CLINICAL SCIENCE
The Cincinnati Procedure: Technique and Outcomes of
Combined Living-Related Conjunctival Limbal Allografts
and Keratolimbal Allografts in Severe Ocular
Surface Failure
Joseph M. Biber, MD,*† Heather M. Skeens, MD,‡ Kristiana D. Neff, MD,§
and Edward J. Holland, MD*†
Purpose: To explain our preferred technique and evaluate the
success of ocular surface transplantation using a combined living-
related conjunctival limbal allograft (lr-CLAL) and keratolimbal
allograft (KLAL) in patients with severe ocular surface failure and
conjunctival deficiency.
Methods: Retrospective study of all patients undergoing combined
lr-CLAL/KLAL at the Cincinnati Eye Institute/University of
Cincinnati. Patients were retrospectively analyzed for demographics,
immunosuppression exposure, ocular surface stability, and need for
keratoplasty. Snellen best-corrected visual acuity was evaluated
preoperatively and at final visit.
Results: Nineteen patients (24 eyes) underwent combined
lr-CLAL/KLAL. Mean follow-up was 43.4 months (range: 12.2 to
125.5 months). At the last recorded visit, the ocular surface was stable
in 54.2% (13 of 24), improved in 33.3% (8 of 24), and failed in
12.5% (3 of 24) of eyes. 79.2% (19 of 24) of patients underwent
staged keratoplasty. For the primary keratoplasty, 73.7% (14 of 19)
of patients underwent penetrating keratoplasty, 21.1% of patients
underwent Boston type I keratoprosthesis, and 5.2% of patients under-
went deep anterior lamellar keratoplasty; 57.9% of patients required
repeat keratoplasty. Preoperative best-corrected visual acuity was
20/400 or worse in 87.5% (21 of 24); 75% (18 of 24) of eyes had
improvement in visual acuity at the last follow-up with 70.8% of
patients (17 of 24) achieving 20/125 vision or better. Of patients with
a Boston keratoprosthesis, 90.0% (9 of 10) had an improvement in vision
with 70.0% achieving 20/125 vision or better at the last follow-up.
Conclusions: Ocular surface transplantation with a combined
lr-CLAL/KLAL and staged keratoplasty is an effective procedure to
Received for publication June 14, 2010; revision received September 20,
2010; accepted September 28, 2010.
From the *Cincinnati Eye Institute, Edgewood, KY; †University of Cincinnati,
Cincinnati, OH; ‡Department of Ophthalmology, University of South
Carolina, Columbia, SC; and §Storm Eye Institute, Medical University of
South Carolina, Charleston, SC.
Supported by Research to Prevent Blindness.
Presented in part at the World Cornea Congress VI, April 9, 2010, Boston, MA.
Reprints: Edward J. Holland, University of Cincinnati, 580 South Loop Road,
Suite 200, Edgewood, KY 41017 (e-mail: eholland@fuse.net).
Copyright Ó 2011 by Lippincott Williams & Wilkins
Cornea  Volume 30, Number 7, July 2011
improve visual acuity in patients with severe ocular surface disease
and conjunctival deficiency. Keratoprosthesis after limbal stem cell
transplantation is an alternative to penetrating or lamellar keratoplasty
in this patient population.
Key Words: limbal stem cell transplants, keratoprosthesis, ocular
surface disease
(Cornea 2011;30:765–771)
D isorders of the ocular surface may result in either limbal
stem cell deficiency (LSCD) alone or a combination of
LSCD and conjunctival deficiency. Conjunctival deficiency
occurs after extensive conjunctival inflammation and consists
of symblepharon formation and extensive goblet cell loss with
mucin deficiency. The end result of conjunctival deficiency is
keratinization of the ocular surface including the conjunctiva
and cornea. Combined limbal stem cell and conjunctival
deficiencies are the most severe and challenging forms of
ocular surface failure. Common causes of this condition are
severe Stevens–Johnson syndrome (SJS), ocular cicatricial
pemphigoid (OCP), chemical/thermal injuries, and severe
atopic keratoconjunctivitis.
Staging of patients with ocular surface disease will aid in
clinical decision making. We proposed a system of staging that
is based on the status of both the limbal stem cells and the
conjunctiva (Table 1).1 The first division, either stage I or stage
II, is based on the percentage of involvement of the limbus.
