Incidence and characteristics of aspiration pneumonia in the Nagasaki Prefecture from 2005 to 2019.

BACKGROUND: Aspiration pneumoniae remains a major health concern, particularly in the older population and has poor prognosis; however, the concept itself remains vague worldwide. This study aimed to determine the actual situation and characteristics of aspiration pneumonia from 2005 to 2019 in Nagasaki Prefecture, Japan. METHODS: Cases of aspiration pneumonia that occurred in the Nagasaki Prefecture between 2005 and 2019 were analyzed using emergency transportation records. The number of occurrences and incidence were analyzed according to age, sex, month, day of the week, and recognition time to clarify the actual situation of aspiration pneumonia. RESULTS: The total number of new aspiration pneumonia cases was 8,321, and the mean age of the patients was 83.0 years. Annual incidence per 100,000 population increased from 12.4 in 2005 to 65.1 in 2019, with the most prominent increase in the ≥ 80-year-old stratum. Males (55.1%) were more commonly affected than females (44.9%), and 82.2% of the cases involved patients aged ≥ 70 years. No significant correlations were observed between the incidence of aspiration pneumonia and season, month, or day of the week. Aspiration pneumonia occurred frequently in houses (39.8%) and facilities for elderly individuals (40.8%). At 7 days after admission, 80.9% of patients were still hospitalized and 6.5% had died. CONCLUSIONS: The incidence of aspiration pneumonia with risks of severity and mortality is increasing among elderly individuals. Valid preventive measures are urgently needed based on the findings that the disease occurs in both household and elderly care facility settings, regardless of the season.

Cytopathic effect of Acanthamoeba on human corneal fibroblasts.

PURPOSE: Acanthamoeba keratitis is associated with keratocyte depletion in humans. We investigated how Acanthamoebae isolated from corneas affected by Acanthamoeba keratitis interacted with human corneal stromal cells in vitro. METHODS: Acanthamoebae were isolated from 6 patients with Acanthamoeba keratitis and genotyping was done. Whether the isolated Acanthamoebae could invade the corneal stroma was assessed with denuded corneal stroma ex vivo. The cytopathic effect of Acanthamoeba on cultured corneal fibroblasts from donor corneas was quantitatively evaluated by the MTT assay after culture under various conditions. Terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL) and Annexin V staining were employed to detect apoptotic cells among the corneal fibroblasts co-cultured with Acanthamoebae. RESULTS: All 6 Acanthamoebae isolated from the patients with Acanthamoeba keratitis were shown to have the T4 genotype by 18S rDNA sequence analysis. Acanthamoebae invaded the denuded corneal stroma in the ex vivo experiments and had a cytopathic effect on human corneal fibroblasts after direct adhesion, but not via chemical mediators. A cytopathic effect was detected with all 6 Acanthamoebae and corneal fibroblasts mainly died by apoptosis, as evidenced by Annexin V staining. CONCLUSIONS: Acanthamoebae isolated from patients with Acanthamoeba keratitis had a cytopathic effect on human corneal fibroblasts, mainly via induction of apoptosis after direct adhesion. Our findings may provide some clues to the pathophysiology of corneal keratocyte depletion in patients with Acanthamoeba keratitis.

Role of Monocytes/Macrophages in the Etiology of Bullous Keratopathy After Argon Laser Iridotomy.

Purpose: The etiologic mechanisms of bullous keratopathy (BK) after argon laser iridotomy (ALI) are still unknown. Therefore, we investigated potential mechanisms on BK after ALI. Methods: Corneal endothelial surface obtained in penetrating keratoplasty for BK after ALI was observed and analyzed immunohistochemically. We investigated how various leukocytes react to cultured human corneal endothelial cells in an inflamed condition and monocytes/macrophages respond to the iris treated by an argon and YAG laser or pigmented and nonpigmented iris treated by an argon laser. Results: We detected infiltration of CD68- and CD11b-positive monocytes/macrophages in the posterior surface of trephined corneas obtained during penetrating keratoplasty for BK after ALI in three of the seven eyes with ALI. In vitro, monocytes/macrophages, but not T cells, B cells, neutrophils, or pan-leukocytes, removed many cultured human corneal endothelial cells in the medium stimulated with proinflammatory cytokines. Human pigmented iris tissues treated by the argon laser, but not those treated by the YAG laser, attracted many monocytes/macrophages and formed large, round colonies. Human monocytes/macrophages formed large colonies on the argon laser-treated pigmented iris from C3H mice but not nonpigmented iris from albino BALB/c mice. Conclusions: Our results suggest that monocytes/macrophages, argon laser, and pigmented iris are all involved in the pathogenesis of BK after LI. Translational Relevance: Etiology in BK after ALI has not been clear, but our findings based on clinical and experimental findings give a critical clue to explain possible mechanisms on BK after ALI.

