The main cause for non-healing epithelial defects is a “neurotrophic state” meaning there is reduced ocular sensitivity. Therefore, the first line management should start with punctal occlusion followed by autologous serum (if available) or insertion of a high DK bandage contact lens.
If the epithelial defect has no/minimal stromal loss, amniotic membrane transplantation (AMT) can be performed by either inserting PROKERA™ or suturing a single layer of amniotic membrane (AM) (AMNIOGRAFT® size 2.5 x 2.0 cm or 2.0 x 1.5 cm) to cover both the cornea and the perilimbal conjunctiva (as if a large bandage contact lens). 10-O nylon sutures should be placed in a purse-string running fashion about 3 mm from the limbus with about 6-8 scleral bites. Start the running suture in the inferior quadrant and after tying, the end can be left long - the knot does not need to be buried.
It is also a good idea to make a small sutured temporary tarsorrhaphy to narrow the lid fissure.
If the epithelial defect has notable stromal loss (up to descemetocele), the area with the stromal loss should be filled with one or multiple layers of AM. A piece of AM (AMNIOGRAFT® size 2.5 x 2.0 cm) should be cut into smaller pieces and placed into the defect. The orientation of the layers of AM filling the defect does not matter.
If fibrin glue is used, it is best to lay all layers of AM first in the ulcer crater and then apply one drop of fibrinogen and wait several seconds to allow it to percolate through the tissue before adding several drops of thrombin over it to secure the tissue.
If fibrin glue is not used, the AM can be secured using several interrupted 10-O nylon sutures.
After securing the AM filling the defect, a larger layer of AM with the stromal surface facing down is laid and sutured to the healthy stroma with 10-O nylon in either interrupted or running (either zig-zag or purse string) fashion to make sure the top layer of membrane, which will act as a permanent graft, is in close contact with the corneal surface. The knot does not need to be buried.
Lay the remaining AMNIOGRAFT® down to cover the entire cornea, limbus, and part of conjunctiva as if a bandage CL (orientation does not matter), and suture it in the same manner as described above under “the epithelial defect with no/minimal stromal loss”.
A sutured tarsorrhaphy is beneficial to narrow the lid fissure.
Videos
Corneal Defect Treatment Overview Video: Review of the causes and symptoms of corneal epithelial defects OSREF Persistent Epithelial Defect Treatment Overview
Office treatment of corneal defect Video: Video of debridement of conjunctivalized corneal epithelium and treatment of the defect with PROKERA™ for aid in re-epithelialization OSREF Amniotic Membrane Transplantation for Corneal Epithelial Defect
Papers
Click here to view PubMed.gov's list of published papers on the use of Amniotic Membrane for Neurotophic Keratopathy. (To receive an updated list of papers availale, click the "Go" button next to the search box at the top of the page.)
Click here to view PubMed.gov's list of published papers on the use of Amniotic Membrane for Corneal Ulcers. (To receive an updated list of papers availale, click the "Go" button next to the search box at the top of the page.)
Click here to view PubMed.gov's list of published papers on the Amniotic Membrane's Antibiotic properties. (To receive an updated list of papers availale, click the "Go" button next to the search box at the top of the page.)
Click here to view standard surgical supplies used for AMT.
Click here to view standard Post-operative care for AMT
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