[Advantages of amniotic membrane transplantation in eye surface diseases]

• Muraine M,
• Gueudry J,
• Toubeau D,
• Gardea E,
• Verspyck E,
• Menguy E,
• Brasseur G.

Service d'Ophtalmologie, Hopital Charles Nicolle, Rouen.

Amniotic membrane transplantation is now a widely adopted technique in the field of eye surface diseases. Depending on the indication, the amniotic membrane can be used as either a graft or a patch. When used as a graft, the amniotic membrane serves as a substrate for regrowth of deficient epithelium; the aim is to integrate this membrane. The basal membrane reinforces the adhesion and differentiation of the corneal epithelial cells, facilitates their migration, and prevents their apoptosis. When used as a patch, the amniotic membrane is sutured epithelium-down so as to maximize the concentration of biological factors delivered by this membrane: the membrane covers the diseased cornea and acts as a biological bandage and analgesic. The best indications for amniotic membrane grafts are acute chemical burns and trophic corneal ulcers refractory to all medical treatment. When these ulcers are perforated or in the early stages of perforation, it is best to use multiple layers of amniotic membrane, restoring the thickness of the cornea. In cases of confirmed limbal deficiency, amniotic membrane grafts may be a useful complement to the necessary limbal stem cell grafts. In the future, amniotic membranes will provide an indispensable support for the expansion of cultured stem cells. Amniotic membrane grafts may also be used to reconstruct the conjunctiva following the exeresis of symblepharons or conjunctival tumors. However, the use of this technique is currently limited to diseases with little inflammation and no extensive fibrosis.

PMID: 17115002 [PubMed - in process]

Analysis of corneal surface evolution after moderate alkaline burns by using impression cytology.

• Lopez-Garcia JS,
• Rivas L,
• Garcia-Lozano I,
• Murube J.

Ophthalmology Services, Hospital Cruz Roja, Madrid, Spain. docsantilopez@hotmail.com

PURPOSE: To compare corneal surface evolution after moderate alkaline burns by impression cytology in patients treated with medical therapy or with amniotic membrane transplantation (AMT). METHODS: A prospective study of 24 eyes from 18 patients (13 men and 5 women) with moderate alkaline burns was performed. All patients were divided according to the clinical ocular severity and the therapy used. Twelve eyes were treated surgically with AMT and the other 12 eyes received only medical therapy. Corneal cytology was obtained immediately after the burns, and 1, 2, 5, and 9 months later. We differentiated between samples obtained from affected areas and areas not affected by the burns. Cellular size, nuclear size, and nuclear-cytoplasmic (N:C) ratio were examined in corneal epithelial cells, as was the presence of goblet cells in corneal epithelium. RESULTS: Nuclear size, cellular size, and N:C ratio in non-burn-affected corneal areas had no significant alterations in comparison with normal eyes. In contrast, in burn-affected corneal areas, these parameters were significantly worse, and the presence of goblet cells in corneal epithelium was frequent 1 month after severe burns. Cellular size, nuclear size, N:C ratio, and corneal conjunctivalization improved during the study in all patients, but corneal reepithelialization occurred earlier in patients treated with AMT than in patients with only medical therapy. CONCLUSION: Morphologic and morphometric analysis of corneal cells by impression cytology after ocular burns permits the establishment of cellular reepithelialization patterns in relation with limbal deficiency level and with clinical ocular severity. AMT improves corneal reepithelialization earlier than medical therapy in moderate alkaline burns.

PMID: 17102665 [PubMed - indexed for MEDLINE]

Technique of cultivating limbal derived corneal epithelium on human amniotic membrane for clinical transplantation.

• Fatima A,
• Sangwan VS,
• Iftekhar G,
• Reddy P,
• Matalia H,
• Balasubramanian D,
• Vemuganti GK.

Sudhakar and Sreekanth Ravi Stem Cell Biology Laboratory, L.V. Prasad Eye Institute, Banjara Hills, Hyderabad - 500 034, India.

BACKGROUND: The technique of transplantation of cultivated limbal epithelium rather than direct limbal tissue isa novel method of "cell therapy" involved in reconstructing the ocular surface in severe limbal stem cell deficiency [LSCD], caused by chemical burns. AIM: To describe a simple feeder-cell free technique of cultivating limbal epithelium on human amniotic membrane[HAM]. MATERIALS AND METHODS: The limbal tissues (2 mm) were harvested from patients with LSCD. These tissues were proliferated in vitro on HAM supplemented by human corneal epithelial cell medium and autologous serum. Cultures covering more > or = 50% area of 2.5 x 5 cm HAM were considered adequate for clinical use. The cultured epithelium was characterized by histopathology and immunophenotyping. RESULTS: A total of 542 cultures out of 250 limbal tissues were cultivated in the laboratory from January 2001 through July 2005. The culture explants showed that clusters of cells emerging from the edge of the explants in one-three days formed a complete monolayer within 10-14 days. In 86% of cultures (464 of 542), the growth was observed within one-two days. Successful explant cultures were observed in 98.5% (534 of 542 cultures) with 91% explant cultures showing an area of > or = 6.25 cm2 (6.25 - 12.5 cm2 range). The cultivated epithelium was terminated between 10-14 days for clinical transplantation. The problems encountered were inadequate growth (2 of 542) and contamination (2 of 542). CONCLUSIONS: We demonstrate a simple technique of generating a sheet of corneal epithelium from a limbal biopsy. This new technique could pave the way for a novel form of cell therapy.

PMID: 17102542 [PubMed - indexed for MEDLINE]

Expansive mortar-induced ocular injury.

• Balasubramanya R,
• Rani A;
• Madhusudan;
• Sangwan VS.

Cornea and Anterior Segment services, L.V. Prasad Eye Institute, Hyderabad, India. bsrmurthy@lvpei.org

We describe here a case of bilateral chemical injury (with an expansive mortar which is being used in recent times to cut the rocks). On examination limbal ischemia was more in the left eye (9 clock hours) than the right eye (2 clock hours). The case was managed by bilateral removal of foreign bodies, along with conjunctival resection and amniotic membrane transplantation in the left eye. At six-month follow-up, patient had best corrected visual acuity of 20/30 and 20/60 in the right and left eyes respectively. Since this being an occupational hazard, proper eye protection gear should be used by persons using this expansive mortar.

PMID: 17090881 [PubMed - indexed for MEDLINE]

Sequels, complications and management of a chemical burn associated with cement splash.

• Lim GC,
• Yeh LK,
• Lin HC,
• Hwang CM.

Department of Ophthalmology, Chang Gung Memorial, Taipei, ROC.

We present a case of successful superficial keratectomy and amniotic membrane grafting to re-establish ocular surface from denuded stroma and significant limbal ischemia caused by a cement splash. We fully documented a case report about the sequels, complications and management strategies of a chemical burn to the eyes associated with a cement splash. Slit lamp examination, visual acuity test as well as all common cultures and stains were performed to measure the outcome. Visual acuity significantly improved from 0.2 to best-corrected visual acuity 0.7 at the 5-month postoperative visit. The cornea regained its clarity. Total re-epithelialization of the injured area was observed. It is of primary importance to remove all the debris from a cement splash at the first available opportunity. Superficial keratectomy and amniotic membrane grafting may be the best methods for the re-epithelialization and reconstruction of the ocular surface.

PMID: 17051842 [PubMed - indexed for MEDLINE]

[Diseases of the adnexa in the tropics: amnion membrane transplantation for noninfectious trachoma-associated corneal ulcers]

• Bialasiewicz AA,
• Shenoy R,
• Al-Muniri A,
• Thakral A.

Department of Ophthalmology and School of Ophthalmic Technicians, College of Medicine and Health Sciences of the Sultan Qaboos University, 123 Al Khod, Muscat, Oman. alexander@squ.edu.om

BACKGROUND: Corneal ulcers with fornix shortening associated with late stages of cicatrizing trachoma contribute significantly to blindness in many developing countries. We report on the outcome of ocular surface and fornix reconstruction using amnion membrane transplantation. PATIENTS AND METHODS: From 2001 to 2005, cryopreserved human amnion membrane without mitomycin C was grafted to 25 eyes of 17 patients with trophic corneal ulcers and symblepharon (cicatrizing trachoma: 19 eyes of 14 patients, Stevens-Johnson syndrome: 4 eyes of 2 patients, alkali burns: 2 eyes of 1 patient) in a controlled case series. Follow-up was done up to 6 months. STATISTICS: Fischer's exact probability test. RESULTS: Of 25 eyes, 9 of 19 eyes with trachoma, 3 of 4 eyes with Stevens-Johnson syndrome, and 2 of 2 eyes with chemical burns showed complete reepithelialization and stromal recovery after 28-35 days (mean: 31+/-2.3 days). The primary success rate of trachoma eyes was not significantly different from the other indications (p=0.256). At 6 months post-op, 15 of 19 trachoma eyes (79%) compared to 2 of 6 non-trachoma eyes (33.3%) had developed a recurrence of symblephara (p=0.0592), and 13 of 15 eyes (86.6%) with a cicatricial trachoma compared to 1 of 6 with non-trachoma diagnosis experienced a recurrence of corneal vascularization (difference nonsignificant: p=0.1752). Persistent long-term reepithelialization was observed only in 1 of 19 trachoma eyes (5.3%) versus 4 of 6 non-trachoma eyes (66.7%, p=0.005); 3 of 19 trachoma eyes with a recurrence of ulcers had perforated after 6 months. CONCLUSIONS: Human amnion membrane without mitomycin C can be used for ocular surface reconstruction in selected patients with cicatrizing trachoma. Its efficacy in the long-term rehabilitation of cicatrizing trachoma seems to be limited due to the progressive scarring.

PMID: 16847650 [PubMed - indexed for MEDLINE]

[Amnion and ocular surface problems]

• Giasson CJ,
• Bouchard C,
• Boisjoly H,
• Germain L.

Ecole d'Optometrie, Universite de Montreal, CP 6128, Succursale Centre-ville, Montreal, Quebec, J1H 5N4 Canada. giassonc@opto.umontreal.ca

The amniotic membrane, the most internal placental membrane, has various properties useful in ophthalmology. Collected on delivery by elective Caesarean section, the amnion is prepared under sterile conditions, and, usually, cryopreserved until its use as a biological bandage or as a substrate for epithelial growth in the management of various ocular surface conditions. Specifically, the amnion is used to : (1) limit formation of adhesive bands between eyelids and eyeball (symblepharon) or the progression of a fibrovascular outgrowth towards the cornea (pterygium) or to (2) facilitate the healing of corneal ulcers, bullous keratopathy, and corneal stem cell deficiency. In this last condition, either hereditary or acquired after a thermal or a chemical burn, corneal stem cells, located at a transitional zone between the cornea and conjunctiva, are lost. These cells are essential for renewal of corneal epithelium in normal and in diseased states. The loss of these cells leaves the corneal surface free for invasion by conjunctival epithelium. Not only, does conjunctival epithelium support the development of vascularisation on the normally avascular cornea, but some conjunctival cells differentiate into mucus secreting goblet cells. Such a change in phenotype leads to loss of corneal transparency and visual disability. The removal of this fibro-vascular outgrowth in combination with transplantation of both amniotic membrane and corneal stem cells are used to treat this condition. The amnion stimulates the proliferation of less differentiated cells which have the potential to reconstruct the cornea. This potential is at the origin of the hypothesis that the amnion may provide an alternative niche for limbal stem cells of the corneal epithelium. It abounds in cytokines and has antalgic, anti-bacterial, anti-inflammatory and anti-immunogenic properties, in addition to allowing, like fetal skin does, wound healing with minimal scar formation. These desirable properties are responsible for the increasing use of amniotic membrane in ophthalmology. The complete understanding of the mechanisms of action of amniotic membrane for ocular surface diseases has yet to be understood. Once revealed by research, they may provide new pharmacological avenues to treat ocular surface diseases.

PMID: 16828041 [PubMed - indexed for MEDLINE]

Modified gunderson conjunctival flap combined with an oral mucosal graft to treat an intractable corneal lysis after chemical burn: a case report.

• Cheng KC,
• Chang CH.

Department of Ophthalmology, Kaohsiung Medical University Chung-Ho Memorial Hospital, Kaohsiung, Taiwan.

Following a severe chemical injury, persistent corneal melting presents as a threatening condition for loss of vision or the eyeball itself. Keratoplasty (both lamellar and penetrating) and amniotic membrane transplantation have been the usual modes of therapy. However, these may not halt the persistent melting process. We introduce here an alternative surgical procedure to resolve corneal melting and preserve the globe. This case concerns the right eye of a 36-year-old male who had suffered from severe ocular alkali chemical burns and sustained intractable corneal melting, despite receiving corneal transplants three times, a limbal stem cell transplantation once, a scleral graft twice, and amniotic membrane transplantation eight times. To circumvent the impending perforation, we performed a modified Gunderson conjunctival flap combined with an oral mucosal graft. The corneal melting was halted, and the eyeball was preserved. The combination of an oral mucosal graft to the modified Gunderson conjunctival flap provided an easy alternative to resolve a case of intractable corneal melting and impending perforation.

PMID: 16793561 [PubMed - indexed for MEDLINE]

Transplantation of reconstructed corneal layer composed of corneal epithelium and fibroblasts on a lyophilized amniotic membrane to severely alkali-burned cornea.

• Jang IK,
• Ahn JI,
• Shin JS,
• Kwon YS,
• Ryu YH,
• Lee JK,
• Park JK,
• Song KY,
• Yang EK,
• Kim JC.

Department of Ophthalmology, Chung-Ang University Hospital, Seoul, Korea.

The purpose of this article was to evaluate the graft efficacy of reconstructed corneal layer, composed of autologous corneal epithelium and fibroblasts on a lyophilized amniotic membrane (LAM), in a severely alkali-burned corneal model. After biopsy specimens were obtained from the left eyes of 24 rabbits, the corneal epithelial cells and fibroblasts were expanded in vitro and the corneal layer was reconstructed on LAM. Thirty-six eyes of rabbits underwent alkali burn (1 N NaOH, 30 s) to create a limbal deficiency and a deeply damaged corneal stroma. Four weeks later, group 1 underwent a graft of the reconstructed corneal layer composed of autologous corneal epithelium and fibroblasts on LAM. Group 2 was transplanted with a graft of the reconstructed autologous corneal epithelium, and group 3 served as a control without surgery. Wound healing and stabilization of the ocular surfaces occurred much faster in group 1 than in groups 2 and 3. The eyes in group 3 revealed typical limbal deficiencies with conjuctivalization and persistent corneal epithelial defects. However, the corneas in group 1 developed only mild peripheral neovascularization. Immunohistochemical staining in group 1 demonstrated that p63, cytokeratin 3, E-cadherin, transforming growth factor (TGF)-beta1, and collagen IV were expressed strongly in the corneal epithelium and basement membrane. On the basis of these results, transplantation of the reconstructed corneal layer, composed of autologous corneal epithelium and fibroblasts on LAM, partially accelerated the recovery of the alkali-injured rabbit ocular surface, and might be useful therapeutically for the treatment of patients with severely damaged cornea.

PMID: 16734593 [PubMed - indexed for MEDLINE]

Severe ocular injury resulting from chuna packets.

• Agarwal T,
• Vajpayee RB,
• Sharma N,
• Tandon R.

Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Science, New Delhi, India.

