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Purpose/Aim: Corneal abrasions and nonhealing corneal epithelial defects are common conditions that cause pain and sometimes are slow to heal. Histatins, a family of histidine-rich peptides, have been implicated in oral and skin epithelial wound healing, and have been shown to be effective in vitro in human corneal epithelial cells. The objective of this study was to test the efficacy of histatin-1 on corneal epithelial wound healing in rabbits. MATERIALS & METHODS: Twenty-two (22) rabbits were separated into four treatment groups, each containing 3-7 rabbits. Treatments included three histatin-1 formulations (0.1 ug/ml. 1 ug/ml, and 10 ug/ml) and one inactive vehicle, one drop given three times per day. Eight (8) mm circular wounds were created using 0.5 ml of 20% ethyl alcohol in the right eye of each rabbit. A masked observer photographed each eye twice daily using slit-lamp biomicrophotography. Wound area was analyzed by using ImageJ. Statistical analysis was conducted using Graphpad Prism. RESULTS: Wound recovery was faster in animals given 0.1 ug/ml, 1 ug/ml, and 10 ug/ml when compared to the vehicle solution at 6, 24, and 30 hours after wound creation (p < 0.01). No adverse events were observed in any eyes. When analyzing area under the curve, % recovered area was higher overall in the 0.1 ug/ml (p < 0.01), 1 ug/ml (p < 0.01), and 10 ug/ml (p < 0.001) groups when compared to the vehicle solution. Hourly healing rate was also observed to be faster in the 0.1 ug/ml, 1 ug/ml, and 10 ug/ml groups (p < 0.001) at 24 hours postinjury suggesting an accelerated healing process as compared to the vehicle group. CONCLUSION: This study represents the first in vivo experiment evaluating and confirming the efficacy of topical histatin on the corneal epithelium wound healing. Further studiesare warranted to better understand the mechanism and safety of topical histatin-1 in corneal epithelial wound-healing and its potential role for human disease treatment.

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PURPOSE: To determine the changes in dry eye disease (DED) severity and the percentage of cells expressing HLA-DR on the ocular surface following treatment with lubricant eyedrops containing polyethylene glycol and propylene glycol (PEG/PG) and the gelling agent hydroxypropyl guar (HP-Guar). PATIENTS AND METHODS: Nineteen patients with DED used PEG/PG + HP-Guar eyedrops four times per day for 30 days. Assessments included DED severity (Ocular Surface Disease Index [OSDI], corneal staining, conjunctival staining, tear film break-up time [TFBUT], and Schirmer testing) and impression cytology of the conjunctiva with masked flow cytometry at baseline and at 30 days. RESULTS: There was a significant decrease in corneal staining (P<0.01), OSDI (P=0.02), and TFBUT (P<0.01) following treatment with PEG/PG + HP-Guar. Results from flow cytometry revealed a significant decrease in cells expressing HLA-DR (P=0.02). CONCLUSION: Treatment with PEG/PG + HP-Guar eyedrops showed improvement in dry eye severity and reduction in surface inflammation as indicated by a reduction in HLA-DR expression.

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PURPOSE: To provide standard operating procedures (SOPs) for measuring tear inflammatory cytokine concentrations and to validate the resulting profile as a minimally invasive objective metric and biomarker of ocular surface inflammation for use in multicenter clinical trials on dry eye disease (DED). METHODS: Standard operating procedures were established and then validated with cytokine standards, quality controls, and masked tear samples collected from local and distant clinical sites. The concentrations of the inflammatory cytokines in tears were quantified using a high-sensitivity human cytokine multiplex kit. RESULTS: A panel of inflammatory cytokines was initially investigated, from which four key inflammatory cytokines (IL-1ß, IL-6, INF-γ, and TNF-α) were chosen. Results with cytokine standards statistically satisfied the manufacturer's quality control criteria. Results with pooled tear samples were highly reproducible and reliable with tear volumes ranging from 4 to 10 µL. Incorporation of the SOPs into clinical trials was subsequently validated. Tear samples were collected at a distant clinical site, stored, and shipped to our Biomarker Laboratory, where a masked analysis of the four tear cytokines was successfully performed. Tear samples were also collected from a feasibility study on DED. Inflammatory cytokine concentrations were decreased in tears of subjects who received anti-inflammatory treatment. CONCLUSIONS: Standard operating procedures for human tear cytokine assessment suitable for multicenter clinical trials were established. Tear cytokine profiling using these SOPs may provide objective metrics useful for diagnosing, classifying, and analyzing treatment efficacy in inflammatory conditions of the ocular surface, which may further elucidate the mechanisms involved in the pathogenesis of ocular surface disease.