Progression of microstructural deterioration in load-bearing immobilization osteopenia.

PURPOSE: Immobilization osteopenia is a major healthcare problem in clinical and social medicine. However, the mechanisms underlying this bone pathology caused by immobilization under load-bearing conditions are not yet fully understood. This study aimed to evaluate sequential changes to the three-dimensional microstructure of bone in load-bearing immobilization osteopenia using a fixed-limb rat model. MATERIALS AND METHOD: Eight-week-old specific-pathogen-free male Wistar rats were divided into an immobilized group and a control group (n = 60 each). Hind limbs in the immobilized group were fixed using orthopedic casts with fixation periods of 1, 2, 4, 8, and 12 weeks. Feeding and weight-bearing were freely permitted. Length of the right femur was measured after each fixation period and bone microstructure was analyzed by micro-computed tomography. The architectural parameters of cortical and cancellous bone were analyzed statistically. RESULTS: Femoral length was significantly shorter in the immobilized group than in the control group after 2 weeks. Total area and marrow area were significantly lower in the immobilized group than in the control group from 1 to 12 weeks. Cortical bone area, cortical thickness, and polar moment of inertia decreased significantly after 2 weeks. Some cancellous bone parameters showed osteoporotic changes at 2 weeks after immobilization and the gap with the control group widened as the fixation period extended (P < 0.05). CONCLUSION: The present results indicate that load-bearing immobilization triggers early deterioration of microstructure in both cortical and cancellous bone after 2 weeks.

Visualization of Airborne Particles as a Risk for Microbial Contamination in Orthopedic Surgery.

Background: The operating theater is recognized to involve a high frequency of occupational blood and body fluid contacts. Objectives: This study aimed to visualize the production of blood and body fluid airborne particles by surgical procedures and to investigate risks of microbial contamination of the conjunctival membranes of surgical staff during orthopedic operations. Methods: Two physicians simulated total knee arthroplasty (TKA) and total hip arthroplasty (THA) in a bio-clean theater using model bones. The generation and behaviors of airborne particles were filmed using a fine particle visualization system, and numbers of airborne particles per 2.83 L of air were counted at the height of the operating and instrument tables. Each action was repeated five times, and particle counts were evaluated statistically. Results: Numerous airborne particles were dispersed to higher and wider areas while "cutting bones in TKA" and "striking and driving the cup component on the pelvic bone in THA" compared to other surgical procedures. The highest particle counts were detected while "cutting bones in TKA" under unidirectional laminar air flow. Discussion: These results provide a clearer image of the dispersion and distribution of airborne particles and identified higher-risk surgical procedures for microbial contamination of the conjunctival membranes. Surgical staff including surgeons, nurses, anesthesiologists, and visitors, should pay attention to and take measures against occupational infection particularly in high-risk surgical situations.

Isolation of adult progenitor cells with neuronal potential from rabbit corneal epithelial cells in serum- and feeder layer-free culture conditions.

