Amniotic membrane transplantation in the management of severe ocular surface disease: indications and outcomes.

• Bouchard CS,
• John T.

From the Department of Ophthalmology, Loyola University Medical Center, Maywood, Illinois, USA.

ABSTRACT Since 1995, with the availability of cryopreserved amniotic membrane (AM), the use of AM as a patch or graft for ocular surface reconstruction has become recognized as an important alternative for treatment of persistent epithelial defects and sterile ulceration that are refractory to conventional therapy. A major problem with evaluating the efficacy of AM transplantation is the lack of controlled clinical studies. Moreover, for some diseases there is no accepted "standard" therapy, and the incidence of the disease is too low to allow proper randomization. In this review, we have attempted to assess the indications and outcomes of AM transplantation based on 661 cases reported in the peer-reviewed literature. Successful outcome was defined as the healing of an epithelial defect (corneal or conjunctival) over a specified time period and the lack of induced motility disturbance.

PMID: 17216092 [PubMed - in process]

Microbial keratitis after amniotic membrane transplantation.

• Al-Kharashi S,
• Al-Khawaja A,
• Gonnah el-S,
• Al-Assiri A,
• Al-Motowa S,
• Al-Towerki AE,
• Wagoner MD.

Anterior Segment Division, King Khaled Eye Specialist Hospital, P.O. Box 7191, Riyadh, 11462, Kingdom of Saudi Arabia.

PURPOSE: To determine the incidence of early-onset (<30 days) and late-onset (>30 days) microbial keratitis after treatment of persistent corneal epithelial defects with amniotic membrane transplantation (AMT) utilizing tissue acquired from a commercial laboratory or prepared by the institutional eye bank. METHODS: A retrospective, non-randomized, sequential, comparative study was performed for every patient with a persistent corneal epithelial defect who underwent primary AMT at KKESH between January 1, 2003 and June 30, 2004. RESULTS: A total of 142 AMT procedures were performed for persistent corneal epithelial defects during the study period. There were 72 cases using commercially prepared tissue and 70 cases using locally prepared tissue. The mean patient age was 50.3+/-25.6 years (range, 1-104 years). The mean follow up was 6.3+/-5.0 months (range, 1-21 months). There were no cases of early-onset microbial keratitis in cases in which either commercially acquired tissue or locally prepared tissue was used. CONCLUSION: Amniotic tissue prepared in a commercial laboratory or by properly qualified eye bank personnel may be used for AMT in eyes with persistent corneal epithelial defects with minimal risk of microbial keratitis in the first postoperative month.

PMID: 16957878 [PubMed - indexed for MEDLINE]

Diagnosis and management of Acanthamoeba keratitis.

• Hammersmith KM.

PURPOSE OF REVIEW: This paper reviews the literature generated on Acanthamoeba keratitis since 1998. RECENT FINDINGS: Acanthamoeba infections may be on the rise. Contact lenses are the biggest risk factor for their development. Silicone hydrogel lenses are increasingly prescribed and may be 'more sticky' to Acanthamoeba organisms. Orthokeratology for the treatment of myopia has been associated with many new cases of Acanthamoeba keratitis. Daily disposable contact lenses are the safest form of soft contact lens. Patients continue to be misdiagnosed as having herpetic keratitis. Impression cytology and confocal microscopy are newer diagnostic modalities. Topical polyhexamethylene biguanide, chlorhexidine and propamidine are the mainstay of medical therapy. Amniotic membrane may be used for cases of persistent epithelial defect and to control inflammation. Penetrating keratoplasty in a medically treated eye affords a good chance of positive outcome. SUMMARY: Acanthamoeba keratitis continues to be a difficult infection to diagnose and manage. The frequency of these infections may be on the rise, most commonly associated with frequent replacement soft contact lenses. The best chance for a good outcome is based on early diagnosis, so it is important for ophthalmologists consider it in patients, especially in the contact lens wearer with suspected herpes simplex keratitis.

PMID: 16900022 [PubMed - indexed for MEDLINE]

Combination of serum eye drops with hydrogel bandage contact lenses in the treatment of persistent epithelial defects.

• Schrader S,
• Wedel T,
• Moll R,
• Geerling G.

Department of Ophthalmology, UK-SH Campus Lubeck, Klinik fur Augenheilkunde, Ratzeburger Allee 160, 23538, Lubeck, Germany. mail@stefanschrader.de

BACKGROUND: The treatment of persistent epithelial defects (PED) with autologous serum eye drops is often combined with conventional medication such as artificial tears and topical antibiotics, but until now no report exists on the use of a bandage contact lens (BCL) in combination with autologous serum eye drops in the treatment of PEDs. We report six eyes (five patients) which were all treated with autologous serum eye drops in combination with an FDA group IV hydrogel contact lens. METHODS: Five patients aged 36-88 years, were suffering from six PEDs for 73.5+/-46.9 days due to rheumatoid sterile corneal ulcer (n=1), neurotrophic keratopathy (n=3) or partial limbal stem cell deficiency (n=1). All patients had been unsuccessfully treated with conventional therapy before. Three of them had already had an amniotic membrane transplantation and two had undergone a keratoplasty; however, the epithelial defect persisted or recurred. In all cases, an FDA group IV hydrogel contact lens (Biomedics 55, ocufilcon D, 55% water content) was fitted and serum eye drops applied 8 times a day. RESULTS: The PED healed in five of six eyes after a treatment period of 14.2+/-8.9 days. In one eye the PED became smaller, but it took 90 days until the lesion healed completely. In three eyes (two patients) white deposits appeared on the surface of the BCL during the treatment after 12.3+/-5.1 days. Because no signs of inflammation were observed and since the epithelial defect improved, a new identical lens was applied and the medication continued unaltered. The surface of contaminated and non-contaminated BCLs were analyzed by scanning electron microscopy and SDS gel-electrophoresis. The scanning electron microscopic examination presented a coating of amorphous material with a wrinkled appearance and many corpuscular deposits. There was no indication of bacterial colonisation. The SDS gel-electrophoresis showed a small band at 65 kDa, probably albumin. CONCLUSION: These findings suggest that the combination of a therapeutic contact lens and serum eye drops can be successfully used in the treatment of persistent epithelial defects. Deposition of albumin may occur on the surface of the contact lenses, which, in the small group presented here, caused no unwanted effects.

