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Current Ophthalmology

Amniotic membrane transplantation: A review of current indications in the

management of ophthalmic disorders

Virender S. Sangwan, MS; Sanghamitra Burman, MD, FRCS; Sushma Tejwani, DO;

Sankaranarayana Pillai Mahesh, MD,FRCS; Ramesh Murthy, FRCS

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Amniotic membrane transplantation is currently being used for a continuously widening spectrum of
ophthalmic indications. It has gained widespread attention as an eective method of reconstruction of the
ocular surface. Amniotic membrane has a unique combination of properties, including the facilitation of
migration of epithelial cells, the reinforcement of basal cellular adhesion and the encouragement of epithelial
dierentiation. Its ability to modulate stromal scarring and its anti-inammatory activity has led to its use in
the treatment of ocular surface pathology as well as an adjunct to limbal stem cell grafts. Amniotic membrane
transplantation has been used for reconstruction of the corneal surface in the setting of persistent epithelial
defects, partial limbal stem cell deciency, bullous keratopathy and corneoscleral ulcers. It has also been used
in conjunction with limbal stem cell transplantation for total limbal stem cell deciency. Amniotic membrane
grafts have been eectively used as a conjunctival substitute for reconstruction of conjunctival defects
following removal of pterygia, conjunctival lesions and symblephara. More recently, amniotic membrane has
been used as a substrate for ex vivo cultivation of limbal, corneal and conjunctival epithelial cells. This article
reviews the current literature on the applications of amniotic membrane transplantation and its outcome in
various ophthalmic conditions.
Key words: Amniotic membrane graft, ocular surface disorders
Indian J Ophthalmol 2007;55:251-60

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Amniotic membrane transplantation (AMT) has been


reportedly used for a variety of ocular surface problems
including persistent corneal epithelial defects (PED), shield
ulcer of vernal keratoconjunctivitis, partial limbal stem cell
deciency (LSCD) and conjunctival defects following excision
of surface tumors and pterygia.1 Significant progress has
been made in ocular surface reconstruction procedures and
understanding limbal stem cell disease. The strategies of
managing limbal deciency include cadaveric or living related
limbal transplantation in bilateral LSCD; simple debridement,
AMT and allotransplantation for unilateral LSCD.2 The latest
approach to limbal stem cell transplantation is based on
cultivation of limbal stem cells on denuded amniotic membrane
(AM).3 Preserved human amnion has been successfully used
as a biological bandage, promoter of epithelialization, inhibitor
of inammation and angiogenesis, as well as a carrier for ex
vivo cultured limbal stem cells. However, there remains a lack
of evidence that AMT is better than the existing treatment
modalities for the various clinical conditions described herein.
The purpose of this review is to present a summary of current
ophthalmic indications and outcome for AMT.

Cornea and Anterior Segment Services, LV Prasad Eye Institute, Banjara


Hills, Hyderabad, India. (VSS,SB,ST); Orbit, Oculoplastic and Ocular
oncology service, LVPEI, Hyderabad, India. ( RM ); Moorelds Eye
Hospital, London, UK. (SB,RM); Laboratory of Immunology, National
Eye Institute, Bethesda, MD, USA (SPM)
Correspondence to Dr. Virender S Sangwan, LV Prasad Eye
Institute, LV Prasad Marg, Banjara Hills, Hyderabad - 500 034, India.
E-mail: vsangwan@lvpei.org
Manuscript received: 20.12.04; Revision accepted: 24.02.07

Scientic Basis of Clinical Application


The human AM is the innermost layer of the placenta.
Histologically the amnion is a 0.02 mm to 0.5 mm ve-layered
membrane, composed of three basic layers.

Epithelial monolayer
Thick basement membrane
Avascular, hypocellular stromal matrix

The epithelium consists of a single layer of cuboidal cells


with a large number of microvilli on the apical surface. The
basement membrane is a thin layer composed of a network of
reticular bers. Histochemically the basement membrane closely
resembles that of the conjunctiva.4 The compact layer contributes
to the tensile strength of the membrane. The broblast layer is the
thickest layer of the AM made up of a loose broblast network.
The outermost layer of the amnion is the spongy layer.
The basement membrane is one of the thickest membranes
found in human tissue. This layer is resistant to current
cryopreservation techniques. The structural integrity,
transparency and elasticity of the amniotic basement membrane
makes it currently the most widely accepted tissue replacement
for ocular surface reconstruction. It is known to promote
epithelial cell migration, adhesion and dierentiation. It is
an ideal substrate for supporting the growth of epithelial
progenitor cells by prolonging their lifespan, maintaining
their clonigenicity and preventing epithelial cell apoptosis.5
This action explains why AMT facilitates epithelialization for
PED with stromal ulceration.6 In tissue cultures AM supports
epithelial cells grown from explant cultures and maintains their
normal morphology and dierentiation. The resultant cultured
epithelium can be transplanted with the AM to reconstruct

