Severe Ocular Surface Disorders Research Articles

Clinical efficacy of a new surgical technique of oral mucosal epithelial transplantation for severe ocular surface disorders

BackgroundSevere ocular surface disorders are one of the major blinding diseases, and a paucity of original tissue obscures successful reconstruction. We developed a new surgical technique of direct oral mucosal epithelial transplantation (OMET) to reconstruct severely damaged ocular surfaces in 2011. This study elaborates on the clinical efficacy of OMET.MethodsA retrospective review of patients with severe ocular surface disorders who underwent OMET from 2011 to 2021 at the Department of Ophthalmology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine was conducted. Patients who were followed up for at least 3 months postoperatively and had sufficient pre or postoperative records were included. Surgical efficacy was evaluated by comparing the best-corrected visual acuity (BCVA), corneal transparency, neovascularization grade, and symblepharon grade. Additionally, postoperative ocular surface impression cytology was used to study the morphology of the newborn epithelial cells.ResultsForty-eight patients (49 eyes; mean age: 42.55 ± 12.40 years, range:12–66 years) were enrolled in the study. The etiology included chemical burns (30 eyes), thermal burns (16 eyes), explosive injuries (1 eye), Stevens-Johnson syndrome (1 eye), and multiple pterygiums (1 eye). The mean follow-up period was 25.97 ± 22.99 months. Postoperatively, 29 eyes (59.18%) showed improved corneal transparency, 26 eyes (53.06%) had improved BCVA, 47 eyes (95.92%) had a stable epithelium until the final follow-up, 44 eyes (89.80%) had a reduced neovascularization grade. Of the 20 eyes with preoperative symblepharon, 15 (75%) were completely resolved, and five (25%) were partially resolved. Impression cytological studies showed no postoperative conjunctival invasion onto the corneal surface.ConclusionsOMET is a safe and effective surgical technique for reconstruction in severe ocular surface disorder by maintaining a stable epithelium and reducing the neovascularization and symblepharon grade.

Ocular surface disorders affect quality of life in patients with autoimmune blistering skin diseases: a cross-sectional study

BackgroundAutoimmune blistering skin diseases (AIBD) are a group of rare chronic autoimmune diseases which are associated with ocular surface diseases especially dry eye disease. This study is designed to investigate the relationship between ocular surface disorders and quality of life among patients with autoimmune blistering skin diseases.MethodsTwenty-four AIBD patients (18 pemphigus and 7 pemphigoid) and twenty-five non-AIBD controls were included. Ocular surface disease index (OSDI), ocular surface evaluation, including slit-lamp examination, Schirmer I test, tear break-up time, corneal fluorescein staining, lid-parallel conjunctival folds, meibomian gland evaluation, presence of symblepharon and corneal opacity were assessed. Life quality was evaluated by multiple questionnaires, including Medical Outcomes Study 36-Item Short Form Questionnaire (SF-36), Hospital Anxiety and Depression Scale (HADS), Pittsburgh Sleep Quality Index (PSQI) and Health Assessment Questionnaire-Disability Index (HAQ-DI). Ocular surface tests and quality of life were compared between AIBD patients and non-AIBD controls. In the AIBD patients, the associations between ocular surface parameters and quality of life were also evaluated.Results92% of AIBD patients and 87.5% of age- and sex-matched non-AIBD controls were diagnosed with dry eye in this study. Compared with non-AIBD controls, AIBD patients reported lower SF-36 scores (P < 0.05) and severer OSDI, Schirmer I test, tear break-up time, corneal fluorescein staining, presence of symblepharon and corneal opacity measures (P < 0.05). OSDI, Schirmer I test were correlated with SF-36 composite scores or scores on the SF-36 subscales.ConclusionsAIBD patients experience reduced quality of life and more severe ocular surface disorders including dry eye, symblepharon and corneal opacity. Early treatments of dry eye and collaborations among multidisciplinary physicians are necessary in patients with AIBD.

Limbal-Rigid Contact Lens Wear for the Treatment of Ocular Surface Disorders: A Review.

