachment in AIDS patients with cytomegalovirus retinitis.

BACKGROUND: The incidence of cytomegalovirus (CMV) retinitis in patients with acquired immunodeficiency syndrome (AIDS) reaches 20-45%. Despite aggressive medical treatment, rhegmatogenous retinal detachments develop in up to 30% of the affected eyes. Surgical repair is often difficult due to multiple large and hardly visible retinal holes with vitreal traction. Pars plana vitrectomy with instillation of silicone oil is the procedure of choice, giving limited functional results with anatomical reattachment. METHODS: We performed prophylactic laser coagulation in AIDS patients with medically treated CMV retinitis to prevent a progressive retinal detachment. Twenty-two quiescent CMV lesions in 22 eyes of 20 patients were treated with argon green laser coagulation. Each CMV lesion was completely surrounded with a double or triple row of laser spots (500-600 mumols; 0.2 s; gray-white lesions). RESULTS: The duration of follow-up was 2-24 months. Histopathologic evaluation was possible in two eyes of one patient. Reactivated or smoldering CMV retinitis crossed the laser scars in 11 eyes, making additional laser coagulation necessary. In four eyes retinal holes in the CMV scar tissue led to retinal detachment, which stopped at the laser scar. In three eyes the detachment is still controlled by the laser scar. In one eye, the detachment stopped at the laser scar for 6.5 months and then slowly progressed across it. There were no complications associated with our laser treatment. CONCLUSION: Prophylactic argon laser coagulation in quiescent CMV retinitis seems to reduce the rate of progressive retinal detachment with no need for vitrectomy and silicone oil tamponade.

AIDS-Related Opportunistic Infections↗
PubMed1998

Rapid method for successful HLA class I and II typing from cadaveric blood for direct matching in cornea transplantation.

BACKGROUND: The aim of the study was to establish fast methods for postmortem HLA class I and II typing of cornea donors using cadaveric blood. METHODS: The commercially available reagents Lymphokwik MN and Dynabeads were evaluated here to provide an enriched living mononuclear cell (MNC) population and B-cell population for HLA class I and II typing of cadaveric blood by serology. Cadaveric blood was obtained 1-80 h post mortem. After isolation of living B-cells and B-cell-depleted living MNC's, cells were serologically typed by double-fluorescence cytotoxicity assay for HLA class I and II antigens. RESULTS: In 373 (81%) of 461 cadaveric blood samples HLA class I typing, and in 36 (62%) of 56 cadaveric blood samples HLA-class II typing, by serology was successful and accomplished within 5 h. Results from the serological HLA class I typing were confirmed by the results of HLA class I typing by RNA-based sequencing in seven cases. To improve the HLA class II typing, DNA typing using PCR with sequence-specific primers was performed in 148 samples and reverse hybridization of PCR-amplified DNA to immobilized HLA class II specific primers in 270 samples. These data were confirmed by DNA-based sequencing in five cases and by sequence-specific oligonucleotide hybridization in all cases. CONCLUSIONS: These results lead to the following typing strategy: HLA class I typing should be performed by serology. HLA class II typing should be performed by DNA technology because of its relative independence of the quality of the blood sample. The strategy we have developed is very successful and fast for tissue typing post mortem, thus expanding the time available for ideal HLA matching, increasing the number of available HLA-matched corneas and therefore reducing the number of graft rejections.

Blood Grouping and Crossmatching↗
PubMed1998

[Bilateral microsporidial keratitis in an HIV-positive patient with AIDS stage infection].

INTRODUCTION: Microsporidia are spore-forming, obligate intracellular protozoa. Humans seem to be infected only by 4 genera of microsporidia. Microsporidial keratoconjunctivitis in immunodeficient patients has a characteristic appearance. CASE REPORT: 34 year old woman with AIDS complained of bilateral blurred vision. The visual acuity was 0.6 on both eyes. She had a mild conjunctivitis and disseminate, not very prominent intraepithelial corneal opacities. She was treated with propamidine isethionate 0.1% 5 times daily and artificial tears under presumptive diagnosis of microsporidial keratoconjunctivitis. We discontinued this treatment because of no improvement. Within 6 months the visual acuity decreased to 0.05. A conjunctival smear was positive for microsporidia. Local Fumagillin-eye-drops 0.07 mg/ml 7 times daily were given. Within 2 weeks an impressively improvement was seen. Because of an persisting diarrhea 400 mg Albendazol twice daily was added orally without success. DISCUSSION: The biomicroscopically changes of microsporidial keratoconjunctivitis are characteristical and lead to the clinical diagnosis. Fumagillin is in vitro and clinically a potent antimicrosporidian agent with an extremely broad therapeutic range.