Next, the conjunctiva is assessed, and the patient is categorized
based on the level of conjunctival inflammation. Stage ‘‘a’’
refers to a patient with normal conjunctiva and is most
commonly associated with patients with aniridia or iatrogenic
causes such as contact lens use. Stage ‘‘b’’ describes the
patients with abnormal conjunctiva from previous inflamma-
tion, but currently, the conjunctiva is quiet. This stage is often
reserved for the patients with a history of a chemical or thermal
injury. Stage ‘‘c’’ defines the patients with active conjunctival
inflammation such as SJS or a recent history of a chemical or
thermal injury.1 Stem cell transplantation is difficult in patients
with stage IIb or IIc disease because of the severe dry eye as
a result of aqueous and mucin deficiency, active inflammation,
abundance of immune mediators present, and conjunctival
scarring with symblepharon. For these reasons, these patients
www.corneajrnl.com | 765
Biber et al
TABLE 1. Staging of Ocular Surface Disease
Stage ‘‘a’’: Normal Conjunctiva
Stage I: Partial stem Stage Ia: Iatrogenic, CTL-induced,
cell deficiency and CIN
Stage II: Total stem Stage IIa: Aniridia, iatrogenic, and
cell deficiency severe CTL-induced
CIN, conjunctival intraepithelial neoplasia; CTL, contact lens.
have not only the worst natural disease course but also the
poorest prognosis for surgical rehabilitation.2 Patients in-
cluded in this study were primarily defined as either stage IIc
or IIb.
Keratolimbal allograft (KLAL) surgery is used to treat
LSCD, which targets the specific cell of dysfunction—the limbal
stem cell. In a KLAL procedure, stem cells are obtained from
a cadaveric donor and transplanted to the recipient host limbus. In
the patients with combined limbal stem cell injury and severe
conjunctival inflammation, healthy conjunctiva needs to be
transplanted along with the stem cells. KLAL does not involve
the transplantation of healthy conjunctiva onto the ocular surface.
Studies have concluded that conjunctival epithelium is derived
from a stem cell population that is separate from the limbus.3
Therefore, KLAL alone is not sufficient to correct eyes with
diffuse surface failure caused by concomitant loss of both the
epithelial stem cell populations. A living-related conjunctival
limbal allograft (lr-CLAL) allows for the transplantation of
healthy conjunctiva and limbal stem cells from a patient’s living
and related donor. This is more beneficial than KLAL alone in
this severely inflamed population of patients. Other advantages of
lr-CLAL include a lower antigenic challenge because of
histocompatibility matching and the replacement of goblet cells
to increase mucin production and better stabilize the recon-
structed ocular surface. The primary disadvantage of lr-CLAL
alone is transplantation of a small number of stem cells that only
cover about 50% of the limbus, leaving the other 50% without a
barrier for possible invasion and spread of conjunctival
inflammation.
We have developed the ‘‘Cincinnati procedure,’’ which
combines an lr-CLAL and a KLAL. Previous reports in
the literature have not reported on the success rate of the
Cincinnati procedure. This article reports the surgical
technique and outcomes of 24 cases of recipients undergoing
lr-CLAL/KLAL for severe combined limbal stem cell and
conjunctival deficiency. This article will also discuss the
utilization and success of keratoplasty and systemic immu-
nosuppression (IS) in this challenging population.
PATIENTS AND METHODS
A retrospective chart review of 19 patients undergoing
the ‘‘Cincinnati procedure’’ between 1999 and 2009 was per-
formed. All patients were included who underwent combined
lr-CLAL/KLAL and had follow-up greater than 1 year.
Parameters obtained included age, sex, indication for surgery,
preoperative Snellen best spectacle–corrected visual acuity,
intraoperative complications, postoperative complications,
766 | www.corneajrnl.com
Cornea  Volume 30, Number 7, July 2011
Stage ‘‘b’’: Previously Inflamed Conjunctiva Stage ‘‘c’’: Actively Inflamed Conjunctiva
Stage Ib: History of chemical or thermal injury Stage Ic Mild SJS, OCP, or recent chemical
or thermal injury
Stage IIb: History of severe chemical or Stage IIc: SJS, OCP, or severe recent
thermal injury chemical or thermal injury
length of follow-up, and postoperative Snellen best spectacle–
corrected visual acuity.