PURPOSE: To isolate progenitor cells from rabbit corneal epithelial cells (CEC) in serum- and feeder layer-free culture conditions and to compare the self-renewal capacity of corneal epithelial progenitor cells obtained from the central and limbal regions of the cornea. METHODS: Tissue samples of New Zealand white rabbit corneas were dissected from the limbal and central regions to obtain CEC for sphere-forming culture, in which the cells formed spheres in serum-free medium containing growth factors. The number of primary and secondary sphere colonies and the size of the primary spheres were compared between the limbal and central regions. To promote differentiation, isolated sphere colonies were plated in dishes coated with poly-L-lysine (PLL)/laminin. The expression of epithelial, neural, and mesenchymal mRNAs was examined in the sphere colonies and their progeny by immunocytochemistry and/or the reverse transcription-polymerase chain reaction (RT-PCR). Adherent differentiated cells from the sphere colonies were also examined morphologically. RESULTS: Primary spheres were isolated from both the limbal and central regions of the cornea. The rate of primary sphere formation by CEC from the limbal region (55.6+/-10.6/10,000 cells) was significantly higher than that by cells from the central cornea (43.1+/-7.2/10,000 cells, p=0.0028), but there was no significant difference in the size of primary spheres derived from both regions. The self-renewal capacity of cells from the limbal region was higher than that of cells from the central region, as evidenced by the significantly higher secondary sphere formation rate of limbal cells (38.7+/-8.5/10,000 cells) in comparison with that for central cells (31.3+/-5.7/10,000 cells, p=0.013). The primary sphere colonies expressed bromodeoxyuridine (BrdU), a 63-kDa protein (p63), p75 neurotrophin receptor (p75(NTR)), and nestin, whereas their progeny expressed cytokeratin 3, cytokeratin 12, vimentin, alpha-smooth muscle actin, microtubule-associated protein 2, and neuron-specific enolase on immunocytochemical analysis. These markers were confirmed by RT-PCR. CONCLUSIONS: Our findings indicate that limbal CEC contain more progenitor cells with a stronger self-renewal capacity than cells from the central region. These progenitor cells differentiate into the epithelial lineage, and can also produce neuronal protein.

[Regenerative medicine and stem cells of corneal epithelium].

Stem cells supply differentiated cells that compose the body organs. Stem cell research is increasing and their use in regenerative medicine is drawing a lot of attention. In ophthalmology, regenerative medicine of the corneal epithelium is already practiced by clinicians, and there is constant improvement in the culture methods. Research leading to the isolation of corneal epithelial stem cells, a kind of adult stem cell whose existence has been suggested, is done using various methods such as flow cytometry and selective culture methods. In this review, regenerative medicine of the corneal epithelium, stem cell isolation and culture methods are explained; and our new discoveries of stem cells' features such as their high adhesive ability is explained.

Goblet Cell Differentiation Potential in Human Corneal Limbal Epithelial Progenitor Cells In Vitro.

Purpose: The existence of goblet cells has been regarded as a critical differential point to distinguish conjunctival epithelium from corneal epithelium in vivo. We tested differentiation potential of single progenitor cells from corneal limbal epithelium with growth factors in vitro. Methods: Dissociated single cells from corneal limbal epithelium were cultured in the serum- and feeder cell-free medium containing B27 and various growth factors using nontissue culture dishes. Specific marker expression was examined in the colonies stimulated with growth factors. Differentiation of some mucosal epithelia was tested. Results: Adherent single cells from dissociated single cells in corneal limbal epithelium did not proliferate in the serum- and feeder cell-free medium containing B27 only and formed corneal epithelium with B27 plus epidermal growth factor, while they gave rise to goblet cell with periodic acid Schiff-positive mucin and cytokeratin-3 and-12 expressing corneal epithelium with fibroblast growth factor (FGF)2 stimulation. Colonies stimulated with FGF2 expressed goblet cell specific MUC5AC and cytokeratin-7 mRNA and protein. FGF receptor 1 was a functional receptor for the differentiation to goblet cells and corneal epithelium. Conclusions: Single corneal limbal progenitor cells give rise to goblet cells and corneal epithelium by FGF2 stimulation via FGF receptor 1 in vitro.

A novel isolation technique of progenitor cells in human corneal epithelium using non-tissue culture dishes.

The existence of adult stem cells or progenitor cells in the human corneal epithelium (i.e., self-renewing squamous cells) has long been suggested, but these cells have not yet been isolated. Here we describe a novel isolation technique using non-tissue culture dishes to enrich progenitor cells, which are able to reconstitute a three-dimensional human corneal epithelial equivalent from single cells in serum-, feeder-, and bovine pituitary extract-free medium. These cells showed original tissue-committed differentiation, a high proliferative capacity, and limited self-renewal. Laminin-5 was measured by mass spectrometric analysis. Pretreatment of cells with anti-laminin-5 antibody demonstrated that laminin-5 was important in allowing corneal epithelial progenitor cells to adhere to non-tissue culture dishes. Hydrophilic tubes (used for cell collection throughout this study) are essential for efficient isolation of adherent corneal epithelial progenitor cells expressing laminin-5. These findings indicate that our new technique using non-tissue culture dishes allows the isolation of progenitor cells from human corneal limbal epithelium and that laminin-5 has a critical role in the adhesion of these cells.

