A surgical team at NYU Langone Health performed the first combined whole eye and face transplant on a 46-year-old man who sustained a high-voltage electrical injury resulting in catastrophic facial tissue loss and left globe injury.
Published in JAMA, the case demonstrated allograft viability, retinal perfusion, and light-responsive retinal activity at 1-year post-transplant. Serial electroretinography (ERG) revealed retinal response amplitudes up to 9.0 μv at 220 days post-transplant, approaching the low end of the normal reference range (10-50 μv).
The procedure, conducted in May 2023, utilized personalized surgical devices and a novel microsurgical approach. Surgeons rerouted the donor ophthalmic artery and vein to the superficial temporal vessels, limiting warm ischemia to 25 minutes. The total operative time was approximately 21 hours with a cold ischemia time of 2 hours 59 minutes. Donor CD34+ bone marrow cells were injected at the optic nerve coaptation site to potentially mitigate ischemia-reperfusion injury.
Postoperative immunosuppression included Thymoglobulin and rituximab induction followed by tacrolimus, mycophenolate mofetil, and prednisone maintenance therapy. No episodes of acute rejection were observed in the facial allograft.
At 1-year, the transplanted eye remained viable with stable globe volume (measured on postoperative days 52, 92, 196, and 305) and intraocular pressures between 8-11 mmHg. Fluorescein and indocyanine green angiography confirmed perfusion of the retinal and choroidal vasculature. Optical coherence tomography showed inner retinal layer atrophy and ellipsoid zone attenuation but not complete loss. The patient experienced a return of itchy sensation deep in the left orbit and slowly improving orbicularis oculi and facial mimetic muscle function.
Visual evoked potentials had reproducible waveforms with Pmax-Nmins of 5.2-7.4 μv in the transplanted eye compared to 10.9-20.7 μv in the unaffected eye.
Diffusion MRI tractography demonstrated reconnection of the eye to the optic tract, though with lower fractional anisotropy values in the left optic nerve. Functional MRI on postoperative days 92 and 196 showed occipital cortex activity on left eye stimulation. However, the patient had no light perception in the transplanted eye at 1-year.
Quality-of-life assessments showed improved self-esteem and social desirability and decreased distress about appearance at 1-year post-transplant.
This case reports the first combined whole eye and face transplantation. While visual recovery was not achieved, evidence of allograft survival, retinal perfusion, and light-responsive retinal activity provide valuable insights to guide future advancements in eye transplantation.
One of the study authors reported having a patent for diffusion image analysis issued (US10307139B2) and a patent for image denoising issued (US11529069B2). No other disclosures were reported.