Cryopreserved Umbilical Cord Tissue For Lid Margin Keratinization In Stevens-Johnson Syndrome And Toxic Epidermal Necrolysis: A Novel Alternative To Mucous Membrane Grafts

Lid margin keratinization (LMK) is a significant complication observed in chronic inflammatory ocular surface diseases, particularly in patients with Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN). Standard management for LMK includes reconstruction with mucous membrane grafts (MMGs) harvested from the oral cavity. Cryopreserved umbilical cord tissue (UCT) has emerged as a promising alternative in ocular surface reconstruction.

The purpose of this study was to evaluate the efficacy of umbilical cord tissue as a novel grafting material for lid margin keratinization in SJS and TEN, where conventional mucous membrane grafts are often limited by donor site morbidity and the timing of intervention.

The study presents an interventional case report. In each patient, eyelid reconstruction was performed using an UCT graft in one eye and a MMG in the other eye after obtaining surgical consents. Surgical procedure involved excision of the keratinized conjunctiva then placement of a cryopreserved, pre-prepared UCT graft. At the end of the procedures, bandage contact lens applied and postoperative medications given. Patients were reviewed at week 1, 3, and 6, then every three months thereafter.

Two patients with severe SJS/TEN–related LMK underwent lid margin reconstruction using UCT grafts as an alternative to the traditional MMG. In the TEN patient, extensive oral mucosal involvement precluded harvesting MMG, necessitating a non-oral, ready-to-use graft. In the SJS patient, four-lid involvement combined with developmental challenges prompted selection of UCT grafts to minimize surgical morbidity and avoid multiple donor sites. Surgical outcomes, graft integration, ocular surface stability, conjunctival inflammation, and symptom improvement were assessed over a 12-month follow-up.

The umbilical cord tissue grafting achieved good graft integration, rapid epithelialization, restoration of the mucocutaneous barrier, and marked reduction in blink-related microtrauma in both patients. Consequently, UCT grafts led to significant symptomatic relief, with reduction in conjunctival inflammation. In the TEN case, UCT grafts enabled complete stabilization of the ocular surface and deep fornix preservation. In the SJS case, UCT grafting allowed successful simultaneous four-lid reconstruction with reduced operative burden. UCT-treated eyes demonstrated faster early healing and less inflammation compared with MMG, while achieving comparable long-term results without graft rejection, contracture, or recurrence.

Cryopreserved UCT provides a ready-to-use, biologically active, non-keratinized alternative for LMK management in SJS/TEN, eliminating donor site complications and reducing surgical burden particularly in complex cases where oral mucosa may be unsuitable. Its extracellular matrix richness and immunomodulatory properties offer both structural support and anti-inflammatory benefits, addressing key limitations of MMG. To our knowledge, this is the first report to document UCT grafts specifically for LMK reconstruction, highlighting their potential as a paradigm-shifting option in complex ocular surface disease. Larger controlled studies are warranted.