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damaged corneas.7 The AM can be used to promote non-goblet


cell dierentiation of the conjunctival epithelium.8
The basement membrane of the AM, cornea and conjunctiva
contain collagen types IV, V and VII, in addition to bronectin
and laminin. 4 Though the laminins are very effective in
facilitating corneal epithelial cell adhesion Type V collagen
helps in the epithelial cell anchorage to the stroma.9
AM produces basic broblast, hepatocyte and transforming
growth factor (TGF). These growth factors can stimulate
epithelialization and modulate proliferation and dierentiation
of stromal broblasts.10

The epithelial cells in fresh or preserved AMG are nonviable.


The viability of amniotic epithelial cells may be associated with
low-grade inammatory response.19 The drawback with the
preserved AM is the need for a -70o refrigerator, which precludes
its use outside big institutions.

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The AM stromal matrix, rich in fetal hyaluronic acid


suppresses TGF B signaling, proliferation and myobroblastic
dierentiation of normal corneal and limbal broblasts as
well as normal conjunctival and pterygium fibroblasts. 11
This action explains why AMT helps reduce scars during
conjunctival surface reconstruction, prevents recurrent scarring
after pterygium removal and reduces corneal haze following
photorefractive keratectomy. The stromal matrix also suppresses
expression of certain inammatory cytokines that originate
from the ocular surface epithelia, including interleukin 1a, IL
2, IL-8, interferon , tumor necrosis factor-, basic broblast
growth factor and platelet derived growth factor.12 The AM
attracts and sequesters inammatory cells inltrating the ocular
surface and contains various forms of protease inhibitors.13 This
may explain some of its anti-inammatory properties.

Ideally, serologic tests on the maternal donor must be done both


at the time of procurement of the donor tissue and again six
months later. This dual testing eliminates the slightest risk of
disease transmission. With the fresh AM the time interval from
tissue procurement to transplantation is short and prevents
repeat testing of the donor. Patients have to be brought to the
hospital at a short notice unlike with preserved AM, which
allows more flexibility in scheduling surgery.23 A distinct
disadvantage is wastage of unused tissue with non-preserved
AM as opposed to frozen AM where up to 30 grafts can be
prepared from one placenta.

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Aminotic membrane graft (AMG) procurement, processing


and preservation
Amniotic membrane is obtained from prospective donors
undergoing Caesarean section, who are negative for
communicable diseases including HIV, hepatitis and syphilis.
Dierent protocols exist for the processing and storage.14,15
According to Kim et al.15 the placenta is cleaned with balanced
salt solution containing a cocktail of antibiotics (50 g/ml
penicillin, 50 g/ml streptomycin, 100 g/ml of neomycin as
well as 2.5 g/ml of amphotericin B) under sterile conditions.
The amnion is separated from the chorion by blunt dissection.
The separated membranes are cut in dierent sizes placed
on nitrocellulose paper strips with the epithelial side up.
Dulbecco Modied Eagles Medium/glycerol (1:1) is used for
cryopreservation and the tissues are frozen at -80 degrees until
further use.16-19 Amnion stored in 50-85% glycerol is reliable
and eective for over a year, with the added advantage of
antibacterial properties.20 Human AM deprived of amniotic
epithelial cells by incubation with EDTA when freeze dried,
vacuum packed and sterilized with gamma-irradiation at 25kGy
retained most of the physical, biological and morphologic
characteristics of cryopreserved AM. 21 Lyophilized AMs
were found to be impermeable to dierent strains of bacteria
- Bacillus, Escherichia coli, Pseudomonas, Citrobacter, Flavimonas
and Staphylococcus. The results indicate that AMs processed
by air-drying are stable and can be stored under dierent
environmental conditions without compromising their clinical
performance.22
Fresh versus preserved AM
Both fresh and preserved AM have been found to function
equally well when transplanted onto the ocular surface.23
However, there are certain concerns when using fresh AM.