OBJECTIVE: To describe a mechanism of severe ocular alkali burns occurring as a result of bursting of chuna packets (edible calcium hydroxide paste), a popular additive to chewing tobacco in India. DESIGN: Retrospective case series. PARTICIPANTS: Twenty-one patients (25 eyes) who experienced ocular burns as a result of bursting of chuna packets. INTERVENTION: Patients were treated medically or with 1 or more of the following surgeries: symblepharon release, amniotic membrane grafting, allograft or autograft stem cell transplantation, or both, and large diameter lamellar keratoplasty. MAIN OUTCOME MEASURES: The main outcome measures were time interval between the injury and presentation, presenting visual acuity, grade of injury, management (medical therapy or surgical intervention), and final visual outcome at the last follow-up. RESULTS: The average age at time of injury was 8.4+/-5.5 years. The median visual acuity at presentation was light perception with projection. The ocular burns were grade 4 in 23 eyes. Eight of 25 eyes were treated medically, and the rest underwent 1 or more surgeries in the form of symblepharon release (n = 6), amniotic membrane grafting (n = 3), allograft or autograft stem cell transplantation (n = 6), and large diameter lamellar keratoplasty (n = 6). At the final follow-up (mean, 637+/-592 days), median visual acuity was 1/60. CONCLUSIONS: Bursting of chuna packets can cause severe ocular alkali burns in children. These patients carry a poor visual prognosis with both medical and surgical therapy.

PMID: 16603245 [PubMed - indexed for MEDLINE]

[Corneo-conjunctival alkali burn--case report]

• Buliga S,
• Carstocea B.

S. C. U. M. C., Bucuresti.

PMID: 16524124 [PubMed - indexed for MEDLINE]

[Significance of immediate affixation of a hard contact lens in the emergency treatment of severe alkali burns of the cornea (case report)]

• Spelsberg H,
• Sundmacher R.

Augenklinik, Universitatsklinikum Dusseldorf (Direktor. Prof. Dr. R. Sundmacher). Helga.Spelsberg@uni-duesseldorf.de

BACKGROUND: Severe alkali burns lead to massive limbal stem cell damage resulting in persistent epithelial defects, infiltration and stromal melting early in the disease process. A glued-on hard contact lens may serve as an "artificial epithelium" and protect the cornea from these complications. CASE REPORT: A 39-year-old male presented with severe lime burns in both eyes one week after injury. The right eye showed a totally denuded cornea and conjunctiva with circular paralimbic ischemia. In the left eye "only" two thirds of the cornea and adjacent conjunctiva and limbus were affected with less ischemia. Amniotic membrane transplantation was performed in both eyes but failed after four days already in the right eye. A hard contact lens was therefore glued on the right eye and allowed for visual acuity of 0.4 without correction in this primarily most heavily afflicted eye for 12 months duration. After removal of the contact lens, reepithelisation was quick, and function remained stable with addition of autologous serum eye drops. The primarily far less injured left eye, however, for which the amniotic membrane surgery was primarily judged to be adequate, could not be stabilised. The cornea perforated 4 weeks later necessitating a mini-keratoplasty plus a glued-on contact lens, and correctable vision never became better than 1/35. CONCLUSION: The clinical course confirms former observations that a glued-on hard contact lens is an effective treatment early after alkali burn and prevents the cornea from infiltration and melting. Moreover, two aspects merit consideration: first, with proper technique and timing of the gluing-on a patient may retain useful vision throughout the period of wearing the contact lens; second, for the long period during which the cornea was sealed by the contact lens, improper repopulation by conjunctival epithelium was inhibited, and proper corneal epithelium was given a chance for repopulation after recovery of the limbal area resulting in a stable surface and useful vision without additional keratoplasty measures.

PMID: 16308824 [PubMed - indexed for MEDLINE]

[Amniotic membrane transplantation for oculopalpebral and reconstructive surgery]

• Oberhansli C,
• Spahn B.

Hopital Ophtalmique Jules Gonin, avenue de France 15, case postale 133, CH-1000 Lausanne 7, Suisse. bspahn@bluewin.ch

INTRODUCTION: Amniotic membrane has been used for many years for ocular surface defects. It is also commonly used in laboratories for cellular growth. Amniotic membrane has antiadhesive properties, can promote epithelialization, and decrease neovascularization, inflammation, and fibrosis. There is no histocompatibility problem, as amniotic membrane has no HLA antigens. In this study, amniotic membrane transplantation was used for oculopalpebral and reconstructive surgery as an alternative to the oral mucous graft, particularly in the reconstruction of the conjunctival fornices after inflammatory disease, burns, conjunctival tumors, and enucleation with orbital implants. MATERIAL AND METHOD: Forty-eight interventions using amniotic membrane transplantation were done on 44 patients. In 16 cases conjunctival fornices were created or reconstructed, allowing the installation of an ocular prosthesis; 14 had reconstruction of fornices for inflammatory disease, or chemical or thermal burns; 11 had palpebral skin and conjunctival reconstruction (malformations or skin tumours); and seven cases had conjunctival reconstruction after conjunctival tumor excision. RESULTS: Thirty-nine cases presented good functional and cosmetic results. One case had no follow-up. Eight cases gave poor results: four cases of conjunctival fornix refection (with two irradiated cavities), three cases of fornix reconstruction after chemical burn, and one case in whom palpebral reconstruction partially failed (coloboma). DISCUSSION AND CONCLUSION: Functional and cosmetic results were good for 39 cases, allowing ocular prosthetic equipment when necessary. In nine cases, two complete fornix retractions and two partial fornix retractions were observed; one palpebral reconstruction for malformation partially failed; and four cases (two with amniotic membrane and two with oral mucus graft) required a second surgery to obtain a satisfactory result. Amniotic membrane transplantation is an excellent alternative material to oral mucous membrane in oculopalpebral and reconstructive surgery except when graft rigidity is necessary. Its use is more difficult in cases of chemical burns or after orbital irradiation.

PMID: 16208227 [PubMed - in process]

Evaluation of amniotic membrane transplantation as an adjunct to medical therapy as compared with medical therapy alone in acute ocular burns.

• Tamhane A,
• Vajpayee RB,
• Biswas NR,
• Pandey RM,
• Sharma N,
• Titiyal JS,
• Tandon R.

Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

PURPOSE: To evaluate the role of amniotic membrane transplantation (AMT) in acute ocular burns. DESIGN: Prospective, randomized, controlled clinical trial. PARTICIPANTS AND CONTROLS: Patients with grade II to IV ocular burns within 3 weeks of injury were recruited. Thirty-seven patients, 7 of whom had bilateral involvement (total, 44 eyes), participated in the trial. Twenty eyes were included in group A (AMT) and 24 eyes were included in group B (controls). INTERVENTION: The eyes in the AMT group underwent AMT in addition to conventional medical therapy. In the control group, only conventional medical therapy was instituted. MAIN OUTCOME MEASURES: The patients' subjective assessments of relief of ocular discomfort, healing of the corneal epithelial defect, visual acuity, extent of corneal vascularization, formation of symblepharon, and tear function tests. RESULTS: At day 1, subjective ocular discomfort scores were reduced significantly in eyes with moderate burns in the AMT group compared with controls (P = 0.05), but there was no difference between the 2 groups in eyes with severe burns. The log mean percentage reduction in size of epithelial defect by day 7 was 7.43+/-0.89 after AMT and 6.23+/-1.10 with medical treatment alone in moderate grade burns at day 7 (P = 0.01), but there was no difference between the 2 groups in eyes with severe burns. There was no overall difference in the final visual acuity, symblepharon formation, corneal vascularization, and tear function tests between the 2 groups over the next 3 months and further follow-up. There was a high dropout rate for long-term follow-up. CONCLUSIONS: Amniotic membrane transplantation in eyes with acute ocular burns has advantages in terms of reduction of pain and promotion of early epithelialization in patients with moderate grade burns, but not so in severe burns. There seems to be no definite advantage to AMT over medical therapy alone in terms of improvement in visual acuity, appearance of symblepharon, corneal vascularization, and results of tear function tests on short-term follow-up.

PMID: 16198422 [PubMed - indexed for MEDLINE]

Limbal graft and/or amniotic membrane transplantation in the treatment of ocular burns.

• Ivekovic R,
• Tedeschi-Reiner E,
• Novak-Laus K,
• Andrijevic-Derk B,
• Cima I,
• Mandic Z.

Department of Ophthalmology, University Hospital Sestre milosrdnice, Zagreb, Croatia. renata.ivekovic@zg.tel.hr

Limbal stem cell transplantation (LSCT) and amniotic membrane transplantation may improve corneal recovery after a chemical burn. Amniotic membrane was applied as a patch in 5 eyes; LSCT from healthy contralateral eye was performed in 6 eyes, and a combination of these techniques was performed in 4 eyes. There were no complications during surgical procedure. Epithelization was completed after 2 weeks in patients with LSCT, and after 3 weeks in the amniotic membrane transplantation group. Visual acuity improved in all patients. No complication was observed on either the donor or the recipient eye during a follow-up period of >13 months in all groups. Amniotic membrane is effective in promoting re-epithelization and reducing inflammation when applied alone in patients with 3- to 6-hour limbal involvement, as well as combined with LSCT in patients with >6-hour limbal ischemia. LSCT is an effective procedure for rehabilitation after severe chemical trauma of the eye with more than 50% limbal involvement. Copyright 2005 S. Karger AG, Basel.

PMID: 16123557 [PubMed - indexed for MEDLINE]

[Corneal combined amniotic membrane transplantation for early severe alkali chemical injury of the eye]

• Xi XH,
• Cao YN,
• Tang LS,
• Qin B,
• Jiang DY.

Department of Ophthalmology, Second Xiangya Hospital, Central South University, Changsha 410011, China. xhx96@yahoo.com.cn

OBJECTIVE: To investigate the effect of lamella corneal transplantation combined amniotic membrane transplantation for the early severe alkali burns of eyes. METHODS: Twenty-three eyes with an over second-degree acute corneal alkali injury in 2 weeks were treated by lamella corneal transplantation combined amniotic membrane transplantation. After the operation the patients were treated with an intense and prolonged regimen of topical steroids and topical and systemic vitamin C. All patients were followed up for 6-12 months. RESULTS: Seven eyes were cornea transparent, 10 semi-transparent, and 6 opaque in the 23 eyes, respectively. The visual acuity of 3 eyes was better than 0.3, that of 5 eyes was between 0.25 to 0.1, and that of the other 15 eyes was below 0.1. No eye was enucleated due to the corneoscleral melting. CONCLUSION: Lamella corneal transplantation combined amniotic membrane transplantation may clear away the necrotic tissues and cells of corneal or conjunctiva, prevent and reduce the complication, and improve the prognosis of the patients.

PMID: 16114563 [PubMed - indexed for MEDLINE]

Reconstruction of chemically burned rat corneal surface by bone marrow-derived human mesenchymal stem cells.

• Ma Y,
• Xu Y,
• Xiao Z,
• Yang W,
• Zhang C,
• Song E,
• Du Y,
• Li L.

Peking University Stem Cell Research Center and Cell Biology Department, The 3rd Hospital, Peking University Health Science Center, 38 Xueyuan Rd., Haidian, Beijing, China 100083.

To examine whether transplantation of human mesenchymal stem cells (MSCs) could reconstruct the corneal damage and also whether grafted MSCs could differentiate into corneal epithelial cells, we isolated MSCs from healthy donors. After growth and expansion on amniotic membrane, cells were transplanted into rat corneas 7 days after chemical burns. Reconstruction of the damaged cornea and the rat vision were measured once a week by slit lamp and by an optokinetic head-tracking instrument, respectively. Corneas were then cut out, fixed, and imbedded for immunofluorescent study of the expression of keratin 3 and keratin-pan as epithelial cell markers. Expression of CD45, interleukin 2, and metalloproteinase-2 was also investigated for inflammation and inflammation-related angiogenesis. The data showed that transplantation of MSCs, like limbal epithelial stem cells, successfully reconstructed damaged rat corneal surface. Interestingly, the therapeutic effect of the transplantation may be associated with the inhibition of inflammation and angiogenesis after transplantation of MSCs rather than the epithelial differentiation from MSCs. This study provides the first line of evidence that MSCs can be used for reconstruction of damaged corneas, presenting a new source for autotransplantation in the treatment of corneal disorders.

PMID: 16109757 [PubMed - indexed for MEDLINE]

[Severe limbal deficiency treated by combined limbal allograft and amniotic membrane transplantation]

• Lopez-Garcia JS,
• Rivas L,
• Garcia-Lozano I.

Hospital Cruz Roja y Hospital Ramon y Cajal, Madrid, Spain. docsantilopez@hotmail.com

PURPOSE: To study the ocular surface evolution in patients with severe limbal deficiency treated with limbal allograft transplantation (LT) combined with amniotic membrane transplantation (AMT). METHODS: We studied 14 eyes with severe limbal deficiency, treated with LT combined with AMT (LT + AMT). We studied the morphology of the limbocorneal epithelium and stroma by impression cytology and limbal biopsy. RESULTS: Visual acuity showed a mean improvement of 0.4 at 24 months of follow-up. Corneal clarity and loss of neovascularization were markedly improved after 3 and 6 months, respectively. We did not find corneal conjuntivalization on cytology performed 6 months after surgery, except in a patient with chemical burn. Cytology and limbal biopsy performed nine months after surgery showed an epithelium and limbocorneal stroma near to normality. Squamous metaplasia was worse in patients with Stevens-Johnson syndrome and ocular cicatricial pemphigoid after 12 months, but was similar in patients with chemical burns and improved in patients with aniridia. CONCLUSIONS: LT + AMT is a very effective procedure for restoring the ocular surface integrity in patients with severe limbal deficiency. This combination improves the outcomes obtained with LT alone.

PMID: 16059817 [PubMed - indexed for MEDLINE]

[Clinical management of severe ocular surface disease]

• Stoiber J,
• Grabner G.

Universitatsklinik fur Augenheilkunde und Optometrie an der Paracelsus Medizinischen Privatuniversitat Salzburg. j.stoiber@salk.at

Severe ocular surface diseases, such as Stevens-Johnson syndrome, ocular cicatricial pemphigoid or severe ocular burns may result in a significant loss of corneal stem cells, eventually leading to vision impairment or even corneal blindness. In case of unilateral involvement, limbal autografting, by means of transplanting limbal stem cells from the healthy fellow eye, has proved to be an effective procedure for restoring the integrity of the ocular surface. Limbal allografts may be performed in patients with bilateral disease, however, systemic immunosuppression is mandatory in these cases, with a long-term outcome that is frequently reduced compared to limbal autografts due to acute or chronic graft rejection. In recent years, amniotic membrane transplantation has been successfully employed as an additional tool in ocular surface reconstruction. The AlphaCor synthetic cornea, which is made of flexible acrylic may be considered as an alternative in patients with repeated corneal graft failures. Both limbal transplantation and the AlphaCor have been shown to be effective in eyes with an adequate tear film, but are most likely to fail in severe dry eyes or in patients with cicatrising diseases. Such conditions are the domain of keratoprostheses (KPros) with rigid optics, which certainly can be considered as the 'last resort' to restore vision in patients with profound corneal blindness not amenable to conventional corneal and limbal grafting. The osteo-odonto-keratoprosthesis according to Strampelli and modified by Falcinelli makes use of a "biological" support consisting of a longitudinal section of one of the patient's teeth that is also supported by the surrounding alveolar bone tissue. Compared to other devices favourable long-term results have been reported. In patients lacking any usable teeth, implantation of a keratoprosthesis with haptics made of Dacron (Pintucci-KPro) or tibial bone (Temprano-KPro) might be considered.

PMID: 16034721 [PubMed - indexed for MEDLINE]

Erratum in:

Chin Med J (Engl). 2005 Sep 20;118(18):1563. Ma, Yang-ling [corrected to Ma, Yan-ling].