PMID: 16544115 [PubMed - in process]

Amniotic membrane transplantation in ocular surface disorders.

• Chandra A,
• Maurya OP,
• Reddy B,
• Kumar G,
• Pandey K,
• Bhaduri G.

Department of Ophthalmology, Institute of Medical Sciences, Banaras Hindu University, Varanasi.

In this prospective study, 81 eyes of 70 patients diagnosed with various ocular surface disorders were enrolled to document the use of amniotic membrane transplantation in various ocular surface disorders. Detailed history and ocular examination was done. Ocular photographs and consent from all patients were taken. Fluorescein staining and impression cytology was done preoperatively and postoperatively in selected cases. Amniotic membrane was prepared from the placenta of a donor (consent taken and negative for infectious disorders), after separating amnion from chorion. It was washed with antibiotic solutions, transferred over nitrocellulose paper and stored in Dulbecco's modified Eagle's minimum essential medium at -80 degrees C. Recipient bed was prepared by removing the fibrovascular pannus and necrosed conjunctiva. Amniotic membrane was transplanted with the epithelial side up and sutured. Sixty-four eyes had good result by clinical evaluation or impression cytology findings, 5 eyes later required limbal stem cell culture and transplantation. All the 3 eyes had failure of the fornix reconstruction and 5 eyes had recurrence of the pterygium. Amniotic membrane provides lower recurrence rate in cases of recurrent pterygium. Alkali injuries are more dangerous but showed good response to amniotic membrane transplantation combined with limbal autografting or ex-vivo expansion and later transfer. Initial proper assessment of limbal involvement, conjunctival necrosis and corneal involvement is the key to the management of acute cases. Contracted sockets showed no improvement. Shield ulcers and persistent epithelial defect and ocular surface defects secondary to tumour excision showed excellent results.

PMID: 16366188 [PubMed - indexed for MEDLINE]

Autologous cultivated conjunctival transplantation for pterygium surgery.

• Ang LP,
• Tan DT,
• Cajucom-Uy H,
• Beuerman RW.

Singapore National Eye Center, Singapore.

PURPOSE: To investigate the safety and efficacy of autologous cultivated conjunctival transplantation for the treatment of primary pterygium. DESIGN: Prospective nonrandomized clinical trial. METHODS: Forty patients with primary pterygium were recruited. Excision of the pterygium was followed by reconstruction using a serum-free derived autologous cultivated conjunctival equivalent in 22 patients (group A) and conventional denuded amniotic membrane transplantation in 18 patients (group B). In group A patients, conjunctival epithelial equivalents were constructed by the ex vivo expansion of conjunctival epithelial cells on human amniotic membranes (HAM). The main outcome measures were conjunctival epithelialization, recurrence, survival analysis, and incidence of complications. RESULTS: The mean follow-up was 14.1 +/- 3.9 months (range, 12 to 25 months). Complete epithelialization was achieved within five days after surgery in group A patients compared with approximately three weeks for group B patients. The proportion of patients that had true recurrences was 22.7% in group A and 25.0% in group B. The mean time to recurrence was 4.8 +/- 1.6 months in group A and 5.0 +/- 2.9 months in group B. No ocular complications were noted in group A, while one eye (6.0%) in group B developed scleral necrosis associated with a persistent epithelial defect. CONCLUSIONS: Transplantation of an autologous cultivated conjunctival epithelial sheet facilitated early postoperative epithelialization and recovery, and may aid in preventing serious complications associated with simple denuded HAM transplantation, such as scleral necrosis and secondary infection. This may provide a novel method for conjunctival epithelial replacement in the treatment of ocular surface disorders.

PMID: 15808155 [PubMed - indexed for MEDLINE]

Detection of corneal epithelial defect through amniotic membrane patch by fluorescein.

• Kobayashi A,
• Ijiri S,
• Sugiyama K,
• Di Pascuale MA,
• Tseng SC.

Department of Ophthalmology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan. kobaya@kenroku.kanazawa-u.ac.jp

PURPOSE: To demonstrate the usefulness of fluorescein dye to detect a corneal epithelial defect through an amniotic membrane patch in 4 cases. PATIENTS AND METHOD: Two patients with painful bullous keratopathy, 1 patient with total limbal deficiency, and 1 patient with acute chemical burn underwent surgeries in conjunction with amniotic membrane as patch. Postoperatively, slit-lamp biomicroscopic examination with and without fluorescein staining was performed. RESULTS: The status of epithelialization, ie, corneal epithelial defect on either denuded corneal stroma or amniotic membrane graft, was indiscernible by slit-lamp biomicroscopy through the amniotic membrane patch. Nevertheless, it could be detected by fluorescein staining, especially after saline rinse, in all 4 cases. CONCLUSIONS: Fluorescein staining permits clinicians to avoid prematurely removing the amniotic membrane patch during the treatment of a persistent corneal epithelial defect.

PMID: 15778616 [PubMed - indexed for MEDLINE]

Application of Preserved Human Amniotic Membrane for Corneal Surface Reconstruction.

• Prabhasawat P,
• Kosrirukvongs P,
• Booranapong W,
• Vajaradul Y.

