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   Table of Contents      
ORIGINAL ARTICLE
Year : 2006  |  Volume : 54  |  Issue : 1  |  Page : 29-34

Clinical outcome of autologous cultivated limbal epithelium transplantation


1 Sudhakar and Sreekanth Ravi Stem Cell Biology Laboratory, Cornea and Anterior Segment Service, L. V. Prasad Eye Institute, Banjara Hills, Hyderabad, India
2 Sudhakar and Sreekanth Ravi Stem Cell Biology Laboratory, Ophthalmic Pathology Laboratory, L. V. Prasad Eye Institute, Banjara Hills, Hyderabad, India
3 Sudhakar and Sreekanth Ravi Stem Cell Biology Laboratory, L. V. Prasad Eye Institute, Banjara Hills, Hyderabad, India
4 Center for Cellular and Molecular Biology, Hyderabad, India
5 International Center for Advancement of Rural Eye Care, L. V. Prasad Eye Institute, Banjara Hills, Hyderabad, India
6 Cornea and Anterior Segment Service, L. V. Prasad Eye Institute, Banjara Hills, Hyderabad, India

Correspondence Address:
Virender S Sangwan
L.V. Prasad Eye Institute, L. V. Prasad Marg, Banjara Hills, Hyderabad 500034
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0301-4738.21611

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  Abstract 

Purpose: To report the clinical outcome of autologous cultivated limbal epithelial transplantation.
Methods: Eighty-six patients' records and their clinical photographs were reviewed for demographics, primary etiology, type of limbal transplantation, ocular surface stability, visual acuity, final outcome, and possible factors affecting outcome and complications.
Results: Eighty-eight eyes of 86 patients with limbal stem cell deficiency (LSCD) underwent autologous cultivated limbal epithelium transplantation between March 2001 and May 2003, with a mean follow-up of 18.3 months. The etiology of LSCD was alkali burns in 64% patients. Sixty-one eyes had total LSCD. Thirty-two of the 88 eyes had undergone amniotic membrane transplantation and 10 eyes had previously undergone limbal transplantation with unfavorable outcome. Nineteen eyes underwent penetrating keratoplasty, of which 11 grafts survived at the final follow-up. Finally, 57 eyes (73.1%, 95% CI: 63.3-82.9) had a successful outcome with a stable ocular surface without conjunctivalization, 21 eyes (26.9%, 95%CI: 17.1-36.7) were considered failures, and 10 patients were lost to follow-up.
Conclusion: LSCD can be successfully treated by autologous cultivated limbal epithelium transplantation in majority of the cases.

Keywords: Cultivated autologous limbal epithelium transplantation, limbal stem cell deficiency


How to cite this article:
Sangwan VS, Matalia HP, Vemuganti GK, Fatima A, Ifthekar G, Singh S, Nutheti R, Rao GN. Clinical outcome of autologous cultivated limbal epithelium transplantation. Indian J Ophthalmol 2006;54:29-34

How to cite this URL:
Sangwan VS, Matalia HP, Vemuganti GK, Fatima A, Ifthekar G, Singh S, Nutheti R, Rao GN. Clinical outcome of autologous cultivated limbal epithelium transplantation. Indian J Ophthalmol [serial online] 2006 [cited 2017 Apr 29];54:29-34. Available from: http://www.ijo.in/text.asp?2006/54/1/29/21611



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The physiology as well as molecular and cellular biology of the ocular surface and its components has not only increased our understanding but has also opened a new chapter in regenerative medicine with the use of tissue engineering.[1],[2],[3] Various scientific discoveries in the past two decades have led to the identification of the limbal location of corneal epithelial stem cells and the role it plays in regenerating the corneal epithelium.[1],[4],[5],[6],[7]Simultaneously, various surgical techniques of limbal transplantation using cadaveric 2 or live-related donor tissues have evolved.[8],[9] However, these methods have met with limited success and require indefinite immunosuppression to avoid limbal allograft rejection.[10],[11] Long-term systemic immunosuppression involves the risk of serious eye and systemic complications apart from being a significant economic burden.