AIDS-Related Opportunistic Infections↗
PubMed1997

Detection of varicella-zoster virus DNA in keratectomy specimens by use of the polymerase chain reaction.

OBJECTIVE: To study the correlation of clinical findings, histopathologic features, and detection of varicella-zoster virus (VZV) DNA in keratectomy specimens. MATERIALS AND METHODS: Fourteen corneal buttons from patients with a confirmed history of herpes zoster ophthalmicus were examined by use of light microscopy and the polymerase chain reaction. The polymerase chain reaction techniques included gel electrophoresis and hybridization for the detection of VZV DNA. RESULTS: Seven (50%) of the 14 specimens were positive for VZV DNA. The positive findings in the specimens correlated with the clinical findings of uveitis (3/3) and the histopathologic features of chronic stromal keratitis (4/4). Patients with stromal scarring, granulomatous keratitis, and neurotrophic ulcers had negative findings. The largest interval between the initial appearance and detection of viral DNA was 51 years. CONCLUSIONS: The results suggest that VZV DNA is not detectable in the cornea in every patient and at every stage of zoster keratitis. This may be due to the low number of VZV particles present in the cornea or the lack of viral DNA in the keratocytes. It remains unclear whether the VZV-related keratopathy is caused by an immunologic response to a viral antigen, the viable virus itself, or both.

Adolescent↗
PubMed1997

The influence of glaucoma history on graft survival after penetrating keratoplasty.

BACKGROUND: It was the purpose of this retrospective study to evaluate the effect of a preoperative history of glaucoma on graft survival after penetrating keratoplasty. PATIENTS AND METHODS: Six hundred and forty-six penetrating keratoplasties with generally good prognosis were analyzed retrospectively. Indications for surgery were corneal dystrophy, degeneration and scarring. Only first keratoplasties in corneas without severe vascularization or acute inflammation were included. Surface disorders, a history of herpes or Acanthamoeba keratitis were further exclusion criteria. Keratoplasties were performed only if glaucoma seemed to be controlled preoperatively. Graft survival ratios were calculated according to Kaplan and Meier, and statistical significance was evaluated by means of the log-rank test. RESULTS: With a glaucoma history the estimated 3-year graft survival rate was 71%, in contrast to 89% without such a history. This difference was statistically significant (P < 0.001). There was no difference between the groups with respect to immune reactions. With a glaucoma history, postoperative episodes of glaucoma decompensation were responsible for half of the graft failures. CONCLUSIONS: A preoperative history of glaucoma affects graft prognosis negatively, presumably through a negative influence of postoperatively elevated intraocular pressure on a vulnerable graft endothelium, and not by an increase in immune reactions. Therefore, keratoplasties in eyes with glaucoma are high-risk procedures and glaucoma has to be monitored more efficiently pre- and postoperatively.

Adolescent↗
PubMed1997

[Therapy of advanced amoeba keratitis with keratoplasty à chaud and adjuvant cryotherapy].

BACKGROUND: Since the mid-1980s acanthamoeba keratitis has been diagnosed with increasing frequency, especially in contact lens wearers. The assignment to specialized centers is often delayed many months and there is hardly any chance of controlling the disease by conservative treatment alone. In these cases, penetrating keratoplasty offers the only chance for rehabilitation. The therapeutic role of penetrating keratoplasty and supportive intraoperative cryotherapy is demonstrated by the courses of six patients with unilateral acanthamoeba keratitis. PATIENTS AND METHODS: The data of six patients aged 41.2 (22-63) years with medically uncontrollable acanthamoeba keratitis were evaluated retrospectively. The diagnosis was confirmed histologically in all cases. All patients were contact lens wearers. They underwent a total of ten keratoplasties between November 1986 and January 1995. The donors were 44.8 (23-58) years of age. The transplant diameters varied between 7.7 and 9.5 mm. The margins of the host cornea were intraoperatively frozen by a cryoprobe in three patients with a far advanced stage of corneolimbal parasitic infiltration. RESULTS: During a follow-up period of +/-10.2 (1-22) months, five of six eyes were rehabilitated with visual acuities between 0.4 and 1.0. One eye went blind after the fourth keratoplasty because of uncontrollable secondary glaucoma. After three keratoplasties with simultaneous application of cryocoagulation because of an especially high risk of persisting acanthamoeba infection, all corneae remained clear and free of recurrences. CONCLUSIONS: In advanced acanthamoeba keratitis which has not responded to conservative treatment, penetrating keratoplasty not only provides elimination of the pathogen, but also good functional results. In far advanced stages, the intraoperative application of cryocoagulation for parasite elimination in the host cornea seems to be a very effective measure against local recurrences of the infection.

