Original article
Oral Mucosal Graft With Amniotic Membrane Transplantation for Total Limbal Stem Cell Deficiency

https://doi.org/10.1016/j.ajo.2011.03.037Get rights and content

Purpose

To report the results of oral mucosal graft for reconstruction of corneas with total limbal stem cell deficiency.

Design

Retrospective, interventional case series.

Methods

Seven patients (7 eyes) with total limbal stem cell deficiency caused by chemical burn (4 eyes), Stevens-Johnson syndrome / toxic epidermal necrolysis (1 eye), ocular cicatricial pemphigoid (1 eye), and multiple cryotherapies and application of mitomycin C for conjunctival melanoma (1 eye) were enrolled in this study. Oral mucosal graft was transplanted as a surrogate limbus together with amniotic membrane transplantation with a follow-up of at least 8 months. Symptomatic relief, restoration of a stable epithelium, corneal clarity, and the best-corrected visual acuity were assessed.

Results

Limbal stem cell deficiency was confirmed by impression cytology in all eyes, among which 6 were bilateral while 1 was unilateral. All 7 patients presented with severe loss of vision, photophobia, pain, chronic inflammation, and corneal vascularization and scarring. For 30 ± 19.8 months, pain and photophobia were resolved in all 7 eyes; 6 eyes exhibited a stable epithelium with regressed corneal vascularization and reduced chronic inflammation. Visual acuity was improved in all 7 eyes. One eye developed partial limbal stem cell deficiency due to exposure at 47 months follow-up and was reoperated. Five eyes had peripheral corneal vascularization.

Conclusions

Oral mucosal graft is a viable alternative for treating total limbal stem cell deficiency in eyes where transplantation of allogeneic limbal stem cells has failed or is not feasible.

Section snippets

Patients and Methods

We retrospectively reviewed the medical records of 7 eyes of 7 patients (4 male and 3 female) with total limbal stem cell deficiency, all confirmed by impression cytology.8 The mean age was 41.9 ± 15 years (range, 24 to 65). The etiology of limbal stem cell deficiency included chemical burn (4 eyes), Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) (1 eye), ocular cicatricial pemphigoid (1 eye), and multiple cryotherapies and application of mitomycin C (MMC) for conjunctival

Results

Limbal stem cell deficiency was confirmed by impression cytology in all eyes, among which 6 were bilateral while 1 was unilateral. Complete conjunctivalization of the entire limbus was observed with the presence of goblet cells in the central cornea. Chronic ocular inflammation (Figure 2, Pre-op) was graded as severe in 1 eye, moderate in 5 eyes, and mild in 1 eye. Corneal vascularization (Figure 2, Pre-op) was detected in all 7 eyes with grade 2 in 1 eye, grade 3 in 2 eyes, and grade 4 in 4

Discussion

This study demonstrated that oral mucosal graft is a viable alternative to restore corneal surfaces suffering from total limbal stem cell deficiency. Symptomatic relief and a stable ocular surface with minimal inflammation and improved corneal clarity and visual acuity were achieved in all 7 eyes during the follow-up of 30 ± 19.8 months.

To circumvent the risk of allograft rejection and potential side effects of systemic immunosuppression by either keratolimbal allograft from cadavers or limbal

Jingbo Liu, MD, PhD, received his medical degree from Weifang Medical College, and got his PhD at Sun Yat-Sen University, China. He worked in Wenzhou Medical College as an attending physician, and completed his fellowship in corneal and ocular surface diseases at Ocular Surface Center, Miami, Florida in 2010. He is currently pursuing postdoctoral training at Dyson Vision Research Institute, Weill Cornell Medical College, New York, New York.

His research interests focus mainly on limbal stem

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    Jingbo Liu, MD, PhD, received his medical degree from Weifang Medical College, and got his PhD at Sun Yat-Sen University, China. He worked in Wenzhou Medical College as an attending physician, and completed his fellowship in corneal and ocular surface diseases at Ocular Surface Center, Miami, Florida in 2010. He is currently pursuing postdoctoral training at Dyson Vision Research Institute, Weill Cornell Medical College, New York, New York.

    His research interests focus mainly on limbal stem cell, amniotic epithelial stem cell, tissue engineering and corneal wound healing after injury.

    Matthew Giegengack is currently practicing at the Department of Ophthalmology, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina.

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