Novel techniques of ex vivo epithelium cell culture have allowed us to treat Limbal Stem Cell Deficiency (LSCD) with a better surgical approach, which requires a very small donor tissue, obviating the need for immunosuppression, minimizing the risk to the donor site, and increasing the possibility of obtaining an autologous donor tissue from a small, uninvolved area of the limbus. [12],[13],[14] This method is called autologous cultivated limbal epithelium transplantation. A few such methods using different culture techniques and carriers have been reported in the literature,[12],[13],[15],[16] but being a relatively new technique there is little information regarding its clinical outcome.

We report the results of our cases of ocular surface reconstruction using autologous cultivated limbal epithelium transplantation. To the best of our knowledge, ours is the largest series of any form of limbal transplantation ever reported.


  Materials and Methods Top


During the study period (March 2001-May 2003), 88 autologous cultivated limbal epithelium transplantation procedures were performed at the L. V. Prasad Eye Institute, Hyderabad, with a diagnosis of LSCD. The medical records and clinical photographs of all consecutive patients following cultivated limbal epithelium transplantation were retrospectively reviewed for the demographics, primary etiology, previous surgeries, and preoperative and postoperative best corrected visual acuity, the type of cultivated limbal epithelium transplantation, complications, and final outcome.

All the grafted eyes were clinically diagnosed as having LSCD with conjunctivalization, absence of limbal palisades of Vogt (radial pigmented folds at the limbus and a biological marker of the location of corneal epithelial stem cells), chronic inflammation, persistent corneal epithelial defect, and/or recurrent corneal epithelial defect.[1] Cases with follow-up of less than 6 weeks were not considered for analysis.

Our surgical techniques for cultivated limbal epithelium transplantation have been reported.[17] Informed consent was obtained from the patients or guardians. Limbal biopsy was performed on the healthy contralateral eye or a healthy area of the ipsilateral eye. The procedure included careful dissection of a 1 x 2 mm 2 piece of limbal epithelium with 0.5 mm into clear corneal stromal tissue at the limbus under strict aseptic conditions. The limbal tissue that contained limbal epithelial cells at the pigmented line (palisades of Vogt) and a part of the corneal stroma was excised. The tissue was transported in human corneal epithelium (HCE) medium to the tissue culture laboratory, where, under strict aseptic conditions, the donor limbal tissue was shredded into small pieces. Human amniotic membrane (HAM) prepared and preserved by our eye bank was used as a carrier. HAM, measuring 3 x 4 cm 2 was de-epithelialized using 0.25% trypsin and EDTA solution for 15 min. Limbal tissue procured by limbal biopsy, shredded into small pieces, was explanted over the center of the de-epithelialized HAM with the basement membrane side-up [Figure - 1]A. A similar parallel culture was prepared as a backup. Ours is a submerged explant culture system without the use of any feeder cell layer. We use HCE medium with 10% fetal bovine serum to nurture the culture. Since October 2002 we have been using autologous serum instead of fetal bovine serum for our culture. The HCE medium was prepared using 9.7 g/l modified Eagle medium with the addition of 16.2 g/l Ham F12 serum, 0.01 mg/l epidermal growth factor, 0.25 mg/l insulin, 0.1 mg/l cholera toxin, and hydrocortisone. The medium was filtered with 0.22 mm membrane filters using a vacuum pump. The sterile medium was supplemented with 10% fetal calf serum or autologous serum at the time of use. The culture was incubated at 37°C with 5% CO 2 and 95% air. The growth was monitored daily under phase-contrast microscope and the medium was changed every alternate day [Figure - 1]B. The culture was terminated when a monolayer of the cells growing from the explants became confluent, in 10-14 days [Figure - 1]C.

At the time of limbal transplantation, the fibrovascular pannus covering the ocular surface was excised from the cornea and sent for histopathological examination. A drop of epinephrine (1: 1000) was instilled in the conjunctival cul-de-sac prior to pannus excision to achieve hemostasis. After release of the symblephara and adequate hemostasis with cautery, the HAM with the monolayer of cultivated limbal epithelial cells with the epithelial side up was spread over the defect. The graft was then secured to the limbal side by interrupted, circumferential 10-0 nylon sutures as well as to the surrounding conjunctival edge by interrupted 8-0 polyglactin sutures. A bandage contact lens was applied. We used to apply bandage contact lens postoperatively in all our earlier cases to prevent any damage from lid action, but we discontinued the use of the same as we failed to make out any beneficial effect.

Following the cultivated limbal epithelium transplantation, all the patients were treated with 1% prednisolone acetate eye drops eight times a day tapered to once a day in 5-6 weeks and 0.3% ciprofloxacin hydrochloride eye drops four times a day for 1 week. 0.3% Ciprofloxacin hydrochloride eye drops were continued if an epithelial defect was present or as long as the bandage contact lens was used. The patients were seen on postoperative day 1, week 1, week 2, week 5, and monthly thereafter. Each examination included a complete history, noting down of new ocular or systemic symptoms, a complete evaluation of recipient as well as donor sites, and any sign of neovascularization or surface instability. Sutures were removed when indicated (loose or vascularized). Epithelialized sutures were left in place indefinitely.

The success of the procedure was defined by stable ocular surface and subjective improvement in the symptoms of the patient with a minimum follow-up of 6 weeks. The cut-off duration of 6 weeks was decided based on our previous study, in which we found that the ocular surface stabilized in a mean of 6 weeks.[17] The stability of the ocular surface was assessed clinically, based on absence of recurrent breakdown of the corneal epithelium, increased permeability to fluorescein, or conjunctivalization. Failure was defined by conjunctivalization, recurrent corneal epithelium breakdown, or persistent corneal epithelial defect. We also studied the complications during the study period, related or unrelated to the procedure. Corneal graft failure was defined as the primary graft failure, in which nonresolving corneal graft edema following penetrating keratoplasty (PKP) persisted more than 2 weeks and secondary graft failure was defined as nonresolving graft edema 3 months following graft rejection.

The factors that could potentially affect the outcome were demographics of the patients, etiology of the LSCD, previous surgical procedures performed, and laterality of the donor tissue (ipsilateral or contralateral).

Best corrected visual acuity (BCVA) was measured at each visit on a standard Snellen visual acuity chart. The ambulatory visual acuity was defined as the BCVA of more than or equal to 20/200 and nonambulatory visual acuity of less than 20/200.

Statistical analysis

The data were analyzed with the help of the Biostatistics Department at the L. V. Prasad Eye Institute. Kaplan-Meier survival analysis was performed to evaluate the survival of autologous cultivated limbal epithelial transplantation. The effect of previously described possible risk factors on survival of autologous cultivated limbal epithelial transplantation was studied by univariate survival analysis and Cox proportional hazards survival regression. SPSS version 12.0 (SPSS Inc., Chicago, IL) was used for data analysis.


  Results Top


Eighty-eight eyes of 86 patients underwent autologous cultivated limbal epithelium transplantation between March 2001 and May 2003. The patients ranged in age from 3 to 47 years (mean ± SD, 21.1 ± 12.5 years); there were 12 females and 74 males. The etiology of LSCD was chemical burns in 78 (88.6%) eyes [Table - 1]; alkali burn was the most common ( n =56). Sixty-one (69.3%) of the 88 eyes had total LSCD with loss of limbal palisades of Vogt and conjunctivalization in 360°, in which the donor tissue was taken from the contralateral eye. Seventeen (19.3%) eyes had partial LSCD with partial loss of limbal palisades of Vogt and focal conjunctivalization in the same area (range 90°-330°) where limbal biopsy was taken from the clinically normal area of the same eye. On clinical examination, 19 (21.6%) eyes showed severe conjunctival damage, including symblephara in 16 eyes.

