Face to face: World’s first whole-eye and partial face transplant

Image credit: ©Herr Hesse – stock.adobe.com

A surgical team of over 140 clinicians, including surgeons, nurses, and related health care clinicians from New York University (NYU) Langone Health, New York, performed the world’s first whole-eye and partial face transplantation on a 46-year-old man. The patient, Aaron James, a military veteran from Hot Springs, Arkansas, survived a work-related, high-voltage electrical accident that occurred in June 2021.

The 7,200 volts of electricity resulted in loss of the patient’s dominant left arm above the elbow, loss of his entire nose and lips, front teeth, left cheek area and chin down to the bone, and destroyed the left eye.

During the surgery, the entire left eye and part of the face of 1 donor were transplanted to Mr. James, resulting in a medical first, ie, a successful human whole-eye transplant combined with a partial facial transplant.

The 21-hour transplantation procedure was performed in May 2023. Thus far, the facial transplant has shown no signs of rejection, which, Eduardo Rodriquez, MD, DDS, said, generally occurs in the early months after the procedure. He is the Helen L. Kimmel Professor of Reconstructive Plastic Surgery, and Chair of the Hansjörg Wyss Department of Plastic Surgery, and director of the Face Transplant Program at NYU Langone.

The transplanted eye is doing remarkably well, in that the retina has a good blood supply and intraocular pressure. It currently is protected by the closed left lid, which prevents the eye from suffering exposure damage. The eye care team in this case is led by Vaidehi S. Dedania, MD, a retina specialist in the Department of Ophthalmology at NYU Langone.

The clinicians do not know yet if the vision ultimately will be restored; however, since the procedure, the transplanted left eye has shown remarkable signs of health, including direct blood flow to the retina, according to a press release. Although the future level of functioning of the eye is unknown, the clinicians believe that this procedure opens new possibilities for future advancements in vision therapies and related medical fields. Functional magnetic resonance imaging has indicated that the retina is seeing light stimulation during testing.

When Mr. James’s treatment began at a Texas medical center after the accident, Rodriguez and his team recommended, before the left eye was removed, that the optic nerve be cut as close to the eyeball as possible, to preserve as much nerve length to maximize reconstructive options, including the hope of a potential transplant later. This began the discussion of the possibility of including an eye with the face, something that had never been attempted previously.

“Given that Mr. James needed a face transplant and will be taking immunosuppressive drugs regardless, the risk versus reward ratio of transplanting the eye was very low. Despite the eye being successfully transplanted, from a cosmetic standpoint, it would still be a remarkable achievement,” Rodriguez explained.

Rodriguez has thus far led a total of 5 face transplant, which includes the procedure under discussion, ie, the first known whole-eye transplantation. “The mere fact that we’ve accomplished the first successful whole-eye transplant with a face is a tremendous feat many have long thought was not possible. We’ve made one major step forward and have paved the way for the next chapter to restore vision,” he stated.

In this case, the transplanted tissues included the partial face, ie, the nose, left upper and lower eyelids, left eyebrow, upper and lower lips, and underlying skull, cheek, nasal and chin bone segments, with all of the tissues below the right eye including the underlying muscles, blood vessels and nerves; and the left whole-eye and socket including the orbital bones and all surrounding eye tissues including the optic nerve.

Transplanting ocular tissue

Up to now only a large number of corneal transplantations have been performed, with thousands performed in the US annually, successful whole-eye transplants to restore vision have remained elusive due to the complex nature of the eye and the challenges associated with nerve regeneration, immune rejection, and retinal blood flow.

Rodriguez, in collaboration with the team at NYU Langone’s Transplantation and Cellular Therapy Center, part of the Blood and Marrow Transplant Program at Perlmutter Cancer Center, made the decision to combine the donor eye with donor bone marrow-derived adult stem cells. Transplanted adult stem cells can work as a replacement therapy and natural repair crew, dividing repeatedly to create heathy cells that replace the damaged or dysfunctional elements, Rodriguez explained.

“This is the first attempt at injecting adult stem cells into a human optic nerve during a transplant in the hopes of enhancing nerve regeneration,” said A Samer Al-Homsi, MD MBA, executive director of the Transplantation and Cellular Therapy Center, and professor in the Department of Medicine at NYU Langone. “We chose to use CD34 positive stem cells that harbor the potential to replace damaged cells and neuroprotective properties.”

During the transplant, bone marrow harvested from the donor’s vertebrae and processed preoperatively to isolate the CD34 positive stem cells were injected at the optic nerve connection of the recipient.

"We have now demonstrated that the procedure is safe and potentially efficacious, but we need time to determine if this step plays a role in enhancing the chance of sight restoration, and if there’s anything further that can be done in the future to optimize the procedure,” added Al-Homsi.

5 Months postoperatively and beyond

“The progress we’ve seen with the eye is exceptional, especially considering that we have a viable cornea paired with a retina showing great blood flow 5 months after the procedure. This far exceeds our initial expectations, given our initial hope was that the eye would survive at least 90 days,” Bruce Gelb, MD, a transplant surgeon at the NYU Langone Transplant Institute and vice chair of Quality in the Department of Surgery, stated. “We will continue to monitor, and I am excited to see what else we may learn over time.”

While the transplanted left eye does not currently have any sight, over the last months, the transplanted eye has shown remarkable signs of health in other regards based on various clinical tests that measure outcome.

Rodriguez, Dedania, and a multidisciplinary team including neurologists, ophthalmologists, radiologists, and neuroradiologists continue to discuss questions related to the eye and ways to measure any indications towards sight restoration.

“What we’re witnessing now is not something we ever expected or thought we’d see,” said Dedania, who regularly tests Mr. James’s eyes. “The first step is having an intact eyeball, a lot of things could come after that, this is a first in the world, so we are really learning as we go.”

James will continue to undergo various clinical tests on the left transplanted eye, including electroretinography to measure the electrical response of the retina to light.