Department of Ophthalmology; The Bangkok Biomaterial Center, Faculty of Medicine, Siriraj Hospital, Madhidol University, Bangkok 10700, Thailand; Department of Ophthalmology, Siriraj Hospital, Faculty of Medicine, Mahidol University, 2 Prannok Road, Bangkoknoi, Bangkok 10700, Thailand (Tel.: (662)411-2006; Fax: (662)411-1906; E-mail: sippb@mahidol.ac.th)

Objective: To evaluate the efficacy of preserved human amniotic membrane transplantation for reconstruction of the corneal surface diseases.Methods: Preserved human amniotic membrane transplantations were performed in 84 eyes of 78 patients for corneal surface reconstruction. The indications were limbal stem cell deficiency from Steven-Johnson syndrome, chemical burn and herpes keratitis (27 eyes), bullous keratopathy (26 eyes), persistent epithelial defect and dellen (17 eyes), band keratopathy (11 eyes), preparing for prosthesis (1 eye), corneal ulcer (1 eye) and acute chemical burn (1 eye).Results: Success was noted in 83.3% (70/84) eyes, partial success in 13.1% (11/84) eyes, and failure in 3.6% (3/84) eyes for an average follow-up of 10.5 months (3 - 29 months). No patient developed major immediate post-operative complications.Conclusion: Amniotic membrane transplantation can reduce inflammation, promote corneal epithelial healing, and decrease irritation in corneal surface problems.

PMID: 15256948 [PubMed - as supplied by publisher]

Reconstruction of the ocular surface by transplantation of a serum-free derived cultivated conjunctival epithelial equivalent.

• Tan DT,
• Ang LP,
• Beuerman RW.

Singapore Eye Research Institute, Singapore, Singapore.snecdt@pacific.net.sg

PURPOSE: The purpose of this study was to investigate the use of a serum-free derived cultivated conjunctival epithelial sheet for ocular surface transplantation and reconstruction. METHODS: Seven subjects with various ocular surface disorders were selected for the procedure: one patient had an extensive conjunctival nevus, three patients had pterygium, two patients had persistent leaking trabeculectomy blebs, and one patient had bilateral superior limbic keratoconjunctivitis. Conjunctival epithelial cells were harvested from the forniceal conjunctiva of patients 2 weeks before the definitive surgery. Cultivation of conjunctival epithelial cells on human amniotic membrane (HAM) was carried out under serum-free conditions. At the time of transplantation, the area of diseased conjunctiva was excised and the cultured conjunctival epithelium-HAM composite was transplanted onto the surgical defect. Patients were followed up with serial slit-lamp examinations, fluorescein staining, and photographic documentation. RESULTS: A confluent stratified conjunctival epithelial sheet was formed on the HAM within 12 to 14 days. Transplanted grafts remained well-epithelialized after surgery. A successful outcome, defined as resolution of the disease, maintenance of conjunctival epithelialization, maintenance of graft integrity, and absence of significant complications, was obtained in all seven patients. A good functional and cosmetic result was achieved in all eyes. The mean follow-up period was 11.6 months (range, 6-18 months). CONCLUSIONS: Transplantation of a serum-free derived autologous cultivated conjunctival epithelial sheet on HAM was successfully performed in seven patients with ocular surface disorders. This may provide a novel method for conjunctival replacement in conditions where the normal conjunctiva is damaged or deficient.

PMID: 15201674 [PubMed - indexed for MEDLINE]

[Place of the transplantation of the amniotic membrane in the treatment of corneal diseases concomitant with corneal neovascularization]

• Novitskii IIa.

Published data and authors' independent observations related with the influence produced by the transplantation of the amniotic sac on corneal neovascularization are described. The epithelial-and-stromal corneal defect as well as the limbic epithelium deficit with a subsequent conjunctivization of the corneal epithelium and corneal neovascularization are one of the key mechanisms of corneal neovascularization. The amniotic sac transplantation, made for the purpose of reconstructing the eye surface, ensures the conditions for a fast recovery of the corneal epithelium and, thus, prevent the corneal neovascularization. The surgery can be recommended as an effective treatment technique applicable to corneal pathologies concomitant with the limbic epithelium deficit, persistent epithelial-and-stromal corneal defect and with the corneal neovascularization.

PMID: 14708164 [PubMed - indexed for MEDLINE]

Amniotic membrane transplantation for pseudomonal keratitis with impending perforation.

• Chen JH,
• Ma DH,
• Tsai RJ.

Department of Ophthalmology, Chang Gung Memorial Hospital, Taipei.

BACKGROUND: To determine whether amniotic membrane transplantation (AMT) can be used as adjunctive therapy to promote wound healing and prevent perforation in bacterial keratitis caused by Pseudomonas aeruginosa. METHODS: We report on 6 eyes from 6 patients with bacterial keratitis caused by Pseudomonas aeruginosa associated with prominent stromal melting and extensive stromal loss. AMT was performed after treatment with fortified antibiotics for at least 1 week. The mean follow-up period was 12.8+/-2.5 months. RESULTS: The lesion became sterile in all but 1 case for which AMT was performed. Rapid reepithelialization and decreased inflammation was observed in 5 cases, with complete reepithelialization occurred at 9.4+/-2.1 days postoperatively. The amniotic membrane dissolved in the remaining case with active, extensive corneal infection and persistent epithelial defect; this case finally received evisceration due to intractable glaucoma. In all other cases, after AMT treatment, lesions did not extend, stromal loss was limited, and considerable stromal thickness was preserved. CONCLUSION: AMT may be considered an alternative method for treating pseudomonal keratitis, especially when stromal melting and loss are extensive, and the infection has been controlled.

PMID: 12022734 [PubMed - indexed for MEDLINE]

Thygeson lecture. Amniotic membrane transplantation: why is it effective?

• Baum J.

julebaum@massmed.org

PURPOSE: To review the uses and previously proposed mechanisms of action of amniotic membrane transplantation (AMT) and to suggest a new mechanism of action for the effectiveness of AMT in resolving a persistent epithelial defect (PED). METHODS: Significant clinical and experimental publications are reviewed. RESULTS: Evidence from the scientific literature suggests a new hypothesis for the effectiveness of AMT in the reepithelialization of a PED and the reduction of corneal stromal inflammation and continued fibrosis. CONCLUSION: It is suggested that reepithelialization of a PED, and hence the reduction of stromal inflammation and continued fibrosis following reepithelialization, is aided by the combination of oxygenation, moisture and protection of the fragile epithelium by the amniotic membrane.

