Contents lists available at ScienceDirect The Ocular Surface journal homepage: www.elsevier.com/locate/jtos Original Research Long-term outcomes of conjunctival limbal autograft in patients with unilateral total limbal stem cell deficiency Medi Eslani a , Albert Y. Cheung a,b , Khaliq Kurji a , Kasey Pierson a , Enrica Sarnicola a,c , Edward J. Holland a,* a Cincinnati Eye Institute/University of Cincinnati, Cincinnati, OH, USA b Virginia Eye Consultants, Norfolk, VA, USA c Clinica Degli Occhi Sarnicola, Grosseto, Italy ARTICLE INFO Keywords: Stem cell Eye Cornea Ocular surface Graft Transplantation Ocular surface stem cell transplantation Conjunctival limbal autograft Limbal stem cell deficiency ABSTRACT Purpose: To investigate the long-term clinical outcomes of conjunctival limbal autograft (CLAU) in patients with unilateral total limbal stem cell deficiency (LSCD). Methods: In 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-cor- rected visual acuity (BCVA), and postoperative complications. Results: 27 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. Conclusions: CLAU can provide long-term ocular surface stability and successful visual outcomes in patients with unilateral LSCD. Introduction Based on the current literature, it is believed that limbal epithelial stem cells (LESCs) are located in the Palisades of Vogt at the limbus. In their niche, they interact closely with the extracellular matrix and mesenchymal stem cells. Together, they contribute to the unique properties of the cornea such as avascularity, clarity, and immune privilege. With injury to the LESCs or their highly regulated micro- environment, limbal stem cell deficiency (LSCD) develops [1]. Etiolo- gies can be categorized into traumatic/toxic, inflammatory, infectious, and congenital. Clinical manifestations include corneal con- junctivalization, poor corneal epithelialization, persistent epithelial defects, stromal scarring, severe visual loss, chronic pain, and vascu- larization of the cornea [2]. LSCD is often diagnosed through clinical assessment or by detection of conjunctival goblet cells on the corneal surface using impression cytology. Management is based on severity (partial vs. total) and laterality (unilateral vs. bilateral) [3]. In the case of total unilateral limbal stem cell deficiency, conjunctival limbal au- tograft (CLAU), cultivated limbal epithelial transplantation (CLET), and simple limbal epithelial transplantation (SLET) are the current treat- ment options. The purpose of this study is to evaluate the long-term outcomes of CLAU in patients with unilateral total LSCD. The vast majority of stu- dies on CLAU are small case series with short-term or intermediate follow-up periods [4–16]. There are a limited number of studies that have assessed the long-term outcomes of autograft ocular surface stem cell transplantation (OSST) [17–19]. Methods This study is a retrospective interventional cohort comprised of patients seen at the Cincinnati Eye Institute (Blue Ash, OH and https://doi.org/10.1016/j.jtos.2019.09.003 Received 2 October 2018; Received in revised form 29 August 2019; Accepted 5 September 2019 * Corresponding author. 580 South Loop Road, Suite 200, Edgewood, KY, 41017, USA. E-mail address: Eholland@holprovision.com (E.J. Holland). The Ocular Surface xxx (xxxx) xxx–xxx 1542-0124/ © 2019 Published by Elsevier Inc. Please cite this article as: Medi Eslani, et al., The Ocular Surface, https://doi.org/10.1016/j.jtos.2019.09.003