title: The cincinnati procedure: technique and outcomes of combined living-related conjunctival limbal allografts and keratolimbal allografts in severe ocular surface failure.
abstract: OBJECTIVE
  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 underwent 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 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.
authors.affiliation: Cincinnati Eye Institute, Edgewood, KY, USA.
authors.forename: Joseph M
authors.initials: JM
authors.lastname: Biber
authors.forename: Heather M
authors.initials: HM
authors.lastname: Skeens
authors.forename: Kristiana D
authors.initials: KD
authors.lastname: Neff
authors.forename: Edward J
authors.initials: EJ
authors.lastname: Holland
mesh_terms: D003228:Conjunctiva / Q000637:transplantation*; D003316:Corneal Diseases / Q000601:surgery*; D004847:Epithelial Cells / Q000637:transplantation*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D016850:Limbus Corneae / Q000166:cytology*; D019520:Living Donors; D008297:Male; D008875:Middle Aged; D013508:Ophthalmologic Surgical Procedures; D012189:Retrospective Studies; D033581:Stem Cell Transplantation; D014184:Transplantation, Homologous; D016896:Treatment Outcome; D014792:Visual Acuity / Q000502:physiology