PMID: 11973378 [PubMed - indexed for MEDLINE]

Comment in:

Br J Ophthalmol. 2001 Dec;85(12):1400-1.

Single and multilayer amniotic membrane transplantation for persistent corneal epithelial defect with and without stromal thinning and perforation.

• Prabhasawat P,
• Tesavibul N,
• Komolsuradej W.

Department of Ophthalmology, Faculty of Medicine, Siriraj Hospital Mahidol University, Bangkok, Thailand. sippb@mahidol.ac.th

AIMS: To evaluate the efficacy of amniotic membrane transplantation (AMT) in persistent corneal epithelial defect with or without stromal thinning and corneal perforation. METHODS: 28 patients (28 eyes) with persistent corneal epithelial defect unresponsive to medical treatment were given preserved human amniotic membrane transplants. The patients were divided into three groups: group A, persistent corneal epithelial defect 10 eyes; group B, epithelial defect with stromal thinning 13 eyes; and group C, corneal perforation five eyes. AMT was performed using one layer in group A and multilayers in group B and C. The causes of persistent epithelial defect were neurotrophic keratopathy (24 eyes), limbal deficiency (six eyes), exposure keratopathy (four eyes), and Mooren's ulcer (one eye). RESULTS: Success was noted in 82.1% (23/28 eyes) in all groups, with 80% (8/10 eyes), 84.6% (11/13 eyes), and 80% (4/5 eyes) in groups A, B, and C respectively, with a mean follow up of 10.9 months (1-30 months). The mean epithelialisation time after AMT was 2.1 weeks. The healing times of groups B and C are also significantly shorter than group A (p=0.017 and 0.018, respectively). Corneal stromal thickness was significantly increased in all cases in groups B and C (p=0.006). Those with corneal perforation in group C were completely healed by multilayer AMT. There was no difference in the epithelialisation time between successful cases treated by a single operation (17 eyes) or repeated operation (six eyes). Vision improved in 18.9% (8/28 eyes) and worsened as a result of cataract formation in 2.3% (1/28 eyes). Failure was noted in 17.9% (5/28 eyes), because of corneal infection (two eyes), neurotrophic keratopathy with and without limbal deficiency (two eyes), and intractable corneal perforation (one eye). No patient developed major immediate postoperative complications or graft rejection. CONCLUSION: Amniotic membrane can successfully treat refractory corneal epithelial defect by promoting epithelial healing and thus prevent corneal perforation. It can be used as a treatment for corneal perforation by restoring corneal stromal thickness so that emergency penetrating keratoplasty can be avoided.

PMID: 11734521 [PubMed - indexed for MEDLINE]

Comment on:

Br J Ophthalmol. 2001 Dec;85(12):1455-63.

Amniotic membrane transplantation for persistent corneal epithelial defect.

• Tseng SC.

PMID: 11734507 [PubMed - indexed for MEDLINE]

[Autologous serum for otherwise therapy resistant corneal epithelial defects - Prospective report on the first 70 eyes]

• Ferreira de Souza R,
• Kruse FE,
• Seitz B.

Augenklinik mit Poliklinik, Friedrich-Alexander-Universitat Erlangen-Nurnberg, Erlangen.

PURPOSE: The purpose of this prospective clinical pilot study was to evaluate the efficiency, practicability and safety of topical autologous serum for therapy resistant corneal epithelial defects. METHODS: Between November 1999 and June 2001 autologous serum therapy was applied in 70 eyes of 67 consecutive patients (age 18 to 92 [average 59 +/- 18] years) with corneal epithelial defects refractory to standard clinical treatment at the Department of Ophthalmology University Erlangen-Nurnberg. We evaluated localization, size of the defect, time until epithelial wound closure and the incidence of recurrences in relation to the clinical diagnosis. The blood was obtained by venipuncture, centrifuged and the non-diluted serum was filled in sterile bottles, kept in the + 4 (o)C refrigerator and hourly applied during daytime. Simultaneous systemic and topical medication depended on the underlying disease. RESULTS: In 45 eyes corneal epithelial defects appeared after penetrating keratoplasty but in 25 eyes corneal epithelial defects were not related to a corneal transplant. The epithelial defect had a medium length of 4.2 +/- 2.4 mm and a width of 3.0 +/- 1.8 mm. Previously, the patients had been treated with maximal topical therapy (including hyaluronic acid) for 13 +/- 11 days. Treatment with autologous serum lasted from 4 to 45 (mean 16 +/- 11) days. A complete corneal re-epithelialization was achieved in 57 of 70 eyes (81 %) after 3 to 45 (mean 15 +/- 12) days. Forty-eight of these 57 eyes (84 %) had no recurrence during a follow-up of 12 +/- 4 months. In 9 eyes (16 %) a recurrent epithelial defect occurred one or two months after initial closure. These eyes were treated successfully with a second autologous serum therapy (6 x), amniotic membrane transplantation (2 x) or repeat keratoplasty (1 x). Thirteen eyes (19 %) without primary success of autologous serum applied for 11 to 50 days were finally treated successfully with amniotic membrane transplantation (10 x) or repeat keratoplasty (3 x). CONCLUSION: In persistent corneal epithelium defects, autologous serum therapy can be considered as an effective and practicable therapy without adverse reactions. Especially in eyes after complicated penetrating keratoplasty the prognosis may be improved and more invasive treatment modalities such as botulinum toxin injection, amniotic membrane transplantation or (repeat) penetrating keratoplasty may be avoided. Definitive determinants for the success of this novel therapy have not been identified, yet. However, eyes with accompanying deep stromal defects do not seem to be good candidates.