Transplantation of human limbal cells cultivated on amniotic membrane for reconstruction of rat corneal epithelium after alkaline burn.

• Song E,
• Yang W,
• Cui ZH,
• Dong Y,
• Sui DM,
• Guan XK,
• Ma YL.

Department of Ophthalmology, First Affiliated Hospital, Jilin University, Changchun 130021, China.

BACKGROUND: The transplantation of limbal epithelial cells cultivated on amniotic membrane is a newly developed treatment for limbal stem cell deficiency. The purpose of our study was to investigate the biological characteristics of limbal epithelial cells and evaluate the effect of transplantation of cultivated human limbal epithelial cells on ocular surface reconstruction in limbal stem cell deficiency rat model. METHODS: Human limbal cells were isolated and cultivated in vitro. Cytokeratins 3, 12, and 19 (K3, K12 and K19) and p63 were detected by immunofluorescent staining or RT-PCR. BrdU labelling test was used to identify the slow cycling cells in the cultures. Limbal stem cell deficiency was established in rat cornea by alkali burn. Two weeks after injury, the rats received transplants of human limbal stem cells cultivated on amniotic membrane carrier. The therapeutic effect was evaluated by slit lamp observation, Hemotoxin and Eosin (HE) staining and immunofluorescent staining. RESULTS: On day 7 in primary culture, p63 and K19 were strongly expressed by most cells but only a few cells expressed K3. On days 14 and 21, p63 and K19 were still expressed by a majority of cells, but the expressive intensity of p63 decreased in a number of cells, while the proportion of K3 positive cells increased slightly and some cells coexpressed p63 and K3. RT-PCR showed that gene expression of both p63 and K12 were positive in cultivated limbal cells, but in mature superficial epithelial cells, only K12 was detected. BrdU labelling test showed that most cells were labelled with BrdU after 7 days' labelling and BrdU label retaining cells were observed after chasing for 21 days with BrdU free medium. For in vivo test, slit lamp observation, HE staining and immunofluorescent staining showed that the rats receiving transplant of human limbal stem cells cultivated on amniotic membrane grew reconstructed corneas with intact epithelium, improved transparency and slight or no neovascularization. A majority of epithelial cells of the reconstructed cornea were positive to antihuman nuclear antibody and cells expressing K3 were found mainly in superfacial epithelium. CONCLUSIONS: Limbal stem cells can be cultivated in vitro: the cells are characterized by high proliferation and slow cycling and identified as p63/K19 positive and K3/K12 negative. During culture, some stem cells can proliferate and differentiate into mature cornea epithelial cells. Amniotic membrane is a suitable carrier for limbal stem cells. Transplantation of human limbal stem cells cultivated on amniotic membrane can functionally reconstruct rat cornea with limbal stem cell deficiency.

PMID: 15978194 [PubMed - indexed for MEDLINE]

Phacoemulsification after penetrating keratoplasty with autologous limbal transplant and amniotic membrane transplant in chemical burns.

• Arora R,
• Narayanan R,
• Jain S,
• Raina UK,
• Mehta DK.

Cornea Service, Guru Nanak Eye Center, Maulana Azad Medical College, New Delhi, India. dr_rituarora@yahoo.com

We report a patient who had earlier penetrating keratoplasty with amniotic membrane transplant and autologous limbal cell transplant for chemical injury who underwent cataract surgery by phacoaspiration. A posterior limbal incision with corneal valve was made superotemporally with extreme caution to avoid damage to the limbal graft. Aspiration flow rates and vacuum were kept low to avoid any turbulence during surgery. A 6.0 mm optic diameter acrylic foldable intraocular lens was inserted in the bag. The patient achieved a best-corrected visual acuity of 6/12 at 10 months' follow-up with a clear corneal graft. We conclude that caution during wound construction and phacoaspiration can help preserve corneal and limbal graft integrity in patients undergoing cataract surgery after corneal graft and limbal transplantation.

PMID: 15976468 [PubMed - indexed for MEDLINE]

Ocular surface reconstruction using amniotic membrane allograft for severe surface disorders in chemical burns: case report and review of the literature.

• Fournier JH,
• McLachlan DL.

Department of Ophthalmology, Northwestern University Medical School, Chicago, Illinois, USA.

Ocular chemical burns are frustrating disorders. The conjunctival surface provides a defense mechanism protecting against infection, desiccation, and injury, being centered in the epithelial lining of the ocular surface. A monocular case of severe acid chemical burn is presented. Postinjury-stratified epithelium in the inferior cul-de-sac with eye movement and contact with the lower eyelid resulted in repeated corneal abrasions, vascularization, and scarring. This vexing problem was recalcitrant to medical and conservative treatment because of delayed and prevented healing from continuous conjunctival abrasive irritation inflicted on the corneal surface. Amniotic membrane allograft transplantation in destructive lesions of the conjunctiva acts as a reconstructive graft in nonhealing lesions of the ocular surface. Successful placement of an amniotic membrane allograft (AmbioDry) in conjunction with excision of an extensive amount of stratified epithelial scar tissue was accomplished. Marked improvement followed surgery, and a definitive solution resulted for the severely burned right eye.

PMID: 15912900 [PubMed - indexed for MEDLINE]

Deep anterior lamellar keratoplasty combined with autologous limbal stem cell transplantation in unilateral severe chemical injury.

• Fogla R,
• Padmanabhan P.

Sankara Nethralaya, Medical and Vision Research Foundations, Chennai, Tamil Nadu, India. fogla@eth.net

PURPOSE: To evaluate the efficacy of deep anterior lamellar keratoplasty combined with autologous limbal stem cell transplantation for ocular surface reconstruction and visual rehabilitation in eyes with unilateral, late-stage, severe chemical injury. METHODS: This was a retrospective, noncomparative, interventional case series that included 7 eyes of 7 patients, with severe unilateral late stage chemical injury, exhibiting corneal vascularization, conjunctivalization, and extensive corneal scarring were treated at the C. J. Shah Cornea Service, Sankara Nethralaya, a tertiary care center. Surgical procedures included releasing symblepharon adhesions, excising epibulbar fibrous tissue, superficial keratectomy to remove fibrovascular tissues over cornea, deep anterior lamellar dissection, grafting a lamellar corneal button, and transplanting autologous limbal graft, with or without amniotic membrane transplantation. The main outcome measures were relief of patient symptoms, postoperative recovery of the ocular surface, corneal clarity, corneal epithelial stability, and best corrected visual acuity. RESULTS: The mean duration between the injury and surgery was 24.4 +/- 21.8 months. No intraoperative complications were noted. Successful epithelialization was achieved in all eyes. The reconstructed corneal surface remained stable during the entire follow-up period (mean follow-up, 16.57 +/- 5.12 months). All patients had resolution of ocular symptoms. Remarkable improvement in vision was noted in all (85.7%) except 1 eye in which recovery was limited due to amblyopia. The average best corrected visual acuity at last follow-up was 20/50. No complications were noted in the donor fellow eye. CONCLUSIONS: DALK combined with autologous limbal transplantation can restore a healthy, stable ocular surface, besides providing a clear cornea that remarkably improves the visual acuity, in patients with unilateral, late stage, severe chemical injury.

PMID: 15829798 [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]

Delayed healing of corneal epithelium after phototherapeutic keratectomy for lattice dystrophy.

• Das S,
• Langenbucher A,
• Seitz B.

Department of Ophthalmology, University of Erlangen-Nurnberg, Erlangen, Germany.

PURPOSE: To evaluate the time period necessary for complete epithelial healing after phototherapeutic keratectomy (o-PTK) carried out for various superficial corneal opacities. SUBJECTS AND METHOD: A total of 197 eyes were divided into 9 groups: group 1, Cogan dystrophy including recurrences (n = 15); group 2, Reis Bucklers dystrophy including recurrences (n = 12); group 3, granular dystrophy including recurrences (n = 63); group 4, lattice dystrophy including recurrences (n = 19); group 5, macular dystrophy including recurrences (n = 10); group 6, herpetic scars (n = 5); group 7, corneal scars of nonherpetic origin (including scrofulous, traumatic, central keratoconus, post-pterygium surgery) (n = 31); group 8, Salzmann nodular degeneration (n = 22); and group 9, miscellaneous (such as bullous keratopathy, acute chemical burn, corneal degeneration) (n = 20). After o-PTK, patients were examined daily at the slit lamp using fluorescein and blue light. The time period necessary for complete healing of the epithelial defect was compared among these groups. Delayed healing was considered where the epithelium was not closed after 7 days. RESULT: One hundred sixty-one eyes (95%) healed within 7 days. Overall, 63%, 80%, and 85% of epithelial defects were closed within 3, 4, and 5 days, respectively. Out of 9 eyes that had delayed healing, 6 eyes (67%) belonged to lattice dystrophy category. Mean time taken for healing in group 4 (8.6 +/- 8.4 days) was significantly longer than those in group 1 (3.0 +/- 1.5 days, P = 0.009), group 2 (3.7 +/- 3.1 days, P = 0.03), group 3 (3.1 +/- 1.5 days, P = 0.001), group 5 (2.7 +/- 0.8 days, P = 0.01), group 7 (3.6 +/- 2.4 days, P = 0.007), group 8 (3.3 +/- 1.3 days, P = 0.009), and group 9 (3.0 +/- 1.9 days, P = 0.011). CONCLUSION: Eyes with lattice corneal dystrophy suffered from delayed epithelial healing after o-PTK. In addition to adequate counseling, these patients should be followed up closely until complete closure of the epithelium to avoid ulceration, scarring, or even infection. These eyes might need additional treatment such as hyaluronic acid drops, autologous serum drops, simultaneous amniotic membrane patching, or even temporary lateral tarsorrhaphy.

PMID: 15778599 [PubMed - indexed for MEDLINE]

[Medical treatment of ocular burns]

• Hoang-Xuan T,
• Hannouche D.

Fondation Ophtalmologique A. de Rothschild et Hopital Bichat, Paris, France. thx@fo-rothschild.fr

Chemical burns, especially alkali burns, can induce severe damage to the eye, not only of its surface, but also of its deep structures. Ocular chemical burns require urgent medical care and sometimes surgery. Medical management of chemical burns of the ocular surface includes controlling the inflammation of the underlying corneal stroma, preserving limbal vasculature, and restoring the limbal stem cell population if necessary, as early as the 3rd week following the injury, which sometimes also requires surgery consisting for the most part of amniotic membrane and/or limbal stem cell transplantation.

PMID: 15687933 [PubMed - indexed for MEDLINE]

[Keratolimbal allografts and multilayer amniotic membrane transplantation in the treatment of ocular surface disease due to chemical burns]

• Jurowski P,
• Gos I.

Z Kliniki Okulistyki i Rehabilitacji Wzrokowej Uniwersyteckiego Szpitala Klinicznego nr 2 im. WAM Uniwersytetu Medycznego w Lodzi.

PURPOSE: To analyze the functional effect and to present the technique of keratolimbal allograft and multilayer amniotic membranetransplantation for the treatment of ocular surface disease after heavy chemical burn. MATERIAL AND METHODS: Treatment comprised 3 eyes of 2 patients suffering form ocular surface deficiency after chemical (acid) burn. Surgeries were provided under local anesthesia. After circumferential peritomy and removal of fibrovascular layer, stem cells in the fashion of keratolimball crescent allograft, following by multilayer amniotic membrane transplantation were performed. RESULTS: 3 months after surgery the corneal surface was covered with fully differentiated epithelium in all patients. In two of three patients, improvement of the visual acuity was also observed. However, in one eye despite good epithelium maintenance the stroma was still not transparent. CONCLUSION: Keratolimbal allograft with multilayer amniotic transplantation is interesting method of ocular surface reconstruction. Combined procedure with use of two different tissues seems to be relevant among patients with bilateral ocular surface dysfunction with complete destruction of stem cells after chemical burn.

PMID: 15646487 [PubMed - indexed for MEDLINE]

Amniotic membrane graft: histopathological findings in five cases.

• Tosi GM,
• Traversi C,
• Schuerfeld K,
• Mittica V,
• Massaro-Giordano M,
• Tilanus MA,
• Caporossi A,
• Toti P.

Department of Ophthalmology and Neurosurgery, University of Siena, Siena, Italy.

Amniotic membrane transplantation (AMT) is an effective treatment for ocular surface reconstruction; however, the mechanisms through which amniotic membrane (AM) exerts its effects as well as its fate after transplantation have not been entirely elucidated and have been investigated only in part. We evaluate the integration of AM in the host cornea in five patients who underwent AMT as the result of Bowen's disease, band keratopathy, radio- or cryotherapy-induced keratopathy, chemical burn or post-herpetic deep corneal ulcer with descemetocele. Due to persistent opacification in four cases and a progressing tumor in one case, penetrating keratoplasty (PK) and enucleation were performed as early as 2 months and up to 20 months after AMT. The corneas were analyzed histopathologically. To evaluate AM remnants, corneas were stained with periodic acid Schiff's reaction (PAS), Alcian blue, and Gomory and Masson trichrome; immunostaining including collagens III and IV antibodies was also performed. None of the corneas showed remnants of AM. In all cases, we observed discontinuity of Bowman's membrane. In three cases, the corneal epithelium was completely restored, ranging from three to six cell layers. In the other two cases, we detected an intense inflammatory reaction with rich neovascularization; the epithelial surface of the central cornea was completely restored, while at the periphery of the cornea goblet mucus-producing cells were present. Although clinically useful in all cases, restoration of a stable corneal epithelium through AMT is limited by the extent and severity of limbal stem cell deficiency (LSCD). The lack of histologically documented AM remnants in our cases seems to explain the efficacy of AMT more through its biological properties than through its mechanical properties. 2004 Wiley-Liss, Inc.

PMID: 15481059 [PubMed - indexed for MEDLINE]

Transplantation of cultivated autologous oral mucosal epithelial cells in patients with severe ocular surface disorders.

• Nakamura T,
• Inatomi T,
• Sotozono C,
• Amemiya T,
• Kanamura N,
• Kinoshita S.

Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kawaramachi Hirokoji, Kamigyo-ku, Kyoto 602-0841 Japan. tnakamur@ophth.kpu-m.ac.jp

BACKGROUND/AIMS: To determine outcomes of transplants of cultivated autologous oral epithelial cells in patients with severe ocular surface disorders. METHODS: The eyes (n = 6) of four patients with Stevens-Johnson syndrome (three eyes) or chemical burns (three eyes) were studied. Autologous oral epithelial cells, grown for 2-3 weeks on a denuded amniotic membrane carrier in the presence of 3T3 fibroblasts, were air lifted. The resultant sheet was transplanted onto the damaged eye, and acceptance of the sheet by the corneal surface was confirmed 48 hours after surgery. The success of ocular surface reconstruction, graft survival, changes in visual acuity, and postoperative complications were assessed and the quality of the cultivated oral epithelial sheet was evaluated histologically. RESULTS: At 48 hours after transplant, the entire corneal surface of all six eyes was free of epithelial defects indicating complete survival of the transplanted oral epithelium. Visual acuity was improved in all eyes. During follow up (mean 13.8 (SD 2.9) months), the corneal surface remained stable, although all eyes manifested mild peripheral neovascularisation. CONCLUSIONS: Autologous oral epithelial cells grown on denuded amniotic membrane can be transplanted to treat severe ocular surface disorders.

PMID: 15377551 [PubMed - indexed for MEDLINE]

Analysis of p63 and cytokeratin expression in a cultivated limbal autograft used in the treatment of limbal stem cell deficiency.

