Report details feasibility of whole eye transplant

Key takeaways:

• Globe and retinal perfusion were observed through fluorescein angiography.
• There was no evidence of acute rejection.

A patient who underwent a combined whole eye and face transplant maintained globe and retinal perfusion as well as retinal response to light with no instance of acute rejection, according to a report in JAMA.

“This case involved multiple specialties of medicine to address the challenges of whole eye and face transplant,” Daniel J. Ceradini, MD, of NYU Langone Health, and colleagues wrote. “Collectively, these remarkable findings illustrate that whole eye transplant is a feasible surgical procedure with evidence of preservation of retinal viability and perfusion.”

The procedure was performed on a 46-year-old man with catastrophic tissue loss to his face and left globe due to a high-voltage electrical injury. Personalized surgical devices and a novel microsurgical strategy were used to perform the transplant.

According to the report, fluorescein angiography showed that globe and retinal perfusion were maintained in the immediate period after surgery, and serial electroretinography showed a retinal response to light in the transplanted eye. Other positive findings included maintenance of a normal range of IOP after surgery. However, imaging with OCT detected atrophy of inner retinal layers, “presumably due to cold ischemia time,” as well as ellipsoid zone attenuation.

At 1-year follow-up, the researchers observed “restored functional and aesthetic units of the face and eye with highly precise bony allograft alignment and globe viability” but reported no light perception, corneal sensation or ocular motility in the transplanted eye.

Daily examination and routine surveillance biopsies of the facial allograft skin revealed no evidence of acute rejection.

“This is the first report of whole eye transplant combined with facial transplant, demonstrating allograft survival including rejection-free graft survival and electroretinographic measurements indicating retinal response to light stimuli,” the authors wrote. “These data highlight the potential for clinical allotransplantation for globe loss.”

Perspective

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Mathieu Bakhoum, MD, PhD

The recent report of a combined whole eye and face transplant represents a remarkable surgical achievement.

The avoidance of acute rejection is encouraging and suggests that ocular allografts can be maintained without significant immune-mediated damage. Moreover, the preservation of retinal structure and partial function post-transplant — evidenced by retinal perfusion and responses to light stimuli via electroretinography and functional MRI, albeit minimal — provides proof of concept that transplanted retinal tissue can survive within a new host environment.

However, it is important to temper enthusiasm with caution. The absence of visual perception highlights the significant challenge of optic nerve regeneration and reconnection to the visual cortex. The optic nerve, being part of the central nervous system, does not readily regenerate. The coaptation of donor and recipient optic nerves, while surgically impressive, has not resulted in functional nerve regeneration or vision restoration. This underscores a fundamental limitation that current surgical techniques alone cannot overcome.

In conclusion, while whole eye transplantation is not yet a viable solution for vision restoration, this work provides a hopeful glimpse into the future of ocular transplantation, at least from an anatomical standpoint. It emphasizes the critical need for basic research focused on overcoming neural regeneration barriers. Without breakthroughs in optic nerve regeneration and neural integration, restoring vision through surgical approaches remains elusive.

Mathieu Bakhoum, MD, PhD

Assistant professor, departments of ophthalmology & visual science and pathology

Yale Cancer Center

Graduate School of Arts and Sciences

Yale University

Disclosures: Bakhoum reports no relevant financial disclosures.

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Disclosures:
Ceradini reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

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