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Principles of surgery
The main objectives of AMT are ocular surface reconstruction,
promotion of epithelialization, providing symptomatic relief
and reducing inammation. There are three basic principles
upon which the nal technique is individualized.

Inlay or graft technique: When the AMG is tailored to the size


of the defect and is meant to act as a scaold for the epithelial
cells, which then merges with the host tissue, it is referred to
as a graft.24 The AM is secured with its basement membrane
or epithelial side up to allow migration of the surrounding
epithelial cells on the membrane.
Overlay or patch technique: When the AM is used akin to a
biological contact lens in order to protect the healing surface
defect beneath, it is referred to as a patch.25,26 A patch also
reduces inammation by its barrier eect against the chemical
mediators from the tear lm. When used as patch the membrane
is secured with its epithelial side up and it either falls o or is
removed.
Filling-in or layered technique: In this technique the entire
depth of an ulcer crater is lled with small pieces of AM
trimmed to the size of the defect.27 A larger graft is sutured to
the edges of the defect in an inlay fashion and an additional
patch may help in preserving the deeper layers for a longer
duration.28
AMG orientation
The preferred surgical orientation of the AM on the ocular
surface is with the epithelial side up. The stromal surface can
be identied by the presence of vitreous-like strands that can be
raised with a sponge. Hu et al.29 elaborated that AM stains with
indocyanine green, rose bengal, trypan blue and lissamine green
B. The dyes stain both the epithelial and stromal surfaces and
may be useful in identifying the edges and wrinkles in the graft.
Intraoperative staining with lissamine green B may be a simple
and eective way to assist surgeons in the proper handling of
AM, while uorescein staining has no role.29

Surgical Technique
Corneal surface reconstruction
Non-absorbable sutures are used to anchor AMGs to the
cornea. A single sheet of AM may be applied as an inlay graft

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Sangwan et al. Amniotic membrane transplantation

or overlay patch and anchored to the supercial cornea with


multiple interrupted 10-0 nylon monofilament sutures. A
Weckcel sponge or blade is used to remove all cellular debris
or exudates from the base of the defect in case of PEDs, shield
ulcers and ulcerative keratitis. Loose epithelium surrounding
an epithelial defect or over an area of bullous keratopathy is
debrided using a ne forceps and a straight crescent blade [Figs
1 and 2]. The size of the graft should be at least 1 mm larger
than the defect. The sutures must be placed circumferentially
or parallel to the cut edge of the graft in an interrupted or
continuous manner. The suture knots must be cut short and
knots buried in corneal tissue.

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If AM is used to ll in deep corneal ulcers, descemetoceles


or perforations, a multilayered approach is preferred. Small
pieces of AM may be layered into the defect or a single sheet
may be folded on itself twice (blanket fold). In either case a
larger patch is anchored over the entire defect in an overlay
fashion as shown in Figs 3 and 4.

Symblepharon release
Fornix formation
Socket reconstruction
Conjunctivochalasis
Entropion correction
Corneal surface reconstruction
PEDs
Non-healing stromal ulcers
Partial LSCD
Total LSCD
Bullous keratopathy
Band keratopathy
Scleral melt
Substrate for ex vivo expansion of limbal stem cells

Conjunctival surface reconstruction


Vicryl sutures are used to anchor AM to the conjunctiva. Given
the rapid healing ability of the conjunctiva, 8-0 or, 9-0 or 10-0
vicryl may be used for this purpose. The essence of the surgical
technique in each of the indications is adequate dissection and
removal of pathological subconjunctival tissue.
In order to anchor a sheet of AM to the fornix two sets of
double armed 4-0 chromic gut sutures on a cutting needle may
be used. The needles are passed from the AM surface through
the inferior fornix, via the full-thickness of the eyelid and exit
through the eyelid skin. The two needles of each of the two sets
of sutures are passed through two segments of an encircling
band and then tied.30

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Ocular surface reconstruction