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There are currently no validated minimally invasive objective metrics for the classification and evaluation of ocular surface diseases and/or for evaluating treatment efficacy. We thus sought to establish a standardized methodology for determining the relative amount of the inflammatory biomarker HLA-DR on the ocular surface and to evaluate the precision, reliability and repeatability of its use for large multicenter clinical trials and translational research studies of ocular surface disease. Multiple studies were conducted to establish a Standard Operating Procedure (SOP) for utilizing HLA-DR expression as a minimally invasive, objective, ocular surface inflammatory biomarker. The established SOPs provide specific guidelines for HLA-DR collection and analysis, in order to incorporate it reliably into multicenter clinical trials and/or translational research. Duplicate cell samples from impression cytology (IC) samples of both normal and dry eye individuals were collected and split to assess repeatability (between the splits and between the duplicate samples). To determine storage capability, one duplicate was stained immediately and the other after 30 days cold storage. To demonstrate the feasibility of the use of the SOP for a multicenter clinical trial, clinicians out-of-state were trained to collect IC samples, and the samples shipped to our Biomarker Laboratory, logged, processed and analyzed. Demonstration of the ability to incorporate of IC into a randomized double masked clinical trial of dry eye disease (DED) was performed. In all cases, processing and analyses were performed by a masked independent observer. The validity/viability of the SOPs was established by demonstrating that: 1) sufficient numbers of cells can be collected via IC; 2) the precision/repeatability of the relative biomarker expression quantified in samples; 3) personnel at distant sites can be taught to collect, store and ship samples successfully; 4) samples can be stored for up to 30 days (refrigeration) before processing without affecting results; 5) IC can be incorporated into a double blind randomized clinical trial (RCT) of DED; and 6) the Biomarker Laboratory can track a large number of masked samples reliably. In conclusion, our standard operating procedure for impression cytology analysis of HLA-DR expression appears to be repeatable and reproducible for use in multicenter clinical trials, providing a minimally invasive objective biomarker of inflammation of the ocular surface.

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PURPOSE: To compare and contrast the distribution patterns of select secretory group two phospholipase A (sPLA2) isoforms in corneal epithelia (CN), conjunctival epithelia (CNJ), and lacrimal glands (LG) of BALB/c and C57BL/6 mice. METHODS: Gene expression of select sPLA2 isoforms was quantified via real-time reverse-transcription PCR (qRT(2)-PCR). Immunofluorescence assay (IFA) of the sPLA2-IIa, -V, and -X isoforms were used to confirm qRT(2)-PCR results. sPLA2-IIa function was confirmed via in vitro CN and CNJ culturing. RESULTS: qRT(2)-PCR revealed that sPLA2 isoforms (pla2g5, 12a, and 12b), cPLA2 isoform (pla2g4a), iPLA2 isoform (pla2g6), and PLA2-receptor (pla2r1) were present in all tissues of both strains, whereas sPLA2 isoforms (pla2g1b, 2e, and 3) were absent. sPLA2 isoforms (pla2g2a, 2d, 2f, and 10) showed tissue- and strain-specific expression: 2a in BALB/c CNJ only; 2d at higher levels in CNJ than LG; and 2f and 10 in CN and CNJ, but absent in LG. Upon dry eye (DE) induction, pla2g2a, 2d, and 2f were upregulated in BALB/c CNJ, and 10 was absent from CN. Furthermore, BALB/c DE mice showed upregulation of pla2r1 in CN and CNJ and downregulation of 12a and 12b in LG. IFA of sPLA2-IIa, -V, and -X in DE CNJ confirmed the upregulation of pla2g2a, 5, and 10. Last, in vitro CN and CNJ culturing confirmed that sPLA2-IIa amplifies ocular surface inflammation in CNJ but not in CN. CONCLUSIONS: sPLA2 isoforms exhibit differential expression patterns when comparing BALB/c with C57BL/6 mice; and DE with control BALB/c mice. These findings suggest that at least some sPLA2 isoforms must have significant roles in ocular surface physiology and inflammation.

