Three-Dimensional Reflectivity Analysis of Corneal Layers Following Cultivated Epithelial Transplantation using Optical Coherence Tomography Short title: Corneal reflectivity analysis following cultivated epithelial transplantation

Abstract Limbal stem cell deficiency (LSCD) is a debilitating condition that impairs corneal transparency and visual function due to damage of the limbal niche. Traditional treatments often fall short in bilateral cases or severe opacity. Cultivated oral mucosal epithelial transplantation (COMET) has recently emerged as a novel regenerative approach to restore the ocular surface in LSCD. Here we show that COMET leads to significant improvements in visual acuity and reduction of corneal surface irregularities. Using anterior segment optical coherence tomography (OCT), we evaluated corneal reflectivity in the epithelial, stromal, and endothelial layers over time. We found early reduction in epithelial opacity, while stromal reflectivity showed a persistent correlation with visual outcomes. Higher-order aberrations also decreased postoperatively and were significantly associated with better vision. These findings demonstrate the clinical potential of COMET to improve both structural and optical quality of the cornea and highlight the value of quantitative OCT imaging in evaluating therapeutic response. This study provides new insight into visual rehabilitation mechanisms in patients with severe LSCD and supports broader application of cultivated epithelial cell therapies in ocular surface reconstruction.