Extensive ocular surface damage seen in severe grades
of chemical injury, Stevens Johnson syndrome (SJS) and
ocular cicatricial pemphigoid warrants sequential surface
reconstruction. It is important to ensure that all brotic tissue
is meticulously dissected and removed from the corneal and
conjunctival surfaces. The AMG must be a continuous sheet
devoid of buttonholes. The lower lid is everted with a large
chalazion clamp. A large sheet of AM is placed on the ocular
surface and it is rst anchored to the inner surface of the everted
lower lid close to the lid margin using multiple interrupted
10-0 vicryl sutures. The anchorage to the inferior fornix is as
described above. A continuous encircling 10-0 nylon suture is
used to anchor the membrane at the limbus or the peripheral
360o cornea. In addition, multiple interrupted vicryl sutures
are placed to attach the membrane to the inner lid surface,
beyond the inferior fornix and onto the bulbar conjunctiva
[Figs. 5 and 6].
Indications of AMT in ocular surgery
Conjunctival surface reconstruction
Pterygium surgery
Chemical burns
Cicatrizing conjunctivitis
Ocular surface squamous neoplasia (OSSN)
Leaking blebs
Filtering surgery

Outcome of AMT
Cicatrizing conjunctivitis

In SJS, ocular cicatricial pemphigoid and toxic epidermal


necrolysis, immune-mediated inammation must be controlled
prior to surgery. John et al. rst reported the benecial eects of
AMT in the acute stage of toxic epidermal necrosis.31 Honavar
et al. evaluated the role of AMT as a preliminary step in the
sequential management of SJS.32 Creditable improvements in
the ocular surface were measured in terms of greater patient
comfort, reduced surface inammation, decrease in the severity
of vascularization and absence of recurrent corneal erosions.

In 9/10 patients there was a signicant improvement in


the ocular surface with deepening of fornices. Barabino et al.
noted a slight deterioration in the clinical eects with time
owing to the ongoing surface inammation33 and deep-seated
conjunctival34 injury.

Chemical and thermal injury


Joseph et al. reported that AMT was not found to be useful in
the restoration of the ocular surface in Grade IV burns.35 In very
severe ocular burns involving 360o of the limbus and entire
conjunctiva there is probably a total loss of epithelial stem cells,
leaving little resource for the amnion to allow regeneration.
Although AMT in eyes with acute ocular burns has advantages
in terms of pain relief and rapid epithelialization in moderate
grade burns, no denite benet of AMT over medical therapy
alone has been reported with respect to severe ocular burns.36
This contrasts with the series in which Meller et al. performed
AMT within two weeks after injury in 13 eyes and concluded
that AMT is eective in promoting re-epithelialization and
reducing inammation in the acute stage of chemical injury,
thereby preventing scarring sequelae in the late stages.37
Performing AMT during the rst 7-10 days following acute
burns maximizes the eects of the treatment. Associated lid
deformities, symblephara and conjunctival foreshortening
complicate management of chemical injury in the late stages.
AMT alone gives satisfactory results in partial LSCD [Figs. 7
9]. In total LSCD it may be used as an adjunct to limbal stem
cell transplantation.
Bullous keratopathy
Results of AMT for bullous keratopathy have been rather
conflicting. Its efficacy has been studied in the palliative
management of symptomatic bullous keratopathy with poor
visual potential.38-40 AMT may also be performed as a temporary
measure in patients waiting for corneal transplantation and

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Multilayered
AMG

After AMG

Figure 1: Schematic diagram representing the cornea with bullous


keratopathy

10-0 sutures

Figure 4: Filling-in technique of amniotic membrane transplantation.


Multiple pieces of amniotic membrane are used to ll the crater, followed
by anchoring a single-layered amniotic membrane graft (AMG) to cover
the defect with 10-0 nylon sutures

AMG

Chronic chemical injury

AMG

Symblepharon

Perilimbal sutures

Figure 2: Technique of amniotic membrane transplantation in bullous


keratopathy. The loose epithelium is debrided and the amniotic
membrane graft is used to cover the entire cornea with 10-0 nylon,
interrupted perilimbal sutures

Figure 5: Schematic diagram depicting the de-epithelized corneal


surface and symblepharon following chemical injury

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Postop symblepheron release

8-0 vicryl
sutures

AMG
10-0 nylon
sutures

Figure 3: Schematic diagram representing a deep corneal ulcer

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Figure 6: Symblephron release and removal of brovascular pannus


is followed by amniotic membrane transplantation. AMG - Amniotic
membrane graft.