Acanthamoeba Keratitis↗
PubMed1997

[Preventive systemic cyclosporin A after keratoplasty at increased risk for immune reactions as the only elevated risk factor].

BACKGROUND: In this retrospective study our aim was to evaluate the effectiveness of systemic cyclosporin A (CsA) after keratoplasties with an elevated risk for immune reactions as the only elevated risk factor. PATIENTS AND METHODS: Between November 1986 and June 1994, 1121 penetrating keratoplasties, 646 normal-risk and 475 high-risk keratoplasties were performed. In 130 out of the 475 high-risk keratoplasties an elevated risk for immune reactions was the only elevated risk factor. Twenty-six of these 130 high-risk keratoplasties were treated with systemic CsA. RESULTS: In the high-risk group keratoplasties with an elevated risk for immune reactions as the only elevated risk factor no permanent graft failure occurred with CsA (100% clear grafts). Without CsA the percentage of clear grafts in this high risk group was only 71.7% according to Kaplan Meier 3 years postoperatively in contrast to 86.0% in normal-risk keratoplasties. The differences between these three groups were statistically significant. In the high-risk group keratoplasties with on elevated risk for immune reactions as the only elevated risk factor more immune reactions occurred than without CsA or than in normal-risk keratoplasties. However, these immune reactions were mostly of the benign chronic types. CONCLUSIONS: Systemic CsA considerably improves graft prognosis after high-risk keratoplasties with an elevated risk for immune reactions as the only elevated risk factor. With CsA application we observed a significant shift from acute to chronic immune reactions, which respond much better to topical steroids.

Cyclosporine↗
PubMed1997

[Surgical management of Marfan-associated and idiopathic lens dislocations].

BACKGROUND: The ideal and safe surgical method for Marfan-associated or idiopathic lens subluxations is still a matter of debate. PATIENTS AND METHODS: Between 1990 and 1995, 23 eyes were operated for lens subluxations, mainly because of decreased visual acuity, but also because of conservatively uncontrolled secondary glaucoma. Marfan patients were 27.0 (5-62) years old at surgery; patients with idiopathic lens subluxations were 38.5 (11-63) years old. Surgical procedure depended on patient age and anatomical conditions. RESULTS: All patients achieved an increase in visual acuity. Amblyopia existed in six patients. All problems due to glaucoma were controlled postoperatively. Our greatest concern was rhegmatogenous retinal detachment. It occurred in only one eye of a non-Marfan patient. CONCLUSION: The prognosis for lens surgery in Martan-associated and idiopathic lens subluxations is good. The implantation of a posterior chamber lens provides a good and secure means of optical rehabilitation. Our preferred primary transscleral suture technique guarantees high security and stability of position. Previously feared surgical risks have been reduced by modern surgical procedures.

Adolescent↗
PubMed1997

[Corneoscleral transplant excision in the cadaver. Experiences of the North Rhine Westphalia Lions Cornea Bank 1995 and 1996].

BACKGROUND: Donor corneas are normally obtained by whole globe enucleation-a procedure often refused by the bereaved. To increase the acceptance of cornea donation, we have exclusively obtained donor corneas by in situ excision since the end of 1994. There have been reports of increased endothelial damage and higher contamination rates. We report our experience in 1995 and 1996. METHODS: The in situ excision was performed by staff trained in microsurgical techniques. Only donor corneas with negative end-storage cultures after at least 10 days and an endothelial cell count of more than 2500 cells/mm2 were used for transplantation. RESULTS: In all, 705 corneoscleral buttons were excised from 1/95 to 12/96. The bereaved consented in 34% in 1996. A total of 30.5% of the corneas were ineligible for transplantation which corresponds to the discard figures from all cornea banks with culture methods. We did not observe any primary transplant failure nor endophthalmitis after 444 perforating keratoplasties. CONCLUSION: In situ corneal excision is safe, and helps to reduce the shortage in donor corneas.

Cadaver↗
PubMed1997

[Postoperative complications of penetrating keratoplasty in herpes infected eyes. Differential diagnosis, therapy and prognostic significance].