:Recently, the prescription of large-diameter rigid gas-permeable contact lenses (CLs), also known as “scleral lenses,” “corneoscleral lenses,” and “limbal-rigid CLs,” is on the rise for the treatment of both moderate and severe ocular surface disorders (OSDs). Compared with scleral lenses, the diameter of limbal-rigid CLs is generally smaller, that is, a diameter ranging from 13.0 to 14.0 mm, and they are designed so that the peripheral edge bears on the limbus. The Suncon Kyoto-CS (Sun Contact Lens Co., Ltd.) is a novel limbal-rigid CL design with multistep curves on the peripheral edge for easy tear exchange during blinking that removes debris and prevents lens clouding or fogging, thus allowing patients to enjoy a longer daily duration of CL wear. In severe OSD cases, limbal-rigid CL wear after surgery is a noninvasive therapeutic approach that can neutralize corneal irregularities, decrease dry eye symptoms, prevent the progression or recurrence of symblepharon, and improve the patient's visual acuity and overall quality of life. Thus, surgeries such as amniotic membrane transplantation and cultivated oral mucosal epithelial transplantation, as well as limbal-rigid CL wear, which is noninvasive, are valuable and effective treatment strategies that can now be applied for the management of patients afflicted with severe OSDs.

Amniotic membrane extract eye drops: a new approach to severe ocular surface pathologies.

A protocol for processing amniotic membrane as an extract to be re-hydrated and administered topically as eye drops (amniotic membrane extract eye drops, AMEED) has been developed. Safety and efficacy of AMEED was assessed in patients with severe ocular surface pathologies. prospective clinical follow-up of ocular surface symptoms before and after regular application of the AMEED for at least 4weeks on patients with severe ocular surface disorders as chronic dry eye disease, limbal stem cell deficiency, neurotrophic ulcer and permanent and disabling symptomatology that were refractory to conventional treatment. Efficacy and tolerability were assessed based on patient-reported symptoms, objective measurements, and reports of adverse events. Thirty-six eyes from 25 patients were included. Although the visual quality function score, by means of a VQF25 questionnaire, was not statistically different after the treatment (p = 0.4657), there was a clear trend, statistically significant, towards the improvement in ocular symptoms like foreign body sensation, itching and stinging (p < 0.05) and clinical presentation of the pathology. All patients with corneal ulcer showed complete epithelization. Topically applied AMEED proved to be safe, well tolerated and effective in reducing the symptoms and clinical signs of severe ocular disease. Further studies are needed to confirm the best indications for AMEED use.

Scleral Contact Lenses for Treatment of Ocular Surface Disorders: A Narrative Review

Scleral lenses have been in the origin of contact lenses back in 1880, when the pioneers did the first glass contact lenses. With the advent of highly oxygen permeable materials and the increasing need for advanced solutions for severe ocular surface disorders has produced the driving pressures for a great amount of different contact lens designs to be available.

Long-term outcomes of Boston keratoprosthesis type I: the Chinese People’s Liberation Army General Hospital experience

PurposeTo report the long-term outcomes of Boston keratoprosthesis type I (B-KPro type I) implantation in the management of severe ocular surface disorders.MethodsRetrospective case series. Patients who underwent B-KPro type I...

Oral Mucosal Epithelial Transplantation and Limbal-Rigid Contact Lens: A Therapeutic Modality for the Treatment of Severe Ocular Surface Disorders.

Stevens-Johnson syndrome, ocular cicatricial pemphigoid, and severe thermal or chemical injury are considered severe ocular surface disorders (OSDs) because they affect the entire ocular surface, including corneal and conjunctival epithelial stem cells. In patients with severe OSDs, the long-term prognosis for limbal transplantation is poor, and the related corneal opacity and cicatrization lead to devastating visual impairment. To date, there is no standardized treatment to improve vision in cases with severe OSD. Investigating novel treatment methods for severe OSDs, our group began cultivated oral mucosal epithelial transplantation in 2002 and developed a limbal-supported rigid-type contact lens that can be applied as a nonsurgical treatment. When used in combination, these treatment methods make it possible to successfully restore vision in cases with severe OSDs.

Long-Term Outcomes of Allogeneic Ocular Surface Reconstruction: Keratolimbal Allograft (KLAL) Followed by Penetrating Keratoplasty (PK).