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Sangwan et al. Amniotic membrane transplantation

intolerant to bandage contact lens (BCL). However, long-term


relief from AMT needs to be studied and compared with other
modalities

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Conjunctival tumors and OSSNs


Amniotic membrane transplantation has been reported to be

successful in conjunctival surface reconstruction after excision


of benign as well as malignant tumors such as conjunctival
melanomas, lymphomas and OSSN. When used as a graft to
cover the conjunctival wound it provides a substrate for the
migration of conjunctival epithelial cells. Surface lesions are
particularly challenging when they arise multifocally or extend
over large areas and warrant an extensive conjunctivectomy
[Figs. 10 and 11]. The advantages of AMT over conjunctival
autografts and mucous membrane grafts in this scenario,
include superior postoperative cosmesis, absence of donor site
morbidity complicating the harvest of mucosal and conjunctival
autografts (CAG) and the ability to clinically monitor local
recurrence of tumor beneath the transparent AMG.41 Combined
therapeutic approaches consisting of extensive tumor removal,
cryotherapy, topical mitomycin C and AM allograft can be
eective in the management of diuse conjunctival melanomas
arising from primary acquired melanosis (PAM).42,43 Successful
treatment of complex choristoma by excision and AMT was
reported by Sangwan et al.44

Figure 8: Clinical picture on the rst postoperative day following


amniotic membrane transplantation

Figure 10: Ocular subepithelial squamous neoplasia involving a large


portion of the superior limbus of the left eye

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Figure 7: Representative case of acid burns two days after injury

PED
PED signify varying degrees of LSCD and chronic inammation.
AM serves to provide a basement membrane substrate for the
migration and adhesion of epithelial cells when used as an

Figure 9: Clear visual axis with inferior pannus, two months following
amniotic membrane transplantation

Figure 11: Bulbar conjunctiva three months after excision of the mass
with amniotic membrane transplantation showing a corneal surface that
healed with minimal scarring

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providing a barrier against inammatory cells and mediators.


The AM, being continuously moistened by tears, provides

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inlay graft. When used as an overlay patch [Figs 12 and 13] it


facilitates epithelialization in a fashion akin to a BCL and by

Figure 12: Schematic diagram of a persistent epithelial defect

Figure 15: Postoperative picture, two weeks after amniotic membrane


transplantation and conjuctival autograft

Postop

Perilimbal
sutures

AMG

Figure 13: Schematic diagram representative of an overlay amniotic


membrane patch. AMG - Amniotic membrane graft.

Figure 16: Schematic diagram depicting corneal involvement with


pterygium

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Pterygium excision + AMG + CLAG

8-0 vicryl
suture

10-0 nylon
sutures

AMG

CLAG

Figure 14: Preoperative clinical picture of a patient with a eshy nasal


pterygium in the right eye

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Figure 17: Schematic diagram demonstrating excision of pterygium,


conjunctival autograft harvested from superior bulbar conjunctiva,
followed by amniotic membrane transplantation to cover the corneal
epithelial defect, bare sclera, as well as the donor site. The conjunctival
limbal autograft (CLAG) is placed over the amniotic membrane graft
(AMG).

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could serve as a useful alternative to conjunctival grafts when


there exists a very large conjunctival defect to cover in primary
double-headed pterygium, in previous multiple failed surgeries
or in the context of preserving superior bulbar conjunctiva for
future glaucoma surgeries.

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Earlier reports on the use of AMG for recurrent pterygia,


showed unsatisfactory results, with reported recurrence rates of
37.5% and 25% respectively.47 Following primary and recurrent
unilateral pterygium excision respectively, recurrences were
noted in 46 (19.4%) and one (33.3%) eyes after bare sclera
technique, in ve (16.7%) and 0 after primary closure, in 28
(26.7%) and 0 with AMG, in 42 (12.2%) and ve (31.3%) with
CAG and in nine (17.3%) and two (40%) with conjunctival
limbal autograft (CLAG) [Figs. 14 and 15].48 Solomon et al.
reported in a non-comparative study that double-layered AMG
combined with the intraoperative injection of triamcinolone
signicantly reduced the recurrence rates to 3% for primary
and 9.5% for recurrent pterygia, a result that is comparable
with that after CAG. 49 Results of AMT as a rst line measure
for recurrent pterygia have been less favorable in comparison
to CAG. A recurrence rate of 37.5% was documented following
excision with AMT, which was considerably higher than the
9.1% obtained with CAG.50 Combining AMT with CLAG may
be employed in the management of recurrent pterygia [Figs. 16
and 17]. A combined approach including pterygium excision,
AMT, CLAG and application of mitomycin C was reported
to be benecial in the management of chronically recurring
pterygium in young patients.51