BACKGROUND: We evaluated in this retrospective study the impact of our diagnostic and therapeutic regimens--as illustrated by typical clinical pictures--on the frequency and prognostic values of postkeratoplasty complications in herpes eyes. PATIENTS AND METHODS: Between November 1986 and June 1994, 112 penetrating keratoplasties (KPS) in herpes eyes were performed, 76 as planned and 36 as emergency procedures. The results were compared with 646 KPS with normal risk. For statistical analysis we used the Kaplan-Meier estimation, and statistical significance was tested by the log rank test. RESULTS: After 6 years, 75% of the grafts in the planned herpes group, 86% of the à chaud KPS and 76% of the grafts of the normal-risk group were still clear without significant differences between these three groups. Fifty-four percent of the planned KPS in herpes eyes, 73% of the à chaud KPS in herpes eyes and 80% of the normal-risk KPS experienced no immune reaction, with both herpes groups showing significantly more reactions than the normal-risk KPS. There was, however, no significant difference in immune reactions between the two herpes groups. The percentage of grafts with recurrence of herpes simplex virus infection after 6 years was significantly higher in the à chaud group. CONCLUSIONS: With proper postoperative care and optimal management of immunologic and virologic complications--but only with this!--the prognosis of penetrating keratoplasties in herpes eyes equals that of normal risk eyes. An particular, the prognosis is not dependent on whether surgery was performed as a planned or as an emergency procedure.

Diagnosis, Differential↗
PubMed1997

[Homologous central limbo-keratoplasty in limbus stem cell damage. Retrospective study of 3 years' experience].

BACKGROUND: Problems with epithelial healing are the main cause of corneal graft failure in patients with limbal stem cell deficiency. This post-operative complication cannot be eliminated by conventional penetrating keratoplasty alone, but only by additional limbal grafting, which is, however, highly immunogenic. We report here our 3 years' experience with a new surgical procedure which we developed called homologous central limbokeratoplasty. PATIENTS AND METHODS: We have performed 52 homologous central limbo-keratoplasties in patients with limbal stem cell deficiency since February 1993. We report here the results of the first 18 transplantations with the longest follow-up periods (mean 22 months). The unmatched donor cornea was trephined in a way such that 40% of its circumference contained limbus. These grafts were then sutured centrally into the host cornea. Systemic cyclosporin A (CSA) was administered for at least 1 year after all transplantations. RESULTS: Fourteen of the 18 grafts failed during the follow-up period. The reasons for graft failure were severe surface disorders (7), severe surface disorders in combination with endothelial immune reactions (5) and endothelial immune reactions alone (2). The four patients with centrally clear grafts no longer receive systemic CSA with follow-up periods between 20 and 30 months. CONCLUSIONS: Central limbo-keratoplasty is a very promising procedure. However, the average results are not yet satisfying, because the majority of limbal stem cells undergo rejection within 2 years. Improved results will be achievable in the future by using well-matched instead of non-matched transplants and by further improving immune modulation beyond the effectiveness of current CSA treatment.

Adolescent↗
PubMed1997

[Acute and chronic immune reactions after penetrating keratoplasty with normal immune risk].

BACKGROUND: For diagnostic and therapeutic reasons it is important to differentiate between acute and chronic immune reactions. Up to now in the literature as well as in clinical follow-up such a differentiation has been performed only very insufficiently. We analysed retrospectively frequency and type of immune reactions after penetrating keratoplasties with normal immune risk in order to have a data basis for comparison with the corresponding data from our high risk keratoplasties. PATIENTS AND METHODS: The clinical courses of 646 penetrating keratoplasties with good prognosis performed between 11/1986 and 6/1994 were analysed. The mean patient age was 58 (12-89) years. Only endothelial and stromal immune reactions were recorded. RESULTS: 18% of the grafts suffered from at least one immune reaction during the first 3 postoperative years (Kaplan Meier value). 94% of the grafts without immune reactions remained clear in contrast to 45% of the grafts with immune reactions during this period of time (Kaplan Meier values, Log Rank Test: p < 0.001). 81 immune reactions were observed after 62 keratoplasties. 45 immune reactions (56%) had an acute course (43 endothelial, 2 stromal). 36 (44%) were chronic (31 endothelial, 5 stromal). 93.7% of the grafts without clinical signs of immune reactions, 100.0% of the grafts with only chronic immune reactions and 38.7% of the grafts with only acute immune reactions were clear 3 years postoperatively (Kaplan Meier values). No graft with a combination of acute and chronic immune reactions was clear 3 years postoperatively. 56% of all acute immune reactions occurred during the first postoperative year, 82% during the first 2 and 91% during the first 3 postoperative years. For chronic immune reactions the corresponding values reached 51%, 94% and 100%. CONCLUSIONS: After penetrating normal-risk keratoplasty acute immune reactions occur more often than chronic immune reactions, but the latter are in fact far more frequent than anticipated. If they are diagnosed in time and treated correctly they do not lead to graft failure in the mean run. Both types occur predominantly during the first 3 postoperative years and only rarely thereafter.

