AMNIOTIC MEMBRANE TRANSPLANTATION

Combined with Antiviral and Steroid Therapy for

Herpes Necrotizing Stromal Keratitis
Journal Reading

Oleh:
dr. Putu Ayu Wulansari

RS MATA BALI MANDARA. 2019.

 DATA
BACKGROUND METHODS
ANALYSIS

• HSV stromal disease accounts for almost 50% cases of recurrent HSV eye disease
• Frequently presenting with ulcer, inflammation, and edema
• Underlying mechanism  severe topical immune response
• Antiviral medications because of persistent immune damage from viral antigens
• Failed adequate medications raised number of complications including corneal perforations
• Corneal transplant is not recommended for perforations caused by necrotizing stromal kerati-
tis
• HSV stromal keratitis could trigger immune rejection and erosion of graft-host junction

• Amniotic Membrane (AM) is able to express multiple anti-angiogenic factors, anti-inflammatory

proteins, and protease inhibitors
• Amniotic Membrane Transplant (AMT) is effective in promoting epithelial healing, reducing
inflammation, scarring, and angiogenesis
• For corneal ulcers caused by neurotrophic matter or others, AMT is very desirable
• Single-layer and multi-layer AMTs have been used successfully to treat these ulcers

RS MATA BALI MANDARA. 2019.

BACKGROUND OCULAR HERPES OVERVIEW

PATHOPHYSIOLOGY OF INFECTION
• HSV enter a new host via mucosal surface or damaged skin at the site of contact
• Two to four hours post infection  acute phase  very rapid replication
• Latent infection is a condition where the DNA/RNA virus is present but no infective particles are
produced. The virus still retain its potential to reactivate, resume replication, and cause disease.
UNIQUE CHARACTERISTIC OF HERPES VIRUS.
• Reactivation is triggered mainly by physiological, chemical, environmental stressors
• The virus will surface in areas dense with sensory receptors, such as: cornea, oral mucosa, lips

1. Primary ocular herpes  initial HSV infection causing

disease in the eye; direct inoculation on the surface
of the eye
2. More commonly, involvement of the eye comes from the
reactivation of latent HSV. Usually establishes latency
following a non-ocular route of infection. Predominant site
of primary infection is oro-facial regions
Zhu, L., Zhu, H. 2014. Ocular herpes: the pathophysiology, management, and treatment of herpetic eye diseases
Virologica Sinica; 29 (6): 327-342
RS MATA BALI MANDARA. 2019.
 BACKGROUND OCULAR HERPES OVERVIEW

In adults, epithelial keratitis is the most common.

In children, stromal keratitis is more likely to develop due to
heightened immune response. Corneal scars will develop in up
to80% of pediatric patients with HSV keratitis. Children are
CLINICAL PRESENTATIONmore at risk for having poor visual outcome.

• Can affect any part of the eye and cause pathology in all three layers of cornea
• Primary HSV infection usually asymptomatic and depends on host’s immune status. Manifesting
as conjunctivitis (usually also involve blepharitis), ulcers and unilateral lid vesicles, or corneal
lesions that remains on the epithelial layer called infectious epithelial keratitis
• Epithelial keratitis is the most frequent type of herpetic eye disease. Earliest manifestations:
small intraepithelial vesicles  dendritic-shaped lesions, central ulceration. Associated with pain,
sensitivity to light, blurring vision, tearing, and redness
• Keratitis with stromal involvement seen more frequently in recurrent HSV infections. Can be
further subcategorized into: necrotizing stromal keratitis and immune stromal keratitis. Corneal
vascularization is a prominent complicating factor in damaging the cornea. The damage to
corneal structural integrity will leave behind irreversible scarring and visual morbidity. CONSID-
ERED THE MOST SERIOUS of the HSV ocular diseases
• Recurrent HSV infection could also result in endothelitis (endothelial keratitis) and neurotrophic
keratopathy. In endothelitis, the virus will damage the pump mechanism. Whereas in NK,
characterized by a decrease/absence of corneal sensation usually after a long history of dendritic
ulcers and multiple treatment of antiviral agents that impair trigeminal innervation