Purpose Long-term results of the patients with total LSCD, who had undergone keratolimbal allograft (KLAL) for limbal reconstruction followed by penetrating keratoplasty (PK). Methods The study analyzes surgical treatment of 43 eyes with severe ocular surface disorders. All subjects underwent KLAL to achieve suitable conditions for consecutive PK. Due to failures of primary treatment in 17 eyes (39%), the KLAL was repeated. PK was performed in all the patients at 9-12 months after KLAL. As a retrospective study we analyzed data from the medical records including the preoperative and postoperative best corrected visual acuity, corneal clarity, surgical outcomes and complications, postoperative intraocular pressure, graft rejection, and other comorbidities and complications. Results The preoperative visual acuity ranged from light perception to 0.01. The final improvement of visual acuity within a gain of one or more lines with the Snellen chart, including the results of successive surgical treatments after PK, was achieved in 23 operated eyes (53%). Early graft rejection was observed in 4 eyes (9%). In 3 eyes, it was manifested as endothelial rejection, and in 1 eye, as combined endothelial and epithelial rejection. PK failure requiring repetitive PK was present in 14 eyes (32%). Phthisis bulbi developed in 6 eyes (14%). Glaucoma or ocular hypertension was reported in 25 eyes (58%). A majority were treated with up to 3 topical agents or referred for trabeculectomy in 3 cases, transscleral cyclophotocoagulation in 2 eyes, and EX-PRESS glaucoma shunt implantation in 3 cases. Conclusions Successful KLAL carries a high risk of subsequent PK failure. Visual function remains the second aim of treatment; the primary one is to stabilize the surface.

Optimized Protocol for Regeneration of the Conjunctival Epithelium Using the Cell Suspension Technique.

To develop autologous tissue-engineered conjunctival epithelial sheets to be used as advanced therapy medicinal products for severe ocular surface disorders involving the conjunctiva. Methods used aimed at 1) mapping the conjunctiva for identification of the stem cell location, 2) establishing proper cell culturing conditions, 3) identifying the proper scaffold, and 4) characterizing the conjunctival grafts better. For these purposes, immunostaining and PAS staining, serial cultivation of cells, and quantitative polymerase chain reaction ([INCREMENT]Np63α and MUC5AC) were performed. The inferior fornix represents the ideal area where to take the conjunctival biopsies from, with at least +3.58% of clonogenic colonies and higher percentages of stem cells compared with other areas, as confirmed by [INCREMENT]Np63α expression levels (6.79% ± 1.18%). The standard culture conditions are necessary when cells are cultured on bare plastic, while animal-free media can be used for conjunctival cell culture on the scaffold. Fibrin glue represents the ideal scaffold for production of epithelial conjunctival grafts because it allows physiological expression of the main conjunctival cell markers, with K19 as the ideal one (98.5% ± 0.5% positive cells). The presence of goblet cells (6.3% ± 1.3%) and expression of the stem cell marker [INCREMENT]Np63α (1.65% ± 0.35% positive cells) were also assessed. Our findings pave the way for ex vivo cultivation of conjunctival epithelial cells onto a scaffold using the cell suspension technique by means of animal-free media. This would allow us to obtain conjunctival grafts for clinical purposes, thus giving a therapeutic option to patients with conjunctival diseases refractory to current therapies.

Proteomics as a tool for stem cell research in the anterior segment of eye

SummaryLimbal epithelial stem cells (LESCs) are essential for corneal transparency and normal vision, as they are responsible for renewing the corneal epithelium. Damage or loss of LESCs may cause the ocular surface to become opaque and vascularized. Patients suffering from such severe ocular surface disorders do not benefit from corneal transplantation alone, because it does not replace the damaged stem cells.LESCs derived from human pluripotent stem cells (hPSCs) offer a novel cell‐based approach for ocular surface reconstruction. However, critical evaluation of these cells is crucial before considering clinical applications. Proteomics can help verify the authenticity of hPSC‐derived cells on a large scale.This talk will discuss proteomics as a tool for stem cell research, focusing on the ocular surface. As an example, a study using proteomics to compare native corneal cells at different maturity levels and LESCs derived from hPSCs in feeder‐free and serum‐free conditions will be presented.