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PURPOSE: sPLA2-IIa is a biomarker for many inflammatory diseases in humans and is found at high levels in human tears. However, its role in ocular surface inflammation remains unclear. An experimentally induced BALB/c mouse dry eye (DE) model was used to elucidate the role of sPLA2-IIa in ocular surface inflammation. METHODS: BALB/c mice were subcutaneously injected with scopolamine and placed in a daytime air-drying device for 5 to 10 days. Control mice received no treatment. DE status was evaluated with tear production with a phenol-red thread method. Tear inflammatory cytokines were quantified by multiplex immunoassays. Ocular surface inflammation and sPLA2-IIa expression were examined by immune-staining and quantitative (q)RT(2)-PCR. Conjunctiva (CNJ) of the mice was cultured for prostaglandin E2 production induced by sPLA2-IIa with various amount of sPLA2-IIa inhibitor, S-3319. RESULTS: Treated mice produced fewer tears and heavier corneal (CN) fluorescein staining than the untreated controls (P < 0.001). They also revealed lower goblet cell density (P < 0.001) with greater inflammatory cell infiltration within the conjunctiva, and higher concentration of tear inflammatory cytokines than the controls. Moreover, treated mice showed heavier sPLA2-IIa immune staining than the controls in the CNJ epithelium, but not in the CN epithelium or the lacrimal gland. Treated mice exhibited upregulated sPLA2-IIa and cytokine gene transcription. Furthermore, CNJ cultures treated with sPLA2-IIa inhibitor showed significantly reduced sPLA2-IIa-induced inflammation. CONCLUSIONS: This is the first report regarding sPLA2-IIa in the regulation of ocular surface inflammation. The findings may therefore lead to new therapeutic strategies for ocular surface inflammation, such as DE disease.

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PURPOSE: Most eye drops contain preservatives; benzalkonium chloride (BAK) is most common. Recent data demonstrated BAK adding to toxicity. BAK is degraded into hydrogen peroxide (H(2)O(2)), which in even small amounts is known to be an irritant. Increased toxicity should cause localized inflammation with increased elaboration of inflammatory biomarkers. To evaluate the inflammation BAK causes to the ocular surface, enzyme linked immunosorbant assays (ELISAs) were utilized to quantify the levels of inflammatory biomarkers in response to BAK and/or H(2)O(2). METHODS: Immortalized human conjunctival and corneal epithelial cells were exposed to: BAK (0.001%-0.1%), hydrogen peroxide (H(2)O(2)) (0.01%-0.1%), and cell media for 1 h. Cytokine quantification was performed via enzyme-linked immunosorbent assays [ELISAs]). Additional experimentation was performed in which testing solutions were replaced with media after 1 h and the resulting supernatants quantified after 24 h. RESULTS: BAK induced significant amounts of interleukin (IL-) 1 and tumor necrosis factor (TNF), but only moderate amounts of C-reactive protein (CRP), IL- 10 and 12, and H(2)O(2). Lower concentrations of BAK induced proportionally less elaboration. Replacing the test solutions with media and providing 23 h for cytokine elaboration significantly increased TNF, but not IL-1. Lipopolysaccharide (LPS) positive controls induced substantial elaboration/release of both IL-1 and TNF as did in increasing the exposure to the full 24 h. CONCLUSIONS: After 1 h of exposure, BAK increased quantities of all biomarkers. The biomarkers in decreasing order of induction/upregulation were: TNF > or = IL-1 > or = IL-12 > or = IL-10 > or = CRP. Even low concentrations caused some degree of inflammation. Replacing the testing solution with media and providing 23 h for cytokine elaboration, significantly increased the elaboration/release of TNF, but not IL-1, as compared to the 1-h BAK exposure. Whereas increasing the exposure to the full 24 h by not removing the testing solution at the 1-h time point significantly increased the elaboration/release of both IL-1 and TNF.

