Stable Ocular Surface Research Articles

Nonhealing epithelial defect after collagen cross-linking for keratoconus with vernal keratoconjunctivitis

Here we report a case of nonhealing epithelial defect after corneal collagen cross-linking (C3R) in a 24-year-old young adult with progressive keratoconus and concomitant vernal keratoconjunctivitis (VKC). Epithelium off C3R with hypoosmolar riboflavin and ultraviolet -A irradiation was done in the right eye for progressive keratoconus. The preoperative minimum corneal thickness was 388 microns. Chronic VKC was stabilized with mast cell stabilizer and lubricants before C3R. The patient presented with nonhealing epithelial defect until 1-month post cross-linking due to possible limbal stem cell deficiency (LSCD) and underlying VKC with giant papillae. Amniotic membrane grafting was done twice for ocular surface stabilization which occurred at the end of 7 weeks. Final best-corrected visual acuity at 1 year was 6/12 with nebular corneal scarring. Preemptive management of giant papillae and proper stabilization of the ocular surface is essential before C3R. In cases of keratoconus with VKC, LSCD should be strongly suspected and reactivation of VKC with a prolonged course of epithelial healing can be a possible complication after C3R.

Indications for Wear, Visual Outcomes, and Complications of Custom Imprint 3D Scanned Scleral Contact Lens Use.

To report indications for wear, visual outcomes, and complications of EyePrintPRO (EPP) scleral contact lens (SCL) use. A retrospective review identified all patients fitted with this device between December 2013 and March 2018. Baseline demographics, wear indication, and contact lens history were determined. Habitual-corrected visual acuity was measured at baseline and follow-up. Adverse wear symptoms and signs, reprinting, and device cessation were tracked. Ninety-five eyes from 69 patients were followed for a median of 12.1 months (interquartile range 4.4-19.6). Indications for wear included vision improvement and/or ocular surface stabilization in the setting of irregular corneal shape (n = 68 eyes, 72%), ocular surface disease (n = 17, 18%), exposure keratopathy (n = 7, 7%), neurotrophic keratitis (n = 5, 5%), and extracorneal topographical abnormalities preventing noncustom lens fitting such as glaucoma drainage devices (n = 8, 8%). Median habitual-corrected visual acuity improved from 0.67 to 0.08 (P = 0.0003). One-third of eyes (33.1%) developed adverse wear symptoms. Fifteen of 95 eyes (16%) developed adverse wear signs. Device cessation occurred in 10 eyes (10.5%) and reprinting occurred in 14 eyes (14.7%) unrelated to prior lens wear or indication (P = 0.67 and 0.15, respectively). In eyes that previously failed SCLs (n = 56), 12 eyes required reprinting and 49 eyes continued use. Indications for EPP wear include irregular corneal shape, ocular surface disease, and extracorneal topographic abnormalities. Visual acuity improves with the use of EPP. Clinicians and patients should be aware of potential adverse wear symptoms/signs and device cessation that may occur with EPP use. EPP is a viable salvage therapy in eyes that previously failed SCLs.

Ocular Sequelae of Stevens-Johnson Syndrome: A Comprehensive Approach.

The chronic sequelae of Stevens-Johnson syndrome cause severe ocular morbidity. Among the various manifestations, including dry eye, cicatrization causing forniceal shortening, adnexal disorders, lid margin keratinization, and limbal stem cell deficiency, keratinization of the lid margin leads to progressive ocular surface damage through constant blink-induced microtrauma. This damage induces corneal punctate keratopathy and neovascularization and can produce epithelial defects leading to corneal infection or perforation. Management strategies for chronic ocular sequelae are broadly categorized into ocular surface stabilization procedures, tectonic procedures, and visual rehabilitation procedures. Interventions in the acute stage of the disease include amniotic membrane grafting. Timely intervention helps to prevent deterioration of the ocular surface in these eyes.

Use of Panel-Reactive Antibody Testing in the Planning and Management of Ocular Surface Stem Cell Transplantation.