• Harkin DG,
• Barnard Z,
• Gillies P,
• Ainscough SL,
• Apel AJ.

Tissue BioRegeneration and Integration Program, Institute for Health and Biomedical Innovation, Queensland University of Technology, 2 George Street, Brisbane 4000, Australia. d.harkin@qut.edu.au

AIM: To investigate the expression of p63 and cytokeratins throughout the course of producing a cultivated autograft of limbal epithelial cells. METHODS: A 75 year old male with a severe alkali burn to his right eye received two cultivated autografts of limbal epithelial cells on amniotic membrane followed by a corneal allograft. Immunostaining for p63 and cytokeratins was performed during ex vivo expansion with 3T3 fibroblasts, following subcultivation on amniotic membrane, and on the excised corneal button. RESULTS: Cultures grown in the presence of 3T3 fibroblasts or on amniotic membrane displayed positive staining for keratins 14 and 19, and p63, but poor staining for keratin 3 (K3). The excised corneal button possessed a stratified epithelium of K3 positive cells residing on amniotic membrane. CONCLUSIONS: Our results document for the first time the co-expression of cytokeratins 14 and 19 with p63 in a cultivated limbal graft. These data support the conclusion that cultivated grafts of limbal epithelium contain predominantly undifferentiated cells with the potential to regenerate a normal corneal epithelium.

PMID: 15317707 [PubMed - indexed for MEDLINE]

Successful primary culture and autologous transplantation of corneal limbal epithelial cells from minimal biopsy for unilateral severe ocular surface disease.

• Nakamura T,
• Inatomi T,
• Sotozono C,
• Koizumi N,
• Kinoshita S.

Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan. tnakamur@ophth.kpu-m.ac.jp

BACKGROUND: Patients with severe unilateral ocular surface disease require reconstruction of the damaged ocular surface. We succeeded in culturing primary corneal limbal epithelial cells taken from minimal biopsy and, once grown, transplanting them on denuded amniotic membrane (AM). METHODS: Autologous corneal limbal epithelial cells from a 3 mm(2) biopsy of the uninjured eye were grown for 3 weeks on a denuded AM carrier. The resultant sheet was then transplanted onto the unilateral severely chemically injured eye. RESULTS: Minimal biopsy showed the autologous cultivated corneal epithelial cells to have 4-5 layers of sufficient stratification and to be well differentiated. At 19 months post-transplantation, the ocular surface epithelium was stable and there were no epithelial defects. CONCLUSION: We document that it is possible to produce sufficiently stratified, well differentiated, autologous cultivated corneal limbal epithelium on AM from a minimal biopsy of the donor eye and to transplant it onto the injured eye.

PMID: 15291944 [PubMed - indexed for MEDLINE]

Amniotic membrane transplantation in acute chemical burns.

• Arora R,
• Mehta D,
• Jain V.

Cornea Services, Guru Nanak Eye Center, New Delhi 110002, India. aroraj@del3.vsnl.net.in

PURPOSE: To evaluate the outcome of fresh amniotic membrane transplantation (AMT) for ocular surface reconstruction in acute chemical burns. METHODS: A prospective study of 15 consecutive eyes with acute chemical burns was performed. In all, 10 eyes had lime burns and five eyes had acid burns. There were three eyes of grade II, four eyes of grade III and eight eyes of grade IV burns. AMT was performed within 3 weeks of injury. RESULTS: Patients were followed up for 10.14 +/- 4.41 months. All patients had immediate relief of pain postoperatively. Of 15 eyes, nine (60%) showed epithelialization within 1-4 weeks (15.33 +/- 9.91 days). The final visual acuity improved in 10 of 15 eyes (66.66%). Eyes with burns of grade II and III showed more visual improvement than those with grade IV burns. None of the eyes showed perforation. Symblepharon was seen in nine of 15 eyes (60%). Of 15 eyes, 12 (80%) experienced limbal stem cell deficiency and showed superficial corneal vascularization. CONCLUSIONS: Amniotic membrane transplantation with fresh amniotic membrane increases patient comfort and reduces inflammation. In mild burns, AMT alone restores corneal and conjunctival surfaces. In moderate to severe burns, it probably reduces conjunctival scarring sequelae, but does not prevent the sequelae of limbal stem cell deficiency that requires further limbal stem cell transplantation. In the acute stage, amniotic membrane transplantation probably has a protective role against the progressive melting and perforation.

PMID: 15286672 [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]

An investigation of removed cultivated epithelial transplants in patients after allocultivated corneal epithelial transplantation.

• Cooper LJ,
• Fullwood NJ,
• Koizumi N,
• Nakamura T,
• Kinoshita S.

Institute of Environmental and Natural Sciences, Lancaster University, LA1 4YQ, Lancaster, UK.

OBJECTIVE: To investigate the ultrastructural changes of removed cultivated corneal epithelial transplants using scanning and transmission electron microscopy. METHODS: Allocultivated corneal epithelial transplantation, using an amniotic membrane carrier, was carried out on 3 patients. The primary diagnoses consisted of 1 with acute-phase chemical burn, one with drug-induced pseudopemphigoid, and 1 with Stevens-Johnson syndrome. After a period of several months the transplants were removed from these patients because of graft opacities. The removed transplants were then prepared for examination by scanning and transmission electron microscopy. RESULTS: In all 3 cases there was a similar pattern of findings: the amniotic membrane remained intact, although it had become partially vascularized and invaded by keratocytes. Inflammatory cells were present in the epithelial layer and within the amniotic membrane. Most of the amniotic membrane was covered by conjunctival epithelial cells and goblet cells. Only a few areas of normal cultivated corneal epithelial cells were found. CONCLUSIONS: We suggest that the process of allograft rejection is responsible for the corneal epithelial loss and that this is followed by conjunctival invasion onto the amniotic membrane.

PMID: 15084855 [PubMed - indexed for MEDLINE]

[Limbal stem cell transplantation from HLA-compatible living donors. Long term observation]

• Wylegala E,
• Tarnawska D,
• Wroblewska EM.

Oddzialu Okulistyki Okregowego Szpitala Kolejowego w Katowicach.

PURPOSE: The assessment of clinical outcome in patients after Ir-CLAL procedure. MATERIALS AND METHODS: Retrospective, interventional case series including 11 patients (12 eyes), all with non-ambulatory visual acuity (from light perception to hand movements). Mean age was 39.4 years (ranging from 18 to 76 years). In 7 eyes Limbal Stem Cells Deficiency (LSCD) resulted from chemical burn, in 2 eyes from ocular cicatricial pemphigoid, in one eye from Stevens-Johnson syndrome (SJS). In one eye congenital LSCD was diagnosed and in another one post-inflammatory LSCD. Mean follow-up was 16.2 months (from 10 to 32). Among donors prospective class I HLA matching was performed. Maximal two mismatches were accepted. General immunosuppressive therapy was switched-on in all subjects. Surgical excision of corneal pannus with clearing of limbal area was performed. Five clock hours stem cells tissue grafts from living related donors were harvested and transplanted to the recipient eye. Three penetrating keratoplasty, one deep lamellar keratoplasty and seven amniotic membrane transplantations were additionally performed. Main outcome measures were graft survival as a restoration of corneal epithelium, visual acuity improvement and complication in donors and recipients. Kaplan-Meyer survival curve and generalized Peto test were used for comparison. RESULTS: The graft survival was 83.6% in mean 20.3 months follow-up (from 10 to 32 months). Two cases of graft failure concern eye with SJS and eye with PKP regrafting after chemical burn. Visual improvement in 7 cases (58.3%), the same visual acuity in 4 cases (33.3%) and deterioration one case (8.3%) were noted. Ambulatory vision in 50% of patients was achieved. Graft rejection syndrome in four eyes was noticed also when ideal matching and CsA serum level 220 ng/ml. Two cases were treated with success and another two grafts failed. No complications in donors eyes were noticed. Impression cytology in eyes with successful grafts not related to pathological changes. CONCLUSIONS: Lr-CLAL are effective in ocular surface restoration. Living-related donors are suitable source of stem cells for cultivation in vitro. The prognosis for stem cells grafting is definitely worse when eyelid anomaly and adhesions exist.

PMID: 15049259 [PubMed - indexed for MEDLINE]

Limbal autograft and allograft transplantations in patients with corneal burns.

• Ozdemir O,
• Tekeli O,
• Ornek K,
• Arslanpence A,
• Yalcindag NF.

Department of Ophthalmology, Ankara University School of Medicine, Turkey.

AIM: To investigate and compare the surgical outcomes of limbal autograft and limbal allograft transplantations in patients with corneal burns. METHODS: In total, 20 patients (n=22 eyes) with chemical burn and two patients (n=2 eyes) with thermal burn were included in this study. Limbal autograft or limbal allograft transplantation surgery was performed in all patients. HLA-typing was tested before allograft surgeries. Limbal allografting was performed in all eyes using donor tissue from live relatives. Systemic cyclosporine A was administered for immunosuppression. RESULTS: The corneal surface was successfully reconstructed in all eyes (100%) after limbal autografting, two eyes required additional amniotic membrane transplantation and one eye required allografting. The mean follow-up period for limbal autografts was 13.9 +/- 7.0 months. Limbal allografting failed to reduce corneal vascularity and opacification in five (55.6%) eyes and was successful only in four (44.4%) eyes (mean follow-up 16.2 +/- 11.2 months) (P=0.002). In all, 15 eyes undergoing limbal autografting completed re-epithelialization of the cornea at a mean of 35.6 +/- 60.2 days. The mean epithelial healing time in nine eyes undergoing limbal allografting was 13.0 +/- 7.3 days (P=0.525). After limbal autografting, functional vision (> or =1/10) was attained in 12 (80%) eyes. Only one eye (11.1%) achieved functional vision after limbal allografting (P=0.036). Penetrating keratoplasty was performed in three patients following limbal allografting. No cyclosporine-associated side effects were observed. CONCLUSIONS: Limbal autograft transplantation is an effective and safe procedure for unilateral corneal burns. It seems that limbal allograft transplantation is better combined with penetrating keratoplasty for a better visual outcome and higher graft survival rate. Systemic immunosuppression seems to be necessary for limbal allografts even in the presence of HLA-matched donor tissues.

PMID: 15004571 [PubMed - indexed for MEDLINE]

Microwave-superheated Vics Vapo Rub: an ocular public health danger.

• Fung AE,
• Oxford KW.

Department of Ophthalmology, Stanford University Medical Center, San Francisco, California, USA. annefungmd@yahoo.com

PURPOSE: To report a case of a microwave-oven superheated petroleum-based liquid causing severe chemical and thermal ocular burns treated successfully with amniotic membrane transplantation. DESIGN: Observational case report. METHODS: Retrospective review of clinical case. RESULTS: A 77-year-old woman sustained a severe combined chemical and thermal burn from microwave-heated Vicks Vapo-Rub requiring amniotic membrane transplant, with subsequent development of phacomorphic glaucoma, requiring cataract extraction, and bullous keratopathy, requiring penetrating keratoplasty. CONCLUSIONS: As microwave oven use becomes more commonplace, the risk of superheating liquids becomes an increasingly significant ocular danger. Continued efforts to educate the public about safe microwave use is necessary. Additionally, amniotic membrane transplantation was found to be effective in managing a combined chemical and thermal ocular burn.

PMID: 14962445 [PubMed - indexed for MEDLINE]

Stepwise surgical approach for in vivo expansion of epithelial stem cells to treating severe acute chemical burns with total limbal deficiency.

• Park GS,
• Je J,
• Kim JC.

Department of Ophthalmology, College of Medicine, Chung-Ang University, Seoul, Korea.

To describe the clinical outcome of a new surgical treatment for the acute stages of severe corneal burn injury and its complications, a prospective study of five acute corneal burn patients with severe limbal damage was performed. Amniotic membrane transplantation (AMT) and conjunctival limbal autograft (CLAU) was performed at the acute stage of corneal burn injury to reconstruct the damaged ocular surface (step I). Three to six months later, the opaque central part of the amniotic membrane containing in vivo grown corneal stem cells were removed and retransplanted to the defect created after the removal of pseudopterygium (step II). All injured eyes were successfully treated, but in one eye with marked stromal lysis, three-layered AMT and penetrating keratoplasty with retransplantation of in vivo grown corneal stem cells was performed. In the former cases, visual acuity was greatly improved more than three lines (ranging from 3 to 12 lines). In short, retransplantation of in vivo grown corneal stem cells after AMT and CLAU is a recommendable modality for restoring a stable corneal epithelium of a severely burned ocular surface in the acute stage and can be considered a preventative measure for avoiding late onset complications.

PMID: 14717484 [PubMed - indexed for MEDLINE]

Donor source affects the outcome of ocular surface reconstruction in chemical or thermal burns of the cornea.

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

Department of Ophthalmology, Tokyo Dental College, Chiba, Japan. jun@eyebank.or.jp

PURPOSE: To study the association between surgical approach and postoperative results in chemical and thermal burns of the cornea. DESIGN: Retrospective, interventional, noncomparable case series. PARTICIPANTS: Thirty-two eyes of 32 patients with chemical (n = 27) or thermal (n = 5) burns of the cornea that were associated with total limbal dysfunction. Eight eyes had a history of previous keratoplasty. INTERVENTION: Patients were treated by amniotic membrane transplantation combined with either conjunctivolimbal autograft transplantation (autograft group, n = 11) or keratolimbal allograft transplantation (allograft group, n = 21). Fifteen eyes had simultaneous penetrating keratoplasty (simultaneous group), and 6 had keratoplasty several months after ocular surface reconstruction (2-step group). MAIN OUTCOME MEASURES: Reconstruction of the corneal surface by corneal epithelium, clarity of the cornea, and incidence of postoperative complications. The outcome was compared between the autograft and allograft groups and also between the simultaneous and 2-step groups. RESULTS: At final examination, 17 eyes (53.1%) showed stable corneal epithelialization. Preoperative conditions were similar in the autograft and allograft groups and also in the simultaneous and 2-step groups. The autograft group showed significantly better results than the allograft group in both corneal epithelialization (Kaplan-Meier analysis, P = 0.003) and clear cornea (P = 0.010). Although the incidences of corneal epithelialization and clear corneas did not significantly differ between the simultaneous and 2-step groups, the former had a higher rate of endothelial rejection in the central graft (P = 0.019). CONCLUSIONS: In chemical or thermal burns of the cornea with monocular involvement, autografting should be considered as a first choice of surgery. Even in eyes with opaque corneal stroma, it may be safer to perform ocular surface reconstruction first, followed by keratoplasty as a secondary procedure.

PMID: 14711712 [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]

Conjunctival healing after amniotic membrane graft over ischemic sclera.

• Gris O,
• Del Campo Z,
• Wolley-Dod C,
• Guell JL,
• Velasco F,
• Adan A.

Department of Ophtalmology, Hospital de la Santa Creu i Sant Pau, Universitat Autonoma de Barcelona, Barcelona, Spain. ogrisc@hsp.santpau.es

PURPOSE: To present a case of chemical injury associated with calcification and severe conjunctival and scleral ischemia, in which tissue regeneration was achieved using an amniotic membrane graft. METHODS: A 65-year-old man presented to our department 8 weeks after suffering a chemical injury of his left eye with sulfuric acid. There was extensive calcification of the cornea and conjunctiva, associated with severe ischemia of the adjacent sclera. After resection of the calcified tissue and nonviable tissue, amniotic membrane was grafted to cover the extensive zone of scleral ischemia. RESULTS: In the weeks following grafting, slow epithelialization and revascularization was observed over the amniotic membrane, stemming from the surrounding healthy conjunctiva. CONCLUSION: Although the presence of ischemia at the base of the graft has been considered a contraindication for amniotic membrane transplantation, this case demonstrates that, provided that the surrounding tissue is not affected, a graft may be useful. In such cases an amniotic membrane graft could be attempted before other alternatives, such as conjuntival or oral mucosal autografts.