The stability of the ocular surface was determined by
slit-lamp examination performed by one examiner (E.J.H.) and
the presence or absence of late staining with fluorescein dye.
The ocular surface was defined as stable, improved, or failed.
A stable ocular surface had an intact corneal epithelium
without any conjunctivalization of the surface or inflamma-
tion. An improved ocular surface was defined as an eye with
partial failure with areas of healthy corneal and areas of
abnormal conjunctival epithelium on the cornea. Eyes labeled
as improved ocular surface did not have any inflammation and
were deemed appropriate for the implantation of a keratopros-
thesis. The lr-CLAL/KLAL improved these patients by
stabilizing the ocular surface, improving the tear film, adding
goblet cells and mucin production to the surface, providing
barriers to symblepharon formation, and creating better
fornices to allow for a better contact lens fitting if keratopros-
thesis was required. A failed ocular surface described an eye
with recurrence of total LSCD.
Preoperatively, a living-related donor was chosen based
on the best histocompatibility match of living-related donors
volunteering for the procedure. If only 1 family member
offered donation, this tissue was used. A full ophthalmic exami-
nation was performed on this individual. All surgeries were
performed at the Cincinnati Eye Institute by a single surgeon
(E.J.H.). The following technique was used for all the cases.
Harvesting the Living-Related Donor Tissue
The previously described technique of obtaining the
conjunctival graft from the living-related donor in the 12- and
6-o’clock meridians was used.4 Briefly, the nondominant
eye of the living-related donor was addressed first in the
12-o’clock meridian. A gentian violet surgical marking pen
was used to mark the conjunctival portions of the grafts. The
conjunctiva was elevated from the Tenon layer with balanced
salt solution on a tuberculin syringe. Dissection of the graft
began by incising with Westcott scissors along the lateral
borders. The tissue was undermined using a blunt Westcott
scissor. The posterior border of the graft was cut. The
conjunctiva was reflected anteriorly over the cornea, and blunt
dissection was continued anteriorly into the peripheral corneal
vascular arcades to ensure inclusion of the stem cells. Once the
tissue was free, it was transferred to balanced salt solution, and
the same procedure was performed in the 6-o’clock meridian.
After retrieval of both meridians of the tissue, the conjunctival
defect was closed with two 7-0 vicryl sutures, 1 mm posterior
to the limbus.
q 2011 Lippincott Williams & Wilkins
Cornea  Volume 30, Number 7, July 2011
Preparation of the Cadaveric Donor Tissue
The preparation of the cadaveric donor tissue for stem
cell transplantation has been described.5 It is important to
request donor tissue from the eye bank that includes a 3- to 4-
mm conjunctival and scleral rim for the limbal stem cell
transplantation.6 The central cornea of the corneoscleral rim
was excised with a 7.5-mm trephine on an Iowa press. The
remaining corneoscleral rim was cut into equal halves, and
scissors were used to dissect the excess peripheral scleral tissue.
The posterior one half to two thirds of each hemisection was
removed by lamellar dissection using a crescent blade. The
2 pieces were placed in Optisol (Chiron Ophthalmics, Irvine,
CA) until placed on the eye later in the operation.
Preparation of the Recipient Eye
The preparation of the recipient eye has also been
described.5 Briefly, a 360-degree limbal peritomy was per-
formed. Any areas of symblepharon were lysed at the limbus,
and the conjunctival tissue was undermined and allowed to
retract posteriorly 2 to 3 mm from the limbus with Westcott
scissors. Light wet-field cautery and topical epinephrine
(1:10,000 dilution) was used to maintain hemostasis. Excess
Tenon tissue was excised with Westcott scissors. Any
abnormal corneal epithelium and fibrovascular pannus were
removed by superficial dissection with a number 64 Beaver
or crescent blade (Fig. 1).
Placement of Donor Tissue
The harvested living-related tissue was sutured in
the same anatomical orientation with the limbal edge at the
recipient limbus in the 12- and 6-o’clock meridians first.