Panel-reactive antibody (PRA) testing has been widely adopted in solid organ transplantation for risk assessment in potential allograft recipients but has not been studied in the context of ophthalmic transplantation. The purpose of this study is to evaluate outcomes in patients undergoing ocular surface stem cell transplantation (OSST) for limbal stem cell deficiency (LSCD) relative to preoperative PRA level. This is retrospective chart review of all eyes with documented PRA level that underwent OSST for LSCD between May 2000 and March 2019 at a single institution. Eyes with stable ocular surface but <1 year of follow-up and eyes without updated PRA before repeat OSST were excluded. Eyes were grouped by PRA <80% and ≥80%. The primary outcome was ocular surface failure, whereas the secondary outcome was clinical allograft rejection. Sixty-nine surgeries met inclusion criteria, consisting of 54 living-related conjunctival limbal allografts, 5 keratolimbal allografts, and 10 combined living-related conjunctival limbal allografts/keratolimbal allografts (Cincinnati procedure). The most common etiologies for LSCD were aniridia (33%), chemical/thermal injury (28%), and contact lens associated (14%). Surface failure occurred in 5 of 12 eyes (58%) with PRA ≥80% versus 12 of 57 eyes (21%) with PRA <80% (P = 0.01). The relative risk for surface failure with PRA ≥80% was 2.8 [confidence interval (CI), 1.38-5.55]. There was no significant difference in acute rejection (P = 1). Pretransplant PRA level is an important prognostic factor for ocular surface stability in eyes undergoing OSST for LSCD, with implications for donor selection, perioperative management, and systemic immunosuppression.

Assessment of surgical outcome using simple limbal epithelial transplantation in patients of unilateral ocular surface chemical burn: Case series

This study aimed to report the surgical outcomes of autologous Simple limbal epithelial transplantation (SLET) performed for unilateral limbal stem cell deficiency (LSCD) following chemical injury. This was single centre prospective case series of patients who developed unilateral LSCD after chemical injury and underwent SLET between December 2018 and September 2019 with follow up of 3-6 months. Primary outcome was restoration of completely epithelized avascular corneal surface. The secondary outcome was percentage of eyes which gained vision. This study included 5 eyes of 5 patients with follow up of 3-6 months. Stable corneal surface was obtained clinically in 4 cases out of 5 and visual acuity gain seen in 3 patients. The factors associated with failure of vision improvement were time of chemical injury (during childhood), duration of injury to SLET procedure and previous history of surgical procedure. Complications seen are haemorrhage under hAM, focal recurrence, symblepharon, keratitis and loss of explants post operatively.Autologous SLET is an effective and safe modality for the treatment of unilateral LSCD. It causes stabilization of ocular surface and also facilitates visual improvement. In a developing country like India, with limited facilities in the healthcare system, auto-SLET is a boon for patients with unilateral LSCD.

Outcomes of Cultivated Oral Mucosal Epithelial Transplantation in Eyes With Chronic Stevens-Johnson Syndrome Sequelae

To study the outcomes of cultivated oral mucosal epithelial transplantation (COMET) in eyes with chronic Stevens-Johnson syndrome (SJS) sequelae. Prospective interventional case series. Forty-five eyes of 41 patients with chronic SJS sequelae were recruited and evaluated from 2013 to 2017 in an institutional setting. All patients underwent COMET, with an aim of fornix reconstruction and visual rehabilitation. Change in corrected distance visual acuity (CDVA), severity scores of various ocular surface parameters, and the occurrence of complications were documented during a follow up period of 2 years. Attainment and maintenance of a stable ocular surface, as assessed by change in the ocular surface severity scores was the primary outcome measure, while change in CDVA was the secondary outcome measure. The mean preoperative CDVA was 2.7± 0.5 logMAR, which improved to 1.5± 0.7 logMAR and 1.49± 0.98 postoperatively, at 1- and 2-year follow-up visit. Overall, 82.2% eyes (37/45) had improvement in visual acuity, 13.3% (6/45) experienced no change, whereas 2 eyes (4.4%) had worsening of visual acuity. The total ocular surface severity scores improved from a mean preoperative value of 29.1± 9.7 to 18.7± 7.2 postoperatively, at 2-year follow-up. Two eyes developed persistent epithelial defects, with progression to corneal melting requiring keratoplasty. COMET allows successful and sustained restoration of ocular surface anatomy with functional improvement, in eyes with chronic sequelae of SJS.

