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Classification of Limbal Stem Cell Deficiency Using Clinical and Confocal Grading

Aravena, Carolina, MD*,†; Bozkurt, Kansu, MD*,‡; Chuephanich, Pichaya, MD*,§; Supiyaphun, Chantaka, MD*,¶; Yu, Fei, PhD*,‖; Deng, Sophie X., MD, PhD*

doi: 10.1097/ICO.0000000000001799
Clinical Science

Purpose: To grade the severity of limbal stem cell deficiency (LSCD) based on the extent of clinical presentation and central corneal basal epithelial cell density (BCD).

Methods: This is a retrospective observational comparative study of 48 eyes of 35 patients with LSCD and 9 eyes of 7 normal subjects (controls). Confocal images of the central cornea were acquired. A clinical scoring system was created based on the extent of limbal and corneal surface involvement. LSCD was graded as mild, moderate, and severe stages based on the clinical scores. The degree of BCD reduction was given a score of 0 to 3.

Results: Compared with BCD in controls, BCD decreased by 23.0%, 40.4%, and 69.5% in the mild, moderate, and severe stages of LSCD classified by the clinical scoring system, respectively. The degree of BCD reduction was positively correlated with larger limbal and corneal surface involvement and when the central visual axis was affected (all P ≤ 0.0005). Mean corrected distance visual acuity logarithm of the minimum angle of resolution was 0.0 ± 0.0 in control eyes, 0.2 ± 0.5 in mild LSCD, 0.6 ± 0.4 in moderate LSCD, and 1.6 ± 1.1 in severe LSCD (P < 0.0001). There was a significant correlation between a higher clinical score and corrected distance visual acuity logarithm of the minimum angle of resolution (rho = 0.82; P < 0.0001) and a greater decrease in BCD (rho = −0.78; P < 0.0001).

Conclusions: A clinical scoring system was developed to assess the extent of clinical presentation of LSCD. A classification system to grade the severity of LSCD can be established by combining the BCD score with the clinical score.

*Cornea Division, Stein Eye Institute, Department of Ophthalmology, University of California, Los Angeles, CA;

Departamento de Oftalmología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile;

University of Health Sciences, Istanbul Umraniye Training and Research Hospital, Istanbul, Turkey;

§Department of Ophthalmology, Phramongkutklao College of Medicine, Bangkok, Thailand;

Department of Ophthalmology, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand; and

Department of Biostatistics, Fielding School of Public Health, University of California, Los Angeles, CA.

Correspondence: Sophie X. Deng, MD, PhD, Stein Eye Institute, 100 Stein Plaza, UCLA, Los Angeles, CA 90095 (e-mail:

Supported by the California Institute for Regenerative Medicine (CLIN1-08686) and in part by an unrestricted grant from Research to Prevent Blindness. S. X. Deng received grant support from the National Eye Institute (5P30EY000331 and 1R01EY021797). The funding organizations had no role in the design or conduct of this research.

S. X. Deng is a consultant for Chiesi Farmaceutici S.p.A. The remaining authors have no conflicts of interest to disclose.

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Received July 05, 2018

Accepted September 12, 2018

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