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PURPOSE: Nearly all eye drops contain preservatives to decrease contamination. Nonpreservatives such as disodium-ethylene diamine tetra-acetate (EDTA) and phosphate-buffered saline are also regularly added as buffering agents. These components can add to the toxicity of eye drops and cause ocular surface disease. To evaluate the potential toxicity of these common components and their comparative effects on the ocular surface, a tissue culture model utilizing immortalized corneal and conjunctival epithelial cells was utilized. METHODS: Immortalized human conjunctival and corneal epithelial cells were grown. At confluency, medium was replaced with 100 microL of varying concentrations of preservatives: benzalkonium chloride (BAK), methyl paraben (MP), sodium perborate (SP), chlorobutanol (Cbl), and stabilized thimerosal (Thi); varying concentrations of buffer: EDTA; media (viable control); and formalin (dead control). After 1 h, solutions were replaced with 150 microL of MTT (3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyl tetrazonium bromide). After 4 h, solutions decanted, 100 microL of acid isopropanol added, and the optical density determined at 572 nm to evaluate cell viability. RESULTS: Conjunctival and corneal cell toxicity was seen with all preservatives. Depending upon concentration, BAK exhibited from 56% to 89% toxicity. In comparison, Cbl exhibited from 50% to 86%, MP from 30% to 76%, SP from 23% to 59%, and Thi from 70% to 95%. EDTA with minimal toxicity (from 6% to 59%) was indistinguishable from SP. CONCLUSIONS: Generally, the order of decreasing toxicity at the most commonly used concentrations: Thi (0.0025%) > BAK (0.025%) > Cbl (0.25%) > MP (0.01%) > SP (0.0025%) approximately EDTA (0.01%). Even at low concentration, these agents will cause some degree of ocular tissue damage.

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sPLA2-IIa is an enzyme at high concentration in tears that has been known as an innate barrier of the ocular surface against microbial infection. sPLA2-IIa and other enzymes in the same protein family are known to hydrolyze fatty acids resulting in the generation of free arachidonic acid (AA) and lysophospholipids, which are the precursors of pro-inflammatory lipid mediators, such as PGE(2). sPLA2-IIa has been shown to be an inflammatory mediator in non-ocular inflammatory diseases such as rheumatoid arthritis (RA). It was also found to be increased in the tears of the patients with dry eye disease, chronic blepharitis and contact lens intolerance. However, the role of sPLA2-IIa in chronic ocular surface inflammation has yet to be determined. In the current study, we examined the potential role of sPLA2-IIa in inflammation of ocular surface diseases. Our results show that the activity of sPLA2-IIa was significantly increased in tears from dry eye disease patients compared with that from normal subjects. Also, sPLA2-IIa stimulated the production of PGE(2) in ocular surface epithelial cell cultures. The stimulating effect was markedly enhanced when the cells or tissues were pre-compromised with TNF-alpha, IL-1beta or desiccation. Furthermore, sPLA2-IIa stimulated inflammatory cytokine production in the ocular surface epithelial cell cultures in vitro. To our knowledge, this is the first report regarding the role of sPLA2-IIa as an inflammatory mediator in ocular surface inflammation. These findings indicate that sPLA2-IIa may play an important role in chronic ocular surface inflammation, especially when the ocular surface is compromised.

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PURPOSE: To evaluate the toxicity of a variety of the fluoroquinolone antibiotics on the ocular surface by using tissue culture models of corneal epithelial cells and conjunctival epithelial cells. METHODS: Immortalized conjunctival (CCC) and human corneal (HCE) epithelial cells were grown and when confluent the cells allowed to air dry for 1 hour. Medium was then replaced with 100 microL of one of the following: 1) Vigamox [moxifloxacin (0.5%: MX)]; (2) Zymar [gatifloxacin (0.3%: GA)]; 3) Quixin [levofloxacin (0.5%: LE)]; 4) Ocuflox [ofloxacin (0.3%: OF)]; 5) Ciloxan [ciprofloxacin (0.3%: CP)]; 6) medium (viable control); 7) "normal"/physiologic saline; 8) formalin (dead control). After one hour, 150 microL of MTT (3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyl tetrazonium bromide was added and incubated for 4 hours. After decanting, precipitate was dissolved in 150 microL of isopropanol. Absorbance was determined at 572 nm. RESULTS: The lowest amount of cell death was associated with the viable control. All ophthalmic preparations showed both corneal and conjunctival cell toxicity. Aside from the viable control, normal saline showed the next lowest amount of toxicity. Of the topical ocular antibiotics tested, MX showed the least amount of toxicity. All of the other antibiotics tested were statistically indistinguishable from each other. CONCLUSIONS: All of the topical ocular antibiotics tested showed evidence of both corneal and conjunctival toxicity (MX < OF < or = LE < or = CP < or = GA), although only MX was statistically significant. Whether this finding reflects on in vivo wound healing remains to be determined. This model provides a rapid and cost-effective method to screen for surface toxicity of topical agents.