PMID: 14508264 [PubMed - indexed for MEDLINE]

Amniotic membrane transplantation to reconstruct the conjunctival surface in cases of chemical burn.

• Katircioglu YA,
• Budak K,
• Salvarli S,
• Duman S.

Ankara Education and Research Hospital, Ankara, Turkey.

PURPOSE: To evaluate the efficiency of preserved human amniotic membrane transplantation for conjunctival surface reconstruction in cases of chemical burn. METHODS: Preserved amniotic membrane transplantation was performed in 6 patients (6 eyes) having symblepharon and fornix insufficiency due to chemical burn. Amniotic membrane was sutured to the intact conjunctiva after the fibrotic tissue was excised. The fornix was reconstructed in cases having fornix insufficiency. These cases were followed up for 4-24 months. RESULTS: During the mean follow-up period (10+/-7.37 months) adequate bulbar conjunctiva and fornix depth was achieved in 5 patients without recurrence and with mild fibrosis. In 1 patient who did not have a healthy conjunctiva preoperatively, conjunctival fibrosis and symblepharon recurred. CONCLUSIONS: Preserved human amniotic membrane transplantation is a good alternative treatment method for conjunctival surface reconstruction in those cases with some healthy peripheral conjunctival tissue.

PMID: 12967871 [PubMed - indexed for MEDLINE]

Amniotic membrane transplantation with conjunctival limbal autograft for total limbal stem cell deficiency.

• Meallet MA,
• Espana EM,
• Grueterich M,
• Ti SE,
• Goto E,
• Tseng SC.

Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami School of Medicine, Miami, Florida, USA.

PURPOSE: To evaluate the outcomes of corneal surface reconstruction with conjunctival limbal autograft when combined with amniotic membrane transplantation on both the donor and recipient eyes. DESIGN: Retrospective, noncomparative, interventional small case series. PARTICIPANTS: Five eyes of five patients with total limbal stem cell deficiency (LSCD) resulting from pseudopemphigoid (n = 1), chemical burns (n = 3), and extensive removal of conjunctival intraepithelial neoplasia (n = 1) were operated on by one surgeon (SCGT). INTERVENTION: After the removal of fibrovascular pannus from the corneal surface, two conjunctival limbal free grafts were harvested from the fellow eyes in all five patients with unilateral LSCD. Amniotic membrane, with the basement membrane side up, was grafted onto the defect created at the donor site and onto the recipient corneal and limbal sclera before placement of conjunctival limbal grafts. MAIN OUTCOME MEASURES: Symptomatic relief, improvement in visual acuity, fornix deepening, and rapid healing and restoration of normal cornea and limbus in the recipient and donor eyes were assessed. RESULTS: During the mean follow-up of 22 months (range, 11-48 months), all eyes experienced symptomatic relief. All recipient eyes had a mean improvement in visual acuity of nine lines (range, 7-12). The three eyes with stromal vascularization showed regression, and all recipient eyes had marked improvement in corneal clarity. Three eyes receiving simultaneous symblepharon lysis and fornix reconstruction successfully regained deep, stable fornices. The donor eyes showed rapid healing and restoration of the normal limbal landmark, even in one eye where nearly the entire limbus was removed. CONCLUSIONS: Limbal conjunctival transplantation is an effective procedure for restoring the corneal surface integrity in eyes with total LSCD. The additional use of amniotic membrane may contribute to a higher rate of success in the recipient eye and a lower rate of complications in the donor eye, as well as allow the simultaneous correction of concomitant cicatricial abnormalities.

PMID: 12917178 [PubMed - indexed for MEDLINE]

[Transplantation of amniotic membrane for patients with bullous keratopathy and chemical and thermal burns]

• Siennicka A,
• Pecold-Stepniewska H,
• Czajka M.

Katedry i Kliniki Okulistycznej Akademii Medycznej im. K. Marcinkowskiego w Poznaniu.

The aim of this paper is, to evaluate the efficacy of amniotic membrane transplantation for ocular surface reconstruction in patients with bullous keratopathy and chemical and thermal burns of cornea and conjunctiva. Amniotic membrane is a thin, semitransparent tissue forming an innermost layer of the fetal membrane, which contains a thick basement membrane with a single layer of epithelium and avascular matrix. This transplantation promotes normal conjunctival epithelization while suppressing fibrosis formation. Amniotic membrane transplant may be considered as an alternative method for treating ocular surface reconstruction in patients with thermal and chemical burns. Authors suggest that this method of treatment is not efficient in patients with bullous keratopathy.

PMID: 12866170 [PubMed - indexed for MEDLINE]

Use of autologous cultured limbal and conjunctival epithelium in a patient with severe bilateral ocular surface disease induced by acid injury: a case report of unique application.

• Sangwan VS,
• Vemuganti GK,
• Iftekhar G,
• Bansal AK,
• Rao GN.

Cornea and Anterior Segment Service, L.V. Prasad Eye Institute, Banjara Hills, Hyderabad, India. vsangwan@lvpeye.stph.net

PURPOSE: Reconstruction of the ocular surface in a case of severe bilateral partial limbal stem cell deficiency (LSCD) with extensive symblephara using autologous cultured conjunctival and limbal epithelium. CASE REPORT: A 31-year-old woman presented with severe bilateral ocular surface disease with partial limbal stem cell deficiency, symblephara, lid and facial scarring, with a vision of 20/400 and counting fingers at 1 m in both eyes. Limbal and conjunctival tissue was harvested from the healthy-appearing left eye and used to generate two sheets of composite epithelium consisting of central limbal and peripheral conjunctival cells. The limbal tissues were explanted in the central region while the conjunctival tissues were explanted on the periphery of the deepithelialized human amniotic membrane (HAM) and nurtured using human corneal epithelial cell medium. After successful generation of a monolayer from both tissues had been confirmed, the composite of cultivated limbal and conjunctival epithelium with HAM was transplanted in each eye after excision of fibrous tissue and release of symblephara. One year postoperatively, the patient had a best spectacle-corrected visual acuity of 20/40 in the right eye (preoperative acuity 20/400) and counting fingers at 1 m in the left eye (same as preoperative) with a stable ocular surface. CONCLUSIONS: Autologous cultured epithelial transplantation is as an excellent option in selected patients with bilateral partial LSCD with small area(s) of healthy limbus in either eye and avoids the attendant risk of rejection and cost and potential toxicity of immunosuppression in allogeneic tissue transplantation. This case also highlights the feasibility of generating a composite culture of limbal and conjunctival epithelium using a single amniotic membrane.

PMID: 12827056 [PubMed - indexed for MEDLINE]

Does amniotic membrane transplantation improve the outcome of autologous limbal transplantation?

• Marinho D,
• Hofling-Lima AL,
• Kwitko S,
• Tseng SC.

Opthalmology Service, Hospital de Clinicas de Porto Alegre, Federal University of Rio Grande do Sul, Brazil. diane@portoweb.com.br

PURPOSE: To evaluate the additional benefits of amniotic membrane transplantation (AMT) when combined with conjunctival limbal autograft (CLAU) in the treatment of chronic chemical burns. METHODS: Thirty eyes of 30 rabbits underwent a chemical burn to create limbal deficiency. Forty-five days later, the animals were randomized into three groups of 10 rabbits each. Eyes from group 1 were treated with CLAU, group 2 underwent CLAU and AMT, and group 3 served as control without surgery. Corneal vascularization and opacity were documented with external photographs at postoperative days 30, 60, and 90. The rabbits were killed 3 months after surgery, and their corneas divided into two halves. One half was prepared for hematoxylin-eosin and periodic acid-Schiff staining and the other for frozen sections and immunostaining with AM3 (to MUC 5AC mucin) and AE5 (to K3 keratin). Final clinical outcome was also scored using external photographs at the last follow-up examination. RESULTS: After chemical burn, all groups showed similar degrees of conjunctivalization. After transplantation, corneal vascularization was worse in controls at 60 and 90 days (p < 0.001). At 30 days, eyes from group 1 had less corneal opacity (p < 0.05). At 90 days, corneal opacity was worse in controls but the same in groups 1 and 2 (p < 0.05). At the same time, limbal deficiency was significantly worse in controls (p < 0.05) but similar between groups 1 and 2. Corneal phenotype was present in 70% of the eyes in group 1, 50% in group 2, but in 10% of the controls. Clinical success with clear corneas was significantly more common in groups 1 and 2 when compared with controls (p < 0.001). CONCLUSIONS: CLAU is effective in treating limbal deficiency. The concurrent AMT does not add benefits in this rabbit model of chemical burns.

PMID: 12792477 [PubMed - indexed for MEDLINE]

Human amniotic membrane transplantation: past, present, and future.

• John T.

Loyola University at Chicago, Department of Ophthalmology, 2160 South First Avenue, Maywood, IL 60153, USA. cornea999@aol.com

This article describes amniotic membrane transplantation from experimental fetal membrane transplantations in the early twentieth century through the present day. The procurement, complications, and solutions of this delicate procedure are covered with a mention of what is in store for the future.

PMID: 12683248 [PubMed - indexed for MEDLINE]

Temporary amniotic membrane patching for acute chemical burns.

• Kobayashi A,
• Shirao Y,
• Yoshita T,
• Yagami K,
• Segawa Y,
• Kawasaki K,
• Shozu M,
• Tseng SC.

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

PURPOSE: To describe the surgical technique, and its usefulness, of temporary amniotic membrane patching (AMP) in the acute phase of ocular chemical injury. METHODS: Temporary AMP with modification in suture placement was performed on five eyes of five consecutive patients inflicted with acute chemical injury having a greater than grade II injury by the Roper-Hall classification. RESULTS: All patients reported herein presented with a large epithelial defect on the cornea and conjunctiva. Case 3 was classified as grade III while the other four cases were classified as grade II. The causative chemical agents were anhydrous acetic acid in Case 1, calcium oxide in Case 2, sodium hydroxide in Case 3, sodium silicate in Case 4, and sulphuric acid in Case 5. All cases experienced rapid relief of pain after AMP. Epithelialization of the cornea with improvement of visual acuity was observed in all cases when the amniotic membrane was removed within 2 weeks after surgery. During the mean follow-up of 19.6 months, the ocular surface remained stable and no cicatricial complications were noted. CONCLUSIONS: These results suggest that immediate AMP is quite useful for managing moderately severe acute ocular chemical injury by facilitating rapid epithelialization and pain relief, and securing ocular surface integrity.

PMID: 12640400 [PubMed - indexed for MEDLINE]

Phenotypic study of a case receiving a keratolimbal allograft and amniotic membrane for total limbal stem cell deficiency.

• Espana EM,
• Grueterich M,
• Ti SE,
• Tseng SC.

Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami School of Medicine, Miami, FL 33176, USA.

PURPOSE: To report the expression pattern of key molecules by the reconstructed corneal epithelium after a keratolimbal allograft (KLAL) and amniotic membrane transplantation (AMT) for total limbal stem cell deficiency. DESIGN: Interventional case report. METHOD: A 50-year-old woman with severe chemical burns in both eyes received an AMT as a temporary patch at the acute stage, and a KLAL with AMT as a graft at the chronic stage for total limbal stem cell deficiency. The corneal button removed during subsequent corneal transplantation was submitted for immunofluorescence staining with monoclonal antibodies against keratin K3, MUC5AC, connexin 43, integrins alpha3beta1 and alpha6beta4, and laminin 5 for comparison with a normal cornea. RESULTS: Histologically, a normal stratified corneal epithelium has five to six cell layers that lay on the thick amniotic membrane basement membrane. The phenotype was of a corneal origin, based on expression of positive keratin K3, negative MUC5AC, and positive connexin 43. Furthermore, intact basement membrane complexes were present, evidenced by positive staining to integrins alpha3beta1 and alpha6beta4 and to laminin 5. CONCLUSIONS: A normal corneal epithelial phenotype with normal basement membrane complexes was restored after a KLAL and AMT in a case with total limbal stem cell deficiency.

PMID: 12623808 [PubMed - indexed for MEDLINE]

Amniotic membrane transplantation for partial and total limbal stem cell deficiency secondary to chemical burn.

• Gomes JA,
• dos Santos MS,
• Cunha MC,
• Mascaro VL,
• Barros Jde N,
• de Sousa LB.

Cornea and External Disease Service, Department of Ophthalmology, Federal University of Sao Paulo (UNIFESP), R. Sabara, 566 Cjuto. 212, 01239-010 Sao Paulo/SP, Brazil.

PURPOSE: To evaluate the surgical outcome of preserved amniotic membrane transplantation (AMT) for ocular surface reconstruction in chemical burn with limbal stem cell deficiency. DESIGN: Prospective, noncomparative, interventional case series. PARTICIPANTS: Twenty eyes of 20 consecutive patients with limbal stem cell deficiency secondary to ocular chemical injury. INTERVENTION: AMT with or without adjunctive limbal transplantation using limbal tissue from either the healthy contralateral eye (CLAU) or a living related donor (lr-CLAL). MAIN OUTCOME MEASURES: Reconstruction of corneal epithelium (clear appearance without epithelial defect, normal fluorescein permeability and the absence of conjunctiva-derived goblet cells on impression cytology), decrease in corneal vascularization and improvement in visual acuity. RESULTS: With a mean follow-up time of 19 months (range, 8-27 months), satisfactory ocular surface reconstruction was obtained in 15 eyes (75%), with reduced inflammation and vascularization of the ocular surface and a mean epithelialization time of 3.3 weeks. Success was observed in all cases of partial limbal stem cell deficiency (PLD) and in 68.75% (11 eyes) of cases of total limbal stem cell deficiency (TLD). Surgical failure was observed in five severe cases (31.25%). A significant visual improvement was observed in all cases after surgery, except for 2 eyes that maintained preoperative visual acuity. CONCLUSIONS: AMT seems to be an efficient adjunct for ocular surface reconstruction in chemical burns with PLD. When performed in conjunction with limbal stem cell transplantation, it is also effective in most cases of TLD.

PMID: 12623806 [PubMed - indexed for MEDLINE]

Ocular surface reconstruction with amnotic membrane transplantation in chemical burn.

• Dos Santos MS,
• Fairbanks D,
• Pedro EA,
• Cunha MC,
• de Freitas D,
• Gomes JA.

Federal University of Sao Paulo-Brazil (UNIFESP), Paulista School of Medicine, Department of Ophthalmology.

PMID: 12614063 [PubMed - indexed for MEDLINE]

Fresh amniotic membrane transplantation for conjunctival surface reconstruction.

• Zhou S,
• Chen J,
• Xu L,
• Lin J,
• Huang T.

Zhongshan Ophthalmic Center, Sun Yat-sen University of Medical Sciences, Guangzhou 510060, China.

PURPOSE: To determine whether fresh human amniotic membrane can be used to reconstruct the conjunctival detect created during symblepharon lysis. METHODS: Forty-two eyes of 39 consecutive patients with eye burns and Stevens-Johnson syndrome were randomized to accept fresh or preserved human amniotic membrane transplantation (AMT) during the period of severe scarring. Impression cytology was performed in 12 eyes with normal tear secretion which received fresh AMT. RESULTS: During a mean follow-up of 11 months (range, 6 to 18 months), thirty-five patients (37 eyes) showed successful ocular surface reconstruction and resolution of motility restriction while four patients (2 eyes with fresh AMT, 3 eye with preserved AMT) with minimal recurrence of symblepharon. There was no significant difference statistically between two groups (Chi-square test). Amniotic epithelial cells can survive about three months after being transplanted onto ocular surfaces with normal tear secretion. CONCLUSION: Both fresh and preserved human amniotic membrane can be considered an ideal alternative substrate for conjunctival surface reconstruction during removal of severe symblepharon.