Clinical Outcomes of Allogeneic Ocular Surface Stem Cell Transplantation in Pediatric Patients.

To describe the outcomes of allograft ocular surface stem cell transplantation (OSST) and the complication profile of systemic immunosuppression (SI) in pediatric patients with limbal stem cell deficiency. This was a retrospective interventional case series from a single tertiary referral institution of 20 eyes from 13 patients who 1) underwent allograft OSST surgery, 2) were 18 years or less at time of OSST, and 3) received SI with 4) a minimum of 12-months follow-up. The main outcome measures were ocular surface stability, visual acuity, and SI adverse events. The mean age of patients was 15.1 ± 3.2 years (range 9-18 years). The mean follow-up was 5.6 ± 5.0 years after OSST. At the last follow-up, 15 eyes (75%) had a stable ocular surface, 1 eye (5%) developed partial failure, and 4 eyes (20%) developed total surface failure. Preoperative mean logarithm of the minimum angle of resolution visual acuity 1.5 improved to 1.1 at the last follow-up (P = 0.1); when 4 eyes of 3 nonadherent patients were excluded, the results were more pronounced and statistically significant (1.5 improved to 1.0, P = 0.002). SI was tolerated well by all patients with minimal adverse events. OSST provides a stable ocular surface and is a successful treatment option for pediatric patients with limbal stem cell deficiency. SI is well-tolerated with a minimal complication profile.

Tenonplasty Combined With Amniotic Membrane Transplantation for Patients With Severe Ocular Burns Induced Anterior Segment Necrosis.

This article describes a novel surgical technique for successful repair of intractable corneoscleral necrosis caused by severe ocular burns. In this prospective case series, 19 eyes of 15 consecutive patients with sectional scleral necrosis and persistent corneal epithelial defects were treated with tenonplasty and amniotic membrane transplantation. The main outcome measure was the stability of the ocular surface after reepithelialization and repair of defects. All patients underwent successful combined surgery involving tenonplasty and amniotic membrane transplantation, in which the conjunctival and corneal surfaces were reconstructed. The interval from injury to surgery was 37.4 ± 24.5 days (3–91 days), and the ocular surfaces became stabilized in 82.2 ± 35.4 days (26–156 days, median 87 days). At the final visit, all cases presented with corneal opacity and neovascularization to various degrees. The best-corrected visual acuity decreased from 2.83 ± 1.02 LogMAR preoperatively to 2.87 ± 1.31 LogMAR postoperatively. The results imply that tenonplasty combined with amniotic membrane transplantation could provide vascular supply to the ischemic sclera, repair defects in the conjunctiva, and promote corneal reepithelialization, thus facilitating ocular surface stabilization after burns.

Long-term outcomes of conjunctival limbal autograft in patients with unilateral total limbal stem cell deficiency

PurposeTo investigate the long-term clinical outcomes of conjunctival limbal autograft (CLAU) in patients with unilateral total limbal stem cell deficiency (LSCD). MethodsIn this retrospective interventional case series, the medical charts of patients with unilateral total LSCD were reviewed. Patients who underwent CLAU and no other allograft ocular stem cell transplantation with a minimum follow-up of 1 year were included. Main outcome measures were ocular surface stability, best-corrected visual acuity (BCVA), and postoperative complications. Results27 eyes fulfilled the inclusion criteria with a mean follow-up period of 49.8 ± 36.6 months (4.15 years; range 12–186.72 months; 1–15.56 years). Ocular surface stability was achieved in 77.8% (n = 21) of eyes at last follow-up, while 22.2% (n = 6) developed partial surface failure. Optical penetrating or deep lamellar anterior keratoplasty was performed in 44.45% (n = 12). BCVA improved from 1.42 ± 0.95 mean LogMAR (equivalent to 20/400) preoperatively to 0.53 ± 0.47 mean LogMAR (equivalent to 20/70) at last follow-up (p < 0.001). BCVA ≥20/40 was achieved in 44.45% (n = 12) at last follow-up. Microbial keratitis occurred in 14.81% (n = 4). Ocular hypertension secondary to corticosteroid use developed in 25.9% (7/27) eyes. There were no other complications in the donor or recipient eyes. ConclusionsCLAU can provide long-term ocular surface stability and successful visual outcomes in patients with unilateral LSCD.