Human corneal epithelial equivalents for ocular surface reconstruction in a complete serum-free culture system without unknown factors.

PURPOSE: To establish a culture technique for human corneal epithelial equivalents that do not require fetal bovine serum (FBS), feeder cells, or bovine pituitary extracts and compare this system with conventional culture medium with FBS and mouse 3T3 fibroblasts. METHODS: Human corneal limbal tissue from donor corneas was dissociated on denuded amniotic membranes and then cultured for 3 weeks in feeder-cell- and serum-free medium containing epidermal growth factor and B-27. Then, the cell sheet was evaluated by light microscopy, immunohistochemistry, and electron microscopy. The epithelial proliferative capacity was compared between serum- and feeder-cell-free medium and conventional medium. The cultured cell sheets were transplanted onto the denuded rabbit ocular surface to cover the resected area. RESULTS: A stratified cell sheet expressing cytokeratin-3 and -12 was grown in serum- and feeder-cell-free medium without unknown growth factors. The epithelial proliferative capacity in feeder-cell- and serum-free medium determined by WST-1 and colony-forming efficiency was significantly higher than that in conventional medium. Scanning and transmission electron microscopy showed well-formed stratified epithelium with clear cell boundaries, microvilli, and hemidesmosomal/desmosomal junctions. The transplanted cell sheets remained transparent without epithelial defects during the follow-up period. CONCLUSIONS: This method using serum- and feeder-cell-free medium not containing unknown growth factors allows the highly proliferative culture of human corneal epithelium. It avoids exposure of the corneal epithelial equivalent to FBS and animal feeder cells, thus minimizing the risk of contamination by pathogens that could transmit diseases to recipients.

Transplantation of a sheet of human corneal endothelial cell in a rabbit model.

PURPOSE: To develop a novel method for constructing a sheet of human corneal endothelial cells (HCECs) and examine the properties of the HCEC sheet. METHODS: HCECs were cultured on a cell culture insert for a week; ethylenediamine tetraacetic acid was applied from the bottom of the cell culture insert to attenuate the attachment of HCECs. The sheet of HCECs was constructed by bluntly detaching the cell sheet with a spatula. HCEC cell sheets were placed on the posterior surface of excised rabbit corneal buttons and transplanted onto the corneal beds of donor rabbits. In two eyes from the HCEC sheet group, cultured HCECs were labeled with PKH26 to observe the localization of HCECs after transplantation. RESULTS: Cultured HCECs could be bluntly detached en bloc from the bottom of a culture insert. Immunostaining for ZO-1, Na+, K+-ATPase, laminin, fibronectin, and type IV collagen was positive in the cell sheet. The average cell density in a HCEC sheet was 2,425 cells/mm(2). After HCEC sheet transplantation, corneal edema decreased much earlier in the HCEC group than in the control group. In the HCEC sheet group, the monolayer of continuous cells attached to the posterior surface of the transplanted rabbit cornea and the posterior surface of transplanted cornea was covered with PKH26-labeled cells. The average endothelial cell density in the HCEC sheet group seven days postoperatively was 2,244 cells/mm(2). CONCLUSIONS: This technique for producing an HCEC sheet might be useful in regenerative medicine for the cornea and reconstruction of the corneal endothelium.

Isolation and distribution of rabbit keratocyte precursors.