PMID: 11731899 [PubMed - indexed for MEDLINE]

[Multilayer amniotic membrane transplantation for corneal ulcers not treatable by conventional therapy - a prospective study of the status of cornea and graft during follow-up]

• Ferreira De Souza R,
• Hofmann-Rummelt C,
• Kruse FE,
• Seitz B.

Augenklinik mit Poliklinik der Friedrich-Alexander Universitat Erlangen-Nurnberg, Schwabachanlage 6, 91054 Erlangen, Germany. berthold.seitz@augen.imed.uni-erlangen.de

PURPOSE: The purpose of this prospective clinical study was to evaluate the condition of the cornea (epithelium and vascularization) and the membrane presence and retraction during follow-up after amniotic membrane transplantation in patients with persistent corneal ulcers. PATIENTS AND METHODS: Between June 1999 and November 2000 AM transplantation was performed in 30 consecutive patients (average age 59 +/- 17 years) with corneal ulcers refractory to clinical treatment. We evaluated the clinical diagnosis, localisation, size and depth of the ulcers, condition of the ocular surface and visual acuity before and after surgery. After complete removal of the epithelium and pannus, one (n=11), two (n=17) or three (n=2) layers of amniotic membrane were fixed with multiple interrupted sutures, depending on the depth of the lesion. A therapeutic contact lens was applied in most eyes and removed after one month. The most frequent diagnoses were chemical burn (5 x lime, 1 x lye and 1 x liquid aluminium), 7 x herpes, 3 x polyarthritis and 3 x blepharo-keratoconjunctivitis in neurodermitis. The ulcers had a medium length of 4.9 +/- 3.2 mm, a width of 3.5 +/- 3.0 mm and a depth ranging between 30 % and 95 % (68 +/- 21 %). RESULTS: Complete epithelial closure was achieved in 27 of 30 eyes (90 %). In 4 eyes a recurrent epithelial defect occurred after initial closure. At the 1-, 3- and 6 month follow-up the amniotic membrane was present in 93 %, 73 % or 30 %, respectively, but was more or less retractet in 52 %, 58 % or 67 %, respectively. A complete corneal epithelium was noted in 79 %, 89 % or 90 % of eyes, respectively. However, corneal neovascularization was observed in 24 %, 58 % or 60 % of eyes. Visual acuity was </= 20/400 in 60 % eyes preoperatively, but in 69 % after 3 months and in 78 % after 6 months of follow-up. CONCLUSION: In persistent corneal ulcers, amniotic membrane transplantation should be considered in early stages to achieve permanent epithelial closure in a less inflamed eye thus avoiding penetrating keratoplasty a chaud or conjunctival flaps. However, in eyes with broad descemetocele especially following chemical burns, this treatment modality does not seem to be effective.

PMID: 11573153 [PubMed - indexed for MEDLINE]

Amniotic membrane transplantation for ocular surface reconstruction.

• Prabhasawat P,
• Kosrirukvongs P,
• Booranapong W,
• Vajaradul Y.

Department of Ophthalmology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.

OBJECTIVE: To study the efficacy of amniotic membrane transplantation in various indications for ocular surface reconstruction. METHOD: Amniotic membrane transplantations were performed in 140 eyes (130 patients) for ocular surface reconstruction. The indications for the corneal group were limbal stem cell deficiency, bullous keratopathy, persistent epithelial defect, band keratopathy, prosthesis, corneal ulcer and acute chemical burn. The indications for the conjunctival group were grafts for pterygium, conjunctival tumors, symblepharon, and covering the scleral graft. RESULTS: Success was noted in 75.7 per cent (106/140) eyes, partial success in 17.9 per cent (25/140) eyes, and failure in 6.4 per cent (9/140) eyes for a mean follow-up of 6.6 months (1-19 months). The success and partial success rate were 80.6 per cent (54/67), 14.9 per cent (10/67) in the corneal group and 71.2 per cent (52/73), 20.6 per cent (15/73) in the conjunctival group. CONCLUSION: Amniotic membrane transplantation can solve some difficult ocular surface problems, and can be used to promote epithelial healing, reduce inflammation and scarring.

PMID: 11560222 [PubMed - indexed for MEDLINE]

Amniotic membrane transplantation for partial limbal stem cell deficiency.

• Anderson DF,
• Ellies P,
• Pires RT,
• Tseng SC.

Ocular Surface and Tear Center, Department of Ophthalmology, Bascom Palmer Eye Institute, Miami, Florida 33136, USA.

AIM: To examine the efficacy, safety, and long term outcomes of amniotic membrane transplantation for corneal surface reconstruction in cases of partial limbal stem cell deficiency. METHODS: 17 eyes of 15 patients with partial limbal stem cell deficiency underwent superficial keratectomy of the conjunctivalised corneal surface followed by amniotic membrane transplantation. Cases were followed up for at least a year. RESULTS: All eyes exhibited a stable, intact corneal epithelial surface after a mean follow up period of 25.8 months with no eyes developing recurrent erosion or persistent epithelial defect. The mean time to re-epithelialisation was 22.8 days. Overall improvement in visual acuity was observed in 92.9% of 14 eyes with visual potential. Of those, five eyes gained six or more lines, two eyes gained between four and five lines, six eyes gained between one and three lines, and one eye lost three lines of Snellen acuity. Pain and photophobia were abolished in 86% of cases and substantially reduced in 14%, with all eyes exhibiting decreased vascularisation and inflammation at final follow up. CONCLUSIONS: Amniotic membrane transplantation appears to be a safe and effective method of restoring a stable corneal epithelium for cases of partial limbal stem cell deficiency and can be considered as an alternative to limbal autograft or allograft.

PMID: 11316719 [PubMed - indexed for MEDLINE]

Multilayered amniotic membrane transplantation for severe ulceration of the cornea and sclera.

• Hanada K,
• Shimazaki J,
• Shimmura S,
• Tsubota K.

