The Fox Center for Vision Restoration organizes an exciting lecture series focusing on ocular regeneration and new therapies.
Distinguished national and international speakers present their innovative and multidisciplinary approaches to finding cures for vision impairment. The objective of this lecture series is to accelerate research through knowledge sharing, partnership building and out of the box thinking.
Dr. Vijay Gorantla is currently an Associate Professor of Surgery in the Department of Surgery, Division of Plastic Surgery at the University of Pittsburgh and Administrative Medical Director of the Pittsburgh Reconstructive Transplant Program at UPMC.
Abstract of the presentation
To date, approximately 1.7 million troops have served in the two theaters of conflict in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). Data from the OEF/OIF indicate that combat trauma to the head and neck (craniomaxillofacial [CMF]) region constitutes 29% of injuries (approximately 2.4 CMF injuries /service member), exceeding the incidence in WWII, Korea or Vietnam. (Joint Theater Trauma Registry data, 2007; Hale RG, 2008).
The most common cause is blast polytrauma that also affects other body regions with significant overlap of injuries. Combat trauma to the upper extremity region constitutes 39% of injuries (Dougherty AL, Injury, 2009). Combat Ocular Trauma (COT) is also very commonly associated with CMF injuries.
The nature of these injuries has ranged from intraocular foreign bodies, and perforations to open-globe injuries and ruptures. Overall, although the number of eye injuries as a proportion of all casualties is low, the injuries are more severe than in civilian practice. COT generally results in poor visual and anatomic outcomes despite the best available surgical intervention. Prophylactic measures, such as eye protection, are helpful in reducing the likelihood of perforating injuries; however, novel surgical and pharmacologic therapies will be required to improve the functional and anatomic outcomes of these devastating injuries (Colyer MH, Ophthalmology, 2008).
Current surgical procedures after major trauma are limited by available tissues for reconstruction, morbidity from extensive surgery, prolonged recovery and costs of multiple surgeries. Despite the best reconstructive efforts, functional and esthetic outcomes are limited to poor. For such complex injuries as sustained in combat trauma, reconstructive transplantation (RT) of composite tissue allografts (CTA) can achieve near perfect restoration of form and function. RT offers the promise of achieving the ideal goal of CMF reconstruction: namely to replace and restore missing tissue as functional “whole” subunits.
During the past decade, more than 100 RT procedures have been performed around the world, including over 67 hand/forearm/arm transplants and 8 facial transplants (including facial/head and neck components like mid-face, maxilla/mandible, tongue, or scalp). Graft survival and functional, immunologic and quality of life outcomes have been highly encouraging.
However, wider application is restricted by the risks (such as infectious, metabolic and neoplastic complications) of prolonged, high dose, multi-drug (a combination of two to three agents) immunosuppression necessary to prevent graft rejection. Taken together, the morbidity of immunosuppression after RT threatens to affect the quality of life outcomes, alter the risk profile and jeopardizes the benefits of a successful procedure.
Recent immunomodulatory approaches evaluated at the University of Pittsburgh in solid organ transplants have enabled significant reduction of overall drug treatment. Early outcomes with similar cell-based therapies (Pittsburgh Protocol) in hand/forearm transplantation performed at the University of Pittsburgh are promising.
In the past 12 months, we have implemented this novel immunomodulatory protocol in 5 hand/forearm transplants performed at the University of Pittsburgh. Our experience is the world’s first successful implementation of an immunomodulatory therapy in clinical RT. Initial and emerging data suggest that the protocol is safe, efficacious and well tolerated and has allowed graft survival under low dose monotherapy with minimal/infrequent immunologic sequelae and negligible complications.
Application of the insights gained from the Pittsburgh Protocol to reconstructive transplantation of the eye from deceased donors could be an option for certain devastating COT where all conventional vision restoration strategies have been exhausted. The ability of innovative reconstructive strategies to recover and restore vision could allow patients with COT or catastrophic visual injuries to reintegrate into professional and personal life.
Location and Address
Eye and Ear Boardroom, 5th floor, Eye and Ear Institute
203 Lothrop Street, Pittsburgh PA 15213