Existence of Normal Limbal Epithelium in Eyes With Clinical Signs of Total Limbal Stem Cell Deficiency

Abstract

Purpose: To report the presence of normal limbal epithelium detected by in vivo confocal laser scanning microscopy (IVCM) in 3 cases of clinically diagnosed total limbal stem cell deficiency (LSCD).

Methods: This is a retrospective case report consisting of 3 patients who were diagnosed with total LSCD based on clinical examination and/or impression cytology. Clinical data including ocular history, presentation, slit-lamp examination, IVCM, and impression cytology were reviewed.

Results: The etiology was chemical burn in 3 cases. One patient had 2 failed penetrating keratoplasties. Another had allogeneic keratolimbal transplantation, but the graft failed 1 year after surgery. The third patient had failed amniotic membrane transplantation. These 3 patients presented with signs of total LSCD including the absence of normal Vogt palisades, complete superficial vascularization of the peripheral cornea, nonhealing epithelial defects, and corneal scarring. Impression cytology was performed in 2 cases to confirm the presence of goblet cells. However, each patient still had distinct areas of corneal and/or limbal epithelial cells detected by IVCM.

Conclusions: Residual normal limbal epithelial cells could be present in eyes with clinical features of total LSCD. IVCM seems to be a more accurate method to evaluate the degree of LSCD.

FIGURE 1

Representative confocal images of a normal eye (top row) and total limbal stem cell deficiency eye (bottom row). The central cornea (top left) and limbus (top right) at the basal cell layer are shown in a normal eye. Distinct individual epithelial cells are observed in both the normal cornea and limbus. The central cornea (bottom left) and temporal limbus (bottom right) at the basal cell layer are shown in the total limbal stem cell deficiency eye. Few epithelial cells with borders and dark cytoplasm can be seen in the cornea. Only few visible cells with clear borders can be detected in the limbus.

FIGURE 2

Slit lamp photo of left eye of patient 1 (top left) shows extensive superficial corneal neovascularization, opacity of the corneal epithelium and keratinization in the inferior corneal surface. Fluorescein staining (top right) shows irregularity and stippling staining pattern. Confocal images of the superior limbus (bottom left), nasal limbus (bottom middle), and inferior limbus (bottom right) show the presence of normal limbal epithelial cells.

FIGURE 3

Slit lamp photo of right eye of patient 2 (top left) shows 360 degree of corneal neovascularization and pannus. Fluorescein staining (top right) shows irregular corneal epithelium. Confocal images of the central cornea wing cell layer (bottom left), and central cornea (bottom middle-left), superior limbus (bottom middle-right), and inferior limbus (bottom right) show the presence of normal limbal epithelium.

FIGURE 4

Slit lamp photo of left eye of patient 3 (top left) shows 360 degree of superficial corneal neovascularization, inferior pannus and corneal scarring. Confocal images of the central cornea (top right), superior limbus (bottom left and bottom right) show the presence of normal basal limbal epithelial cells.