Acute Disease↗
PubMed1997

[Local cyclosporin A therapy of nummuli after epidemic keratoconjunctivitis--case report].

BACKGROUND: Steroid therapy for persistent or recurrent nummular adenoviral keratoconjunctivitis (AK) has little benefit because of the frequent recurrences, and mostly "offers" only serious steroid side effects. Since January 1995, we have treated different patients with nummuli after AK with topical Ciclosporin A (CSA) in an attempt to achieve at least the same symptomatic effect as with steroids, however, without side effects. Here, we report about our experiences in a very severe case with longterm treatment. CASE REPORT: The patient was sent to our clinic 4 months after AK with confluent nummuli and Descemet folds, more severe in the right than in the left eye. Best corrected visual acuity was 0.05 in the right and 0.5 in the left eye. Topical CSA 2% 4 times daily was first administered only in the right eye. When after 6 weeks a reduction of nummuli was noted in the right eye, the left eye, which had not improved, was started on the same regime. Therapy was tapered and finally stopped after 12 months in the right and 10 months in the left eye, when only minor changes were left in the corneae. A prompt recurrence of nummuli in both eyes within 4 weeks forced us to resume CSA therapy. At present, both corneae are clear with full vision, and this result is stable with 1 drop of CSA daily. No side effects of CSA therapy have been noted. CONCLUSIONS: The disappearance of nummuli with topical CSA and even more the reappearance of nummuli after cessation of CSA therapy show that topical CSA is about as effective as topical steroids in the symptomatic treatment of non-scarred nummuli after KE without the serious steroid side effects. Topical CSA treatment of nummuli after KE is, therefore, a very recommendable alternative for the potentially dangerous steroid therapy. Generally valid data on risk of recurrences, dosage and general effectiveness could only be learned from prospective studies with large numbers of AK patients, which, however, are not available outside epidemics.

Adenovirus Infections, Human↗
PubMed1997

[Bilateral candida endophthalmitis in 2 i. v. drug-dependent patients with oral L-methadone substitution].

BACKGROUND: Controlled therapy programs for former i.v. heroin abusers supervised by physicians offer levomethadone (L-Polamidon) as an oral substitute for heroin to allow social stabilisation of the addict. As well they reduce the risk of bloodborne infections (e.g. HIV and hepatitis) by giving up "needle sharing". Assuming that i.v. drug abuse is one of the major risk factors for Candida endophthalmitis in young, otherwise healthy patients, in case of strict oral substitution no onset of Candida endophthalmitis should be expected. CASE REPORT: The clinical courses of two HIV-negative and primarily i.v. heroin addicted young male white patients are presented. While participating in an exclusively controlled, oral program of methadone substitution for several months, both patients developed bilateral Candida endophthalmitis. CONCLUSION: A persisting i.v. abuse, either of heroin or of L-methadone, parallel to the supposingly strict orally applied substituting drug L-methadone has definitely to be suspected leading to the Candida endophthalmitis.

Administration, Oral↗
PubMed1997

[Mooren ulcer. 4 severe bilateral disease courses with systemic cyclosporin A therapy].

BACKGROUND: Mooren's ulcer is a rare autoimmunologic disease of the cornea. Many forms of medical and surgical treatments have been proposed in the past, but none of them was regularly successful. Severe progressive cases of Mooren's ulcer are therefore still a blinding disease. Only the use of systemic cyclosporin A (CSA) treatment appears for the first time to have a significant positive effect on the outcome. PATIENTS: One male (30 years old) and three female (52 y, 68 y, 84 y) patients with severe progressive bilateral Mooren's ulcer were treated with cyclosporin A systemically. RESULTS: On the male patient constant blood levels of CSA were not achievable and he became blind suffering basically from a severe proliferative diabetic retinopathy. The 52-year-old female patient got a relapse of Mooren's ulcer in the graft after penetrating keratoplasty à chaud. With increased blood levels of CSA the progression of the relapsing of Mooren's ulcer could be stopped. Also only with high-dose CSA further progression of the rapidly progressive colliquation of both corneas of a 68-year-old female could be stopped. A definitive improvement with some residual activity could be achieved in a 84-year-old female after only three months of follow-up. CONCLUSIONS: High-dose systemic CSA treatment with plasma trough levels of 150-200 ng/ml is recommended as initial treatment of choice and should be started immediately. For what period of time after clinical healing this high-dose therapy must be contained without the risk of a relapse of Mooren's ulcer remains to be seen.