The tissue was sutured with 10-0 nylon, and the knots were
not buried to prevent trauma and cheese wiring of the donor
tissue. The cadaveric donor segments were placed at the 3- and
FIGURE 1. Schematic diagram of
lr-CLAL/KLAL.
q 2011 Lippincott Williams & Wilkins
Cincinnati Procedure in Ocular Surface Failure
9-o’clock meridians also in the same anatomical orientation
with the limbal edge at the recipient limbus. A 10-0 nylon
suture was used, and the knots were not buried (Figures 1–4).
Postoperative Medications
Postoperative topical management of stem cell trans-
plantation is consistent with the topical management of
postoperative penetrating keratoplasty (PK) in our facility.
Four hours after the completion of the procedure, recipients
begin a topical cyclosporine 0.05% 2 times daily, along with
topical prednisolone acetate 1% 4 times daily, and a topical
fourth-generation fluoroquinolone 4 times daily. Oral immu-
nosuppressive medications are administered as determined
preoperatively by the University of Cincinnati Renal Trans-
plant Team. Our current IS regimen consists of tacrolimus,
mycophenolate mofetil, and a short course of oral prednisone
(3 months or less). Tacrolimus dosing is adjusted based on
levels taken on a monthly basis and is typically tapered off at
12 to 18 months. Most patients are maintained on mycophe-
nolate mofetil as monotherapy for at least 24 to 36 months
depending on the level of inflammation and tolerance to
medicine. Topical prednisolone was maintained at 4 times daily
for the first 3 months and then decreased by 1 drop per month
until an appropriate maintenance dose was achieved. Topical
cyclosporine was continued twice daily throughout the follow-
up period, and the topical fluoroquinolone was discontinued
after the epithelium was healed.
Keratoplasty Techniques
In a patient who has undergone previous stem cell
transplantation, keratoplasty is often more technically chal-
lenging. We advocate making some minor adjustments to the
technique to ensure long-term success. First, large-diameter
PK is necessary to allow for optimal wound healing. We size
www.corneajrnl.com | 767
Biber et al
FIGURE 2. Preoperative photograph of 30-year-old woman
with SJS.
the graft to abut the KLAL segments. This typically calls for
a 9.5- to 11.0-mm grafts, and we do not oversize the donor
button except in patients with chemical injury. Recipient beds
in patients with chemical injury often contract after
trephination of the host cornea; therefore, we advocate
oversizing by 0.5 to 0.75 mm in these cases. Second, each
suture needs to approximate donor cornea to the host cornea,
avoiding suturing only to the superficial KLAL tissue. This
reduces the risks of epithelial ingrowth between the limbal
transplant and underlying host tissue. Finally, we use single
interrupted sutures in this setting as vascularization of the
graft–host junction and sutures is common and may require
early selective suture removal. Patients with ocular surface
disease may demonstrate asymmetric healing; therefore,
FIGURE 3. Preoperative photograph of patient from Figure 2
demonstrating severe ocular surface failure.
768 | www.corneajrnl.com
Cornea  Volume 30, Number 7, July 2011
FIGURE 4. Preoperative photograph of patient from Figure 2
demonstrating severe ocular surface failure.
interrupted sutures allow for selective suture removal to
manage postoperative astigmatism.7
RESULTS
Nineteen patients (24 eyes) underwent combined lr-
CLAL/KLAL at the Cincinnati Eye Institute between 1999
and 2009. Mean age at the time of lr-CLAL/KLAL was 51.7 6
16.9 years. Mean follow-up was 43.4 months (range: 12.2 to
125.5 months). SJS was the most common diagnosis (79.2%),
followed by chemical injuries (8.4%), OCP (8.4%), and
atopic keratoconjunctivitis (4.2%). Patient demographics are
included in Table 2.
Ocular Surface Stability
At the last recorded visit, 54.2% (13 of 24) eyes had
a stable ocular surface, 33.3% (8 of 24) eyes had an improved
ocular surface, and 12.5% (3 of 24) eyes had a failed ocular
surface. Of the eyes with a failed ocular surface, 1 patient
failed after 2 episodes of infectious keratitis.