PMID: 12579695 [PubMed - indexed for MEDLINE]

[Amniotic membrane transplantation with limbal stem cell transplantation as a combined procedure for corneal surface reconstruction after severe thermal or chemical burns]

• Stoiber J,
• Ruckhofer J,
• Muss W,
• Grabner G.

Landesklinik fur Augenheilkunde und Optometrie, Landeskliniken Salzburg, Germany. j.stoiber@lks.at

BACKGROUND: Severe thermal and chemical burns may result in limbal deficiency leading to persistent epithelial defects, complete conjunctival epithelial ingrowth and vascularisation of the cornea. If sufficiently severe, these burns may lead to very significant visual impairment. Amniotic membrane transplantation with limbal transplantation has recently been proposed as a new method for corneal surface reconstruction. PATIENTS AND METHODS: A total of 14 patients (age 18-62 years, mean age 42 years) with limbal deficiency resulting from thermal ( n=1) or chemical burns ( n=13) underwent surgery. The corneal pannus was completely removed and the amniotic membrane was grafted onto the cornea. Limbal transplantation using autografts obtained from contralateral eyes was performed simultaneously in seven cases. Allografts from a donor were transplanted in seven cases with bilateral involvement. These patients received oral cyclosporin A postoperatively. The mean follow-up time was 18 months. RESULTS: In all cases of limbal autografts the corneal surface showed a complete and stable epithelialisation within a few weeks. Out of seven patients with limbal allografts three displayed recurrent epithelial defects in the long term. The initially semitransparent amniotic membrane became more translucent and biomicroscopically invisible within several months after surgery. There was an increase in visual acuity in most cases, limited mostly by irregular astigmatism due to the initial stromal loss. CONCLUSIONS: Amniotic membrane transplantation with limbal transplantation allows reconstruction ocular surfaces severely damaged by chemical or thermal burns. In most cases, however, additional surgical procedures such as lamellar or penetrating keratoplasty are required for adequate visual rehabilitation.

PMID: 12430036 [PubMed - indexed for MEDLINE]

[Corneal burns and matrix metalloproteinases (MMP-2 and -9): the effects of human amniotic membrane transplantation]

• Rigal-Sastourne JC,
• Tixier JM,
• Renard JP,
• Maurin JF,
• Pouliquen Y,
• Legeais JM.

Service d'Ophtalmologie, HIA Val de Grace, 74, boulevard de Port-royal, 75230 Paris Cedex 05, France.

PURPOSE: Human amniotic membranes have recently been used in ophthalmology to restore deleted ocular surface after burns. Matrix metalloproteinases-2 and -9 have been implicated in the development of neovascularization. In this study, MMP-2 and MMP-9 expression was analyzed by in situ zymography on rabbit corneal chemical burns with and without human amniotic membrane graft. Method: Corneal neovascularization was induced in 10 Fauve de Bourgogne rabbits by means of a heptanol chemical burn on controlled deep keratotomy using a Chiron ALK-E corneal shaper. Half of rabbits received acute amniotic membrane transplantation 30mn after chemical burn; the remaining five rabbits received medical treatment. In situ zymography is a recent nondestructive technique which preserved the fine morphological details of the cornea and showed the active enzyme location in different corneal layers. The MMP-2 and -9 substrate was gelatin, which was detected by fluorescent microscopy. RESULTS: There was an overexpression of MMP-2 and -9 in corneal burns versus control corneas. Expression of MMP-2 and -9 was low in corneal burn without amniotic membrane graft. Following amniotic membrane transplantation, MMP-2 and -9 were strongly expressed and clinical neovascularization and inflammation decreased. Active enzymes were located in epithelium layers in the uncovered group. In the covered group, the active enzymes were located in the anterior and posterior stromal layers. CONCLUSION: The results support a role for MMP-2 and MMP-9 in corneal burn neovascularization. Amniotic membrane transplantation can play a protective role by up-regulation of their biological expression.

PMID: 12399724 [PubMed - indexed for MEDLINE]

Factors affecting outcome following transplantation of ex vivo expanded limbal epithelium on amniotic membrane for total limbal deficiency in rabbits.

• Ti SE,
• Anderson D,
• Touhami A,
• Kim C,
• Tseng SC.

Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami School of Medicine, Miami, Florida, USA.

PURPOSE: To determine factors affecting the outcome of corneal surface reconstruction in rabbits with total limbal stem cell deficiency (LSCD), by using autologous limbal epithelial stem cells (LSC) ex vivo, expanded on rabbit amniotic membrane (AM). METHODS: Left eyes of 52 rabbits were rendered totally limbal stem cell deficient by n-heptanol debridement of the entire corneal epithelium followed by surgical removal of 360 degrees of limbal rim. After cytologic verification of LSCD, the fibrovascular pannus of each cornea was removed. Group I (n = 10) received a rabbit AM transplant, whereas groups II, III, and IV (n = 42) underwent transplantation of LSCs cultured on rabbit AM (LSC-AM graft) derived from a small limbal biopsy specimen from the right eye. Clinical outcome was graded as a success if a smooth, avascular corneal surface was restored, a partial success if more than two quadrants of corneal surface were smooth, or a failure if the corneal surface was revascularized and irregular. RESULTS: A long-term follow-up of more than 1 year was achieved. Compared with the 100% failure rate in group I, inclusion of expanded LSCs resulted in variable success rates in groups II, III, and IV (all P < 0.001). Kaplan-Meier survival analysis showed that different suturing techniques, subconjunctival injection of long-acting steroid, and tarsorrhaphy used in groups II (n = 17) and III (n = 13) did not significantly alter the outcome (P = 0.89). However, the use of a larger graft and human AM as a temporary patch with the explant retained for 1 week in group IV (n = 12) significantly improved the success rate to 83% (P = 0.002). Among eyes showing clinical failure, there was a significant correlation between the logarithm of the first day when an epithelial defect was noted and the time of graft failure (r(2) = 0.60, P < 0.001). Furthermore, the presence of severe lid deformity was borderline significant when correlated with failure cases in all four groups (P = 0.069). CONCLUSIONS: Ex vivo expansion of LSCs can be achieved by using rabbit AM culture. Such expanded LSCs can successfully reconstruct corneal surfaces affected by total LSCD. This animal model is useful to investigate culturing variables affecting epithelial stemness so that surgical reconstruction of corneas with total LSCD can be successfully performed. Furthermore, this model can be used to test the feasibility of gene therapies targeting LSCD in the future.

PMID: 12147589 [PubMed - indexed for MEDLINE]

Transplantation of corneal stem cells cultured on amniotic membrane for corneal burn: experimental and clinical study.

• Pan Z,
• Zhang W,
• Wu Y,
• Sun B.

Beijing Institute of Ophthalmology, Tong Ren Hospital, Capital University of Medical Sciences, Beijing 100730, China.

OBJECTIVE: To investigate the proliferation and differentiation of cultured corneal stem cells and determine the effect of corneal stem cells cultured on amniotic membranes on the limbal area for treating corneal burns. METHODS: The proliferation and differentiation of corneal stem cells in vitro had been examined using colony-forming efficiency and immunohistochemistry. The stem cells had been cultured on amniotic membranes and transplanted to the limbal area for treating corneal burns. RESULTS: Corneal stem cells had a high proliferation capacity in primary and first passage, cytokeratin 3 was not expressed in primary culture but partly in first passage. The stem cells could proliferate to form cell layer on an amniotic membrane. When transplanted, stem cells could survive on limbus. After transplantation, ocular inflammation resolved, the cornea re-epithelialized, the stromal opacity reduced, the superficial neovascularity was lessened and the conjunctival fornix re-established. CONCLUSIONS: Ocular surface conditions could be improved by allograft of corneal stem cells cultured on amniotic membranes.

PMID: 12133553 [PubMed - indexed for MEDLINE]

Transplantation of human limbal epithelium cultivated on amniotic membrane for the treatment of severe ocular surface disorders.

• Shimazaki J,
• Aiba M,
• Goto E,
• Kato N,
• Shimmura S,
• Tsubota K.

Department of Ophthalmology, Tokyo Dental College, 5-11-13 Sugano, Ichikawa-shi, Chiba 272-8513, Japan.

PURPOSE: To study the short-term clinical results of transplanting of cultivated corneal/limbal epithelial cells on human amniotic membrane (AM) for limbal deficiency. DESIGN: Noncomparative, retrospective interventional case series. PARTICIPANTS: Thirteen eyes of 13 patients with severe limbal deficiency (Stevens-Johnson syndrome in eight eyes, ocular cicatricial pemphigoid in three eyes, and chemical burns in two eyes) were treated at the department of Ophthalmology, Tokyo Dental College, Japan. INTERVENTION: Cultivated allo-limbal epithelium was transplanted onto the ocular surface of patients with severe limbal deficiency. MAIN OUTCOME MEASURES: Ocular surface reconstruction with corneal epithelialization, changes in visual acuity, and postoperative complications were studied. Histologic examinations were also performed on cultivated epithelium. RESULTS: Cultivated corneal epithelium on AM formed two to three layers with the formation of basement membrane-like structures. After the surgery, the epithelium regenerated and covered the ocular surface in eight eyes (61.5%). However, three of the eight eyes developed partial conjunctival invasion, and two eyes later developed epithelial defects. At last examination, corneal epithelialization was achieved in six eyes (46.2%). Five eyes had conjunctivalization, one eye had dermal epithelialization, and one eye was not epithelialized. Complications were corneal perforation in four eyes and infectious keratitis in two eyes. CONCLUSIONS: This study demonstrates that the success rate for transplanting cultivated allo-limbal epithelium on the AM is not different from the conventional limbal and AM transplantation for the treatment of severe limbal stem cell dysfunction.

PMID: 12093651 [PubMed - indexed for MEDLINE]

Histopathology of human corneas after amniotic membrane and limbal stem cell transplantation for severe chemical burn.

• Stoiber J,
• Muss WH,
• Pohla-Gubo G,
• Ruckhofer J,
• Grabner G.

Department of Ophthalmology and Optometry, St. Johanns-Spital, Landeskliniken Salzburg, Muellner Hauptstrasse 48, 5020 Salzburg, Austria. j.stoiber@lks.at

PURPOSE: To describe the histopathologic changes in the cornea following amniotic membrane transplantation (AMT) combined with limbal transplantation. METHODS: Four eyes with complete limbal stem cell deficiency after severe chemical burn underwent AMT with either a living-related conjunctival limbal allograft (lr-CLAL) (three eyes) or a conjunctival limbal autograft (CLAU) (one eye) for ocular surface reconstruction. Penetrating keratoplasty was performed several months after the initial procedure for further visual rehabilitation. Mean follow up time was 20 months. Light and transmission electron microscopy (TEM) and indirect immunofluorescence microscopy of the excised corneal buttons were performed. RESULTS: All specimens displayed a multilayered epithelium without conjunctival goblet cells over the entire corneal surface. Basal epithelial cells demonstrated a firm connection to the remnants of the transplanted amniotic membrane (AM), which at some places appeared to be in a state of "modification" or "remodeling" in the collagen layers. The basement membrane zone displayed a positive staining when using antibodies against collagen IV and VII, integrin alpha6 and beta4, laminin 5, and bullous pemphigoid antigen 2. Remnants of the AM in the specimen showed staining of collagen IV, which was found also in cross-sections of cryopreserved AM. The recipients Bowman's membranes that were only partially present after the initial trauma were significantly disturbed. CONCLUSION: Within the time frame studied, the transplanted AM apparently survives and integrates into the host tissue being modified or remodeled by recipient cells. AMT in combination with a CLAU or lr-CLAL is a useful technique in promoting a rapid and stable reepithelialization of a corneal surface following severe chemical or thermal damage.

PMID: 12072723 [PubMed - indexed for MEDLINE]

[Corneal acid burning after facial peeling]

• Zidi M,
• Bourcier T,
• Legall JC,
• Touzeau O,
• Borderie V,
• Laroche L.

Service du Pr Laroche, Centre Hospitalier National d'Ophtalmologie des Quinze-Vingts, 28, rue de Charenton, 75012 Paris.

We describe the case of a 66-year-old woman who had previously undergone facial peeling and developed severe bilateral corneal burn due to direct contact Exopeel((R)) with her eyes. Despite medical treatment and an amniotic membrane graft, deep stromal opacity persisted in one eye.

PMID: 12048516 [PubMed - indexed for MEDLINE]

Comment in:

Ophthalmology. 2003 Oct;110(10):2071; author reply 2071-2.

Long-term outcome of keratolimbal allograft with or without penetrating keratoplasty for total limbal stem cell deficiency.

• Solomon A,
• Ellies P,
• Anderson DF,
• Touhami A,
• Grueterich M,
• Espana EM,
• Ti SE,
• Goto E,
• Feuer WJ,
• Tseng SC.

Department of Ophthalmology, Bascom Palmer Eye Institute, Miami, Florida, USA.

PURPOSE: To evaluate the long-term outcome of ocular surface reconstruction, including keratolimbal allograft (KLAL) and amniotic membrane transplantation (AMT) with or without penetrating keratoplasty (PKP), in patients with nonambulatory vision secondary to total limbal stem cell deficiency (LSCD). DESIGN: Retrospective, non-comparative interventional case series. PARTICIPANTS: Thirty-nine eyes in 31 consecutive patients with total LSCD, as defined by impression cytology, who had a preoperative best-corrected visual acuity of less than 20/200 and a minimum follow-up of 12 months. Patients were divided into three groups: group 1 (16 eyes) with chemical burns, group 2 (9 eyes) with Stevens-Johnson syndrome (SJS), and group 3 (14 eyes) with other causes of LSCD, including ocular cicatricial pemphigoid, atopic keratoconjunctivitis, and aniridia. INTERVENTION: All patients underwent KLAL and AMT by one surgeon (SCGT). If needed, PKP was performed at the same surgical setting using tissue from the same donor. MAIN OUTCOME MEASURES: Cumulative rates of survival of ambulatory vision (> or = 20/200), survival of KLAL, survival of PKP, and incidence of complications. RESULTS: Fifty-three KLAL with AMT procedures were performed in 39 eyes, of which 23 eyes received simultaneous PKP at the time of the first KLAL. The mean follow-up was 34.0 +/- 21.5 months (range, 12-117.6). The mean period of ambulatory vision was 23.9 +/- 20.9 months (range, 0-104). The overall survival of ambulatory vision was 53.6% at 3 years and 44.6% at 5 years. The survival of ambulatory vision was significantly worse in SJS compared with other causes (67%, 81%, and 92% for groups 1, 2, and 3, respectively; P = 0.06 for group 1 versus 2, P = 0.0008 for group 1 versus 3). KLAL performed alone resulted in higher survival of ambulatory vision at 2 years (86.1% +/- 9.1%) compared with KLAL with PKP (46.9% +/- 10.6%, P = 0.100). The survival of PKP was significantly worse in SJS compared with the other causes (20.0% +/- 17.9% compared with 55.6% +/- 11.7%, respectively, P = 0.028). After 2 years, the survival of the second KLAL was better than that of the first: 68.2% +/- 15.4% compared with 27.3% +/- 13.4%, respectively (P = 0.041). CONCLUSIONS: Ambulatory vision for a period of more than 2 years can be achieved by KLAL with or without PKP in eyes with severe ocular surface disorders caused by total LSCD. However, a progressive decline of the visual outcome and graft survival is evident with time. Performing PKP simultaneously with KLAL may be associated with a less favorable outcome. The failure of KLAL is associated with the loss of donor cells in the recipient. Augmentation of ocular surface defense is essential in securing the success of KLAL and PKP. Future modifications of the surgical procedure and of the immune suppressive protocols may improve survival of the allogeneic grafts and the final visual outcome.