Pearls for Secondary Intraocular Lens Implantation

Marjan Farid is Director of the Cornea, Cataract, and Refractive Surgery Faculty and Vice-chair of the Ophthalmic Faculty at the Gavin Herbert Eye Institute (GHEI) at the University of California, Irvine (UCI), California, US. Dr Farid’s clinical practice is divided between patient care, teaching, and research. She enjoys teaching ophthalmology to medical students, ophthalmology residents, and cornea fellows. She serves on the Residency Education Committee and is the Director of the cornea fellowship program at the GHEI. Her research interests focus on corneal surgery, specifically in the use of the femtosecond laser for corneal transplantation. She performs all forms of corneal transplantation—femtosecond enabled and lamellar keratoplasty (DSEK and DALK). Dr Farid is also the founder of the severe ocular surface disease center at UCI. She performs limbal stem cell transplants, as well as artificial corneal transplantation for the treatment of patients with severe ocular surface disorders. She serves as an associate medical director for the Sight Life Eye Bank. Her work has been published in numerous peer-reviewed journals, she has authored six textbook chapters, and travels to multiple national meetings to present her research work. She serves as an Editorial Board member of Ophthalmology, the leading journal in her field. Dr Farid graduated summa cum laude from UCLA with a degree in biology. She earned her medical degree at UC-San Diego in 2002 and completed a transitional year internship at Scripps-Mercy Hospital in San Diego. She completed her residency training in ophthalmology at UCI. She subsequently completed her fellowship training in the area of cornea/external disease and refractive surgery under the mentorship of Dr Roger Steinert at UCI.

Keratoprosthesis: A Review of Recent Advances in the Field.

Since its discovery in the years of the French Revolution, the field of keratoprostheses has evolved significantly. However, the path towards its present state has not always been an easy one. Initially discarded for its devastating complications, the introduction of new materials and the discovery of antibiotics in the last century gave new life to the field. Since then, the use of keratoprostheses for severe ocular surface disorders and corneal opacities has increased significantly, to the point that it has become a standard procedure for corneal specialists worldwide. Although the rate of complications has significantly been reduced, these can impede the long-term success, since some of them can be visually devastating. In an attempt to overcome these complications, researchers in the field have been recently working on improving the design of the currently available devices, by introducing the use of new materials that are more biocompatible with the eye. Here we present an update on the most recent research in the field.

Autologous serum eye drops for ocular surface disorders- a clinical study

Introduction: Tears have antimicrobial, nourishing, mechanical a nd optical properties. Several tear factors that ha ve been identified to be, of importance in the maintenance of normal corneal and conjunctiva epithelium. A lac k of these factors results in severe ocular surface disorders. Autolog ous serum in the form of eye drops has been reporte d as an effective treatment for severe ocular surface disorders. The present study was designed to determine the efficac y and safety of autologous serum application in various ocular surf ace disorders. Methods: This is a prospective case analysis of 30 eyes of 18 patients between June 2009 & November 2010. The following tests were performed: Schirmer I, Basic s ecretion test, Tear film Breakup time, Fluorescein staining, Rose Benga l Staining. 20% concentration of Serum eye drop was used for 30 days and no other tear substitutes were prescribed to pa tients while during treatment. Results: After one month treatment marked improvement was observed - 19 eyes in Schirmer I, 18 eyes in Basic tear secretion, 23 eyes in tear fil m Break up time, 21 eyes in Fluorescein staining pattern and 29 eye in Rose Bengal staining pattern. Conclusion: It was observed that Hypovitaminosis A and Neurotrophic keratitis showed 100% improvement, kerato conjunctivitis sicca, sjo gren's syndrome, persistent epithelial defect, Recurrent erosion syn drome, Marginal corneal ulcer also showed excellent results but Stevens - Johnson syndrome showed very poor response to treatment.

Treatment of severe ocular surface disorders with albumin eye drops.

Promising healing effects by albumin eye drops (AED) on the corneal epithelium have been demonstrated. The aim of this study was to analyze retrospectively if AED are an effective treatment for severe ocular surface defects and if recurrences can be reduced. Seventeen patients with persistent epithelial defects (PED) and 30 patients with sterile corneal ulcers (CU) were treated either with 5% AED or 0.1% hyaluronan eye drops (HED) 8 times daily until complete epithelium closure. Sizes of the corneal defects, length of treatment and follow-up period, as well as recurrence rate were evaluated. Follow-up of PED was carried out for 126 ± 21 days in the AED group and 142 ± 39 days in the HED group. For CU cases, regular follow-up visits were performed for 117 ± 15 days in the AED group and 112 ± 28 days in the HED group. Nine patients in PED group were treated for 11 ± 4 days with AED and the HED group (8 patients) was treated for 10 ± 3 days until corneal epithelium was closed, with only one recurrence in the HED group (P = 0.67). Fifteen patients in CU group were treated for 18 ± 6 days with AED and the HED group (15 patients) was treated for 21 ± 7 days until epithelial closure, with 1 recurrence in the AED group and 8 in the HED group (P = 0.03). This comparative retrospective case-control study showed that AED are able to close corneal epithelial defects like CU and PED as good as HED. Even though times of healing were similar for both treatments, AED seem to reduce the recurrence of sterile CU. Our findings suggest that AED might be beneficial in the management of ocular surface epithelial damage; however, further larger studies are necessary to confirm these results.