PURPOSE: To isolate multipotent precursors from the rabbit corneal stroma and to compare the distribution and proliferative capacity of keratocyte precursors obtained from the central and peripheral regions of the corneal stroma. METHODS: The rabbit corneal stroma was divided into a peripheral region (6.0-10.0 mm in diameter) and a central region (6.0 mm in diameter). A sphere-forming assay was then performed to isolate precursors from the stroma of each region. To promote differentiation, isolated sphere colonies were plated in wells with a medium containing fetal bovine serum. Expression of various markers by the sphere colonies and their progeny was examined using immunocytochemistry and/or reverse-transcription polymerase chain reaction (RT-PCR). RESULTS: The rate of primary sphere formation by cells from the peripheral stroma (51.4+/-10.1/10,000 cells) was significantly higher than by cells from the central stroma (35.9+/-3.0/10,000 cells; p=0.00021). Secondary sphere formation rate was significantly higher in the peripheral stroma (45.6+/-6.4/10,000 cells) than in the central stroma (33.4+/-2.1/10,000 cells; p=0.00002). Cells from the spheres were positive for CD34 and nestin. Their progeny showed a keratocyte-like spindle shape and expressed vimentin, alpha-smooth muscle actin, and two neural differentiation markers (microtubule-associated protein-2 and neuron-specific enolase). Expression of nestin and vimentin was confirmed by RT-PCR. CONCLUSIONS: Our findings demonstrate that both the peripheral and central regions of the corneal stroma contain a significant number of precursors, but the peripheral stroma has more precursors with a stronger proliferative capacity than that of cells from the central stroma.

Decellularizing corneal stroma using N2 gas.

PURPOSE: To examine the efficacy of a novel method of decellularizing porcine corneal stroma using N(2) gas from liquid N(2) and the feasibility of using decellularized porcine corneal stroma in a corneal transplantation model in rabbits. METHODS: Porcine corneas were placed in a tube, and N(2) gas from liquid N(2) was poured into the tube to freeze the corneas and make the inside of the tube hypoxic. After fastening the cap firmly, the tube was kept at room temperature for seven days, and the porcine corneas were examined histologically. A porcine corneal stromal disk treated with the aforementioned method was inserted into a pocket of rabbit corneal stroma and observed for six months. RESULTS: Hoechst 33342 and hematoxylin and eosin staining both showed few cellular nuclei in the porcine corneal stroma incubated in N(2) gas for one week. A terminal deoxynucleotidyl transferase-mediated dUTP nick end-labeling (TUNEL) assay showed many positively stained nuclei in the porcine corneal stroma incubated in N(2) gas for three days. The porcine corneal stroma that was decellularized and transplanted into a rabbit corneal stromal pocket remained clear for six months after transplantation. CONCLUSIONS: This method using N(2) gas decellularizes corneal stroma without reducing corneal transparency.

Tissue engineering of corneal stroma with rabbit fibroblast precursors and gelatin hydrogels.

PURPOSE: To isolate fibroblast precursors from rabbit corneal stroma using a sphere-forming assay, to engineer corneal stroma with the precursors and gelatin, and to establish the therapeutic application of precursors in a rabbit corneal stroma. METHODS: In the in vitro study, a sphere-forming assay was performed to produce precursors from rabbit corneal stroma. Corneal stroma was engineered by cultivating precursors in porous gelatin for one week. In the in vivo study, the engineered corneal stromal sheet with precursors (precursor/gelatin group) or with fibroblasts (fibroblast /gelatin group) or without cells (gelatin group) was transplanted to a pocket of rabbit corneal stroma. Gene expression and extracellular matrix production were examined immunohistochemically in each group one week and four weeks after surgery. RESULTS: In the in vitro study, cells in the spheres were BrdU-positive, and their progeny were keratocan-positive. The study also showed that the corneas transplanted with a porous gelatin sheet did not show any opacity four weeks after transplantation in any group. In the gelatin sheet of the precursor/gelatin group, a more intense expression of type I collagen was observed relative to the other two groups four weeks after the surgery. CONCLUSIONS: Our findings demonstrate that the transplantation of fibroblast precursors combined with gelatin hydrogel into the corneal stroma is a possible treatment strategy for corneal stromal regeneration.

Ocular Surface Reconstruction with the Autologous Conjunctival Epithelium and Establishment of a Feeder-Free and Serum-Free Culture System.