PMID: 12045060 [PubMed - indexed for MEDLINE]

[Amniotic membrane graft in ocular surface disease. Prospective study with 31 cases]

• Muraine M,
• Descargues G,
• Franck O,
• Villeroy F,
• Toubeau D,
• Menguy E,
• Martin J,
• Brasseur G.

Service d'ophtalmologie, Hopital Charles Nicolle. Marc.Muraine@chu-rouen.fr

INTRODUCTION: Amniotic membrane's unique combination of properties including the facilitation of migration of epithelial cells, the reinforcement of basal cellular adhesion and the encouragement of epithelial differentiation [6] together with its ability to modulate stromal scarring and its anti-inflammatory and anti-bacterial activity has led to its use in the treatment of ocular surface pathology as well as an adjunct to stem cell grafts of the corneal limbus [6-4]. We report a prospective study of 30 patients so treated. MATERIAL AND METHODS: We studied 31 eyes of 30 patients subjected to amniotic membrane grafts between September 1999 and May 2000. There were 25 men and 5 women with an average age of 60.1 (range 25-86) years who were followed for a mean of 7.7 (range 4-11) months. 5 groups (A to D) were observed: A: 6 eyes. Small chronic ulcers without limbal involvement. B: 4 eyes. Ulcers of at least 75% corneal area or occupying 75% of the limbus. C: 9 eyes. Corneal burns. D: 8 eyes. Painful bullous corneal dystrophies unresponsive to other treatment. E: 4 eyes. Symblepharons. Amniotic membrane was placed on the corneal lesion, epithelial surface externally [6, 15], trimmed and sutured with interrupted 10/0 nylon, removed at one month. In two patients (11, 12) inflamed conjunctiva was recessed and amnion sutured to the recessed margin. For the bullous dystrophies we removed all the corneal epithelium and either sutured the amnion to peri-limbal conjunctiva (4 eyes) or to the limbus (4 eyes). For the symblepharons the conjunctiva was dissected to reform the fornix which was lined with amniotic membrane, sutured with 8/0 vicryl. Patients were reviewed regularity. RESULTS: Group A: All healed within 15 days, in most with dissolution of the amnion over 2-3 months although some persisted, covered with corneal epithelium. An eye with a Descemetocoele and one with a microperforation both healed. Vision improved more than two lines in 4 of 6 eyes. Group B: 2 of 4 eyes healed, one despite detachment of the membrane after 15 days. One eye was salvaged by tarsorrhaphy over a fresh keratoplasty after perforation of a neuroparalytic ulcer on failure of three successive amnion grafts. The final cornea vascularised despite an amnion graft for a meta-herpetic ulcer. Group C: 2 of 9 eyes had limbal damage in one quadrant but 7 had vessels in at least three-quarters of the circumference. One (15) also had a limbal autograft. 3 of 9 eyes healed satisfactorily with more than 2/10 improvement in acuity in each case. 2 showed further neovascularisation despite surface healing. One old chemical burn healed satisfactorily but vascularisation remained 5 eyes failed to heal with lysis of the graft, the patient who had a limbal autograft developed a vascular pannus, and in 4 eyes neovascularisation progressed to cover the entire cornea. Group D: 3 eyes settled with loss of symptoms but in 5 the graft detached within 15 days. All eyes where the membrane had been sutured to the conjunctiva beyond the limbus failed whilst 3 of 4 in which it had been sutured anterior to the limbus succeeded, leaving a persistent whitish membrane under the epithelium. Group E: We were able to reconstruct the cul de sac in 3 out of 4 eyes. In one patient with recurrent pterygium good ocular movement was restored, previously limited by scarring. One with associated ocular surface damage from a thermal burn failed by scarring of the cul de sac a month after surgery. DISCUSSION: Our best results were in persistent trophic ulcers of the cornea (Groups A and B) with a success rate of 80%, comparable to those of others [49, 37, 38]. The ready availability of amniotic membrane in our facility makes amniotic membrane transplantation the main secondary treatment for such lesions, especially because of the visual improvement we obtained. Because we did not observe any improvement in corneal thickness after this treatment we advise its early use before significant stromal lysis. The technique was not sufficient to control the effect of corneal anaesthesia in two eyes [40] or in chemical burns suggesting that amniotic membrane alone is insufficient to promote corneal healing in the absence of limbal stem cells. Nevertheless, three eyes did benefit. It has been suggested [13] that the anti-apoptotic function of amnion may prevent stem cell loss in such eyes [42], thus it appears logical to offer an amniotic membrane graft first, before stem cell transplantation, which may entrain complications in the donor eye if autografted [43] or because of the rejection risk of an allograft. It may be that an amniotic membrane graft simply becomes a holding procedure allowing time to settle the eye so as to allow secondary procedures to address the underlying cause of further damage. Our treatment of bullous dystrophy only succeeded on confining the graft to within the limbus, 3 out of 4 eyes becoming comfortable. By contrast we found amniotic membrane helpful in reconstructing symblepharons in the absence of local inflammation. CONCLUSION: Amniotic membrane grafting is a simple and straightforward surgical technique which should form part of the therapeutic arsenal for the treatment of ocular surface disease. Indications for the technique need further clarification for it is evident that it cannot correct all secondary pathology associated with limbal destruction. It is certainly preferable to conjunctival advancement and has proved useful in the reconstruction of the cul-de-sac.

PMID: 11894530 [PubMed - indexed for MEDLINE]

Nonpreserved human amniotic membrane transplantation in acute and chronic chemical eye injuries.

• Ucakhan OO,
• Koklu G,
• Firat E.

Department of Ophthalmology, Ankara University School of Medicine, Cinnah Caddesi 9/7, Cankaya 06680, Ankara, Turkey. omuru@yahoo.com

PURPOSE: To evaluate the safety and efficacy of nonpreserved amniotic membrane transplantation (AMT) with or without limbal autograft transplantation (LAT) in management of acute and chronic chemical eye injuries. METHODS: Amniotic membrane transplantation or AMT + LAT was performed on nine eyes of seven consecutive patients, five eyes with acute chemical burn and four eyes with limbal stem cell deficiency secondary to previous chemical burn. Nonpreserved amniotic membrane was used in all procedures. RESULTS: Five patients (71.5%) were men and two (28.5%) were women. The average age at the time of surgery was 32.7 +/- 10.9 years (range, 20-45). Mean follow-up after last surgery was 8.9 +/- 3.2 months (range, 6-14). The average epithelial healing time was 24.6 +/- 17.3 days (range, 3-45). At the end of the follow-up period, visual acuity improved in all eyes, inflammation subsided, and the subjective complaints decreased remarkably. CONCLUSION: AMT with nonpreserved amniotic membrane promoted epithelial healing, reduced surface inflammation, increased patient comfort, and decreased the extent and severity of vascularization when used in patients with acute chemical burns. When used in limbal stem cell deficiency owing to past chemical burns, AMT alone or in combination with LAT aided in ocular surface reconstruction. Infectious, inflammatory, or toxic/allergic reactions were not encountered in any patient owing to the use of nonpreserved amniotic membrane. Further studies are required to establish the safety and efficacy of preserved and nonpreserved AMT in ocular surface reconstruction.

PMID: 11862088 [PubMed - indexed for MEDLINE]

[An experimental study on treatment of limbal alkali burn by allograft transplantation with cultured stem cells on amniotic membrane]

• Pan Z,
• Zhang W,
• Wu Y.

Beijing Institute of Ophthalmology, Beijing 100005, China. panxiaow@public3.bta.net.cn

OBJECTIVE: To study the treatment of rabbit limbal alkali burn by cultured limbal stem cells growing on amniotic membrane for allograft transplantation. METHODS: After the primary culture of the rabbit corneal stem cells, they were cultured on amniotic membrane in DMEM/HamF12 medium for one week. Corneal stem cells and amniotic membrane were transplanted on the limbal and scleral area of the rabbit model with alkali burn. The corneal changes were observed by a slitlamp everyday, and the corneal pathological changes were examined. RESULTS: Cultured rabbit corneal stem cells continued to proliferate, differentiate and form multiple cell layers on amniotic membrane. After transplantation with cultured stem cells and amniotic membrane, the rabbit epithelium showed corneal phenotype and progressive decrease of vascularity and stromal infiltration in the limbal and peripheral zone. Pathological examination verified that the limbal and peripheral corneal epithelium was composed of multilayer cells, the neo-vascularization was reduced and stromal inflammatory cells were decreased. CONCLUSIONS: Allograft transplantation with cultured limbal stem cells can restore corneal epithelial cell composition, decrease neovascularization, maintain limbal cellular barrier function and provide better condition for keratoplasty later.

PMID: 11853579 [PubMed - indexed for MEDLINE]

[Amniotic membrane transplantation for reconstruction of the ocular surface]

• Kruse FE,
• Meller D.

Augenklinik der Universitat Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg. Friedrich_Kruse@med.uni-heidelberg.de

Amniotic membrane transplantation has been recently gained wide-spread attention as a new method for reconstruction of the ocular surface. However long term prognosis of the surgical intervention as well as action mechanism are poorly defined. Therefore, we review the current literature concerning the application of amniotic membrane in ophthalmology and the outcome of the surgery. Amniotic membrane is used as graft or patch to promote epithelial healing of persistent epithelial defects, corneal ulcers and following penetrating keratoplasty. It is also used to seal corneal perforations and to treat bullous keratopathy. Amniotic membrane patches facilitate epithelial healing and reduce the number of complications after chemical burns. For partial limbal deficiency, amniotic membrane alone can be sufficient, while total limbal deficiency requires combination with stem-cell transplantation. Furthermore amniotic membrane grafts restore conjunctival surfaces following removal of lesions such as pterygium, tumor, scar, symblepharon, and conjunctivochalasis. The prognosis of amniotic membrane transplantation depends on the underlying disease and the quality of the ocular surface and is inversely related to the degree of inflammation. Recent investigations of the action mechanisms describe intrinsic antiinflammatory properties of the amniotic membrane.

PMID: 11594219 [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]

Comment in:

Br J Ophthalmol. 2002 Jul;86(7):831.

Failure of amniotic membrane transplantation in the treatment of acute ocular burns.

• Joseph A,
• Dua HS,
• King AJ.

Division of Ophthalmology and Visual Sciences, University Hospital, Queen's Medical Centre, Nottingham NG7 2UH, UK.

AIM: To report the failure of amniotic membrane transplantation (AMT) for ocular surface reconstruction in patients with severe acute chemical and thermal burns. METHODS: Four eyes of three patients who suffered severe chemical (n=3) and thermal (n=1) burns were studied. The aim of AMT was to prevent symblepharon formation, promote conjunctival regeneration, inhibit corneal melting by promoting epithelialisation, and to protect the ocular surface while associated lid burns were treated. AMT was used to cover the entire ocular surface of all the severely burnt and ischaemic eyes, 2-3 weeks after the injury. Where indicated, AMT was repeated by itself or in combination with other procedures in all patients. RESULTS: Three of the four eyes developed symblepharon and progressive corneal melt requiring urgent tectonic keratoplasty. All four eyes had persistent epithelial defects. Less than 25% of conjunctival regeneration occurred in three eyes. Two eyes autoeviscerated, one patient underwent lid sparing exenteration for a painful blind eye and one eye became phthysical. CONCLUSIONS: AMT did not help to restore the ocular surface or preserve the integrity of the eye in all our patients with severe acute burns, when used by itself or in combination with other surgical procedures. This reflects the extreme severity of the ocular burns in these patients and, in turn, draws attention to the fact that the current classification system does not adequately reflect such severity. In the current system such burns would be grouped under grade IV injuries to the eye (more than 50% limbal ischaemia). The prognosis of patients with 100% limbal ischaemia is much worse than patients with just over 50% limbal ischaemia. This inadequacy of the classification system probably also explains the difference between outcomes of management of grade IV burns (with AMT) in this series, compared with others.

PMID: 11520758 [PubMed - indexed for MEDLINE]

Ipsilateral limbal translocation for treatment of partial limbal deficiency secondary to ocular alkali burn.

• Nishiwaki-Dantas MC,
• Dantas PE,
• Reggi JR.

Department of Ophthalmology, Santa Casa of Sao Paulo, Corneal and External Disease Service, Ocular Emergency Service, Sao Paulo, Brazil. speyecare@originet.com.br

BACKGROUND/AIM: Chemical ocular burn, especially by alkali, may result in damage to the limbal stem cells, fundamental in maintaining the integrity of ocular surface. Clinically, patients manifest abnormal conjunctival-corneal healing with peripheral neovessels, chronic epithelial defect, severe stromal inflammation, and conjunctivalisation of the corneal, which is characteristic of limbal deficiency. Penetrating keratoplasty has a poor prognosis in these cases. Available therapeutic options included limbal autograft and allograft transplantation associated or not with human amniotic membrane transplant. The authors propose an alternative treatment with ipsilateral autologous limbal transplantation, transferring the healthy portion of the limbus from the partially burned eye to the deficient area in patients with partial limbal deficiency secondary to alkali burn. METHODS: Ipsilateral limbal autografts were performed in five patients with partial limbal deficiency secondary to alkali burn, transferring the healthy portion of the limbus to the burned area of the same eye, without intervening in the contralateral eye. RESULTS: All cases had regression of the limbal deficiency with improvement of visual acuity to a minimum of 20/60-20/20 (partial), without complications during the follow up period (range 7-11 months). CONCLUSION: Ipsilateral autologous limbal autograft is a therapeutic option for partial limbal deficient eyes.

PMID: 11520748 [PubMed - indexed for MEDLINE]

Reconstruction of ocular surface with heterologous limbal epithelium and amniotic membrane in a rabbit model.

• Avila M,
• Espana M,
• Moreno C,
• Pena C.

Departamento de Oftalmologia, Facultad de Medicina, Hospital San Juan de Dios, Universidad Nacional de Colombia, Colombia. mavila@mail.med.upenn.edu

PURPOSE: To report in vivo reconstruction of the ocular surface using amniotic membrane and heterologous transplants of epithelial limbal cells in rabbits with chemical burns. METHODS: After severe damage to the ocular surface with n-heptanol and keratectomy, 15 rabbits developed total limbal deficiency with conjunctival epithelialization, vascularization, and chronic inflammation. One month later, a complete keratectomy was performed in all eyes: 12 received additional transplantation of human amniotic membrane and heterologous limbal epithelial cells in a double amniotic membrane layer, 2 received amniotic membrane only, and 1 control eye received no procedure. RESULTS: After 1 month of follow-up, corneas in eight of the operated eyes presented minimal vascularization, without signs of rejection. Corneal surface reconstruction was demonstrated with the growth of new corneal-like epithelial phenotype and integration of amniotic membrane to the basal corneal surface. A superficial amniotic membrane (with the amnion side up as a dressing) peeled off after 7 to 10 days. The epithelialization with heterologous limbal epithelial cells was evident underneath. The other four operated eyes were followed for 6 months; the ocular surface was also stable with a corneal-like epithelial phenotype. CONCLUSION: Simultaneous transplantation of amniotic membrane and heterologous limbal epithelial cells in severe ocular surface disorders could restore ocular surface and may be useful in patients with severe bilateral limbal epithelial loss, giving new perspectives for the treatment of severe ocular surface disorders.

