Corneal endothelial diseases are the leading cause of corneal transplantation. The global shortage of donor corneas has resulted in the investigation of alternative methods, such as cell therapy and tissue-engineered endothelial keratoplasty (TEEK), using primary cultures of human corneal endothelial cells (hCECs). The main challenge is optimizing the hCEC culture process to increase the endothelial cell density (ECD) and overall yield while preventing endothelial–mesenchymal transition (EndMT). Fetal bovine serum (FBS) is necessary for hCEC expansion but contains TGF-βs, which have been shown to be detrimental to hCECs. Therefore, we investigated various TGF-β signaling pathways using inhibitors to improve hCEC culture. Initially, we confirmed that TGF-β1, 2, and 3 induced EndMT on confluent hCECs without FBS. Using this TGF-β-induced EndMT model, we validated NCAM as a reliable biomarker to assess EndMT. We then demonstrated that, in a culture medium containing 8% FBS for hCEC expansion, TGF-β1 and 3, but not 2, significantly reduced the ECD and caused EndMT. TGF-β receptor inhibition had an anti-EndMT effect. Inhibition of the ROCK pathway, notably that of the P38 MAPK pathway, increased the ECD, while inhibition of the ERK pathway decreased the ECD. In conclusion, the presence of TGF-β1 and 3 in 8% FBS leads to a reduction in ECD and induces EndMT. The use of SB431542 or LY2109761 may prevent EndMT, while Y27632 or Ripasudil, and SB203580 or SB202190, can increase the ECD.

The bioengineering of corneal endothelial grafts consists of seeding in vitro cultured corneal endothelial cells onto a thin, transparent, biocompatible, and sufficiently robust carrier which can withstand surgical manipulations. This is one of the most realistic alternatives to donor corneas, which are in chronic global shortage. The anterior capsule of the crystalline lens has already been identified as one of the best possible carriers, but its challenging manual preparation has limited its use. In this study, we describe a femtosecond laser cutting process of the anterior capsule of whole lenses in order to obtain capsule discs of 8 mm diameter, similar to conventional endothelial grafts. Circular marks made on the periphery of the disc indicate its orientation. Immersion in water for 3 days is sufficient to completely remove the lens epithelial cells and to enable the seeding of corneal endothelial cells, which remain viable after 27 days of culture. Therefore, this method provides a transparent, decellularized disc ready to form viable tissue engineered endothelial grafts.

The monolayer of approximately 300,000 human corneal endothelial cells (hCECs) on the posterior surface of the cornea is essential to maintain transparency but is non-self-regenerative. Corneal blindness can currently only be treated by corneal transplantation, hindered by a global donor shortage, highlighting the need for developing tissue and/or cell therapy. The mass production of these advanced therapy medicinal products requires obtaining high-yield, high-quality endothelial cell culture characterized by hexagonal shape, low size variability, and high endothelial cell density (ECD). Among the usual critical quality attributes which combine the expression of differentiation markers, ECD and cell morphology parameters, the latter are not optimally measured in vitro by conventional image analysis which poorly recognize adherent cultured cells. We developed a high-performance automated segmentation using Cellpose algorithm and an original analysis method, improving calculation of classical morphological parameters (coefficient of variation of cell area and hexagonality) and introducing new parameters specific to hCECs culture in vitro . Considering the importance of the extracellular matrix in vivo , and the panel of molecules available for coating cell culture plastics, we used these new tools to perform a comprehensive comparison of 13 molecules (laminins and collagens). We demonstrated their ability to discriminate subtle differences between cultures.

Over the past 20 years, endothelial keratoplasty procedures have revolutionized the treatment of corneal endothelial disorders. These conditions have now become the leading indication for corneal transplantation in Western countries and account for half of all donor cornea usage. Despite their undeniable success, the global shortage of donor tissues and major disparities between nations justify the development of alternatives to donor grafts. Cell therapy using injections of suspended endothelial cells has proven effective, and tissue-engineered endothelial keratoplasty (TEEK) comprising a membrane coated with cultured endothelial cells is under development to better mimic the native endothelial graft. Our team utilizes a femtosecond-laser-cut lens capsule disc as a bioengineering scaffold, taking advantage of this novel tissue’s biocompatibility, transparency, curvature, and availability. In the present study, we provide proof of concept, in 12 TEEKs, that it is possible to control the final endothelial cell density (ECD) by varying the seeding density per mm ² . Cell characterization was performed through morphometric analysis of the endothelial mosaic stained with anti-NCAM (a lateral membrane marker used as a differentiation marker), using the CellPose artificial intelligence algorithm specifically trained for in vitro endothelium segmentation. Five criteria related to pleomorphism, polymorphism, and elongation were combined into a single endothelial quality score. The median cell viability at 28 days of culture, assessed by Hoechst 33342 and Calcein-AM staining, reached 98% (range: 83–99%). The median viable ECD (number of live cells per surface unit) in the highest-density group was 3,245 cells/mm ² (range: 2,778–3,753), paving the way for the bioengineering of supra-physiological TEEKs, or super TEEKs. Impact statement: The process of manufacturing tissue-engineered endothelial keratoplasty (TEEK) allows for the control of endothelial cell density (DCE) and, in particular, the creation of super TEEKs, meaning grafts with supra-physiological DCE that are more likely to better withstand the challenges of surgery and have a prolonged lifespan in recipients.