Department of Ophthalmology, Tokyo Dental College, Chiba, Japan. hanada@asahikawa-med.ac.jp

PURPOSE: To examine the efficacy of amniotic membrane transplantation in the treatment of deep corneal and scleral ulcers. PATIENTS: A total of 11 patients were recruited for this study: four patients (four eyes) with corneal perforation, five patients (five eyes) with a deep corneal ulcer and descemetocele, and two patients (two eyes) with a scleral ulcer. METHODS: Ulcers were treated by amniotic membrane transplantation. Separate amniotic membranes were transplanted as material to fill the stromal layer (amniotic membrane filling), as a basement membrane (amniotic membrane graft), and as a wound cover (amniotic membrane patch). After surgery, all cases were treated with artificial tears, autologous serum drops, antibiotic eyedrops, topical corticosteroids, and sodium hyaluronate eyedrops. RESULTS: Eight eyes (72.7%) healed with epithelialization in 16.5 +/- 8.0 days (range, 7 to 29 days), with five and three eyes showing corneal epithelialization and conjunctival epithelialization, respectively. A persistent epithelial defect was noted in one eye with corneal ulcer after limbal allograft transplantation for a chemical burn and in two eyes with corneal ulcers as a complication of rheumatoid arthritis. CONCLUSION: Multilayered amniotic membrane transplantation may be effective for the treatment of deep ulceration of the cornea and sclera. In some eyes with total corneal limbal dysfunction or autoimmune disorders, amniotic membrane transplantation alone is not effective.

PMID: 11239864 [PubMed - indexed for MEDLINE]

Treatment of persistent corneal epithelial defect with extended wear of a fluid-ventilated gas-permeable scleral contact lens.

• Rosenthal P,
• Cotter JM,
• Baum J.

The Boston Foundation for Sight (Drs Rosenthal and Cotter), Boston, Massachusetts 02467, USA. perry-rosenthal@polymer.com

PURPOSE: To report treatment of persistent corneal epithelial defects unresponsive to other therapies by extended wear of a fluid-ventilated gas-permeable scleral contact lens.METHODS: In this retrospective study, 14 eyes of 13 consecutive patients referred for the treatment of persistent corneal epithelial defects that failed to heal with conventional therapies or developed epithelial defects after penetrating keratoplasty for persistent corneal epithelial defects were fitted with an extended-wear gas-permeable scleral lens. These included seven eyes of six patients with Stevens-Johnson syndrome and seven eyes of seven patients who did not have Stevens-Johnson syndrome. Twelve eyes had undergone recent penetrating keratoplasty. All 14 eyes were fitted with a gas-permeable scleral contact lens designed to avoid the intrusion of air bubbles under its optic. An antibiotic and corticosteroid were added to the lens fluid reservoir or instilled before each lens insertion in 12 of 14 eyes. The lenses were worn continuously except for brief periods of removal for purposes of cleaning, replacement of the lens fluid reservoir, and examination and photography of the cornea.RESULTS: Five of the seven persistent corneal epithelial defects associated with Stevens-Johnson syndrome healed. The persistent corneal epithelial defects of four of these eyes re-epithelialized within 7 days, and a fifth healed in 27 days of gas-permeable scleral lens extended wear. A sixth persistent corneal epithelial defect that failed to heal initially re-epithelialized after a subsequent penetrating keratoplasty and gas-permeable scleral lens extended wear. The seventh eye healed after 3 days of gas-permeable scleral lens extended wear, but the persistent corneal epithelial defect subsequently recurred. Three of seven non-Stevens-Johnson syndrome persistent corneal epithelial defects re-epithelialized within 36 hours, 6 days, and 36 days, respectively. Of the six (six of 14) persistent corneal epithelial defects that failed to heal with a gas-permeable scleral lens extended wear, one subsequently healed after multiple amniotic membrane grafts. Microbial keratitis occurred in four eyes (four of 14) and graft failure in one eye, all of which required repeat penetrating keratoplasty.CONCLUSION: Extended wear of an appropriately designed gas-permeable scleral contact lens was effective in promoting the healing of persistent corneal epithelial defects in some eyes that failed to heal after other therapeutic measures. Re-epithelialization appears to be aided by a combination of oxygenation, moisture, and protection of the fragile epithelium afforded by the scleral lens. However, microbial keratitis represents a significant risk.

PMID: 11004257 [PubMed - indexed for MEDLINE]

Human amniotic membrane in the reconstruction of the ocular surface.

• Gabric N,
• Mravicic I,
• Dekaris I,
• Karaman Z,
• Mitrovic S.

Lions Croatian Eye Bank, Department of Ophthalmology, Sveti Duh General Hospital, Zagreb. lhob@yahoo.com

We sought to determine the efficacy of amniotic membrane transplantation (AMT) in the reconstruction of ocular surface. AMT was performed on 40 eyes with following indications: I, persistent corneal ulceration (n = 12); II, impending perforation (n = 6); III, persistent epithelial defect on the corneal graft (n = 6); IV, recurrent pterygia (n = 10), and V, risk of conjunctival scarring (n = 6). Amniotic membrane was prepared from a fresh placenta under sterile conditions, washed with BSS containing penicillin, streptomycin, neomycin and amphotericin B and stored at -80 degrees C in 1:1 InoSol:Glycerol solution. Donor serological test for HIV, HBV and HCV were all negative. Associated surgical procedures according to indication were performed. Healing of the corneal ulcer in Group I was obtained in 67% of eyes at 1-3 weeks after surgery, Group II: AMT was followed by 'a chaud' keratoplasty in 33% and by planned keratoplasty in 67% patients, Group III: healing of the defect in 33% of eyes in 2-5 postoperative weeks, Group IV: no recurrence of pterygium ingrowth in 70% in the follow up period of 6-14 months, and V: 84% of patients had good eye motility without any synechia formation. We concluded that AMT have shown to be effective in enhancing healing of the corneal defects, in prevention of symblepharon formation and recurrent pterygium ingrowth. In case of impending perforation, AMT alone was not a method of treatment but is useful as a first step procedure in preparing the eye for the corneal transplantation.

