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Gargi K. Vora, Bernardo Cavalcanti, Monique Trinidad, Candice Williams, Pedram Hamrah; In Vivo Confocal Microscopy Analysis and Image-Guided Therapy of Limbal Stem Cell Insufficiency. Invest. Ophthalmol. Vis. Sci. 2012;53(14):3523.
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Limbal stem cell insufficiency (LSCI) from chronic contact lens wear leads to conjunctival injection, tearing, photophobia, and irritation. Slit-lamp examination demonstrates corneal pannus formation, geographic areas of staining, and superficial punctate keratopathy. We describe a series of 3 patients, followed both clinically and by In Vivo Confocal Microscopy (IVCM), that were successfully treated with anti-inflammatory therapy alone.
The clinical charts of three patients diagnosed with LSCI were retrospectively reviewed. These patients underwent a complete clinical exam and IVCM (HRT3/RCM) at each visit. Three representative images from the central cornea and superior limbus were selected for each parameter and compared with images of previously tested normal subjects. Images were quantified for dendritic immune cell density (DC) and nerve count and density with ImageJ/NeuronJ.
The patients had been wearing contact lenses for an average of 10.7 years. The average visual acuity (VA) was 20/30 (range 20/20 to 20/60) at presentation.IVCM demonstrated a mean central corneal DC density of 577.4±323.8 cells/mm2 at presentation, which was significantly higher than normal subjects (42.5±40.5, p<0.05).Based on the increased presence of DC topical treatment with loteprednol etabonate (n=2 patients; 4 eyes) or rimexolone (1 patient; 2 eyes) taper was started. After at least 3 months of treatment, the average DC density decreased to 234.6±233.7 cells/mm2, which was significant compared to initial presentation (p=0.001). Furthermore, while patients demonstrated a decrease of corneal nerve numbers and density at presentation as compared to controls, a significant increase in the total number of nerves and branches, as well as nerve branch density was observed by IVCM after treatment (p<0.05).The corneal epithelium in each patient qualitatively showed a higher rate of conjunctivalization by IVCM, which subsequently decreased with treatment. IVCM changes corresponded to improvement of mean VA of 20/20 and decrease in corneal staining.
IVCM suggests that inflammation plays a crucial role in the pathogenesis of LSCI, which can be adequately treated with topical steroid drops. IVCM can objectively assess inflammation at a cellular level following treatment response, allowing more effective image-guided therapy.
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