| PURPOSE. To develop a new kind of surgery to reconstruct the cicatricial ocular surface using oral mucosal epithelium. Evaluate the clinical efficacy and study the characteristics of post-operative surface epithelium.METHODS. Retrospective, noncomparative, interventional case series. Patients who underwent ocular surface reconstruction surgery with combined oral mucosa and amniotic transplantation during August 2011 to March 2014 were enrolled (The Department of Ophthalmology, Sir Run Run Shaw Hospital, affiliated to Zhejiang University, School of Medicine). Pre- and post-surgery subjective complaints (including photophobia, pain, and dry eye), best corrected visual acuity (BCVA), post-operative surface epithelium, corneal opacity, symblepharon and neovascularization grades were recorded and compared. Secondary keratoplasty was carried on in successfully reconstructed patients. The final visual acuity, neovascularization grade and cornea graft survival condition were analyzed. Impression cytology, immunohistochemistry and scanning electron microscope were used to study the ocular surface epithelium features post oral mucosal transplantation through surgical specimens.RESULTS.Part 1. Eighty eight patients (given a total of 89 eyes) were studied with an average age of 42.78±12.40 years old. Seventy seven (86.5%) of them were male. The cause of cicatricial surface including chemical burns in 47 eyes (52.8%), thermal burns in 33 eyes(37.1%), blast trauma in 3 eyes (3.4%), Steven-Johnson syndrome in 3 eyes (3.4%) and multiple pterygium in 3 eyes (3.4%).The average follow-up time reached to 355.9±233.8 days, with a longest time of 847 days, and 43.8% of them were followed longer than 1 year. Fifty two eyes (58.45%) were taken full circle transplantation of oral mucosa and the rest were taken partial transplantation. A combined lamellar or deep lamellar keratoplasty were taken in 5 stroma melting cases. After surgery, uncomfortable complaints were obviously reduced in 74 eyes (83.1%), the postoperative total score was 1.02±0.64 compared to 2.24±1.09 before surgery. Visual acuity were improved in 43 eyes (48.3%), corneal opacity and neovascularization grade were obviously decreased in 25 eyes (28.9%) and 84 eyes (94.3%) respectively. Symblepharon were degraded in all 57 eyes (100%) with a lower partial recurrence rate of 5 eyes (8.8%).Post-operative corneal epithelization cost 29.95±61.13 days in average. Seventy six eyes kept on a stable surface and 13 eyes had a small and persistent epithelium defects in the early stage. Twelve were recovered through extra therapy resulted in a stable surface without implications. The rest one was caused a local stroma infiltration. The epithelization time was closely related to the uncomfortable complaints scores (r=0.336, P<0.01), pre-surgery PED (r=0.364, P<0.01), the corneal opacity grade (r=0.331, P<0.01) and the limbal stem cell deficiency scale (r=0.375, p<0.01).Part2. Secondary Yao’s deep lamellar keratoplasty was performed on 15 eyes and penetrating keratoplasty on 4 eyes, with a main post-surgery follow-up time of 305.1±152.4 days. All grafts were survived till last visit. Corneal transparency were improved greatly and a 0.05 or higher BCVA was seem in 13 eyes (68.4%) which were hand motion or finger count before keratoplasty. Neovascularization were also got further degraded. Post keratoplasty epithelium were stable in 12 eyes (63.1%). PED was seen in 7 eyes and persisted in one eye until the last visit. Stroma infiltration was involved in 4 of them. Surgery complications including double anterior chamber caused by descemet’s membrane puncture in one case, corticosteroid-related glaucoma in one case, complicated cataract in one case. Double anterior chamber was re- covered spontaneously 1 month after surgery, and intro ocular pressure was declined to normal scale when lower concentration corticosteroid eye drops was replaced.Part3. The Impression cytological study, HE staining for cornea paraffin sections and scanning electron microscope results indicate that the new surface epithelium post oral mucosa transplantation was morphologically differed from all three kind of epithelium (cornea, conjunctiva and oral mucosa), but more close to cornea epithelium. Epithelium in the central part of corneal was better transdifferentiated than those in peripheral position, and part limbal transplantation was better than total. Immunohistochemistry study showed that the new corneal epithelium came from the mucosal graft but not conjunctiva and both had some features of corneal and oral mucosa.CONCLUTIONS. The surgery we designed in this study effectively reconstructed the cicatricial ocular surface and successfully performed a secondary keratoplasty, oral mucosal epithelium was a reasonable alternative tissue for limbal stem cell deficency. |
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