Date of download: 6/1/2016 Copyright © 2016 American Medical Association. All rights reserved. From: Long-term Outcomes of Keratolimbal Allograft for Total Limbal Stem Cell Deficiency Using Combined Immunosuppressive Agents and Correction of Ocular Surface Deficits Arch Ophthalmol. 2009;127(11): doi: /archophthalmol Postoperative management of corneal epithelial breakdown. Poor contact lens fit and epithelial defect caused by infrequent blinking and increased scleral show in the right eye of case 2 (A) was corrected by punctal occlusion, autologous serum drops, and permanent tarsorrhaphy and remained stable for 63 months thereafter (B). Poor contact lens fit caused by recurrent symblepharon (C) and lagophthalmos (C, inset) in case 7 resulted in a corneal epithelial defect (D). After symblepharon lysis and amniotic membrane transplantation, a deep fornix (E), complete eyelid closure (E, inset), and a stable epithelium were maintained 14 months thereafter (F). Progressive cicatricial eyelid deformity (G) caused by lagophthalmos (G, inset) and persistent epithelial defect led to penetrating keratoplasty graft failure in case 8 (H). Eyelid margin reconstruction (I) allowed the eye to close completely (I, inset) and the cornea remained clear 27 months after the subsequent penetrating keratoplasty (J). Figure Legend:

Date of download: 6/1/2016 Copyright © 2016 American Medical Association. All rights reserved. From: Long-term Outcomes of Keratolimbal Allograft for Total Limbal Stem Cell Deficiency Using Combined Immunosuppressive Agents and Correction of Ocular Surface Deficits Arch Ophthalmol. 2009;127(11): doi: /archophthalmol Postoperative complications. Perilimbal injection signifying early keratolimbal allograft (KLAL) rejection (A) was accompanied by several small epithelial defect spots (B), dry eye, and trichiasis (not shown) in the right eye of case 5. One week after subconjunctival injection of 20 mg of triamcinolone, an increase in the dose of mycophenolate mofetil from 500 mg to 1000 mg daily, a change to a soft bandage contact lens, and epilation, the eye became noninflamed without epithelial defect for 32 months (C). Keratolimbal allograft failure was associated with diffuse neovascularization and focal melt at the 12- to 3-o’clock position, where there was scleral ischemia (D, arrows) 1 year after KLAL in case 10. Vivid late fluorescein staining suggestive of limbal stem cell deficiency was noted 12 months later (E). This eye had irreversible KLAL and penetrating keratoplasty graft failure 3 months later (F). Figure Legend:

Date of download: 6/1/2016 Copyright © 2016 American Medical Association. All rights reserved. From: Long-term Outcomes of Keratolimbal Allograft for Total Limbal Stem Cell Deficiency Using Combined Immunosuppressive Agents and Correction of Ocular Surface Deficits Arch Ophthalmol. 2009;127(11): doi: /archophthalmol Preoperative and postoperative appearances of eyes with successful treatment. A vascularized and scarred cornea of case 3 following prior lamellar keratoplasty (A) became stable and clear with a best-corrected visual acuity (BCVA) that improved from 20/200 to 20/25 for 84 months after keratolimbal allograft (KLAL) (B). A vascularized and scarred cornea in case 4 (C) had BCVA improve from 20/400 to 20/40 and a clear and stable cornea 60 months after KLAL (D). A vascularized and scarred cornea in the left eye of case 5 (E) had BCVA recover from hand motions to 20/20 with a stable and clear cornea 67 months after KLAL (F). A vascularized and scarred cornea of case 6 (G) became clear and safe, with BCVA improving from hand motions to 20/20 seventy- nine months after KLAL (H). Figure Legend: