The Application Of Human Amniotic Membrane In The Surgical Management Of Limbal Stem Cell Deficiency : Pseudo-Ocular Cicatricial Pemphigoid In A Bilateral Cicatrizing

Cicatricial conjunctivitis is chronic disease with conjunctival fibrosis that may lead to alterations of conjunctival architecture, potentially sight-threatening. Causes of conjunctival cicatrization are not limited to autoimmune diseases, such as ocular cicatricial pemphigoid. Other well-known causes : thermal and chemical burns, Stevens-Johnson , Ocular rosacea,eye drops in the treatment of glaucoma, often underdiagnosed.

This case study aims to describe a similar process, an atypical case about a Pseudo-ocular pemphigoid cicatricial after chemical ocular burns, limited only to the conjunctiva, amniotic membrane is an ideal biological substrate that can help maintain and support the expansion of limbal epithelial stem cells.

We received a 35yo man in the ophthalmological department. The medical history was relevant for chronic exposure to lime due to his mason profesion, no associated ophtalmological or systemic disease. He consults for a progressive visual acuity decline since 6months. Hehad a chronic bilateral cicatrizing conjunctivitis.

On clinical examination, in the left eye reduced vision : 20/400,meibomian gland dysfunction, severe inflammation, upper tarsal scarring, lateral canthal fibrosis, limbal stem-cell deficiency characterized by extents of conjunctival ingrowth, symblepharon formation and severe fornix shortening was also noted, with total ocular surface dermalization, in addition to deep corneal neovascularization.
In the right eye, visual acuity was 20/40, we found ocular surface dermalization with neovascularization only on the inferior half of the cornea.

No characteristic extraocular findings like peri-ocular vitiligo, alopecia, and lack of sweating were found. Nasofibroscopy was normal.

Conjunctival biopsy with immunostaining from nasal fornix, to distinguish for suspected mucus membrane pemphigoid : no vesiculobullous formation.

The patient underwent ocular surface reconstruction :amniotic membrane :

a conjunctival epitheliectomy after scar tissue was removed, the first layer of amniotic membrane attached with tissue adhesive and fibrin glue while the second layer placed over the cornea, the bulbar, and tarsal conjunctiva, secured with 8-0 Vicryl sutures to the conjunctival edges. to transplant a bio-engineered graft by expanding limbal epithelial stem cells ex vivo on amniotic membrane. stem cells could not be obtained from the contralateral eye, we choose to expand cells to decrease the need for large limbal resection. No recurrence of symblepharon was noted during the 6months follow-up.

To perform a limbal stem cell transplantation procedure, the ocular surface was optimized by controlling comorbid conditions.

These factors include adequate control of the ocular surface inflammatory status, and a well-lubricated ocular surface.

Systemic immunosuppressive agents were discussed, we indicated prednisolone.

We aim at highlighting the important role of Amniotic membrane in the treatment of pseudoocular pemphigoid, 
Effective management of patients requires knowledge of multiple modalities such as systemic immunosuppressive therapy, use of scleral contact lenses, and surgery like limbal stem cell transplantation grafts