Burman and Sangwan 10–0 monoﬁlament nylon sutures and the AM with cultivated limbal epithelium is placed on the entire de-epithelized surface. Alternatively, a deep anterior lamellar keratoplasty may be performed to provide a smooth interface. Penetrating keratoplasty (PK) after limbal stem cell transplantation (LSCT) A penetrating keratoplasty is usually planned 3 months post operatively once the ocular surface has stabilised for visual loss related to corneal scarring in the visual axis. The recipient cornea is trephined in the centre with a disposable trephine and a donor tissue 0.5 mm larger is anchored to the recipient bed with interrupted 10–0 monoﬁlament sutures. A lensectomy, vitrectomy, synechiolysis, and/or intraocular lens implantation may be carried out if deemed necessary. In the immediate post-operative period, it is imperative to watch for signs of epithelial breakdown and allograft rejec- tion. It is worthwhile to perform a primary tarsorrhaphy in such cases. Eleven of the 19 corneal grafts were successful with a mean follow up of 17.4 months. It is important to note that all these grafts met the criterion for of high risk for corneal graft rejection and none of them were on systemic immunosup- pression. The authors attribute these results to a multistaged approach wherein the PK is performed three months post CLSCT as it not only ensures a stable ocular surface but also decreases the risk of corneal graft rejection by controlling inﬂammation. A second hypothesis is decreased sensitization by decreasing antigen presentation as the cultivated epithe- lium is devoid of dendritic cells. The early outcome of PK following cultivated limbal epithelial transplantation is very promising with 87% of grafts remaining clear at mean fol- low up of 8.3 months post PK and 25% developing corneal allograft rejection (Sangwan et al 2005). Outcome of cultivated LSCT Pelligrini and colleagues (1997) were the ﬁrst to show that cultured limbal cells generated cohesive sheets of authentic corneal epithelium, and the autologous cultured corneal epithelium restored the corneal surface of two patients with complete loss of the corneal-limbal epithelium. Long-term follow-up at more than 2 years showed the stability of re- generated corneal epithelium and the striking improvement in patient’s comfort and visual acuity. Schwab and colleagues (2000) reported a successful outcome, deﬁned as restoration or improvement of vision, 498 along with maintenance of corneal re-epithelialization and absence or recurrence of surface disease, obtained in 6 of the 10 patients with autologous procedures and in all 4 of the allogenic procedures (Tsai et al 2000). Follow up ranged 16–19 months with a mean of 13 months. They concluded that both amniotic membrane and corneal epithelial stem cells present within the bio-engineered graft were necessary for successful repair. Tsai and colleagues (2000) documented complete reepithelialization of the corneal surface occurred within two to four days of transplantation in all six eyes receiving transplants. By one month, the ocular surface was covered with corneal epithelium, and the clarity of the cornea was improved. In ﬁve of the six eyes receiving transplants (83%), the mean visual acuity improved from 20/112 to 20/45. In one patient with a chemical burn who had total opaciﬁca- tion of the cornea, the acuity improved from the ability to count ﬁngers at 40 cm to 20/200. No patient had recurrent neovascularization or inﬂammation in the transplanted area during the follow-up period. Thirteen eyes of 11 patients were studied by Koizumi and colleagues (2001a). These consisted of ﬁve eyes with acute SJS, two with chronic SJS, one with an acute chemi- cal injury, two with chronic chemical injuries, two with ocular cicatricial pemphigoid, and one with drug-induced pseudopemphigoid. All of these eyes had total stem cell deﬁciencies. Corneal limbal epithelium from donor corneas was cultivated for 4 weeks on a denuded AM carrier, with 3T3 ﬁbroblast coculture and air lifting. The cultivated corneal epithelium showed four to ﬁve layers of stratiﬁca- tion and was well differentiated. After conjunctival tissue removal from the cornea up to 3 mm outside the limbus and subconjunctival tissue treatment with 0.04% mitomycin C, cultivated allocorneal epithelium, including the AM carrier, was transplanted onto the corneal surface up to the limbus. Lamellar keratoplasty, using preserved donor graft without epithelium, was performed simultaneously for ﬁve chronic-phase patients showing corneal stromal scarring. Systemic immunosuppression was used to pre- vent allograft rejection. In all 13 eyes, the entire corneal surface, on which cultivated allocorneal epithelium had been placed, was free from epithelial defects 48 hours after surgery, indicating complete survival of the transplanted corneal epithelium. Visual acuity improved in all eyes after surgery, and 10 of the 13 eyes were restored to good vision (post-operative visual acuity improved two or more lines) 6 months after the operation. During the follow-up period (mean +/− standard deviation, 11.2 +/− 1.3 months), the Clinical Ophthalmology 2008:2(3)