PMID: 10945447 [PubMed - indexed for MEDLINE]

Association of preoperative tear function with surgical outcome in severe Stevens-Johnson syndrome.

• Shimazaki J,
• Shimmura S,
• Fujishima H,
• Tsubota K.

Department of Ophthalmology, Tokyo Dental College, Chiba, Japan.

OBJECTIVE: To retrospectively study the surgical outcome in severe Stevens-Johnson syndrome (SJS). DESIGN: Retrospective noncomparative case series. PARTICIPANTS: Twenty-nine eyes of patients with severe SJS associated with total conjunctivalization were examined. INTERVENTION: Preserved human amniotic membrane grafting and keratolimbal allograft transplantation was performed. Intensive immunosuppression and epithelial management were continued postoperatively. MAIN OUTCOME MEASURES: Successful ocular surface reconstruction was determined by epithelialization with corneal epithelium. The association between surgical outcome and preoperative tear function was studied. RESULTS: The ocular surface was successfully covered by corneal epithelium in 13 eyes (44.8%). The mean corrected visual acuity recovered from 0.0039 to 0.017. Persistent epithelial defect was the most common complication. Eyes with successful ocular surface reconstruction had significantly better preoperative Schirmer's test values (P = 0.025) and tear clearance rates (P = 0.043) than those that failed. CONCLUSIONS: In patients with severe SJS, preoperative tear function significantly influenced surgical outcome. Eyes with Schirmer's test value of >10 mm have a greater chance of successful ocular surface reconstruction.

PMID: 10919901 [PubMed - indexed for MEDLINE]

Application of the amniotic membrane in ocular surface pathology.

• Gris O,
• Guell JL,
• Lopez-Navidad A,
• Caballero F,
• Del Campo Z.

Department of Ophthalmology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.

The amnion is a fine semi-transparent membrane that has been used in clinical practice to encourage epithelization in burns, in skin ulcers, or as a skin graft. Application in ocular surface disorders first took place in 1940. We carried out the membrane amniotic implantation on 11 patients with different pathologies: three cases of limbal stem cell deficiency (caustication with failure of prior keratoplasty, congenital aniridia and post-radiotherapy keratopathy), one case with persistent neurotrophic corneal ulcer after prior keratoplasty, four cases with epithelial defect of long evolution, one case of extensive Salzmann's degeneration of the cornea, and two cases after the resection of conjunctival tumour. The follow-up period varied between 2 and 6.5 months (mean = 4 months). Amniotic membrane was obtained by elective Caesarean, and it was preserved at -80 degrees C. In all transplanted patients the reabsorption of the amniotic membrane took place between the third and the fifth week. In the cases of resection of conjunctival tumour the epithelialization was completed between the first and the second post-operative week, with minimal residual scarring. In the other cases, with affliction of the corneal epithelium, the complete epithelialization, together with a marked reduction in the inflammatory response, occurred in all except 2 cases. In conclusion, the implantation of preserved human amniotic membrane can favour the recovery of a normal ocular surface in different pathologies, both in corneal and conjunctival lesions.

PMID: 10853789 [PubMed - indexed for MEDLINE]

Comment in:

Cornea. 2001 Oct;20(7):773-4.

Use of nonpreserved human amniotic membrane for the reconstruction of the ocular surface.

• Mejia LF,
• Acosta C,
• Santamaria JP.

Instituto de Ciencias de la Salud-CES, Medellin, Colombia. lfmejia@epm.net.co

PURPOSE: To describe the use of nonpreserved human amniotic membrane (NP-AMT) as an alternative to preserved human amniotic membrane (AMT) for the reconstruction of the ocular surface in several diseases. METHODS: NP-AMT was used in the treatment of five patients with the following diseases: noninvasive conjunctival squamous cell carcinoma, corneal persistent epithelial defect, severe alkali burn, near total limbal deficiency secondary to multiple surgeries, and ocular cicatricial pemphigoid. In some cases, a limbal autograft or allograft was employed simultaneously, sutured on top of the NP-AMT. All sutures were made with 10-0 Nylon and were removed at two weeks. RESULTS: Ocular surface was satisfactorily reconstructed, eyes were quiet, and patients were comfortable despite prolonged deepithelialization in some cases. There was a case of a limbal autograft ischemia--in the burned patient--that caused partial corneal conjunctivalization. Initially, the NP-AMT looks thickened but thins around the fifth day and looks similar to AMT. CONCLUSION: Results using NP-AMT are similar to those of AMT. It is a good alternative and it is easily obtained in places were AMT is not available or is too expensive to procure.

PMID: 10832685 [PubMed - indexed for MEDLINE]

[Limbal autograft transplantation, eight consecutive cases]

• Muraine M,
• Salessy P,
• Watt L,
• Retout A,
• Brasseur G.

Service d'Ophtalmologie, Hopital Charles Nicolle, Boulevard Gambetta, 76031 Rouen Cedex.

BACKGROUND: Limbal autograft transplantation is the procedure of choice in the management of ocular surface disorders secondary to stem cells deficiency. The aim of our study was to investigate the indications, results and limits of this infrequent surgery. METHODS: Limbal autograft transplantation was performed in 8 patients and the mean follow-up period was 11 months. Limbal stem cell deficiency was due to chemical burns in 4 patients, history of prior surgery extending to the limbus in 2 patients, chronic limbitis with dystichiasis in one patient and persistent corneal epithelial defect after keratoplasty in one case. RESULTS: In 6 out of 8 cases, the stability of the ocular surface normalized and comfort significantly improved. Four of these patients had increased visual acuity after surgery. Two patients who presented with severe alkali burn did not respond well to limbal autotransplantation. CONCLUSION: Limbal autograft transplantation is a reliable and effective procedure in limbal stem cells deficiencies. New associate procedures such as amniotic membrane transplantation will however be necessary to improve the prognosis of very severe corneal surface disorders.