Transplantation of the autologous cultured corneal limbal epithelium and oral mucosal epithelium is a standard technique for ocular surface reconstruction under corneal limbal stem cell deficiency. As an option for bilateral cases, we recommend utilization of autologous conjunctivae for ocular surface reconstruction. Autologous conjunctival epithelium sheet transplantation was effective for bilateral corneal limbal stem cell deficiency without symblepharon or severe keratinization. Moreover, we established a feeder-free and serum-free culture system of the limbal epithelium. This system can be applied for culturing conjunctival epithelia. Autologous cultured conjunctival epithelium transplantation is a practical option for treating bilateral corneal limbal stem cell deficiency.

High Permeability and Intercellular Space Widening With Brimonidine Tartrate Eye Drops in Cultured Stratified Human Corneal Epithelial Sheets.

PURPOSE: To investigate the toxicity of topical glaucoma medications using cultured stratified human corneal epithelial sheets (HCES). METHODS: HCES were exposed for 30 minutes to the following glaucoma medications: 0.1% brimonidine with sodium chlorite as the preservative, 0.005% latanoprost with 0.02% benzalkonium chloride (BAC) as the preservative, and 0.5% timolol with 0.005% BAC as the preservative. Then, cell viability and barrier function were tested by the WST-1 assay and carboxyfluorescein permeability assay, respectively. After exposure to glaucoma medications, HCES were evaluated by hematoxylin and eosin staining, periodic acid-Schiff staining, scanning electron microscopy, and transmission electron microscopy. RESULTS: HCES exposed to brimonidine showed higher viability and better preservation of cell morphology and microvilli compared with cell sheets exposed to latanoprost or timolol. The carboxyfluorescein permeability assay demonstrated that the barrier function was preserved after HCES were exposed to timolol, but not after exposure to brimonidine or latanoprost. Transmission electron microscopy revealed widening of intercellular junctions with prominent deposits of glycogen or mucopolysaccharide (periodic acid-Schiff positive) after exposure of HCES to brimonidine. CONCLUSIONS: The toxicity of 0.1% brimonidine containing sodium chlorite for HCES was lower than that of ophthalmic preparations containing BAC. Reduction of the barrier function occurred after HCES were exposed to brimonidine because of widening of intercellular junctions.

Characterization of bone marrow derived cells in the substantia propria of the human conjunctiva.

PURPOSE: To characterize the main population of bone marrow-derived cells (BMCs) in human normal subconjunctiva and make a comparison with BMCs in the corneal stroma and epithelium. METHODS: Normal human donor corneas with attached conjunctiva were examined by fluorescence microscopy after single and double staining for multiple markers. CD68(+) cells were separated from the conjunctival tissues by using magnetic beads, and the expression of toll-like receptor (TLR) 2 and TLR4 was examined. Surface markers of CD68(+) cells were compared with those of BMCs from the corneal stroma and epithelium. RESULTS: CD45(+) cells were detected in the substantia propria of the conjunctiva, and approximately 60% of these cells were CD68(+). All the CD68(+) cells expressed HLA-DR and CD14. CD68(+) cells isolated from conjunctival tissues expressed TLR2 and TLR4 on flow cytometry. BMCs in both the corneal stroma and the subconjunctiva expressed scavenger receptor CD163. Macrophage mannose receptor CD206 was expressed by BMCs in the substantia propria of the conjunctiva, but not by BMCs in the corneal stroma or epithelium. CONCLUSIONS: These findings demonstrated that the main population of BMCs in the substantia propria of normal human conjunctiva is CD68(+)CD14(+)HLA-DR(+) cells. These BMCs express scavenger receptor, macrophage mannose receptor, TLR2, and TLR4 and may play a role in adaptive and innate immune responses in the human ocular surface. These cells are phenotypically different from the CD68(-)CD206(-) monocyte- lineage cells found in the corneal stroma and the CD11c(+)CD68(-)CD163(-)CD206(-) dendritic cells residing in the corneal epithelium.

Autologous transplantation of conjunctival epithelial cells cultured on amniotic membrane in a rabbit model.