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PURPOSE: Herpes simplex virus (HSV)-1 infections of the human cornea range in severity from uncomplicated episodes that readily resolve to severe, recurring disease that invades the stroma, having a devastating permanent effect on vision. Recent published data implicate an apoptotic component to stromal HSV-1 infection. In a prior study, it was found that wild type (wt) HSV-1 infection induces, then blocks, apoptosis in epithelial cells derived from skin and that this block requires infected cell proteins (ICPs) synthesized between 3 and 6 hours post infection (hpi). This inhibition of apoptosis is in part dependent on the activation of inducible nuclear transcription factor kappaB (NF-kappaB). METHODS: HSV-1-dependent apoptosis in rabbit corneal epithelial (SIRC) cells was compared with that in infected human epithelial (HEp-2) cells. RESULTS: SIRC cells were sensitive to apoptotic cell death induced by environmental treatment with tumor necrosis factor (TNF)-alpha plus cycloheximide (CHX). HSV-1 stimulated the degradation of regulatory IkappaBalpha protein, resulting in nuclear translocation of NF-kappaB. This phenomenon was dependent on ICP synthesis. Neither wt nor apoptotic HSV-1 infection resulted in apoptosis in these cells. However, wt HSV-1-infected cells produced detectable levels of cleaved poly(ADP-ribose) (PARP). Inhibition of SIRC cell protein synthesis with CHX during wt HSV-1 infection led to a reduction in the amount of PARP cleavage. Whereas PARP cleavage defined cell death in most other cell types, its processing in SIRC cells was a reproducible characteristic of wt HSV-1 infection. CONCLUSIONS: This is the first report of such an effect, and it suggests that in corneal epithelial cells, activation of apoptotic pathways may be necessary for productive viral replication. Thus, efficient replication of HSV-1 in the corneal milieu proceeds via a different mechanism than it does in skin. However, it appears that NF-kappaB participates in inhibiting apoptosis during HSV-1 infection in both systems.

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PURPOSE: Pseudomonas aeruginosa ocular infections most frequently originate from an environmental source; successful treatment with various ocular antibiotics is well established. However, emergence of resistant clones to available antibiotics poses a real threat to successful treatment. The purpose of this study was to evaluate the antibiotic susceptibilities of 100 random clinical isolates of P. aeruginosa to levofloxacin, moxifloxacin, and gatifloxacin, potential agents for the treatment of ocular infections caused by this microorganism. METHODS: One hundred consecutive strains of P. aeruginosa were isolated from clinical specimens submitted to the clinical microbiology hospital laboratory. Duplicate isolates were not included. The minimum inhibitory concentrations (MICs) of these isolates were determined by using Etests, performed according to the manufacturer's instructions. American Type Culture Collection (ATCC) strains of Escherichia coli, P. aeruginosa, and Staphylococcus aureus served as reference controls. RESULTS: Although most isolates were susceptible to levofloxacin, moxifloxacin, and gatifloxacin and the MICs were not significantly different, significant numbers were resistant. The standardized controls rendered expected MICs. The susceptibility of the isolates varied with regard to source, and resistant strains showed increased resistance. CONCLUSIONS: Based on the data, the treatment of ocular infections caused by P. aeruginosa with levofloxacin, moxifloxacin, and gatifloxacin still has a high likelihood of success. However, six of the isolates collected were resistant to all three of the fluoroquinolones tested. Based on the data, clinicians must be aware that clinical resistance can occur even with the newer fluoroquinolones.

