PMC9938410_01
Profound pannus ingrowth onto the cornea after limbal stem cell deficiency (LSCD) [A] and fluorescence revealed bizarre ocular surface in her left eye [B]. Symblepharon causes superior fornix shortening [C] and vision occlusion by pannus formation [D]. After surgical procedure of allogeneic limbal stem cell transplantation (LSCT) with living-related conjunctival limbal allograft (lr-CLAL) & simple limbal epithelial transplantation (SLET), combined with 17 times of HBOT. Postoperative 4-month image showing a stable well-epithelialized ocular surface with mild neovascularization, a faint residual deep stromal scarring as seen in the left eye [E], fluorescence staining of the same eye shows no cornea epithelium defect and stable tear film [F].
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The initial slit lamp examination showed a total epithelial defect with severely engorged vessels, inflamed eye, corneal neovasculature pannus, and symblepharon with loss of the fornix in both eyes (Figure 1A). Although the epithelial defect subsequently improved, her condition fluctuated with poor epithelial growth, whorl-like epitheliopathy with fluorescein pooling, abnormal epithelial opaque deposition, recurrent neovascularization, and prominent pannus ingrowth onto the central cornea (Figure 1A-D); the poor corneal condition was attributed to limbal stem cell deficiency (LSCD).
Illustration of surgical procedure. A. Pannus removal from disease eye of bulbar conjunctiva and Palpebral conjunctiva. B. Buccal mucosal flap and minor salivary gland transplantation.B1. Oral buccal mucosa taken from patient's right cheek, sliced into 2 pieces, then transplanted to the patient's upper and inferior palpebral conjunctiva. B2. Minor salivary gland taken from patient's left labial area transplanted to diseased eye's superior conjunctiva and superior fornix. C. Lr-CLAL (living related conjunctiva limbal allograft) + SLET (Simple Limbal Epithelial Transplantation). The limbal stem cell within the conjunctiva limbal graft is taken from her sister's donor eye, suture to the patients' superior and inferior limbus area, extra limbus tissue was sliced into small pieces, and then transplanted to patient's central denuded cornea vie fibrin glue (Artiss ). D. Amniotic membrane, taken from uterus, was grafted over the patient's cornea, bulbal conjuncitiva, upper and lower fornix, palpebral conjunctiva.
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Simultaneously, minor salivary gland transplantation from labial and buccal area, mucous membrane graft from the patient's oral buccal mucosa, and AMT patch graft over the SLET and conjunctiva limbal graft were performed (Figure 2).
Ocular Surface Grading Score (OSGS) and images of Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) patient. C, conjunctivalization; N, neovascularization; O, opacification; K, keratinization; S, symblepharon; U, upper conjunctival sac shortening; L, lower conjunctival sac shortening; T, total OSGS. (A-B) Pre-operation surgery OSGS status: pre-operation (C3,N3,O2,K0,S2,U2,L2:T14), (C) Post operation 4 months OSGS status: (C1,N1,O1,K0,S0,U0,L0: T3). (D) Post op 12 months OSGS status: (C2,N1,O1K0,S0, U0, L0: T4).
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F). Four month after operation, her Ocular Surface Grading Score (OSGS) improvement to T3, (C1,N1,O1,K0,S0,U0,L0:T3) (Figure 3A-D) and the results of Schirmer's test without anesthesia was 6 mm in 5 min.