Failure of simple limbal epithelial transplantation after penetrating keratoplasty: A case report

Limbal stem cell deficiency (LSCD) disrupts corneal epithelial homeostasis, leading to epithelial defects, neovascularization, and corneal opacity. The preferred treatment for severe LSCD is limbal transplantation, with simple limbal epithelial transplantation (SLET) being a minimally invasive and effective approach. This case report presents a 42-year-old male with unilateral LSCD secondary to a chemical burn that progressed to total corneal conjunctivalization. Two years after the injury, auto-SLET was performed, and complete re-epithelialization was achieved within 3 weeks. Despite a stable ocular surface at 4 months, visual acuity remained poor because of corneal stromal opacity, necessitating penetrating keratoplasty (PK). After PK, progressive conjunctivalization and epithelial defects were observed, indicating SLET failure. We hypothesized that the extensive removal of corneal tissue during PK eliminates transplanted stem cells, which is associated with postoperative inflammation and loss of ocular surface homeostasis. This case highlights a possible limitation of SLET in patients requiring subsequent keratoplasty. The findings suggest that extensive corneal tissue removal during PK may compromise previously transplanted stem cells. Further studies with larger patient series are required to confirm this observation and to better define the indications and limitations of SLET in complex ocular surface reconstruction.