Timing and Type of Keratoplasty
79.2% (19 of 24) eyes underwent staged keratoplasty
performed preferably at least 3 months after ocular surface
reconstruction. Mean time from limbal stem cell trans-
plantation to keratoplasty was 8.7 6 8.3 months. For the
primary keratoplasty, 73.7% (14 of 19) patients underwent
PK, 21.1% patients underwent Boston type I keratoprosthesis
(KPro), and 5.2% of patients underwent deep anterior lamellar
TABLE 2. Patient Demographics
Total No. Patients 19
Male 8
Females 11
Total No. Eyes 24
Right 12
Left 12
Age at lr-CLAL/KLAL 51.7 6 16.9 yr
Total follow-up 43.4 mo (12.2–125.5 mo)
q 2011 Lippincott Williams & Wilkins
Cornea  Volume 30, Number 7, July 2011
keratoplasty. 57.9% (11 of 19) patients underwent repeat
keratoplasty with 5 PK and 6 KPro (Fig. 5).
Visual Outcomes
Preoperative best-corrected visual acuity was 20/400 or
worse in 87.5% (21 of 24) of eyes; 75% (18 of 24) of eyes had
an improvement in vision of at least 1 line at the last follow-up;
16.6% (4 of 24) eyes had the same postoperative visual acuity
as those estimated preoperatively. Two eyes (8.3%) had
a decrease in vision from their preoperative vision. One patient
lost vision because of end stage glaucoma, and the other
required enucleation after perforation; 70.8% of patients (17 of
24) achieved 20/125 vision or better at the last follow-up.
37.5% (9 of 24) of patients achieved 20/50 vision or better
postoperatively at the last follow-up visit (Fig. 6). Of patients
with a KPro, 90.0% (9 of 10) had an improvement in vision
with 70.0% achieving 20/125 vision or better at the last
follow-up.
IS Exposure and Adverse Events
95.8% (23 of 24) of patients received systemic IS. Mean
time on IS was 34.1 months (range: 7.6 to 99.7 months). 17.4%
(4 of 23) of patients were able to be successfully tapered off IS.
Mean time to tapering of IS was 43.2 months (range: 18.0 to
89.1 months). Systemic side effects of IS include severe
adverse events such as death, myocardial infarction, cerebro-
vascular event, and secondary tumors, and minor adverse
events of IS include alterations in biochemistry, increase in
cardiovascular risk factors, and infections requiring hospital-
izations. We report 0 severe adverse events and 6 (26.1%)
minor adverse events. Of the minor adverse events, 4 patients
had a temporary increase in the blood creatinine level, and 2
patients had a transient increase in liver function tests. All
FIGURE 5. Patient procedures.
q 2011 Lippincott Williams & Wilkins
Cincinnati Procedure in Ocular Surface Failure
these abnormal levels returned to normal with modifications in
the medication regimen.
DISCUSSION
Successful treatment of the patients with ocular surface
disease requires the clinician to aggressively treat not only the
underlying condition but also all the comorbidities that can
affect the patients’ visual outcome. Patients with ocular surface
failure often have a combination of 2 or more of the following:
LSCD, conjunctival deficiency, severe dry eye, corneal
scarring and melting, glaucoma, cataract, or lid abnormalities.
Conjunctival deficiency is defined as an extensive conjunctival
inflammation, which can result in symblepharon formation
and extensive goblet cell loss with mucin deficiency. The end
result of conjunctival deficiency is the keratinization of the
ocular surface including the conjunctiva and cornea. Stem cell
transplantation is difficult in patients with stage IIb or IIc
disease because of the severe dry eye as a result of aqueous and
mucin deficiency, active inflammation, abundance of immune
mediators present, and conjunctival scarring with symble-
pharon. For these reasons, these patients have not only the
worst natural disease course but also the poorest prognosis for
surgical rehabilitation.2 Transplantation of the limbal stem
cells only, such as in KLAL, addresses only one of the factors
that contribute to their ocular surface failure. Therefore, we
proposed combining conjunctival limbal allograft and KLAL
as a procedure in patients with both limbal and conjunctival
deficiency.