Administration, Oral↗
PubMed1996

Systemic ciclosporin A in high-risk keratoplasties.

BACKGROUND: It was the purpose of this study to compile the results of all high-risk keratoplasties (kp) performed in our hospital under systemic ciclosporin A (Ci A) cover from 1987 through 1994. METHODS: One hundred and thirty-one keratoplasties were performed. Ci A was administered for an average period of 9.4 months. We aimed at trough levels of 100-150 ng/ml (monoclonal RIA/TDx). The 29 kp in group A were second or third repeat kp and/or the recipient cornea had severe deep vascularization in all quadrants and/or a transplant position at the limbus was inevitable (expected risk: only immune reactions). The 40 kp in group B were threatened by severe ocular surface disorders (without severe limbal stem cell insufficiency) and by immune reactions (atopic keratopathy, keratoconus with severe endogenous eczema or chronic blepharokeratoconjunctivitis). In the 45 kp of group C resurfacing problems from severe limbal stem cell insufficiency and immune reactions were anticipated (severe burns, pseudopemphigoid or Lyell syndrome). Group D comprised 17 kp with various diagnoses (e.g. kp in newborns, rheumatic and Acanthamoeba keratitis). RESULTS: In group A 91% of the grafts were clear 2 years postoperatively, in group B 76%, in group C 38% and in group D 18%. In 32 of 41 failed grafts (78%), resurfacing problems were the only reason for or participated in final graft failure. Immune reactions and other causes of graft failure were of minor importance. CONCLUSIONS: (1) Systemic Ci A cover can efficiently suppress immune reactions. (2) With the suppression of immune reactions, resurfacing disorders become the most important single cause for functional graft failure. (3) For eyes with a considerable loss of limbal stem cells, limbal stem cell transplantation should be combined with systemic Ci A cover in order to improve the long-term prognosis for penetrating keratoplasty.

Adolescent↗
PubMed1996

Central corneolimbal transplantation under systemic ciclosporin A cover for severe limbal stem cell insufficiency.

BACKGROUND: Severe stem cell deficiencies uniformly lead to superficial conjunctivalization of corneal grafts with subsequent functional failure. We sought better long-term results by transplanting central corneolimbal grafts and simultaneously protecting the graft and its stem cells from immunological destruction by means of systemic administration of ciclosporin A. PATIENTS AND METHODS: In an ongoing pilot study, up to April 1995 20 eyes with stem cell dysfunctions of various etiology (e.g. chemical burn, ocular pseudopemphigoid, congenital aniridia) received eccentrically trephined fresh corneal grafts of 7.7-10.0 mm diameter. About one third of the circumference of the grafts contained limbal area. The mean age of the patients was 46.2 years (range 9-84 years). All patients received systemic ciclosporin A for at least 12 months. At present, the mean follow-up period is 9.6 months (mean 1-20.6 months). RESULTS: Fourteen of 20 grafts (70%) have remained clear so far. Reasons for six graft failures were surface disorders in four eyes, immune reactions in one eye and surface disorders in combination with immune reactions in another eye. Ten of 20 grafts (50%) experienced severe surface disorders. In six eyes surface disorders were coincident with endothelial immune reactions, in four eyes they were not. In four of 20 grafts (20%) conjunctivalization was observed in front of the transplanted limbal area; in seven of 20 grafts (35%) conjunctivalization occurred only distant from the transplanted limbal stem cells. CONCLUSIONS: Our method of central corneolimbal transplantation with simultaneous protection of the transplanted stem cell population from immunological destruction by means of systemic ciclosporin A has been successful for 14 eyes with severe stem cell deficiencies up to 20.6 months postoperatively. This new treatment principle promises - for the first time - long-term rehabilitation for a majority of eyes with severe limbal stem cell deficiencies.

Adolescent↗