Xenogeneic acellular conjunctiva matrix as a scaffold of tissue-engineered corneal epithelium.

Amniotic membrane-based tissue-engineered corneal epithelium has been widely used in the reconstruction of the ocular surface. However, it often degrades too early to ensure the success of the transplanted corneal epithelium when treating patients with severe ocular surface disorders. In the present study, we investigated the preparation of xenogeneic acellular conjunctiva matrix (aCM) and evaluated its efficacy and safety as a scaffold of tissue-engineered corneal epithelium. Native porcine conjunctiva was decellularized with 0.1% sodium dodecyl sulfate (SDS) for 12 h at 37°C and sterilized via γ-irradiation. Compared with native conjunctiva, more than 92% of the DNA was removed, and more than 90% of the extracellular matrix components (glycosaminoglycan and collagen) remained after the decellularization treatment. Compared with denuded amniotic membrane (dAM), the aCM possessed favorable optical transmittance, tensile strength, stability and biocompatibility as well as stronger resistance to degradation both in vitro and in vivo. The corneal epithelial cells seeded on aCM formed a multilayered epithelial structure and endured longer than did those on dAM. The aCM-based tissue-engineered corneal epithelium was more effective in the reconstruction of the ocular surface in rabbits with limbal stem cell deficiency. These findings support the application of xenogeneic acellular conjunctiva matrix as a scaffold for reconstructing the ocular surface.

Rebamipide ophthalmic suspension for the treatment of dry eye syndrome: a critical appraisal.

Rebamipide was initially developed and approved for use in treating gastric ulcers and lesions associated with gastritis. Discovery of its ability to increase gastric mucin led to investigations of its effect on ocular surface mucin and the subsequent development for use in dry eye patients. Investigations have confirmed that rebamipide increases corneal and conjunctival mucin-like substances along with improving corneal and conjunctival injury. Clinically, rebamipide ophthalmic suspensions can effectively treat tear deficiency and mucin-caused corneal epithelial damage, and can restore the microstructure responsible for tear stability. Topical rebamipide has also been shown to be effective in treating other ocular surface disorders such as lagophthalmos, lid wiper epitheliopathy, and persistent corneal erosion. Rebamipide’s ability to modify epithelial cell function, improve tear stability, and suppress inflammation in the absence of any known major side effects suggest that it may be a beneficial first drug of choice for severe dry eye treatment and other ocular surface disorders. This review summarizes the history and development of this innovative dry eye treatment from its initial use as an effective stomach medication to its current use in the treatment of dry eye in Japan.

Ready‐made allogeneic ABO‐specific serum eye drops: production from regular male blood donors, clinical routine, safety and efficacy

To overcome problems and delays of the preparation of autologous serum eye drops, a production line of ABO-specific allogeneic serum eye drops from male blood donors was set up in a blood bank. Feasibility, clinical routine, safety and efficacy were evaluated in a cohort of patients with severe ocular surface disorders. Serum was derived from 450 ml whole-blood donations from regular male blood donors, produced and tested according to good manufacturing practice and legislation regulating blood products in Denmark. Serum was diluted to 20% (v/v) with NaCl 0.9%, filtered, bottled, registered and stored at -30°C in the blood bank. Upon request, frozen ABO-identical serum drops in lots of 14 bottles could be provided immediately. Safety and efficacy were evaluated in 34 patients with severe ocular surface disease refractory to conventional medical therapy. Patients were treated six times daily for minimum 2-4 weeks. Objective findings and subjective symptoms were compared between day 0 and after 4 weeks of treatment using the Wilcoxon signed-rank test. Clinically, no side-effects were observed. In total, 59% of the patients with ocular surface changes improved objectively (slit-lamp examination). Partial or full healing of corneal changes, as well as subjective relief of symptoms, was observed in 16 of 20 patients with keratoconjunctivitis sicca (p < 0.001). The 14 patients with persistent epithelial defect experienced neither objective nor subjective improvements during serum treatment. Ready-made ABO-identical allogeneic serum eye drops were straightforwardly produced, quality-assured and registered as a safe standard blood product for the treatment of certain cases of severe dry eye disease. Therapeutic efficacy was comparable to previous reports on autologous serum drops.