Figure 18: Representative case of a shield ulcer in vernal


keratoconjunctivitis

Recently, a larger study (47 versus 48 eyes) with a longer


follow-up, found that single-layered AMG alone reduced
the recurrence rate to 12.5%. The addition of intraoperative
mitomycin C did not further reduce the recurrence rate.50

Figure 19: Six-week postoperative picture shows complete healing


with a faint scar and absence of vascularization

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adequate hydration to the regenerating epithelium and


protects it from the abrasive eect of an abnormal palpebral
conjunctiva.45

Amniotic membrane transplantation may be considered


an alternative method for treating PEDs that are refractory to
conventional treatment such as lubrication, elimination of toxic
drugs, BCL and punctal occlusion. Although results have been
promising in the epithelialization of PEDs from various causes,
early detachment of the patch remains a major problem despite
the use of multiple sutures or a protective BCL.46
Pterygium surgery
Pterygium excision with a CAG has gained worldwide
acceptance as the most favorable technique as it has proven to
be both safe and eective in reducing pterygium recurrence.
The benets of using AMT in pterygium surgery were rst
reported by Prabhasawat et al.47 They reported a recurrence
rate of 10.9% for primary pterygium following excision with
AMT in a prospective study, which was further reduced to 3%
by modifying the surgical technique. They concluded that AM

Shield ulcers of vernal keratoconjunctivitis


Severe shield ulcers that do not respond to surgical debridement
and BCL may be eradicated with supercial keratectomy or
excimer photo therapeutic keratectomy (PTK).
Amniotic membrane transplantation combined with
surgical debridement is an eective alternative modality in
the management of these ulcers.52 The renewed basement
membrane promotes epithelialization, reinforces cellular
adhesion and prevents epithelial apoptosis.

The surgical procedure involves complete debridement


of the mucous plaque and cellular debris from the ulcer base
and edge. The surrounding loose epithelium is gently peeled
o until normal adherent epithelium is reached. The AMG is
tailored to be a millimeter larger than the defect and sutured
with 10-0 nylon interrupted sutures. Using this technique
Sridhar et al.52 achieved a success rate of 94.7% with shield
ulcers [Figs. 18 and 19].
Ulcerative keratitis
Although performed in an uncontrolled and non-randomized
series of patients, studies indicate that AMT shows promise
in selected cases for the restoration of the ocular surface and
reduction of stromal inflammation in ulcerative keratitis.
Amniotic membrane transplantation can be considered an

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have been attributed to ciprooxacin therapy.25 The key to


reducing postoperative complications is meticulous selection
of both donor and recipient and maintaining high standards
of quality assurance.
Ex vivo expansion of epithelial cells on the AM
One of the newer and exciting applications of AM has been
its use as a carrier for cultured limbal cells for ocular surface
reconstruction procedures.3 It is now accepted that the surface
epithelium regenerates from progenitor stem cells located at
the limbus (cornea) or fornices (conjunctiva), from which new
cells migrate and dierentiate into daughter cells.70
An alternative therapeutic strategy that has been in vogue
recently is the concept of expanding limbal epithelial cells in vitro
using AM as a carrier or substrate. Schwab et al. earlier showed
with similar technique of cultured limbal transplantation in 19
eyes (18 patients) 75% success with ocular surface destruction
with no complications.71 Expanding corneal epithelial cells from
limbal biopsies ex vivo for use in ocular surface damage oers
many signicant advantages. One of them being only a small
amount of limbal tissue is harvested from the uninvolved eye.
Conventional limbal allografts require up to 12-clock hrs of
limbal tissue and have the potential risk for limbal deciency
developing in the donor eye. Several studies reported excellent
outcome of transplantation of cultivated limbal stem cell on
denuded AM for LSCD.72-74