PMID: 10705110 [PubMed - indexed for MEDLINE]

Multilayer amniotic membrane transplantation for reconstruction of deep corneal ulcers.

• Kruse FE,
• Rohrschneider K,
• Volcker HE.

Department of Ophthalmology, University of Heidelberg, Germany. Friedrich_Kruse@ukl.uni-heidelberg.de

PURPOSE: To evaluate the efficacy of multilayer amniotic membrane transplantation for reconstruction of corneal epithelium and stroma in the context of deep corneal ulcers. DESIGN: Prospective, noncomparative, interventional case series. PARTICIPANTS: Eleven consecutive patients with deep corneal ulcers refractory to conventional treatment; six patients had herpetic keratitis and five had other forms of neurotrophic keratitis. INTERVENTION: Multilayer amniotic membrane transplantation with kryopreserved human amniotic membrane. MAIN OUTCOME MEASURES: Integrity of corneal epithelium and stroma, opacification, and appearance of grafted membrane during 12 months follow-up. RESULTS: Amniotic membrane transplantation markedly reduced ocular inflammation in all patients. Epithelium healed above all corneal ulcers within 4 weeks and remained stable in 9 of 11 patients for 1 year. Two patients with recurrent epithelial defect suffered from severe neurotrophic keratitis. Following transplantation the amniotic membranes gradually dissolved over a period of 12 months, but stromal thickness remained stable. CONCLUSION: Amniotic membrane transplantation allows corneal surface reconstruction in patients with persistent epithelial defects. The multilayer technique is useful for treating deep corneal ulcers and even descemetoceles. Because the procedure results in stability of the ocular surface over a period of more than 12 months in most patients, it may be considered an alternative to conventional surgical techniques for ocular surface reconstruction.

PMID: 10442895 [PubMed - indexed for MEDLINE]

Comment in:

Br J Ophthalmol. 1999 Dec;83(12):1410-1.

Amniotic membrane transplantation for ocular surface reconstruction.

• Azuara-Blanco A,
• Pillai CT,
• Dua HS.

Department of Ophthalmology, Queen's Medical Centre, University of Nottingham.

AIMS: To evaluate the efficacy of amniotic membrane transplantation (AMT) for ocular surface reconstruction. METHODS: 10 consecutive patients who underwent AMT were included. The indications were: group A, cases with persistent epithelial defect after corneal abscess (n = 1), radiation (n = 1), or chemical burn (n = 3); group B, cases with epithelial defect and severe stromal thinning and impending or recent perforation, due to chemical burn (two patients, three eyes) or corneal abscess (n = 2); group C, to promote corneal epithelium healing and prevent scarring after symblepharon surgery with extensive corneo-conjunctival adhesion (n = 1). Under sterile conditions amniotic membrane was prepared from a fresh placenta of a seronegative pregnant woman and stored at -70 degrees C. This technique involved the use of amniotic membrane to cover the entire cornea and perilimbal area in groups A and B, and the epithelial defect only in group C. RESULTS: The cornea healed satisfactorily in four of five patients in group A, but the epithelial defect recurred in one of these patients. After AMT three patients underwent limbal transplantation and one penetrating keratoplasty and cataract extraction. In group B amniotic membrane transplantation was not helpful, and all cases underwent an urgent tectonic corneal graft. Surgery successfully released the symblepharon, promoted epithelialisation and prevented adhesions in the case of group C. CONCLUSION: AMT was effective to promote corneal healing in patients with persistent epithelial defect, and appeared to be helpful after surgery to release corneo-conjunctival adhesion. Most cases required further surgery for visual and ocular surface rehabilitation. Amniotic membrane used as a patch was not effective to prevent tectonic corneal graft in cases with severe stromal thinning and impending or recent perforation.

PMID: 10434859 [PubMed - indexed for MEDLINE]

Comment in:

Ophthalmology. 2000 Mar;107(3):411-2.

Amniotic membrane transplantation for ocular surface reconstruction in patients with chemical and thermal burns.

• Shimazaki J,
• Yang HY,
• Tsubota K.

Department of Ophthalmology, Tokyo Dental College, Chiba, Japan.

OBJECTIVE: The purpose of the study is to examine the usefulness of preserved human amniotic membrane transplantation in patients with chemical and thermal burns. DESIGN: The study design was a nonrandomized clinical trial. PARTICIPANTS: Seven eyes of six patients with severe chemical (n = 5) and thermal (n = 2) burns were studied. INTERVENTION: Eyes were treated with excision of cicatricial tissues followed by a placement of amniotic membrane on the sclera. Transplantation of limbal grafts from an opposite eye (n = 4) or from donor eyes preserved at -80 degrees C (n = 2) was performed simultaneously. MAIN OUTCOME MEASURES: Reconstruction of ocular surface epithelia and visual acuity were measured. RESULTS: With the mean observation period of 53.3 weeks, central corneal epithelium was reconstructed successfully in all eyes. Neither amniotic membrane nor limbal grafts were rejected. A persistent epithelial defect developed in one eye, which was treated successfully by tarsorrhaphy. After surgery, the corneal epithelium showed normal arrangements on specular microscopy, and its barrier function recovered to seminormal. Corrected visual acuity markedly improved in each eye. Regenerated conjunctiva on the amniotic membrane was stable and uninflammed with minimum-to-mild scarring. Slight recurrence of conjunctivalization was noted in three eyes. However, because these eyes were stable and central cornea was clear, no further surgery was needed. CONCLUSIONS: Amniotic membrane transplantation promotes normal conjunctival epithelialization while suppressing fibrosis formation. The procedure, especially when performed with limbal autograft transplantation, appears to be effective for the treatment of chemical or thermal burns of the ocular surface.

PMID: 9400767 [PubMed - indexed for MEDLINE]