Efficacy and Safety of Topical Chloroquine in Mild to Moderate Dry Eye Disease

ABSTRACTPurpose: To evaluate the role of topical chloroquine (CHQ) as an adjunct to topical lubricants in the management of mild-moderate dry eye disease (DED)Methods: Prospective comparative pilot study allocated 150 patients with symptoms of mild to moderate DED to receive topical CMC 0.5% three times a day (group I, n = 75) or topical CHQ 0.03% twice a day with carboxymethylcellulose (CMC) 0.5% three times a day (group II, n = 75), for three months. Primary outcome measures were ocular surface disease index (OSDI) score and conjunctival impression cytology at 3 months. Secondary outcome measures were TBUT, Schirmer’s test, ocular surface staining and any adverse effects at 3 months. Follow up was performed at 1 and 3 months.Results: At three months, the OSDI score was significantly better in the CHQ group as compared with the CMC group (CMC-18.36 ± 4.03 (SD), CHQ group- 15.9 ± 5.18 (SD); p = .002). Nelson’s score was 0.92 ± 0.69 (SD) in the CHQ group as compared with 1.60 ± 0.77 (SD) in the CMC group (p < .001). Abnormal impression cytology was observed in 20% cases in the CHQ group as compared with 61.3% cases in CMC group (p < .001). A significant correlation was observed between Nelson’s score and OSDI (Spearman’s rho correlation coefficient 0.414, p < .001). TBUT, Schirmer test and ocular surface staining were significantly better in the CHQ group (p < .001). No adverse effects were observed in any group.Conclusion: Topical chloroquine is a useful adjunct to topical lubricants in the management of DED as it decreases the underlying chronic inflammation and helps maintain ocular surface stability.

Femtosecond Laser-Assisted Keratolimbal Allograft Transplantation for the Treatment of Total Limbal Stem Cell Deficiency.

To investigate the surgical procedure and therapeutic efficacy of femtosecond (FS) laser-assisted keratolimbal allograft (KLAL) transplantation in the treatment of eyes with total limbal stem cell deficiency. Ten eyes from 10 patients who underwent FS laser-assisted KLAL transplantation were enrolled. The best-corrected visual acuity (BCVA), ocular surface stability, corneal transparency, and postoperative complications were recorded. The keratolimbal grafts prepared using the FS laser were even in thickness and width. After the surgery, glucocorticoid and tacrolimus eye drops were administered locally to the eyes with concentration gradients, and a medium dose was prescribed for maintenance. Within the mean follow-up period of 16.8 ± 7.3 months, 9 of 10 eyes (90.0%) maintained a stable ocular surface and showed significant improvements in corneal transparency and BCVA. Persistent corneal edema only occurred in one eye because of repeated epithelial defects, and the BCVA of this eye did not improve. Confocal microscopy revealed activated dendritic cells in the Bowman membrane at the limbus, but they were always low in density with small dendritic processes. No acute immune rejection, cataracts, or elevation of intraocular pressure were detected. The FS laser-assisted KLAL technique can produce ring-shaped grafts with an even depth and width, resulting in a stable ocular surface and good visual prognosis. After surgery, glucocorticoids and potent immunosuppressive eye drops were administered locally with concentration gradients and effectively inhibited acute immune rejection.

Comparison of the efficacy of different cell sources for transplantation in total limbal stem cell deficiency.