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eective alternative for treating persistent neurotrophic ulcers,


non-traumatic corneal perforations and descemetoceles.53,54
It can serve as a permanent therapy or as a temporizing
measure until the inammation has subsided and a denitive
reconstructive procedure can be performed. Being a relatively
simple procedure without risks of allograft rejection it could be
particularly useful when faced with shortage of donor corneas.
Chen et al. performed AMT after treatment of Pseudomonas
keratitis with fortied antibiotics for at least one week. In 5/6
cases, after AMT it was noted that the progression of the lesions
and stromal loss was limited.55 In a series of seven patients
with herpes simplex virus or varicella zoster-induced severe
ulcerative keratitis, 5/7 eyes healed after the rst AMT.56 The
stromal defect was lled up with multiple layers of AM. In
eyes with deep corneal ulcers multilayer technique proved to
be better than monolayer procedure.27,28,57 More recently Hick
et al. demonstrated the advantages of brin glue in association
with AMT in the management of perforations of up to 3 mm
in diameter. The combination had a success rate of 92% in
perforated ulcers compared to 74% in non-perforated eyes
with AMT alone.58
Lid and orbital surgery
There are limited reports on the application of AMT in
oculoplastic procedures. Ti et al. evaluated the role of AM in
the correction of cicatricial entropion.59 Park et al. successfully
managed a patient with cicatricial entropion due to SJS using
autologous allogeneic AM, in an attempt to reduce disease
transmission.60 It has also been applied as a punctal patch
for punctal occlusion in the treatment of dry eyes.61 Amniotic
membrane has been used as a cover for orbital prostheses
and successfully used for the closure of a conjunctival defect
following hydroxyapatite orbital implant exposure.62 Stewart
et al. successfully used AM for reconstruction of the upper
lid and the fornix in cryptophthalmos.63 Due to its benecial
eect in facilitating rapid epithelialization it appears to be
a promising substitute to conventional grafts like mucous
membrane grafts.

Th

Postoperative management
A broad-spectrum topical antibiotic is used for one to two
weeks initially, until the epithelium heals. Topical steroids
are used for six to eight weeks in tapering doses to reduce
surface inammation. Systemic immunosuppression is not
required.64

Complications of AMT
In the immediate postoperative period one may come across
hematoma formation under the membrane.65 The blood usually
absorbs or may need drainage, by making a small opening in
the graft, if excessive. Premature degradation of the membrane
and cheese wiring may need frequent repeat transplantations.
Occasionally, a residual subepithelial membrane may persist in
some cases and inadvertently opacify the visual axis.

Amniotic membrane as a carrier in this instance has several


distinct advantages over the other substrates that have been
used. The basement membrane of AM contains Type IV collagen
and laminin which plays an important role in cell adhesion.75
Further, it acts as a natural substrate for the cell growth and
when transplanted gets integrated onto the corneal surface.
It also enables easier handling during transplantation. Tseng
et al. proposed that culturing the explants on an intact AM
with devitalized epithelium favors expansion of an epithelial
phenotype that closely resembles limbal stem cells.

Conclusion

The success of AMT is dependent on the underlying condition


and given the sub-optimal results in some indications, stringent
case selection is recommended. The spectrum of clinical
indications continues to expand and encompass a varying range
of ocular surface pathology.76

It is now evident that AMT has certainly gained an acceptable


position in the surgical armamentarium of the ocular surface
surgeon. The relative ease of the procedure, repeatability and
freedom from intraocular intervention makes it an attractive
surgical option. The low rate of intraoperative and postoperative
complications and the avoidance of immunosuppression are
other advantageous features of this procedure.

The incidence of post AMT microbial infections is as low as


1.6%.66 This value is much lower than the 8% reported with use
of fresh AM. Gram-positive organisms are the most frequent
isolates.67 Gabler et al. reported a case of sterile hypopyon after
repeated AMT.68

The future of AMT looks promising and seems like it is here


to stay in the management of ocular surface disorders. With
continued technological advancements in tissue processing,
newer preserved forms such as the low-heat dehydrated AM
are being made commercially available. Sutureless applications
with brin glue have been aimed at making the procedure easier
and more comfortable for the patient.77

Calcication occurs in about 12.8% of cases.69 White plaques

Further non-surgical innovations such as AMX and Prokera

258 CMYK

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July - August 2007
259
Sangwan et al. Amniotic membrane transplantation

have made access to amnion easier than ever before. AMX is a


topical application of AM extracts, currently available for use
in Europe. Tseng et al. have devised Prokera, which comprises
AM attached to a soft contact lens-sized conformer for easy
insertion. The utility of AM in healing ocular surface defects is
unquestionable. However, there is still a lack of evidence based
on randomized controlled studies to prove the benets of AMT
compared to other alternative modalities of treatment.78

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Source of Support: Nil, Conict of Interest: None declared.