Success was achieved in 57 of the 78 eyes (73.1%, 95% CI: 63.3-82.9) and 21 eyes (26.9%, 95% CI: 17.1-36.7) had failure with a mean follow-up of 18.3 ± 11.2 months (range 3-40.5 months) following cultivated limbal epithelium transplantation [Figure - 2][Figure - 3]. Ten of the first 86 patients (88 eyes) were lost to follow up. Considering the best-case scenario, if we presume all those cases lost to follow up had a successful outcome, the mean success rate would be 76.1% (95% CI: 67.2-85.0). Similarly, for the worst-case scenario, in which we considered all the 10 cases lost to follow up as failures, the mean success rate would be 64.8% (95% CI: 54.8-74.8). A Kaplan-Meier analysis of probability of survival of the cultivated limbal epithelium transplantation showed that most of the failures occurred in the first six months. The latter part of the follow-up showed fewer failures [Figure - 4].

Nineteen eyes had undergone PKP following cultivated limbal epithelium transplantation for optical purposes. Eleven of these grafts were successful with a mean follow-up of 17.4 months.

BCVA on Snellen chart improved from 17/78 (21.8%) eyes to 41/78 (52.6%) eyes having functional ambulatory vision (> 20/200) postoperatively; 11 of these eyes had undergone PKP. Thirty-three of the 41 eyes with postoperative ambulatory visual acuity had visual acuity of more than or equal to 20/80 [Figure - 5][Figure - 6]; 9 of these eyes had undergone PKP. The outcome of PKP following cultivated limbal stem cell transplantation has already been reported.[17]

Univariate analysis of factors affecting final outcome of the transplantation did not demonstrate any statistically significant effect of the type of transplantation, duration of symptoms, and etiology of LSCD or previous surgical intervention on the outcome of cultivated limbal epithelium transplantation [Table - 1].

Two patients developed phthisis bulbi. One of these cases had corneal perforation and developed panophthalmitis. Two cases with corneal grafts had microbial keratitis and two had uncontrolled glaucoma, which did not respond to the treatment and developed glaucomatous optic atrophy.


  Discussion Top


Reconstruction of the ocular surface in cases of LSCD is one of the most challenging problems in ophthalmology. The therapeutic measure to treat the condition aims at replenishing the deficient limbal epithelium with the stem cells for corneal epithelium, which would maintain the stable ocular surface indefinitely.[1],[3] Various techniques have been reported with the aim of restoring limbal stem cell functions by using allogenic tissue of cadaveric origin (cadaveric keratolimbal allograft) or from live-related donors (conjunctival limbal allograft) with limited success.[8],[10],[11] Apart from the limited growth potential of the cadaveric tissue,[18] long-term immunosuppression to avoid limbal allograft rejection may have significant systemic adverse effects and place an economic burden on the recipient. The use of autologous tissue to reconstruct the ocular surface was reported by Kenyon and Tseng with conjunctival limbal autograft.[19] However, cases with total LSCD were seldom treated by this method owing to concerns about donor site deficiency. Pellegrini et al . in 1997 reported successful reconstruction of the ocular surface using autologous limbal epithelium cultivated ex vivo on amniotic membrane as substrate.[12] Use of this tissue engineering technology for ocular surface reconstruction is considered the best of current methods.

Our group has developed the technique of ex vivo cultivated limbal epithelium. Our technique, reported earlier, is ingenious and unique in several aspects.[17],[20] Ours is a submerged explant culture technique in which we use de-epithelialized amniotic membrane as a substrate and human corneal epithelium medium for ex vivo cultivation. We do not use the complicated system of 3T3 fibroblast feeder layer or air-lifting contrary to previous reports that have stressed their need. We do not wait for the ex vivo stratification or the epithelium tight junction to form. Instead, we transplant a confluent monolayer of the cultivated cell. We hypothesized and successfully proved that the inherent nature of this epithelium would lead to in vivo stratification.[17] The 2-week culture that we use is shorter than that previously reported. [12],[13],[14],[15]Lately, we have successfully started using autologous serum instead of bovine serum for our culture medium. We report here the outcome of our cases with autologous cultivated limbal epithelium transplantation, which is to the best of our knowledge the largest series of any kind of limbal transplantation procedure reported till date.

