Korean J Ophthalmol.  2019 Feb;33(1):16-25. 10.3341/kjo.2018.0111.

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

• Choe HR
• Yoon CH
• Kim MK

• KMID: 2434301
• DOI: http://doi.org/10.3341/kjo.2018.0111

Abstract

PURPOSE
To 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.
METHODS
Patients 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.
RESULTS
Four 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.
CONCLUSIONS
Transplantation of circumferential autologous oral mucosal grafts may be effective for the treatment of limbal stem cell deficiency.

Keyword

Reconstructive surgical procedures; Stevens-Johnson syndrome; Transplants

MeSH Terms

Follow-Up Studies
Humans
Keratitis
Lip
Medical Records
Reconstructive Surgical Procedures
Retrospective Studies
Rodentia
Seoul
Stem Cells*
Stevens-Johnson Syndrome
Tissue Donors
Transplants*
Vacuum
Visual Acuity

Figure

• 

  Fig. 1 Key surgical steps of autologous oral mucosal graft transplantation in patients with limbal stem cell deficiency. (A) Markings for inside incisions were made with a 9-mm-diameter donor vacuum trephine using gentian violet ink, and outside markings were made with a 14-mm intraoperative keratometer. (B) The oral mucosal graft was dissected using a Beaver mini-blade or Vanna scissors in a ring or a crescent-shaped strip of 5-mm width and 250-µm depth. (C) Prior to graft transplantation, the fibrotic vascular membrane and pannus overlying the cornea were fully removed and (D) a conjunctival peritomy was circumferentially performed along the limbal stem cell-deficient area. (E) The free mucosal graft was placed onto the limbus and (F) the inside margin of the graft was fixed with 10-0 nylon anchoring sutures. (G) Tissue glue was used to firmly attach the mucosal graft to the bed. (H) After trimming excess tissue in the outside margin of the graft, it was sutured to the conjunctiva with continuous 10-0 nylon sutures to hold the graft onto the limbus. (I) Transient amniotic membrane transplantation was performed to protect the transplanted graft during the healing process.

• 

  Fig. 2 Surgical outcomes of autologous oral mucosal graft transplantation in patients with limbal stem cell deficiency. (A) Prior to oral mucosal graft transplantation, cases 1 and 2 showed total limbal stem cell deficiency with a severe degree of inflammation and neovascularization. The other cases showed partial limbal stem cell deficiency (relevant areas are marked by dotted lines), and the clinical signs were less severe than those of total limbal stem cell deficiency. In cases 2, 3, and 5, corneal conjunctivalization, surface irregularity, and corneal opacity persisted despite amniotic membrane transplantation. (B) After 4 months, corneal neovascularization had fully regressed in cases 4 and 5 and decreased in cases 1 and 2. Corneal opacity decreased in cases 2 and 5 and was maintained in cases 3 and 4. In case 1, in which the patient received a permanent amniotic membrane transplantation, the eye presented increased opacity. In case 3, neovascularization was increased, and a persistent epithelial defect was apparent (marked by the dotted circle).

• 

  Fig. 3 Best-corrected visual acuity (BCVA) measured at 4 months after surgery. Visual acuity was improved in all patients, and the mean improvement of visual acuity was 0.526 ± 0.470 logarithm of the minimum angle of resolution (0.15 to 1.10 logarithm of the minimum angle of resolution). OS = oculus sinister; OD = oculus dexter; HM = hand motion; CF = count fingers.

• 

  Fig. 4 Final outcomes of oral mucosal graft transplantations in patients who received subsequent surgeries. (A) shows the status just prior to the subsequent surgery, and (B) shows the final corneal states. In case 1, the graft was conjunctivalized well 11 months following the oral mucosal graft transplantation, and a penetrating keratoplasty with phacoemulsification and intraocular lens implantation was performed. During the last follow-up 5 months after the subsequent surgery, corneal clarity was well maintained, and visual acuity had improved to 20 / 100. In case 3, the epithelial defect persisted, and the cornea had started to melt (marked by dotted circle). Transient and permanent amniotic membrane transplantations were performed to prevent the progression. The melted area was filled with amniotic membrane (marked by the double-lined dotted circle) and only a small epithelial defect remained (marked by the dotted circle).

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