Zhu, L., Zhu, H. 2014. Ocular herpes: the pathophysiology, management, and treatment of herpetic eye diseases
RS MATA BALI MANDARA. 2019. Virologica Sinica; 29 (6): 327-342
 BACKGROUND OCULAR HERPES OVERVIEW

MANAGEMENT AND TREATMENT

Treatment in stromal keratitis can help to prevent the otherwise profound corneal vascularization
complications and scarring associated with the body’s potent immune response. Corticosteroids
dampen the immune response. The Herpetic Eye Disease Study determined that a tapering regimen
of topical corticosteroid (1% prednisone for the first 5 weeks followed by 0,125% prednisone for the
next 5 weeks) with a topical antiviral agent was able to significantly reduce the duration of stromal
inflammation and progression of herpetic stromal disease.

Zhu, L., Zhu, H. 2014. Ocular herpes: the pathophysiology, management, and treatment of herpetic eye diseases
RS MATA BALI MANDARA. 2019. Virologica Sinica; 29 (6): 327-342
 AMNION MEMBRANE
BACKGROUND
TRANSPLANT

AMT VS CORNEAL GRAFT TRANSPLANTATION

• Corneal perforations is one of the most serious complications of infections and/or traumata
• Penetrating Keratoplasty (PK) is an effective treatment. In clinical practice, cornea demand
exceeds cornea supply
• The success rate is generally satisfying, but in cases of infective corneal perforations – the
disease can easily cause graft rejection and infection  GRAFT FAILURE
• AMT for corneal ulcers was first introduced in 1997, and thereafter been widely used for
ocular surface reconstructions
• AM contains a remarkable mixture of growth factors and cytokines facilitating proliferation and
differentiation of epithelial cells, reducing inflammatory response and cell activity
• Therefore AMT could promote ocular surface tissue healing
• Success rate of treatment for corneal ulcers with single layer or multi layer AMs was
over 80%, while for corneal perforations with multilayer AMT it was about 73%
• Treatment for corneal perforations with fibrin glue-assisted augmented AMT was about 90%
• A newly developed AM roll technique has been introduced with even higher success rate for
cornea perforation treatments, however related study is still very limited

RS MATA BALI MANDARA. 2019. Fan J., et al. 2016. Improvement of Amniotic Membrane Method for The Treatment of Corneal Perforation. Biomed Research Intl. doi: 10.1155/2016/1693815
 DATA
BACKGROUND METHODS
ANALYSIS

• Fifteen patients (15 eyes) with herpes necrotizing stromal keratitis, referred from April 2003 – March 2005
• Nine were male, six were female, ranging 30 – 59 y.o.
• All patients visiting within 2 weeks after onset of keratitis. Diagnosis criteria were based on previous re-
port
• The majority of patients had history of recurrent episodes. They had been predisposed to antiviral
treatments in previous hospitals, but clinical appearance became complicated b/c of inappropriate drug
use due to misdiagnosis
• Smears and cultures were made to rule out bacterial/fungal origin. Impression cytological exam was
employed to confirm HSV antigen
• AM was prepared and preserved. All surgeries were carried out by the same operator
• All patients were examined weekly within the first post operative month and monthly thereafter
• Exam includes: VA, IOP, corneal status (ulceration, edema, opacification), and AM transformation (using
Fluorescein staining for corneal epithelial defects and confocal microscopy for AM remodelling and
RS MATA BALI MANDARA. 2019.
growth)