In this study, we report the outcome as defined by stable ocular surface following cultivated autologous limbal epithelium transplantation with a minimum follow-up of six weeks. The six week cut-off period was based on our previous studies, which showed that the ocular surface took a mean of six weeks to stabilize.[17] The analysis of probability of survival of our cases interestingly showed the first six months to be a critical period when most of the failures occurred, whereas there were fewer failures as time progressed. This observation not only suggests that a closer follow-up is needed in the first six months of the postoperative period, but that this may also help in prognostication of the cases. The literature about the clinical outcomes of cultivated limbal epithelium transplantation is not only sparse but most studies have a smaller sample size and/or inadequate follow-up.[12],[13],[14],[21] Our study had a very encouraging overall initial success of 73.1% and we presume it to remain good in the long run owing to the autologous nature of our grafts. The fact that the long-term success rate declines with time, as reported earlier, owing to clinical or subclinical limbal allograft rejection, may therefore not hold true in our cases. However, it does not decrease the need for the long-term follow-up. The population of our cultivated limbal epithelium cells is presumed to be limbal stem cells, are responsible for the indefinite production of progeny and maintenance of a stable ocular surface.

Although the aim of cultivated limbal epithelium transplantation is not to improve vision but to stabilize the ocular surface epithelium, the functional ambulatory visual acuity (< 20/200) could be improved from 17 preoperative eyes (21.8%) to 41 postoperative eyes (52.6%). The ambulatory vision was achieved without performing PKP in 30 of these eyes. The BCVA was more than or equal to 20/80 in 33 of these eyes postoperatively.

We follow a multistaged approach for the management of LSCD, wherein the first stage comprises stabilization of the ocular surface by performing pannus resection and cultivated limbal epithelium transplantation, and the second stage, if required for visual rehabilitation, comprises PKP. Eleven of the nineteen PKPs performed following autologous cultivated limbal epithelium transplantation were successful (with a mean follow-up of 17.4 months), which is better than reported previously. However, it is important to note that all these corneal grafts met the criterion of high risk for the corneal graft rejection[22] and none of them were on systemic immunosuppression. We attribute this to our multistaged approach, wherein we prefer to perform PKP with a minimum duration of 3 months following cultivated limbal epithelium transplantation as it not only ensures the stable ocular surface but also decreases the risk of corneal graft rejection by controlling inflammation. Another hypothesis could be decreased sensitization by decreasing antigen presentation following PKP as the cultivated limbal epithelium is devoid of dendritic cell. Further studies are definitely warranted in this direction.[17]

On the basis of previous literature and our experience, we hypothesized a few factors that might affect the outcome of cultivated autologous limbal epithelium transplantation. The etiology of LSCD is one of the important factors reported in the literature, which could affect the outcome of any limbal transplantation procedure. Chemical injury was the etiology of LSCD in 78 (89%) of our cases in this study, of which alkali burns were the most common ( n =56). This could be explained by very high prevalence of tobacco and betel nut leaf chewing in the Indian subcontinent.[23] The favorable outcome in our cases could be partly explained by the high number of chemical injury as an etiology. The chemical injury would lead to a one-time damage to the ocular surface, hence would have a better outcome. However, conditions such as Stevens Johnson syndrome and ocular cicatricial pemphigoid would have persistent inflammation, severe dry eye, extensive conjunctival involvement, and poor lid status, which could decrease the success rate in these cases. We have reported a novel technique of cocultivation of conjunctival and limbal epithelium transplantation on a single amniotic membrane to successfully treat LSCD with severe ocular surface disorders.[20]

Selection of the donor site for autologous cultivated limbal epithelium transplantation depends upon the extent of the damage. In cases of partial LSCD, limbal biopsy can be performed on the unaffected area of the ipsilateral eye without any risk to the contralateral eye. The limbal biopsy was performed in 61 cases on the contralateral unaffected eye and in 17 cases on the unaffected area of the ipsilateral eye. None of our cases had any donor site changes or abnormality, there by proving the safety of the procedure (limbal biopsy).

