latter will be removed on the day following the operation. There is a risk of atrophic rhinitis. The sample of nasal mucosa is from 4 to 15 cm2 big and about 1–2 mm thick. The nasal mucosa is sutured to the sclera and to the tarsal conjunctiva by separated stitches of resorbable thread. A silicone strip may be used to maintain and stick the graft to the conjunctival sacs, for about 1 month. A 1-week local therapy by antibiotics is prescribed and a local therapy by corticoids for several weeks. The advantage of the transplant of nasal mucosa is the opportunity to sample big size grafts and the transplantation of intra-epithelial mucus cells. It thus enables the restoration of the mucous constituent of the lacrymal film.

Kuckelkorn does not advise the practice of this intervention during the critical phase of the burn but prefers the Tenon’s plastics [12].

8.1.6  The Transplantation of Limbus

Proposed by Schermer and developed by Tseng, the theory of the limbal stem cells (LSC) is the basis of the transplant of limbus [13, 14]. The corneal epithelium quickly regenerates, from undifferentiated LSC located in the basement layers of the limbus. LSC divide and generate some differentiated epithelial cells: the amplifying transitional cells, which migrate toward the center of the cornea in order to form a basement foundation with intense mitotic activity in this location. During various successive cellular cycles, the amplifying transitional cells progressively acquire the phenotypic characteristics of the corneal epithelial cells. These then vertically migrate with a decreasing mitotic activity, and mute into hyperdifferentiated cells at the surface of the cornea. Then, they disappear and therefore desquamate the lacrymal film.

The syndrome of LSC deficiency is characterized by the invasion of the corneal surface by a conjunctival type of epithelium. In this epithelium, the presence of calciform cells is phatognomic of the syndrome of LSC deficiency. The latter is highlighted by a late and bad quality reepithelialization and a superficial and stromal “neovascularization.” The grading of ocular burns such as proposed by Dua and Wagoner are based on the importance of the LSC deficit [15, 16].

8.1.6.1  Exeresis of the Conjunctival Pannus

This technique has been introduced by Dua and others [17]. It consists in the exeresis of the conjunctival pannus that is invading the cornea and also enables the development of the corneal epithelium and its migration toward the damaged corneal surface. It is practiced when the conjunctival proliferation covers the cornea by more than 2 mm. The mechanical debridement by scraping is processed from the center toward the edge until 5–7 mm at the back of the limbus. In a series of 14 patients studied for about 8 months, there has been a covering surface by the corneal epithelium. Longer-term results have not been mentioned. This method is an interesting option in comparison with the limbal transplantation when the damage alters a small zone or when the transplantation cannot be operated.

8.1.6.2  The Limbus Autograft

The limbus autograft is the first class technique for the treatment of a destruction of the corneal limbus and the so generated complications [18]. This conjunctival and limbal transplantation technique was described by Kenyon and Tseng in 1989 [19]. It treats the unilateral limbal deficiencies when one eye can be used as a contralateral safe donor. All of the conjunctival pannus covering the cornea is taken off beyond the limbus on about 3 mm. The dissection goes from the cornea – as a starting point – toward the conjunctiva [64]. The graft is sampled from an incision into the cornea, made 1 mm before the limbus. The dissection makes a surgical formation of tunnel from about 2 mm at the back of the limbus. In order to prevent the donor eye from a limbal deficiency, the graft must not be longer than 180° [20]. The sample is sutured to the receiving site by some separated stitches of 10/0 nylon thread to the cornea and by some resorbable 8/0 thread to the conjunctiva.

The limbus autograft requires a good quality corneal reepithelialization for 75–100% patients and the constitution of a barrier preventing the neovascular cicatricial phenomena of conjunctival origin [18, 21, 22]. The date of intervention from the date of burn is a subject of argument. Most authors consider that it is better to wait several months for the inflammatory reaction to decrease. However, some authors recommend an earlier intervention, before the development of complications due to the LSC deficit [16, 23].