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BACKGROUND: Adenovirus (Ad), associated with significant morbidity, has no topical treatment. A leading CTC compound (CTC-96), a Co(III) chelate, was found to have potent in vitro and in vivo antiviral efficacy against herpes viruses. In this study CTC-96 is being tested for possible anti-Adenovirus activity. METHODS: The biological anti-adenovirus activity of CTC-96 in concentrations from 5 to 250 ug/ml, was evaluated initially by viral inactivation (viral exposure to CTC-96 followed by dilution and inoculation of cells), virucidal (viral exposure to CTC-96 and inoculation of cells without dilution) and antiviral (effect of CTC-96 on previously adsorbed virus) plaque assays on HeLa (human cervical carcinoma), A549 (human lung carcinoma) and SIRC (rabbit corneal) cells. After verifying the antiviral activity, New Zealand White rabbits were infected with Ad-5 into: 1) the anterior cul-de-sac scarifying the conjunctiva (Group "C+"); 2) the anterior cul-de-sac scarifying the conjunctiva and cornea (Group "CC+"); 3) the stroma (Group "CI+"). Controls were sham-infected ("C-", "CC-", "CI-"). Other rabbits, after "CC", were treated for 21 days with: 1) placebo, 9x/day ("-"); 2) CTC-96, 50 ug/ml, 9x/day ("50/9"); CTC-96, 50 ug/ml, 6x/day ("50/6"); CTC-96, 25 ug/ml, 6x/day ("25/6"). All animals were monitored via examination and plaque assays. RESULTS: In vitro viral inactivation, virucidal and antiviral assays all demonstrated CTC-96 to be effective against Adenvirus type 5 (ad-5). The in vivo model of Ad keratoconjunctivitis most similar to human disease and producing highest viral yield was "CC". All eyes (6/6) developed acute conjunctivitis. "CI" yielded more stromal involvement (1/6) and iritis (5/6), but lower clinical scores (area x severity). Infection via "C" was inconsistent (4/6). Fifty (50) ug/ml was effective against Ad-5 at 6x, 9x dosings while 25 ug/ml (6x) was only marginally effective. CONCLUSION: CTC-96 demonstrated virucidal activity against Ad5 in tissue culture with HeLa, A549 and SIRC cell lines. Animal Model Development: 1) "CC" produced conjunctival infection with occasional keratitis similar to human disease; "CI" yielded primarily stromal involvement; 2) "C" consistently produced neither conjunctivitis nor keratitis.CTC Testing: 1) Conjunctivitis in all eyes; 2) Resolution fastest in "50/9" ("50/9". "50/6" > "25/6" > "-"); 3) Efficacy in "50/6" was not statistically different than "50/9"; 4) Conjunctival severity was lower in treatment groups then controls; 5) Little corneal or intra-ocular changes were noted.

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Cataract, opacification of the lens, is one of the commonest causes of loss of useful vision, with an estimated 16 million people worldwide affected. Several risk factors have been identified in addition to increasing age--genetic composition, exposure to ultraviolet light, and diabetes. However, no method to halt the formation of a cataractous lens has been shown to be effective. Nevertheless, advances in surgical removal of cataracts, including small-incision surgery, use of viscoelastics, and the development of intraocular lenses, have made treatment very effective and visual recovery rapid in most cases. Despite these advances, cataract continues to be a leading public-health issue that will grow in importance as the population increases and life expectancy is extended worldwide.

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PURPOSE: Because stem cells exhibit high self-renewal capacity, slow cycling, and high proliferative potential, and one of many markers postulated for epithelial stem cells, p63, is challenged by widespread expression within stem cell-free regions, we examined p63 expression in these stem cell-associated cohorts compared with their controls. METHODS: Rabbit limbocorneal cryosections, cytospun cell-sorted (by fluorescence-activated cell sorter) side population (SP) and low side scatter (LSSC) cells, and limbal epithelial cells over feeders were stained for p63 by indirect immunofluorescence. Clones were fixed and stained daily for 7 days. Image analysis measured p63 intensity, plotting it against colony size. RESULTS: All basal limbal cells were positive for p63, yet only 5% to 7% expressed high p63 intensities, 40% intermediate, and the majority low. Side population cells were less than 1% of total cells. The average intensity of SP staining was three times that of controls. Subpopulations displaying stemlike features exhibited highest p63 expression. Replication rates of isolated cells differed. Day 5 colonies contained 256 (16 hours/cycle) to two (96 hours/cycle) cells. Whereas all cells were positive for p63, intensity in slow-cycling cells was three to four times that in rapidly proliferating congeners. Increased cell doublings did not decrease fluorescence. CONCLUSIONS: Results suggest that p63 concentration is maximal in stem cells and decreases with differentiation. High p63 levels seem to correlate with cells of the SP and LSSC phenotypes, indicating high cell stemness. With identification of stem cells, further studies can elucidate their use in supporting ocular surface health.

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