To summarize, we report here the successful reconstruction of the ocular surface in LSCD by autologous cultivated limbal epithelium transplantation in majority of the cases. Long-term results are still awaited.





 
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    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6]
 
 
    Tables

  [Table - 1]


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17 Cultivated Limbal and Oral Mucosal Epithelial Transplantation
Medi Eslani,Alireza Baradaran-Rafii,Sajjad Ahmad
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18 Ex Vivo expanded autologous limbal epithelial cells on amniotic membrane using a culture medium with human serum as single supplement
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19 Ocular epithelial transplantation: current uses and future potential
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20 Comparative Analysis of Human-Derived Feeder Layers with 3T3 Fibroblasts for the Ex Vivo Expansion of Human Limbal and Oral Epithelium
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Stem Cell Reviews and Reports. 2011;
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21 Clinical Outcomes of Penetrating Keratoplasty after Autologous Cultivated Limbal Epithelial Transplantation for Ocular Surface Burns
Sayan Basu, Ashik Mohamed, Sunita Chaurasia, Kunjal Sejpal, Geeta K. Vemuganti, Virender S. Sangwan
American Journal of Ophthalmology. 2011;
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22 Effects of fibroblast origin and phenotype on the proliferative potential of limbal epithelial progenitor cells
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Experimental Eye Research. 2011; 92(1): 10-19
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23 Molecular and cellular characterization of expanded and cryopreserved human limbal epithelial stem cells reveal unique immunological properties
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24 13 years of cultured limbal epithelial cell therapy: A review of the outcomes
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25 Corneal stem cells in the eye clinic
A. J. Shortt, S. J. Tuft, J. T. Daniels
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26 Molecular and cellular characterization of expanded and cryopreserved human limbal epithelial stem cells reveal unique immunological properties
Viraf S. Vasania, Parvathy Prasad, Rajdeep Kaur Gill, Ashish Mehta, Chandra Viswanathan, Shabari Sarang, Anish Sen Majumdar
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27 Effects of fibroblast origin and phenotype on the proliferative potential of limbal epithelial progenitor cells
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28 Successful clinical implementation of corneal epithelial stem cell therapy for treatment of unilateral limbal stem cell deficiency
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29 Using poly(lactide-co-glycolide) electrospun scaffolds to deliver cultured epithelial cells to the cornea
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Regenerative Medicine. 2010; 5(3): 395-401
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30 Evaluation of Molecular Markers in Corneal Regeneration by Means of Autologous Cultures of Limbal Cells and Keratoplasty :
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31 Using poly(lactide-co-glycolide) electrospun scaffolds to deliver cultured epithelial cells to the cornea
Pallavi Deshpande,Rob McKean,Keith A Blackwood,Richard A Senior,Adekemi Ogunbanjo,Anthony J Ryan,Sheila MacNeil
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32 Techniques for Culture and Assessment of Limbal stem Cell Grafts
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33 Ex Vivo Cultured Limbal Epithelial Transplantation. A Clinical Perspective
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34 The impact of De-epithelialization of the amniotic membrane matrix on morphology of cultured human limbal epithelial cells subject to eye bank storage
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35 Cornea and ocular surface treatment
de Miguel, M.P., Alio, J.L., Arnalich-Montiel, F., Fuentes-Julian, S., de Benito-Llopis, L., Amparo, F., Bataille, L.
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36 Techniques for culture and assessment of limbal stem cell grafts