The purpose of this study was to compare the efficacy of allogeneic cultured limbal epithelial transplantation (ACLET) and cultivated oral mucosal epithelial transplantation (COMET) in treating total limbal stem cell deficiency (LSCD). In this retrospective cohort study, 73 patients (76 eyes) with total LSCD, including 41 patients (42 eyes) treated with ACLET and 32 patients (34 eyes) receiving COMET, were evaluated. The age, gender and injury cause of all patients were recorded. The mean follow-up was 23.3 ± 9.9months in the ACLET group and 16.1 ± 5.8months in the COMET group. A higher incidence of persistent epithelial defect was observed after COMET (P = 0.023). The overall ocular surface grading scores were all lower in the ACLET group than in the COMET group at 3, 6, and 12months after surgery and the last follow-up. Kaplan-Meier survival curve analysis demonstrated a significantly higher success rate of ACLET (71.4%), compared with that of COMET (52.9%; P = 0.043). The risk of graft failure was higher in patients with entropion and trichiasis, incomplete eyelid closure and treated with COMET. The graft failure risk rate after COMET was 3.5 times higher than that of ACLET. For total LSCD patients, ACLET should be prioritized, since limbal epithelial cells have better ability to maintain corneal epithelial integrity and ocular surface stability and benefit the ocular surface when compared with oral mucosal epithelial cells. Preoperative and postoperative eyelid abnormalities should be corrected as early as possible.

Evaluation of limbal transplantation in eyes with bilateral severe ocular surface damage secondary to chemical injury.

PurposeTo evaluate the outcome of limbal transplantation in eyes with bilateral severe ocular surface damage secondary to chemical injury.Patients and methodsThis was a retrospective case series that included 20 patients who had undergone living related limbal transplantation due to the presence of bilateral severe stem cell deficiency resulting from chemical injury. Medical records of the selected patients were reviewed. The following data were recorded and analyzed: gender; age at the time of the surgery; duration of follow-up; corrected distance visual acuity (CDVA); symptoms; intraocular pressure (IOP); any complications; postoperative treatment; and other surgical procedures needed.ResultsThe mean age of the included patients was 27.4±9.3 years. The causative agent was an alkali in 14 patients. Fifteen patients (75%) had a stable ocular surface (ie, complete corneal re-epithelization and resolution of postoperative inflammation) after the first limbal transplantation, while the other five patients (25%) needed regrafting. As regards the IOP; five patients (25%) needed Ahmed’s valve implantation to control the IOP. Other surgical procedures needed were penetrating keratoplasty (PKP) in three patients (15%), cataract surgery in six patients (30%), and lid surgery in one patient (5%).ConclusionIn conclusion, living related conjunctival limbal allograft transplantation, especially when combined with amniotic membrane transplantation, yielded good results in the management of cases with bilateral severe chemical eye injuries.

Long-term outcomes of donor eyes after conjunctival limbal autograft and allograft harvesting

ObjectiveTo investigate the ocular surface stability of donor eyes after conjunctival limbal autograft (CLAU) or conjunctival limbal allograft (CLAL). DesignRetrospective interventional case series. ParticipantsPatients diagnosed with limbal stem cell deficiency (LSCD) who underwent ocular surface stem cell transplantation with postoperative follow-up of at least 3 months. MethodsDonor eye data collected included preoperative and postoperative Snellen best-corrected visual acuity (BCVA), intraoperative and postoperative complications, re-epithelialization times, and ocular surface stability at the last follow-up. ResultsSixteen donor eyes of 16 patients were included, the mean age at the time of surgery was 59.3 years, and the mean follow-up period was 53 months. The most common injury etiology was chemical injury, followed by iatrogenic causes and Stevens-Johnson syndrome, then congenital aniridia. Eleven patients underwent CLAU, 3 underwent living-related CLAL, and 2 underwent CLAL combined with keratolimbal allograft. Preoperative mean donor eye BCVA was 0.22 ± 0.32 logMAR (Snellen equivalent ≈ 20/33), and mean BCVA at the last follow-up was 0.18 ± 0.24 logMAR (Snellen equivalent ≈ 20/30) (p = 0.4). All donor eyes had a stable ocular surface at the last follow-up, with no signs of iatrogenic LSCD or delayed corneal epithelial healing. There were no intraoperative or postoperative complications such as infections, persistent epithelial defects, corneal neovascularization, or chronic inflammation. ConclusionThis study provides additional evidence for the long-term safety of donor eyes when providing limbal stem cell tissue for CLAU or CLAL.