PURPOSE: To evaluate the feasibility of autologous transplantation in a rabbit model of conjunctival epithelial cells cultured on amniotic membrane for ocular surface reconstruction. METHODS: Limbal stem cell deficiency was induced in the right eyes of 30 rabbits. This was done by performing a lamellar keratectomy of the entire cornea and a complete removal of the limbus and conjunctiva, extending 5 mm outside the limbus. Autologous conjunctival specimens were obtained from the left eyes of ten of those rabbits and cultured for four weeks on denuded amniotic membrane. Cultured epithelium was examined by transmission electron microscopy. Four weeks after lamellar keratectomy, conjunctivalized corneal surfaces were excised and autologous cultured conjunctival epithelial sheets transplanted (Conj-AM group, n=10). The controls were rabbits that underwent corneal surface removal but not transplantation (No Transplantation group, n=10) and those that underwent corneal surface removal but received only amniotic membrane (AM Alone group, n=10). A neovascularization and corneal opacity scoring system was used to evaluate each eye in the two months after surgery. RESULTS: Cultured conjunctival epithelium formed three to four layers on denuded amniotic membrane. Averaged scores of corneal neovascularization and corneal opacity two months after transplantation were significantly low in the Conj-AM group as compared with those in the AM and no transplantation groups. CONCLUSIONS: Transplantation of autologous conjunctival epithelial cells cultured on amniotic membrane should prove an effective strategy for treating total limbal stem cell deficiency.

Distribution of precursors in human corneal stromal cells and endothelial cells.

PURPOSE: We identified original tissue-committed precursors with limited self-renewal capacity from human corneal stromal (HCS) cells and human corneal endothelial (HCE) cells, then tried to determine the distribution and proliferative capacity of the precursors. DESIGN: Experimental study. PARTICIPANTS: Eighteen human corneas from donors 56 to 68 years old. METHODS: Human corneal stromal cells were divided into groups based on distance from the center of the cornea: <6 mm (central), 6 to 8 mm (paracentral), and 8 to 10 mm (peripheral). Human corneal endothelial cells were separated into 2 groups: <7.5 mm (central) and 7.5 to 10 mm (peripheral) from the center. Each group was subjected to the sphere-forming assay using serum-free medium containing growth factors in floating culture. Sphere numbers and the proliferative capacity of spheres in adherent culture were compared among the groups. MAIN OUTCOME MEASURES: Density and proliferative capacity of precursors from each area of HCS and HCE cells. RESULTS: Primary spheres were isolated from all groups of HCS and HCE cells. The rate of primary sphere formation from peripheral HCS cells was higher than those of the other 2 groups, being 1.5-fold greater than in the paracentral cornea and 4-fold greater than in the central cornea. The rate of primary sphere formation by peripheral HCE cells was significantly higher than that by central HCE cells, being 4-fold greater than in the central cornea. There were no differences in the proliferative capacity of HCS and HCE cell spheres from the different areas after adherent culture. CONCLUSIONS: All HCS and HCE cells contain a significant number of precursors, but the peripheral cells have a density of precursors higher than that of the central cells. Precursors from each area do not show differences of proliferative capacity. Our findings may in part explain changes after excimer laser treatment and may have implications for corneal transplantation procedures.

Preoperative evaluation of cultured human corneal limbal epithelium on amniotic membrane by confocal microscopy.

PURPOSE: Although sheet transplantation with cultured corneal limbal epithelium has been widely performed as a strategy for ocular surface reconstruction, there has been no optimal method for evaluating the morphology of these sheets prior to transplantation. We propose the use of in vivo confocal microscopy as a novel method for the evaluation of limbal corneal epithelium cultured on amniotic membrane. METHODS: Human limbal epithelial sheets were grown on amniotic membranes by following a standard protocol and were stained with hematoxylin and eosin. Morphology was studied using in vivo confocal microscopy for cultured corneal epithelium on amniotic membrane, human intact amniotic membranes, and epithelium-denuded human amniotic membranes. RESULTS: Histologic examination showed a stratified corneal epithelium sheet by the fourth week of culture. The surface and basal layers of the cultured limbal epithelium and amniotic membrane were clearly distinguished by in vivo confocal microscopy. A monolayer of amniotic epithelial cells was observed on the intact amniotic membrane, but not on the epithelium-denuded human amniotic membrane. CONCLUSIONS: Our findings support the use of in vivo confocal microscopy as a valid technique for the preoperative evaluation of cultured corneal limbal epithelial cell sheets on amniotic membrane.