Comparison of Application Systems for Autologous Serum Eye Drops

Purpose: Autologous serum eye drops are used for therapy of severe ocular surface disorders by patients with visual and manual impairments. Until recently, they were prepared under sterile conditions from open blood sampling systems. Closed blood donation systems simplify production. This study compares handling and costs of a new day dosage vial (“Meise-vial”) and a single-dose tube system (“Maco-tube”) based on closed production systems with conventional dropper bottles.Methods: Nonimpaired volunteers and patients with visual or manual impairment (n = 10 each group) single-handedly tested the applicators filled with 1.5 ml sterile isotonic saline solution. Participants rated convenience of opening the containers and applying eye drops on a scale from 1.0 (very good) to 6.0 (very bad). Number of retrievable drops was counted. Participants were asked which system they prefer, both with and without knowledge of the price for the systems.Results: The median for convenience of opening (eye drop application) was 2.0 (1.0) for Meise-vials, 5.0 (4.0) for Maco-tubes, and 2.0 (2.0) for dropper bottles (p < 0.001). Median number of drops retrieved from the systems was 30.5 (vials), 2 (tubes), and 30 (bottles). Ranking did not differ between nonimpaired and impaired participants. Assuming equal prices, 16 participants chose Meise-vials, 14 dropper bottles, and no tubes. With knowledge of pricing, preference changed (p = 0.001), 20 participants (67%) opted for dropper bottles and 5 (17%) preferred the other containers.Conclusion: Convenience of opening, applying eye drops, and number of drops retrieved was substantially better for dropper bottles and Meise-vials compared with Maco-tubes. Bottles and vials were equally well received. With regard to price, nonimpaired as well as impaired participants preferred dropper bottles. While closed systems simplify production, patients preferred dropper bottles for daily application of autologous serum eye drops for a number of reasons.

The tooth – a treasure chest of stem cells

Mesenchymal stem cells can be obtained with ease from dental/oral tissue, making them an attractive source of autologous stem cells. They offer a biological solution for restoring damaged dental tissues such as vital pulp engineering, regeneration of periodontal ligament lost in periodontal disease, and for generation of complete or partial tooth structures to form biological implants. Dental mesenchymal stem cells share properties with mesenchymal stem cells from bone marrow and there is a considerable potential for these cells to be used in different stem-cell-based therapies, such as bone and muscle regeneration. In addition, their immunosuppressive-immunomodulatory properties make these cells a suitable source for treating immunodisorders like systematic lupus erythematosus. In addition, gingival tissue might also be a very good source of epithelial cells used in the treatment of severe ocular surface disorders. Being such an accessible source for different stem cells, the tooth and the attached gingival tissue (usually discarded in the clinics) represent an ideal source of autologous or allogeneic stem cells that can be used in the treatment of many clinical conditions in dentistry and medicine.

Coculture of autologous limbal and conjunctival epithelial cells to treat severe ocular surface disorders: Long-term survival analysis

Background:Cultivated limbal epithelium for reconstruction of corneal surface is a well-established procedure; however, it is not adequate for damage which also extensively involves the conjunctiva. In severe cases of ocular surface damage that warrant additional conjunctival transplantation apart from cultivated limbal stem cell transplantation, we describe the long-term survival of a novel method of cocultivating autologous limbal and conjunctival epithelium on a single substrate.Materials and Methods:Forty eyes of 39 patients with severe limbal stem cell deficiency and conjunctival scarring or symblepharon underwent transplantation of autologous cocultivated epithelium on human amniotic membrane. A ring barrier was used to segregate the central limbal and peripheral conjunctival epithelia in vitro. Patients were followed up at regular intervals to assess stability of the ocular surface, defined by absence of conjunctivalization into the central 4 mm of the cornea and absence of diffuse fluorescein staining. Penetrating keratoplasty (PKP) was subsequently performed, where indicated, in patients with surface stability.Results:The cumulative survival probability was 60% at 1 year and 45% at 4 years by Kaplan–Meier analysis (mean follow-up duration: 33 ± 29 months, range: 1–87 months). Best-corrected visual acuity improved to greater than 20/200 in 38% eyes at the last follow-up, compared with 5% eyes before surgery. Immunohistochemistry in five of the corneal buttons excised for PKP showed an epithelial phenotype similar to cornea in all five.Conclusions:Synchronous use of cultured limbal and conjunctival epithelium offers a feasible alternative and a simpler one-step surgical approach to treat severe ocular surface disorders involving limbus and conjunctiva.