Stevens-Johnson syndrome (SJS), also known as the erythema multiform,
is an acute, self-limited, inflammatory disorder of the skin and mucous membranes.
Although the skin lesions are self-limited, the ocular disease gets worse
and often results in bilateral blindness owing to a lack of corneal stem cells,1 corneal scarring, and subconjunctival fibrosis.
Prognosis of corneal transplantation in the acute phase is poor because of
the difficulty of overcoming the severe inflammation and allograft rejection.
Even in the chronic phase, it is difficult to control persistent inflammation,
dry eye, and trichiasis, which induce persistent epithelial defect and allograft
rejection. Although corneal stem cell transplantation and amniotic membrane
(AM) transplantation, combined with dry eye treatment and strong immunosuppressive
therapy, have been attempted at the scarring stage,2
the management is difficult, and the visual prognosis is not satisfactory.
However, if it were possible to control the severe inflammation and manage
the corneal transplantation in the acute phase with less scarring change,
the visual prognosis could be greatly improved. Recently, attention has focused
on cultivated corneal epithelial transplantation as a new approach for ocular
surface reconstruction in limbal-deficient disorders.3
We ensured the suitability of the denuded AM as a carrier for the corneal
epithelial cell culture4 and have successfully
established a surgical system for cultivated corneal limbal epithelium transplantation
in rabbits using AM as a carrier.5 We applied
this procedure in 2 patients with the acute phase of SJS, and we achieved
successful ocular surface reconstruction.
Human AM was obtained at cesarean section,5
and the amniotic epithelium was removed by EDTA treatment.4
Small pieces of donor limbal cornea were cultured on acellular AM with 3T3
fibroblasts. The culture was submerged in the medium for 2 weeks, after which
it was exposed to the air to promote epithelial stratification for 1 to 2
weeks. The cultivated corneal epithelium consisted of 4 to 5 layers, appeared
very similar to normal corneal epithelium, and stained with antibodies specific
for corneal epithelium keratin 3 (AE5) and keratin 12 (J7) (Figure 1).
A, Cultivated corneal epithelium
on amniotic stroma (asterisk) consists of 4 to 5 layers that are very similar
in appearance to normal corneal epithelium (B) (hematoxylin-eosin, original
magnification ×100). C and D, Cultivated corneal epithelium stained
with antibodies specific to corneal epithelium keratin 3 and keratin 12.
The patients were a 32-year-old man (patient 1) and a 21-year-old man
(patient 2), each of whom had had SJS for 3 months. Their eyes showed persistent
corneal epithelial defects surrounded by inflammatory subconjunctival fibrosis
that was resistant to conventional therapy (Figure 2, A and B). They showed total stem cell deficiency. After
informed consent from the patients and approval from the university ethics
committee were obtained, we performed the cultivated corneal epithelial transplantation
on the right eye of patient 1 and in both eyes of patient 2. After removal
of the conjunctival tissue on the cornea up to 3 mm outside the limbus, we
treated the subconjunctival fibroblasts for 5 minutes with 0.04% mitomycin
and vigorous saline washing. We secured the cultivated allocorneal epithelium
on AM onto the corneal surface with 10-0 nylon sutures, then we covered it
with a therapeutic soft contact lens. Postoperatively, 0.3% ofloxacin and
0.1% dexamethasone were instilled 4 times per day, and corticosteroid (1 mg/d),
cyclosporin (150 mg/d), and cyclophosphamide (100 mg/d) were administered
to prevent postoperative inflammation and allograft rejection. Forty-eight
hours after transplantation, the corneal surfaces of the 3 eyes were clear
and smooth, and the entire corneal surfaces were perfectly covered with transplanted
allocorneal epithelium that did not stain with fluorescein (Figure 2, C). The transplanted corneal epithelium was surrounded
by a conjunctival epithelial defect at 360°, suggesting there was no contamination
of host conjunctival epithelium. Five days after transplantation, all areas
of the ocular surface were covered with transparent epithelium. Shortly after
the transplantation, conjunctival inflammation rapidly subsided, and visual
acuity recovered to 20/20 OD in patient 1 and 20/20 OU in patient 2. After
a posttransplantation observation period of 6 months, their ocular surface
epithelia were stable and without defects (Figure 2, D). We are carefully monitoring the transplanted allocorneal
epithelial cells to determine their longevity.
A, Persistent corneal epithelial
defects of patient 2 (right eye) surrounded by inflammatory subconjunctival
fibrosis. B, Fluorescein staining clearly shows the area of epithelial defect
surrounded by conjunctival invasion. C, Two days after the cultivated corneal
epithelial transplantation, corneal surface is covered with transplanted corneal
epithelium, which shows no fluorescein staining. D, Three months after transplantation,
a clear corneal surface is maintained, and visual acuity is 20/20 OD.
The concept that corneal epithelial stem cells reside in the limbal
basal epithelium was established in the 1980s.1
Conventional stem cell transplantation has great potential as a treatment
for stem cell deficiency. However, this procedure needs several weeks to cover
the total corneal surface with migrated corneal epithelium from donor cornea,
and the denuded corneal surface induces severe inflammation, especially in
acute phase SJS. The patients we report here were in acute phase and would
have been contraindicated for conventional stem cell transplantation. Our
method of cultivated allocorneal epithelial transplantation allowed us to
cover their ocular surfaces with clear and silent corneal epithelium during
surgery, and subside their inflammation. In conclusion, cultivated corneal
epithelial transplantation using AM as a carrier is an effective ocular surface
reconstruction technique for acute phase SJS.
This work was supported by the Japanese Ministry of Health and Welfare,
grant 10470365 from the Japanese Ministry of Education, the Kyoto Foundation
for the Promotion of Medical Science, and the Intramural Research Fund of
the Kyoto Prefectural University of Medicine.
The authors thank Nigel Fullwood, PhD, for reviewing the manuscript,
and Satoshi Kawasaki, MD, for immunohistochemistry.
Corresponding author and reprints: Shigeru Kinoshita MD, PhD, Department
of Ophthalmology, Kyoto Prefectural University of Medicine, Kawaramachi-hirokoji,
Kamigyo-ku, Kyoto 602-0841, Japan (e-mail: email@example.com).
TT Differentiation-related expression of a major 64K corneal keratin in
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