The ocular surface is a highly specialised environment with complex homeostatic mechanisms. Severe ocular surface disease can cause significant morbidity through recurrent epithelial breakdown, predisposition to infection and blindness. Ocular surface reconstruction (OSR) strategies aim to restore sufficient ocular surface function to permit the maintenance of an intact transparent epithelium. OSR begins by addressing the quality and volume of tears. Next the position and closure of the eyelids are evaluated and addressed. Only once these factors have been addressed can attention be turned to surgical reconstruction of the ocular surface. The algorithms that guide the choice and timing of surgical interventions are becoming more clear. These universally advocate transplantation of limbal epithelial stem cells prior to surgical replacement of stroma with or without endothelium. Results for autologous ex-vivo expanded limbal stem cell transplants in chemical injuries are excellent. Results for allogeneic grafts are no better than older whole limbal transplants such as keratolimbal allografts. Ex-vivo cultured autologous oral mucosal stem cells offer an alternative in bilateral disease but such grafts are less optically transparent.