The transplantation of the conjunctiva and stem cells
provides the additional benefit of goblet cells from the
additional conjunctiva, which makes this procedure useful in
the management of eyes with cicatrizing conjunctival disease
www.corneajrnl.com | 769
Biber et al
FIGURE 6. Visual outcomes.
such as SJS, OCP, and some chemical injuries. However, this
procedure is not successful in patients who have progressed to
diffuse keratinization of the ocular surface. A disadvantage of
lr-CLAL alone compared with KLAL is that the amount of
limbus that can be harvested from the donor eye is limited,
resulting in significantly fewer stem cells with lr-CLAL
compared with KLAL. With regard to tissue utilization, the
combined procedure uses only 1 corneoscleral rim, which is
divided into 2 KLAL segments, as opposed to 2 donor eyes for
KLAL. Another potential disadvantage of this procedure
compared with KLAL alone is the risks to the donor and the
time required to identify and test the donor and increased
operative time. In this series, we did not have any adverse
events to the donor such as LSCD, persistent epithelial defects,
infection, or loss of vision.
In this population, corneal scarring was often visually
limiting and did not improve to a satisfactory level after
surface reconstruction. To achieve better vision, 79.2% of the
eyes in this study required keratoplasty. We advocate a staged
approach to decrease the amount of inflammation in hopes
of providing the optimal recipient bed for the keratoplasty
success. At 3 months postoperatively, the ocular surface is
evaluated and determined to be stable, improved, or failed.
Patients with a failed ocular surface were offered repeat or
sectoral KLAL or KPro. If keratoplasty is indicated, it is
typically recommended to patients with either stable or
improved ocular surfaces. As for type of keratoplasty, we
commonly advocate 3 types of transplants: PK, deep anterior
lamellar keratoplasty, or Boston type I KPro (Fig. 7) The
health of the endothelial layer is vital to decide between
penetrating and lamellar keratoplasty. In cases of abnormal
endothelium, we use PK. Lamellar keratoplasty has the
primary advantage of avoiding the unnecessary replacement
of healthy endothelium, thus obviating the problems of
endothelial rejection and hence subsequent endothelial graft
failure.8 We believe that this is even more significant in this
population because of the highly inflamed and often
770 | www.corneajrnl.com
Cornea  Volume 30, Number 7, July 2011
vascularized nature of the recipient’s cornea before trans-
plantation, often increasing the risks of rejection. Oral and
topical IS does lower this risk; however, other important
advantages of lamellar keratoplasty include reduction of
intraocular complications, such as expulsive hemorrhage,
glaucoma, cataract, and endophthalmitis.8 One major disad-
vantage of lamellar keratoplasty in this setting is the inability
to assess the health of the endothelium because of anterior
stromal scarring.9
Historically, the Boston type I or II KPro has been
reserved for patients without a stable ocular surface, a history of
multiple failed grafts, or those unable to tolerate surface
reconstruction and IS. The type II KPro is designed to be
inserted through the lid in patients with a severely dry ocular
surface and no fornices to support the keratoprosthesis.
Complications of the type II KPro include endophthalmitis,
skin retraction, retroprosthetic membrane, worsening of
glaucoma, and tissue melting.10 We did not implant any
patients with a type II KPro. Implantation of a type I KPro in
patients with severe ocular surface disease (stage IIb or IIc) and
conjunctival deficiency is challenging for multiple reasons.
Symblepharon and shortened fornices make maintaining
a bandage contact lens difficult, which can increase the risk
of corneal melting and infectious keratitis.11 Sayegh et al
reported on the outcomes and complication of 16 eyes of
patients with SJS that underwent implantation of either type I or
type II Boston KPro; 25% of these patients developed tissue
melting and aqueous leakage that required surgical manage-
ment.10 Based on this study, tissue melting and leaking are
higher in patients with SJS compared with the overall incidence
of corneal melting (17%) with Boston KPro for all indications.12
We believe that the Boston type I KPro can be used as
the primary keratoplasty in patients who have undergone
ocular surface reconstruction and have a stable or improved
surface as well. Combined lr-CLAL/KLAL before implanta-
tion of a KPro is beneficial because it improves the ocular
surface and tear film, which we believe would lower the
q 2011 Lippincott Williams & Wilkins
Cornea  Volume 30, Number 7, July 2011
FIGURE 7. Treatment algorithm for
cases of severe ocular surface
disease.
incidence of melting and possible extrusion of the implant.