PMID: 11333332 [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]

Development of a newly designed double-fixed Seoul-type keratoprosthesis.

• Lee JH,
• Wee WR,
• Chung ES,
• Kim HY,
• Park SH,
• Kim YH.

Department of Ophthalmology, Seoul National University College of Medicine, 28 Yongon-dong, Chongno-gu, Seoul 110-744, Korea. jjhlee@plaza.snu.ac.kr

OBJECTIVE: To develop a newly designed double-fixed keratoprosthesis (Seoul-type keratoprosthesis [S-KPro]) and to assess its mechanical stability and biocompatibility. METHODS: Twenty-five rabbits were divided into 4 groups by fixation technique, amniotic membrane (AM) implantation, and skirt material. The eyes were studied with the use of slitlamp, light, and electron microscopy. Stress testing was performed. In addition, 2 human subjects underwent S-KPro implantation. Best-corrected visual acuity was checked, and ophthalmic examination was performed. RESULTS: The average retention period of the group receiving double-fixated polyurethane-S-KPro with AM was longer (>24 weeks) than that of the others. Fibroblast invasions were found in polyurethane pores but not in polytetrafluoroethylene (Gore-Tex) pores on light microscopy. The minimal pressure that induced aqueous leakage was greater than 250 mm Hg in all of the tested eyes. Two human subjects have maintained a good postoperative condition for 18 and 8 months. CONCLUSIONS: The double-fixation technique of applied S-KPro and AM appears to be helpful in improving the stability of the keratoprosthesis. Polyurethane with relatively large pore size (40 microm) may be used successfully as a material for the keratoprosthesis skirt. CLINICAL RELEVANCE: Our results may be important for improving the clinical outcome of keratoprosthesis.

PMID: 11115262 [PubMed - indexed for MEDLINE]

Amniotic membrane transplantation in acute chemical and thermal injury.

• Sridhar MS,
• Bansal AK,
• Sangwan VS,
• Rao GN.

Cornea Centre, L.V. Prasad Eye Institute, Hyderabad, India. mss@lvpeye.stph.net

PURPOSE: To present a case of chemical injury and a case of thermal injury treated by amniotic membrane transplantation in acute phase. METHODS: Case reports. An eye with sodium hydroxide injury, opaque cornea, and limbal ischemia of more than 180 degrees and an eye with hot tea injury, opaque cornea, stromal edema, and scarring were treated by amniotic membrane transplantation within the first few weeks of injury. RESULTS: In the eye with sodium hydroxide injury, 4 months after amniotic membrane transplantation, the ocular surface is stable, superficial corneal scarring with vascularization is present, and visual acuity is 20/25. In the eye with thermal injury, 6 months after amniotic membrane transplantation, the ocular surface is stable, but there is superficial scarring and vascularization, and visual acuity is 20/20. CONCLUSIONS: Amniotic membrane transplantation can be considered in chemical injury with severe limbal ischemia and in severe thermal injury in acute phase. Long-term studies are warranted to evaluate further the efficacy of amniotic membrane transplantation in these clinical situations.

PMID: 11004281 [PubMed - indexed for MEDLINE]

[Limbal stem cell deficiency]

• Gatinel D,
• Hoang-Xuan T.

Fondation ophtalmologique Adolphe de Rothschild, Service d'Ophtalmologie, 25 rue Manin, 75019 Paris, France.

PMID: 10992070 [PubMed - indexed for MEDLINE]

Comment in:

N Engl J Med. 2000 Jul 13;343(2):136-8.

Reconstruction of damaged corneas by transplantation of autologous limbal epithelial cells.

• Tsai RJ,
• Li LM,
• Chen JK.

Department of Ophthalmology, Chang Gung Memorial Hospital, Taoyuan, Taiwan. raytsai@ms4.hinet.net

BACKGROUND: Stevens-Johnson syndrome, ocular pemphigoid, and thermal or chemical burns can cause scarring and opacification of the cornea and loss of vision. Transplantation of epithelial cells from the limbus of the contralateral cornea can restore useful vision. However, this procedure requires a large limbal graft from the healthy eye and is not possible in patients who have bilateral lesions. METHODS: We took specimens of limbal epithelial cells from the healthy contralateral eyes of six patients with severe unilateral corneal disease. The epithelial cells were cultured and expanded on amniotic membrane. The amniotic membrane, together with the sheet of limbal epithelial cells, was transplanted to the denuded corneal surface of the damaged eye after superficial keratectomy to remove fibrovascular ingrowth. The mean (+/-SD) follow-up period was 15+/-2 months. RESULTS: Complete reepithelialization of the corneal surface occurred within two to four days of transplantation in all six eyes receiving transplants. By one month, the ocular surface was covered with corneal epithelium, and the clarity of the cornea was improved. In five of the six eyes receiving transplants (83 percent), the mean visual acuity improved from 20/112 to 20/45. In one patient with a chemical burn who had total opacification of the cornea, the acuity improved from the ability to count fingers at 40 cm to 20/200. No patient had recurrent neovascularization or inflammation in the transplanted area during the follow-up period. CONCLUSIONS: Transplantation of autologous limbal epithelial cells cultured on amniotic membrane is a simple and effective method of reconstructing the corneal surface and restoring useful vision in patients with unilateral deficiency of limbal epithelial cells.

PMID: 10891515 [PubMed - indexed for MEDLINE]

Amniotic membrane transplantation for acute chemical or thermal burns.

• Meller D,
• Pires RT,
• Mack RJ,
• Figueiredo F,
• Heiligenhaus A,
• Park WC,
• Prabhasawat P,
• John T,
• McLeod SD,
• Steuhl KP,
• Tseng SC.

Department of Ophthalmology, Bascom Palmer Eye Institute, Miami, Florida 33136, USA.

PURPOSE: To determine whether preserved human amniotic membrane (AM) can be used to treat ocular burns in the acute stage. DESIGN: Prospective, noncomparative, interventional case series. PARTICIPANTS: Thirteen eyes from 11 patients with acute burns, 10 eyes with chemical burns and 3 with thermal burns of grades II-III (7 eyes) and grade IV (6 eyes), treated at 7 different facilities. METHODS: Patients received amniotic membrane transplantation (AMT) within 2 weeks after the injury. MAIN OUTCOME MEASURES: Integrity of ocular surface epithelium and visual acuity during 9 months of follow-up. RESULTS: Ten patients were male and one patient was female; most were young (38.2 +/- 10.6 years). For a follow-up of 8.8 + 4.7 months, 11 of 13 eyes (84.63%) showed epithelialization within 2 to 5 weeks (23.7 +/- 9.8 days), and final visual acuity improved > or = 6 lines (6 eyes), 4 to 5 lines (2 eyes), and 1 to 3 lines (2 eyes); only one eye experienced a symblepharon. Eyes with burns of grade II to III showed more visual improvement (7.3 +/- 3 lines) than those with burns of grade IV (2.3 +/- 3.0 lines; P < 0.05, unpaired t test). In the group with grade II or III burns, none had limbal stem cell deficiency. All eyes in the group with grade IV burns did experience limbal stem cell deficiency. CONCLUSIONS: Amniotic membrane transplantation is effective in promoting re-epithelialization and reducing inflammation, thus preventing scarring sequelae in the late stage. In mild to moderate burns, AMT alone rapidly restores both corneal and conjunctival surfaces. In severe burns, however, it restores the conjunctival ocular surface without debilitating symblepharon and reduces limbal stromal inflammation, but does not prevent limbal stem cell deficiency, which requires further limbal stem cell transplantation. These results underscore the importance of immediate intervention in the acute stage of eyes with severely damaged ocular surface. Further prospective randomized studies including a control group are required to determine the effectiveness of AMT in acute chemical and thermal burns of the eye.

PMID: 10811094 [PubMed - indexed for MEDLINE]

Combined use of an amniotic membrane and tissue adhesive in treating corneal perforation: a case report.

• Su CY,
• Lin CP.

Department of Ophthalmology, Kaohsiung Medical College, Taiwan, Republic of China.

We report a new method combining the use of an amniotic membrane and cyanocrylate tissue adhesive to seal a corneal perforation. A 47-year-old male suffered from an alkali injury complicated with corneal melting and perforation in the left eye. We placed an amniotic membrane of optimal size in the anterior chamber directly under the corneal perforation lesion. The cyanocrylate tissue adhesive was then applied over the perforation site and sealed successfully. Three weeks later, the tissue adhesive had dislodged. The amniotic membrane had sealed the perforated lesion and was well adhered to the surrounding corneal tissue with complete epithelial covering. Vision was 20/25 six months after the operation. The combined use of an amniotic membrane and tissue adhesive is a promising method in the treatment of corneal perforation.

PMID: 10743929 [PubMed - indexed for MEDLINE]

Amniotic membrane patching promotes healing and inhibits proteinase activity on wound healing following acute corneal alkali burn.

• Kim JS,
• Kim JC,
• Na BK,
• Jeong JM,
• Song CY.

Department of Ophthalmology, Chung-Ang University Hospital, Hangang-Ro 3ka 65-207, Seoul, Yongsan-ku, 140-757, Korea.

Amniotic membrane (AM) contains basement membrane components and various proteinase inhibitors. Furthermore, when used as a graft, the basement membrane of AM could block inflammatory insults to a damaged corneal surface. Thus, we evaluated whether amniotic membrane patching could promote the healing process by inhibiting proteolytic damage. Alkali wounds were inflicted on the central corneas of rabbits by applying a round filter paper, 6.0 mm in diameter, soaked in 1 N NaOH for 30 sec. Amniotic membrane patching was performed over the perilimbal sclera immediately after wounding. A total of 115 rabbits were divided into four groups: (1) immediately covered by AM with the amnion cell side down up to the perilimbal sclera (n =26); (2) covered by AM with the stromal side down up to the perilimbal sclera (n =19); (3) anchored to the fornix (n =29); and (4) uncovered as a control (n =41). AM was removed 3 days postoperatively. During follow-ups, epithelial defects, corneal thickness and its opacity of each eye were measured. Some corneas were removed for histopathologic studies and for proteinase activity assay and zymography. The epithelial healing was faster and the corneal thickness was thicker in all three AM-covered groups than in the control (P<0.05). No significant difference was found between covered and anchored groups (P>0.05). Corneal opacity was least in the amnion cell side down group. Infiltration of polymorphonuclear leukocytes (PMNs) was much less in AM-covered groups than in the control. Pathological results were associated with zymographic findings, which revealed much higher proteinase activity in uncovered group than AM-covered groups. Immediate intervention for acute alkali burns with AM as a temporary patch promotes wound healing by inhibiting proteinase activity and PMNs infiltration. Copyright 2000 Academic Press.

PMID: 10712819 [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]

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]

Amniotic membrane transplantation with or without limbal allografts for corneal surface reconstruction in patients with limbal stem cell deficiency.

• Tseng SC,
• Prabhasawat P,
• Barton K,
• Gray T,
• Meller D.

Ocular Surface and Tear Center, Department of Ophthalmology, Bascom Palmer Eye Institute, Miami, Fla 33136, USA. stseng@bpei.med.miami.edu

OBJECTIVE: To examine whether amniotic membrane transplantation (AMT), in preparing the perilimbal stroma, enhances the success of allograft limbal transplantation (ALT). METHODS: Thirty-one eyes of 26 consecutive patients had cytologically proven limbal deficiency resulting from chemical burns (14 eyes); Stevens-Johnson syndrome, toxic epidermal necrolysis, or pseudopemphigoid (5 eyes); contact lens-induced keratopathy (3 eyes); aniridia (3 eyes); multiple surgical procedures (2 eyes); atopy (2 eyes); or an unknown cause (2 eyes). Based on the severity of limbal deficiency, group A (mild), comprising 10 eyes, received AMT alone; group B (moderate), comprising 7 eyes, received AMT and ALT; and group C (severe), comprising 14 eyes, received AMT, ALT, and penetrating keratoplasty. All patients except those in group A received continuous oral cyclosporine. RESULTS: Except for the 2 eyes with atopy, all amniotic membrane-covered surfaces showed rapid epithelialization (in 2 to 4 weeks) and reduced inflammation, vascularization, and scarring, and the surfaces became smooth and wettable. For the mean follow-up period of 15.4 months, 25 (83%) of 30 eyes showed visual improvement, consisting of 6 or more lines (13 eyes), 4 to 5 lines (6 eyes), or 1 to 3 lines (6 eyes). Visual improvement decreased with the severity of limbal deficiency from 8 (100%) of 8 eyes in group A to 5 (71%) of 7 eyes in group B and 11 (79%) of 14 eyes in group C. In group C, corneal graft rejection occurred in 9 (64%) of 14 eyes, and reversible early limbal allograft rejection was noted in 3 (14%) of 21 eyes of groups B and C. CONCLUSIONS: For partial limbal deficiency with superficial involvement, AMT alone is sufficient and hence superior to ALT because there is no need to administer cyclosporine. For total limbal deficiency, additional ALT is needed, and AMT helps reconstruct the perilimbal stroma, with reduced inflammation and vascularization, which collectively may enhance the success of ALT.

PMID: 9565039 [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]

Impression cytology study of epithelial phenotype of ocular surface reconstructed by preserved human amniotic membrane.

• Prabhasawat P,
• Tseng SC.

Department of Ophthalmology, Bascom Palmer Eye Institute, Miami, Fla., USA.

OBJECTIVE: To determine the epithelial phenotype of the ocular surface reconstructed by preserved human amniotic membrane. METHODS: Impression cytology was performed in 6 patients who received a large patch of amniotic membrane for conjunctival surface reconstruction during removal of acquired melanosis, conjunctival intraepithelial neoplasia, or bilateral inferior conjunctival chalasis, or for corneal surface reconstruction during removal of pannus associated with limbal deficiency caused by aniridia, toxic epidermal necrolysis, or chemical burn. RESULTS: The nongoblet epithelial cells covering the amniotic membrane were uniformly smaller and the cell density was almost twice that of age- and sex-matched normal control eyes at the corresponding site, and the goblet cell density was almost 10 times that of the control (both P < .05; Student paired t test) (N = 7 eyes). Furthermore, the conjunctival epithelial phenotype with goblet cells was found on corneal surfaces of all 3 patients with limbal deficiency. CONCLUSIONS: The success of conjunctival surface reconstruction correlated well with recovery of the conjunctival epithelial phenotype. The lack of corneal epithelial phenotype even on an avascular corneal stroma supports the concept that conjunctival transdifferentiation does not occur in vivo, and indicates that additional limbal stem cell transplantation is needed for effective corneal surface reconstruction in patients with limbal deficiency.

PMID: 9366664 [PubMed - indexed for MEDLINE]

Vaginal epithelialization with human amnion.

• Tancer ML,
• Katz M,
• Veridiano NP.

Human amnion is a readily available and inexpensive allograft with low antigenicity, high antimicrobial potential, and the ability to foster epithelialization. It has been used to reconstruct the vagina in 2 patients following vaginectomy for diffuse carcinoma in situ (CIS) and in 1 patient following severe, corrosive, vulvovaginal burns. It was also used to construct the vagina in 1 patient with mullerian agenesis. In all 4 cases, epithelialization was complete within 8 weeks.

PMID: 471375 [PubMed - indexed for MEDLINE]

[Surgical treatment of caustic eye injuries]

• Alberth B,
• Kettesy A.

PMID: 4935835 [PubMed - indexed for MEDLINE]