Clinical Outcome Of Amniotic Membrane Grafting For Ocular Surface Reconstruction Presenting author :...

Clinical Outcome Of Amniotic Membrane Grafting For Ocular Surface Reconstruction


Presenting author : M.VANATHI MD 1

Contributing Authors : A Panda MD 1

Radhika Tandon MD 1, 2

1 Cornea Services, 2 Officer In – Charge National Eye Bank

Dr R P Centre for Ophthalmic SciencesAll India Institute of Medical Sciences, New Delhi, INDIA

[email protected]

Authors have no financial interest in the subject matter or any product mentioned in this study

Acknowledgements:Department of Obstetrics & Gynaecology, AIIMSDepartment of Ocular Pharmacology, RPC, AIIMSMs Meena Verma, Ophthalmic Technical Staff, Cornea lab, RPC, AIIMS

Presenting author : M.VANATHI MD 1

Contributing Authors : A Panda MD 1

Radhika Tandon MD 1, 2

1 Cornea Services, 2 Officer In – Charge National Eye Bank

Dr R P Centre for Ophthalmic SciencesAll India Institute of Medical Sciences, New Delhi, INDIA

[email protected]

Authors have no financial interest in the subject matter or any product mentioned in this study

Acknowledgements:Department of Obstetrics & Gynaecology, AIIMSDepartment of Ocular Pharmacology, RPC, AIIMSMs Meena Verma, Ophthalmic Technical Staff, Cornea lab, RPC, AIIMS

Introduction

Wound healing characteristics of amniotic membrane 1

• AM provides a new basement membrane, which forms a substrate for enhancing adhesion and growth of epithelial progenitor cells, including stem cells.

• AM exerts an antiinflammatory effect suppressing expression of 1L-1 and 1L-1

• AM stromal matrix has a direct anti-scarring secondary to its suppression of TFG- signaling and myofibroblast differentiation.

• All these act in combination to restore the micro-environmental conditions conducive to the growth of the epithelial progenitor cells.

• AM is also thought to promote nerve regeneration by maintaining nerve growth factor signalling

1. Tseng et. How does amniotic membrane work? The Ocular Surface 2004; 2, 177-187.



A. AMT in the presence of stem cell deficiency Ocular chemical injury

B. AMT in the absence of stem cell deficiency Corneal epithelial defects Corneal/Corneoscleral ulcers Bullous keratopathy

C. AMT for conjunctival reconstructions Pterygium Conjunctivochalasis OSSN Limbal Dermoid Symblepharon Conjunctival lesions Leaking blebs

D. AMT in ocular cicatricial diseases Toxic epidermal necrolysis Ocular cicatricial pemphigoid Oculopalpebral and reconstructive surgery

E. Other indications of AM use Stem cell cultures

Introduction

Common Indications 2



2. Bouchard CS, John T. Amniotic membrane transplantation in the management of severe ocular surface disease: indications and outcomes. Ocul Surf. 2004 Jul;2(3):201-11.

Methods

Retrospective analysis of case records of AMG for ocular surface reconstruction

of a single surgeon (MV) from January 2006 – September 2009.

Parameters noted: • Age / sex• Indication• Time taken for complete ocular surface epithelialisation• Complications• Improvement in tear film stability• Success in achieving optimal ocular surface reconstruction

Purpose

Despite widespread use of amniotic membrane grafting (AMG) in various procedures, standardization of the use of AM and of outcome measures is still lacking. Herein, we report, our results of AMG in ocular surface reconstruction.



(Successful outcome was defined as the healing of an epithelial defect (corneal or conjunctival) over a specified time period and the lack of induced motility disturbance)

Introduction

Surgical Technique 3

Schematic diagram (sagittal view) showing multilayered amniotic membrane lining the entire ocular surface

Double armed 6-0 silk fornix retaining sutures tied over rubber pegs

10-0 monofilament nylon sutures / human fibrin glue of AMG to lid margins



4. Sangwan et al. Amniotic membrane transplantation: A review of current indications in the management of various ophthalmic disorders. Indian J Ophthalmol 2007; 55: 251 – 60.

AMGs done include 4 :

Inlay AMG (graft technique)

Multilayered Onlay AMG ( Patch technique)

Multilayered Inlay + Onlay AMG (layered technique)

3. Augusto Azuara-Blanco, C T Pillai and Harminder S Dua. Amniotic membrane transplantation for ocular surface reconstruction. Br J Ophthalmol 1999 83: 399-402



Multilayered Inlay + Onlay AMG in acute chemical injury

Multilayered Inlay + Onlay AMG in neurotrophic ulceration

Symblepharon release + AMG with Fibrin glue

Multilayered AMG with suture fixation with symblepharon shell insitu

Multilayered AMG after OSSN resection

Healed neurotrophic ulcer after AMG

Results Clinical Outcome Of Amniotic Membrane Grafting

For Ocular Surface Reconstruction


INDICATIONS No of eyes

Time to

epithelialisation

Success

AMT in the presence of stem cell deficiency

(Alkali -3, acid -1, molten aluminium – 3)

7 3 – 6 weeks

(3.39 + 2.71)

85.7%

(6 eyes)

AMT in the absence of stem cell deficiency

Post-PK non-healing PED

Viral keratitis

Neurotrophic keratopathy

Shields ulcer

Moorens ulcer

13

2

3

4

3

1

1- 3 weeks

(1.9 + 1.12)

100%

AMT for conjunctival reconstructions

post chemical injury symblepharon dermoid excision ocular surface squamous neoplasia

19

13

4

2

1- 6 weeks

(3.91 + 2.18)

89.4%

(17 eyes)

Results

Successful ocular surface stabilization was achieved in 36 eyes (91%). The remaining 3 eyes required multiple interventions to achieve ocular surface reconstruction.

Time to complete ocular surface epithelialisation varies in various indications.

Prolonged postoperative topical lubricant and anti-inflammatory therapy is mandatory.



Ocular surface reconstruction for acute chemical injuries and post chemical injury symblepharon was the leading indication for amniotic membrane grafting.

Ocular surface stability can be successfully achieved by use of amniotic membrane grafting techniques.

ConclusionClinical Outcome Of Amniotic Membrane Grafting



Our findings concur with that of Kheirkhah et al 5.

The complete success is more likely in less severe grades of symblepharon and with use of anchoring sutures

Recurrence is more likely in younger age groups and with higher grades of chemical injury, canthal involvement

DiscussionClinical Outcome Of Amniotic Membrane Grafting



5. Kheirkhah A, Blanco G, Casas V, Hayashida Y, Raju VK, Tseng SC. Surgical strategies for fornix reconstruction based on symblepharon severity. Am J Ophthalmol. 2008 Aug;146(2):266-275. Epub 2008 Jun 2.

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