In addition, the limbal stem cell grafts provide barriers for
recurrent symblepharon formation and help to create and
maintain the fornix. This structural function enhances the
ability of the patient to maintain a bandage contact lens, which
is imperative for the safety of the keratoprosthesis.11 In our
study, the success of the keratoprosthesis is measured by both
visual outcomes and long-term survivability of the kerato-
prosthesis. In regard to visual outcomes, 90.0% (9 of 10) of
patients with a KPro had an improvement in vision with 70.0%
achieving 20/125 vision or better at the last follow-up, In this
series, none of our patients required either removal of KPro
or patch graft because of corneal thinning or melting. These
results are better than prior studies of patients with SJS under-
going KPro alone without limbal stem cell transplantation.10,13
In one study, 56.2% (9 of 16) of eyes had 20/200 vision or
worse at the last follow-up, and 25% required surgery for
corneal melting and leaking.10 One weakness of this study is
that 5 patients had bilateral lr-CLAL/KLAL, and therefore,
given the small size of this study, both the eyes were included
in this study population.
In conclusion, we believe that the recognition of
conjunctival inflammation and deficiency in patients with
limbal stem cell failure is important in determining the optimal
surgical procedure for surface reconstruction. This article
provides support for combined lr-CLAL/KLAL and staged
keratoplasty as an effective procedure to improve visual acuity
in patients with severe ocular surface disease and conjunctival
deficiency. In addition, keratoprosthesis after limbal stem cell
transplantation is an alternative to PK in this patient
population. Finally, KPro following the Cincinnati procedure
is preferable and has better outcomes than primary
q 2011 Lippincott Williams & Wilkins
Cincinnati Procedure in Ocular Surface Failure
keratoprosthesis without stem cell transplantation in patients
with severe stage IIb or IIc ocular surface disease.
REFERENCES
1. Schwartz GS, Gomes JAP, Holland EJ. Preoperative staging of disease
severity. In: Holland EJ, Mannis MJ, eds. Ocular Surface Disease. New
York, NY: Springer; 2002. pp. 158–168.
2. Holland EJ. Epithelial transplantation for the management of severe ocular
surface disease. Trans Am Ophthalmol Soc. 1996;44:677–743.
3. Wei Z-G, Sun T-T, Lavker RM. Rabbit conjunctival corneal epithelial cells
belong to two separate lineages. Invest Ophthalmol Vis Sci. 1996;37:523–533.
4. Daya SM, Holland EJ, Mannis MJ. Living-related conjunctival limbal
allograft. In: Holland EJ, Mannis MJ, eds. Ocular Surface Disease. New
York, NY: Springer; 2002. pp. 201–207.
5. Schwartz GS, Tsubota K, Tseng SG, et al. Keratolimbal allograft. In:
Holland EJ, Mannis MJ, eds. Ocular Surface Disease. New York, NY:
Springer; 2002. pp. 208–223.
6. Croasdale CR, Schwartz GS, Malling JV, et al. Keratolimbal allograft:
recommendations for tissue procurement and preparation by eye banks,
and standard surgical technique. Cornea. 1999;18:52–58.
7. Biber JM, Neff KD, Holland EJ, et al. Corneal transplantation in ocular
surface disease. In: Krachmer J, Mannis M, Holland E, eds. Cornea. 3rd
ed. London, United Kingdom: Elsevier; 2010.
8. Han DC, Mehta JS, Por YM, et al. Comparison of outcomes of lamellar
keratoplasty and penetrating keratoplasty in keratoconus. Am J
Ophthalmol. 2009;148:744–751.
9. Fogla R, Padmanabhan P. Deep anterior lamellar keratoplasty combined
with autologous limbal stem cell transplanation in unilateral severe
chemical injury. Cornea. 2005;24:421–425.
10. Sayegh RR, Ang LP, Foster S, et al. The Boston keratoprosthesis in
Stevens-Johnson syndrome. Am J Ophthalmol. 2008;145:438–444.
11. Dohlman CH, Dudenhoefer EJ, Khan BF, et al. Protection of the ocular
surface after keratoprosthesis surgery: the role of soft contact lenses.
CLAO J. 2002;28:72–74.
12. Bradley JC, Graue Hernandez E, Schwab IR, et al. Boston Type 1
keratoprosthesis: the University of California Davis experience. Cornea.
2009;28:321–327.
13. Yaghouti F, Nouri M, Abad JC, et al. Keratoprosthesis: preoperative
prognostic categories. Cornea. 2001;20:19–23.
www.corneajrnl.com | 771