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Amnion-assisted conjunctival epithelial redirection in limbal stem cell grafting
  1. Harminder S Dua,
  2. Ammar Miri,
  3. Mohamed S Elalfy,
  4. Anna Lencova,
  5. Dalia G Said
  1. Section of Academic Ophthalmology, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK
  1. Correspondence to Professor HS Dua, Department of Ophthalmology, B Floor, Eye ENT Centre, Queens Medical Centre, Derby Road, Nottingham NG7 2UH, UK; harminder.dua{at}


Aims To develop a technique using amniotic membrane (AM) to prevent admixture of conjunctival epithelial cells and limbal explant-derived corneal epithelial cells in patients undergoing limbal stem cell transplantation. To compare this technique with the current method of ‘sequential sector conjunctival epitheliectomy’ (SSCE).

Methods 26 patients with total limbal stem cell deficiency who underwent ocular surface reconstruction with limbal stem cells transplantation were retrospectively studied. Patients were categorised into group A (11) in which AM was used to direct the conjunctival epithelial cells away from the corneal surface so that the latter could be covered by the limbal explant-derived epithelial cells—the procedure was termed ‘amnion-assisted conjunctival epithelial redirection’ (ACER)—and group B (15) in which the conjunctival epithelium was prevented from migrating on to the corneal surface by SSCE.

Results In nine eyes of group A, the conjunctival epithelium was successfully directed on to the AM, preventing admixture with limbal explant-derived corneal epithelial cells. The AM was removed or it came off spontaneously within 1–4 weeks. Patients treated with SSCE (group B) underwent two to four interventions until complete re-epithelialisation. 12 patients had pain or discomfort. 11 patients had conjunctival haemorrhage during SSCE. The cornea was epithelised from the limbal explant-derived epithelium in all patients.

Conclusions ACER is a viable option in limbal transplantation that reduces multiple patient visits, bleeding and pain that can be associated with SSCE.

  • Conjunctiva
  • Cornea
  • Stem Cells

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  • Contributors HSD and DGS were responsible for the concept, design, data acquisition and interpretation and surgery. AM and MSE undertook the literature review and also participated in data acquisition. AL and DGS helped with the images. HSD wrote the manuscript and all authors suggested changes and approved the final version.

  • Funding Elizabeth C King Trust.

  • Competing interests HSD receives personal fees from Allergan, Thea, Santen, Nicox and Dompe and has shares in GlaxoSmithKline Beecham. None of the other authors have any competing interest to declare.

  • Ethics approval Nottingham Research Ethics/Audit Committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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