Ocular Surface Reconstruction Using Circumferentially-trephined Autologous Oral Mucosal Graft Transplantation in Limbal Stem Cell Deficiency.

PurposeTo investigate the effects of transplantation of a circumferentially-trephined autologous oral mucosal graft using a vacuum trephine on ocular surface reconstruction in patients with limbal stem cell deficiency.MethodsPatients with a limbal stem cell deficiency who underwent transplantation of autologous oral mucosal graft performed by a particular surgeon in Seoul National University Hospital were included. The medical records of these five patients were retrospectively reviewed. The lower labial mucosal graft inside the inferior lip was trephined to a depth of 250 µm using a donor vacuum trephine with a 9-mm diameter. Outside markings were made using a 14-mm intraoperative keratometer. The oral mucosal graft was dissected under a microscope using a Beaver mini-blade as either a ring or a crescent-shaped strip with a 5-mm width. The mucosal graft was transplanted onto the limbus in the limbal-deficient eye. Best-corrected visual acuity and corneal status were measured during the follow-up period.ResultsFour patients were diagnosed with Stevens-Johnson syndrome and one was diagnosed with atopy-associated immune keratitis. The mean follow-up period was 10.4 ± 2.9 months. After 4 months, visual acuity improved in all patients, and the mean improvement in logarithm of the minimum angle of resolution visual acuity was 0.526 ± 0.470 (range, 0.15 to 1.10). Corneal surface erosion and neovascularization decreased in four patients, and stromal opacity decreased in two patients. The engraftments maintained ocular surface stabilization in four of the five patients at the last follow-up.ConclusionsTransplantation of circumferential autologous oral mucosal grafts may be effective for the treatment of limbal stem cell deficiency.

Severe Dry Eye With Combined Mechanisms is Involved in the Ocular Sequelae of SJS/TEN at the Chronic Stage.

Stevens-Johnson syndrome (SJS), and its more severe variant, toxic epidermal necrolysis (TEN), are life-threatening diseases of the skin and mucous membranes. After the acute-stage damage subsides, serious visual impairment and severe dry eye remains as ocular sequelae. At the acute stage, ocular complications occur in 77% of SJS/TEN patients. In cases with pseudomembranous formation and/or epithelial defects, the risk of ocular sequelae increases. Among 13 slit-lamp microscopy images that we obtained of SJS/TEN patients at the chronic stage, the loss of corneal epithelial stem cells and severe meibomian gland involvement were found to be the most common disorders. Severe dry eye in SJS includes three important mechanisms: (1) aqueous tear deficiency, (2) decreased wettability of corneal surface, and (3) increased evaporation. Dry eye severity in SJS patients is often underestimated when the meniscus is first observed, as the punctum is closed due to scarring or surgery. In SJS patients with severe dry eye, the dryness results in immense eye pain, and unstable tear film related to dry eye result in a change/loss of vision. For the treatment of dry eye in SJS, it is important to suppress chronic inflammation on the ocular surface, and 2% rebamipide ophthalmic solution reportedly helps to obtain ocular surface stabilization. Scleral contact lenses, as well as the newly developed limbal-rigid contact lenses, improve the patients' visual acuity and reduce symptoms related to severe dry eye. Further studies and new therapeutic methods are needed to more effectively treat dry eye in patients afflicted with SJS/TEN.

Effect of ethanol pretreatment in Acanthamoeba keratitis: a long-term follow-up study.

