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Limbal Epithelial Cells Detected in Stage III Limbal Stem Cell Deficiency by Multimodal Anterior Segment Imaging
Clemence Bonnet1, Mehrnoosh Maalhaghfard1, Sophie X Deng2
1From the Stein Eye Institute, Department of Ophthalmology, David Geffen School of Medicine (C.B., M.M., S.X.D.), University of California, Los Angeles, California, USA.
Purpose:
Limbal stem cell deficiency (LSCD) is a potentially blinding corneal condition with heterogeneous clinical presentations. Anterior segment imaging, in particular anterior segment optical coherence tomography (AS-OCT) and in vivo confocal microscopy (IVCM) provide objective staging of LSCD. The goal of this study was to evaluate whether the fluorescein staining test is accurate in staging LSCD.
Design:
Diagnostic and staging validity analysis.
Subjects:
Subjects without eye diseases and those diagnosed with LSCD based on clinical exam, AS-OCT, and IVCM.
Methods:
The severity of LSCD was staged clinically according to the global consensus guidelines using fluorescein staining. Multimodal imaging (AS-OCT and IVCM) was performed in the central cornea and four limbal quadrants (superior, inferior, nasal, and temporal). Imaging findings were correlated with clinical stage.
Main Outcomes Measures:
Detection of morphologically limbal epithelial cells in eyes clinically graded as stage III LSCD, and AS-OCT characteristics corresponding to these identified clusters.
Results:
A total of 220 eyes from 156 patients were analyzed. Based on fluorescein staining, 49 eyes (22.3%) were classified as stage I, 93 eyes (42.3%) as stage II, and 75 eyes (34.1%) as stage III LSCD. In all cases of stage III LSCD, AS-OCT confirmed severe central epithelial thinning, and IVCM demonstrated significantly reduced mean basal cell density in the central cornea. Despite this, clusters of limbal epithelial cells with normal morphology were detected by IVCM in 30 eyes (40.0%), appearing in one limbal quadrant in 26 eyes (86.7%) and in two quadrants in 4 eyes (13.3%). Correlation between IVCM and AS-OCT findings at the cluster locations was variable. Absence of hyporeflective epithelial layer was observed in 20 eyes (74.1%) and presence of hyporeflective layer was detected in 7 eyes (25.9%) by AS-OCT.
Conclusions:
Despite being graded as total stage III LSCD by clinical exam using fluorescein staining, a significant proportion of eyes retained morphologically normal limbal epithelial cells. These findings highlight the importance of multimodal anterior segment imaging to achieve LSCD diagnostic accuracy, refine disease staging, and guide future personalized management strategies.
