title: Late Acute Rejection After Allograft Limbal Stem Cell Transplantation: Evidence for Long-Term Donor Survival.
abstract: OBJECTIVE
  To describe the clinical presentation and management of late (>3.0 years) acute graft rejection in keratolimbal allograft (KLAL) recipients.
  
  
  METHODS
  This was a multicenter, retrospective observational case series. Six eyes of 6 patients with ocular surface transplant at a mean age of 36.2 years were seen at 3 tertiary referral centers for acute graft rejection between 2007 and 2013. Main outcome measures included strength of systemic immunosuppression (SI) at the time of rejection, time to rejection, and clinical presentation of rejection.
  
  
  RESULTS
  Preoperative diagnoses included total limbal stem cell deficiency because of aniridia (n = 2) or chemical injury (n = 4). After an initially successful outcome, patients experienced late acute graft rejection at a mean time of 67.8 ± 24.1 months (range: 41-98) after KLAL while receiving suboptimal levels of SI because of medication taper (n = 5) or noncompliance (n = 1). Objective findings included an epithelial rejection line (n = 6), edema (n = 2), corneal epithelial irregularities (n = 2), and neovascularization (n = 1). Antirejection management consisted of topical corticosteroids (n = 6) and augmentation of SI therapy (n = 5).
  
  
  CONCLUSIONS
  These cases of late acute graft rejection in KLAL patients support the notion that allodonor cells can persist over the long run and remain at risk for immunologic rejection. It further underscores the fact that long-term success with KLAL may require extension of SI beyond the first few years, albeit at lower levels individualized to each patient.
authors.affiliation: *Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL; †Department of Ophthalmology, Cincinnati Eye Institute, University of Cincinnati, Cincinnati, OH; ‡Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; and §Department of Internal Medicine, University of Cincinnati, Cincinnati, OH.
authors.forename: Medi
authors.initials: M
authors.lastname: Eslani
authors.forename: Zeeshan
authors.initials: Z
authors.lastname: Haq
authors.forename: Asadolah
authors.initials: A
authors.lastname: Movahedan
authors.forename: Adam
authors.initials: A
authors.lastname: Moss
authors.forename: Alireza
authors.initials: A
authors.lastname: Baradaran-Rafii
authors.forename: Gautham
authors.initials: G
authors.lastname: Mogilishetty
authors.forename: Edward J
authors.initials: EJ
authors.lastname: Holland
authors.forename: Ali R
authors.initials: AR
authors.lastname: Djalilian
mesh_terms: D000208:Acute Disease; D000328:Adult; D003316:Corneal Diseases / Q000601:surgery*; D005260:Female; D006084:Graft Rejection / Q000188:drug therapy / Q000209:etiology*; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D016850:Limbus Corneae / Q000166:cytology*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D033581:Stem Cell Transplantation; D013997:Time Factors; D014184:Transplantation, Homologous; D055815:Young Adult
chemical_list: D007166:Immunosuppressive Agents