PurposeThe aim of this study was to evaluate the long-term outcomes of ethanol pretreatment in Acanthamoeba keratitis (AK).Patients and methodsThis single-center, retrospective, interventional study included 22 patients (24 eyes) who developed AK and underwent ethanol pretreatment between 2009 and 2015. Samples for smears, polymerase chain reaction, and culture for evidence of Acanthamoeba were collected. After ethanol pretreatment, the patients were treated with corneal epithelial debridement, topical 0.02% polyhexamethylene biguanide, and 0.1% propamidine isethionate. The primary outcomes were a clinically stable ocular surface, complete recovery from corneal infection, and acceptable corneal haze. The secondary outcome measure was improvement in best-corrected visual acuity. Complications and predictors of the visual outcome were also recorded.ResultsEthanol pretreatment was successful in 20 (83.3%) of the 24 eyes, and no further optical keratoplasty was required. Four eyes required rescue therapeutic keratoplasty because of rapid progression of AK. Patients in whom ethanol pretreatment was successful achieved good final visual outcomes regardless of sex, age, or causative Acanthamoeba species. Patients with worse initial best-corrected visual acuity and rigid gas permeable lens-related AK had better improvement in vision.ConclusionEthanol as a pretreatment for AK is safe and effective. Combined with corneal epithelial debridement, ethanol pretreatment may preclude the need for optical and therapeutic keratoplasty. This technique is suitable for all stages of AK presenting within 3 weeks of symptom onset and achieves favorable results especially in early AK.

Cryopreserved limbal lamellar keratoplasty for peripheral corneal and limbal reconstruction

This study aimed to evaluate the outcomes and described the recovery process of cryopreserved limbal lamellar keratoplasty (CLLK) for peripheral corneal and limbal diseases. Thirteen eyes of 12 patients with a mean age of 41±23.9y were included. The average follow-up was 12.1±5.6mo. Stable ocular surface was achieved in all eyes at last follow-up. Epithelialization originated from both recipient and graft in 9 eyes. We conclude that CLLK compensates for the shortage of donor corneas and cryopreserved limbal grafts provide epithelialization sources in ocular surface reconstruction.

Surgical management of severe ocular surface injury due to Roman candle explosion accidents

PurposeTo report the clinical features, management, and outcomes of patients with ocular surface damage secondary to Roman candle explosion accidents. MethodsRetrospective, noncomparative, interventional case series of 11 patients with Roman candle explosion-related ocular surface injuries referred to the Cincinnati Eye Institute between 2007 and 2016. ResultsEleven patients (10 male, 1 female, mean age 22.4 years) sustained unilateral ocular surface injuries with presenting visual acuity ranging from count fingers to light perception. All patients had severe limbal stem cell deficiency with total ocular surface failure. Eight eyes received a conjunctival-limbal autograft (CLAU) with a keratolimbal allograft (KLAL), 1 eye received a living related-conjunctival limbal allograft (lr-CLAL) with a KLAL, and 2 eyes received a CLAU with lr-CLAL. Nine eyes underwent subsequent penetrating keratoplasty, and 7 eyes had reconstructive eyelid surgery. Nine eyes demonstrated improved visual acuity at last follow-up; seven eyes demonstrated a stable ocular surface at last follow-up. Nonadherence was noted in 7 patients, either with poor adherence with post-operative treatment or poor follow-up; this portended a worse visual result. ConclusionsRoman candle-related accidents can lead to severe ocular surface injury. Despite total ocular surface failure, these eyes can achieve good postoperative visual results following limbal stem cell transplantation and subsequent keratoplasty with appropriate compliance.

Cataract surgery in ocular surface diseases: clinical challenges and outcomes.

Cataracts are a significant cause of blindness and visual impairment worldwide. With the recent advances in cataract surgery techniques, outcomes have improved significantly in uncomplicated cases. This article discusses the challenges and outcomes of cataract surgery in complex cases targeting eyes with ocular surface diseases like Stevens-Johnson syndrome, ocular cicatricial pemphigoid, Mooren's ulcer, vernal keratoconjunctivitis and limbal stem cell deficiency. Ocular surface diseases are commonly associated with corneal scarring and vascularization, conjunctival inflammation, symblepharon and forniceal shortening. Any surgical intervention in a hostile ocular surface environment may worsen the disease, which may result in visual deterioration. In recent past, with the use of immunosuppressants and with the introduction of different ocular surface reconstruction surgeries; stabilization of ocular surface can be achieved prior to planning cataract surgery. This kind of step-wise approach can considerably improve visual outcomes in such cases. Cataract surgery in ocular surface diseases needs careful preoperative, intraoperative and postoperative planning. Performed in a staged manner under favorable ocular environment, it has good visual outcomes and can improve the quality of life in such patients.