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37 Midterm results of cultivated autologous and allogeneic limbal epithelial transplantation in limbal stem cell deficiency
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38 Gene expression profile of epithelial cells and mesenchymal cells derived from limbal explant culture
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39 Ex vivo cultured limbal epithelial transplantation. A clinical perspective
Shortt, A.J., Tuft, S.J., Daniels, J.T.
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40 Ocular Surface Reconstruction With Conjunctival Epithelial Cells Cultivated Ex Vivo : Surgical Technique
José Reinaldo da Silva Ricardo, José Alvaro Pereira Gomes
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41 Chirurgie des pathologies sévères de la surface oculaire
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42 In vitro culture and expansion of human limbal epithelial cells
Indumathi Mariappan, Savitri Maddileti, Soumya Savy, Shubha Tiwari, Subhash Gaddipati, Anees Fatima, Virender S Sangwan, Dorairajan Balasubramanian, Geeta K Vemuganti
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43 Midterm Outcomes of Autologous Cultivated Limbal Stem Cell Transplantation With or Without Penetrating Keratoplasty :
Marzieh Ebrahimi, Mozhgan Rezaei Kanavi, Ehsan Taghi-Abadi, Alireza Baradaran-Rafii, Nasser Aghdami, Medi Eslani, Pejman Bakhtiari, Bahram Einollahi, Hossein Baharvand, Mohammad-Ali Javadi
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44 Myogel supports the ex-vivo amplification of corneal epithelial cells
D. Francis,K. Abberton,E. Thompson,M. Daniell
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45 The effect of amniotic membrane preparation method on its ability to serve as a substrate for the ex-vivo expansion of limbal epithelial cells
Alex J. Shortt,Genevieve A. Secker,Richard J. Lomas,Stacy P. Wilshaw,John N. Kearney,Stephen J. Tuft,Julie T. Daniels
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46 Limbale Stammzellinsuffizienz nach Verätzung : Untersuchungen zum epithelialen Phänotyp und Entzündungsstatus
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47 Tissue-engineered corneal epithelium transplantation for treatment of corneal alkaline burn in rabbits: Morphological observation
Pi, Y.-L., Tang, W.-Q., Lu, J.-Y., Dong, Y.
Journal of Clinical Rehabilitative Tissue Engineering Research. 2009; 13(41): 8011-8016
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48 The effect of amniotic membrane preparation method on its ability to serve as a substrate for the ex-vivo expansion of limbal epithelial cells
Shortt, A.J. and Secker, G.A. and Lomas, R.J. and Wilshaw, S.P. and Kearney, J.N. and Tuft, S.J. and Daniels, J.T.
Biomaterials. 2009; 30(6): 1056-1065
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49 Genetically Engineered Elastin-Like Polymer as a Substratum to Culture Cells from the Ocular Surface
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50 Advances in corneal surgery and cell therapy: challenges and perspectives for eye banks
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Expert Review of Ophthalmology. 2009; 4(3): 317
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51 A serum- and feeder-free technique of culturing human corneal epithelial stem cells on amniotic membrane
Lekhanont, K., Choubtum, L., Chuck, R.S., Sa-ngiampornpanit, T., Chuckpaiwong, V., Vongthongsri, A.
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52 Chapter 5 Limbal Stem Cells. Application in Ocular Biomedicine
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International Review of Cell and Molecular Biology. 2009; 275(C): 133-181
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53 Myogel supports the ex-vivo amplification of corneal epithelial cells
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54 Stem cell transplantation in pediatrics
Seth, T., Mohanty, S.
Journal International Medical Sciences Academy. 2009; 22(1): 37-42
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55 Differences in the protein expression in limbal versus central human corneal epithelium - a search for stem cell markers
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56 Ocular surface reconstruction: recent innovations, surgical candidate selection and postoperative management
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57 Mesenchymal cells from limbal stroma of human eye
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58 Abnormal keratocytes and stromal inflammation in chronic phase of severe ocular surface diseases with stem cell deficiency
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59 A systematic literature review of surgical interventions for limbal stem cell deficiency in humans
Cauchi, P.A. and Ang, G.S. and Azuara-Blanco, A. and Burr, J.M.
American Journal of Ophthalmology. 2008; 146(2): 251-259 e2
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60 Ex Vivo Expansion and Transplantation of Limbal Epithelial Stem Cells
Shortt, A.J. and Secker, G.A. and Rajan, M.S. and Meligonis, G. and Dart, J.K. and Tuft, S.J. and Daniels, J.T.
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61 Culture and characterization of oral mucosal epithelial cells on human amniotic membrane for ocular surface reconstruction
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62 Differences in the protein expression in limbal versus central human corneal epithelium – a search for stem cell markers
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63 Corneal Epithelial Stem Cells: A Biological and Clinical Approach
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64 A staged penetrating keratoplasty following limbal stem cells allograft in severe chemical injury leading to successful restoration of the ocular surface anatomy
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65 A review of the potential to restore vision with stem cells: REVIEW
Mooney, I., LaMotte, J
Clinical and Experimental Optometry. 2008; 91(1): 78-84
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66 A biomimetic scaffold for culturing limbal stem cells: a promising alternative for clinical transplantation
Subhadra Dravida, Subhash Gaddipati, May Griffith, Kim Merrett, Soundarya Lakshmi Madhira, Virender S. Sangwan, Geeta K. Vemuganti
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67 A Systematic Literature Review of Surgical Interventions for Limbal Stem Cell Deficiency in Humans
Paul A. Cauchi,Ghee S. Ang,Augusto Azuara-Blanco,Jennifer M. Burr
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68 Ex Vivo Expansion and Transplantation of Limbal Epithelial Stem Cells
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69 A review of the potential to restore vision with stem cells
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70 In vivo survival and stratification of cultured limbal epithelium
Anees Fatima,Geeta K Vemuganti,Ghazala Iftekhar,Gullapalli N Rao,Virender S Sangwan
Clinical & Experimental Ophthalmology. 2007; 35(1): 96
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71 The promise of stem cell therapy for eye disorders
Geeta K Vemuganti,Virender S Sangwan,Gullapalli N Rao
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72 Transplantation of Ex Vivo Cultured Limbal Epithelial Stem Cells: A Review of Techniques and Clinical Results
Alex J. Shortt,Genevieve A. Secker,Maria D. Notara,G. Astrid Limb,Peng T. Khaw,Stephen J. Tuft,Julie T. Daniels
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73 The promise of stem cell therapy for eye disorders: Guest Editorial
Vemuganti, G.K., Sangwan, V.S., Rao, G.N.
Clinical and Experimental Optometry. 2007; 90(5): 315-316
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74 In vivo survival and stratification of cultured limbal epithelium
Fatima, A., Vemuganti, G.K., Iftekhar, G., Rao, G.N., Sangwan, V.S.
Clinical and Experimental Ophthalmology. 2007; 35(1): 96-98
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75 Transplantation of Ex Vivo Cultured Limbal Epithelial Stem Cells: A Review of Techniques and Clinical Results
Shortt, A.J., Secker, G.A., Notara, M.D., Limb, G.A., Khaw, P.T., Tuft, S.J., Daniels, J.T.
Survey of Ophthalmology. 2007; 52(5): 483-502
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76 Phenotypic study after cultivated limbal epithelial transplantation for limbal stem cell deficiency
Kawashima, M. and Kawakita, T. and Satake, Y. and Higa, K. and Shimazaki, J.
Archives of Ophthalmology. 2007; 125(10): 1337-1344
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77 Technique of cultivating limbal derived corneal epithelium on human amniotic membrane for clinical transplantation
Fatima, A., Sangwan, V.S., Iftekhar, G., Reddy, P., Matalia, H., Balasubramanian, D., Vemuganti, G.K.
Journal of Postgraduate Medicine. 2006; 52(4): 257-261
[Pubmed]



 

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