BACKGROUND
PREOPERATIVE
Dendritic lesions developed
into stromal ulcers in 11 eyes
for the administration of
topical steroids (7 eyes) or
antibiotics (4 eyes). The other
4 eyes also had deepened
ulcers due to combined
medications. All ulcers were >
4mm in diameter and one fifth
of cornea stroma in depth w/o
descemetocele, persisted in 6
eyes and deteriorate in 9 eye-
safter 2-weeks systemic and
topical antiviral medication at
the study’s institution.
METHODS
ANALYSIS
INTRAOPERATIVE
Topical anesthesia was given before
cellular debris and necrotic tissue
were removed from the base and wall
of corneal ulcer. Human AM was placed
with basement membrane side up, layer
by layer, to fill up the ulcer and cover
thedefect, and cut to a graft larger than
the ulcer by trimming off excess parts.
After
the graft was secured to the edge of
ulceration with interrupted 10-0 nylon
sutures, the knot were cut short but not
buried into stroma to avoid AM
detachment at time of suture removal.
Finally, another superficial AM patch
wassutured onto the surface covering
entire cornea with a continuous 10-0 ny-
lon
sutures placed within 1 mm of the lim-
busand 8 to 10 interrupted sutures at
superficial sclera. No bandage lens
wereused.
RS MATA BALI MANDARA. 2019.
DATA
POSTOPERATIVE
All were given 1% tobramycin
and dexamethasone ED @ 2
hours, pranoprofen ED 4x daily,
and 1% tobramycin and
dexamethasone EO at night.
Topical 0,1% acyclovir was
administered 4x daily for 2 weeks
and 2 – 3x daily thereafter until 2
months after surgery.
Corticosteroid ED were re-
ducedto 4x daily after 1 week &
tapered off within 1 month. Corti-
costeroidEO terminated at ap-
prox. 2 week.
Systemic acyclovir was
administered 5x daily for 7 days
including pre-op application
(40mg/kgBB) and for the following
1-3
months post surgery (20mg/kgBB)
 DATA
BACKGROUND METHODS
ANALYSIS

Student’s t-test was used to compare healing time of corneal ulcers and restoration of stromal thickness,
respectively. P<0,05 was considered statistically significant.

RS MATA BALI MANDARA. 2019.

RESULTS DISCUSSION CONCLUSION

Ophthalmology 2007; 114: 1476-1481

RS MATA BALI MANDARA. 2019.

 Patients were followed up for 7 to 13 months
(mean±SD, 8.9±1.8 months)
RESULTS
VISUAL ACUITY AND INTRAOCULAR PRESSURE
At the last visit, VA improved > 2 lines in 14 eyes. Another eye had VA of below
20/400 for the presence of corneal leukoma, attributed to the pre-operative ulcer
located on the central involving deep stroma. Intraocular pressure were 15±1,8,
16.5±1.1, and 15.9±2.3 mmHg on post-op days 7, 15, and 30, respectively

DISCUSSION CORNEAL STATUS (Ulceration, Edema, Opacification)

In eyes with superficial ulcers, stromal edema subsidized in 10 days. In deeper ul-
cer> 20 days. Central ulcers healed completely at 2.0±0.6 weeks and paracentral at
2.1±0.6 weeks (p = 0.759). It took 2.4±1.2 weeks for central ulcer and 2.6±0.7
weeks
for paracentral to restore stromal thickness (p = 0.678). Although paracentral ul-
cerwas more severe than the central, no significant difference was observed
in
CONCLUSION
the healing of corneal ulcers and cessation of stromal edema. Hypopyon in 2
eyes were absorbed completely on post-op day 10 and 12. There were corneal
nebula in 11 eyes, macula in 3, and leukoma in 1 eye at the end (Confocal
AM TRANSFORMATION of follow-up period
Microscopy)
Suture removal was started at post-op 7 to 10 days, when the superficial patch
dissolved, and was completed at 20 days for the remaining inferior grafts. Clear
structure of AM grafts without inflammatory cell migration was seen readily by
confocal microscopy on post-op day 7. Healthy epithelial cells surrounding the ulcer
gradually migrated to the AM surface on post-op weeks 1 to 3. AM gradually remodeled
and dissolved within no more than 2 months.
RS MATA BALI MANDARA. 2019.
RESULTS DISCUSSION CONCLUSION

RS MATA BALI MANDARA. 2019. Ophthalmology 2007; 114: 1476-1481

 RESULTS DISCUSSION CONCLUSION

RS MATA BALI MANDARA. 2019. Ophthalmology 2007; 114: 1476-1481

 Management of herpes stromal keratitis
 CORRECT DIAGNOSIS
RESULTS
• Making correct diagnosis by ruling out bacterial/fungal infection
• Further confirming the diagnosis  history of recurrent episode and clinical
presentation
• In circumstances where reliable experimental assays are lacking, these cases must
be responsive to antiviral medications to support the diagnosis
• Cytological exam has significant advantage in diagnosing epithelial > stromal ker-
atitis
DISCUSSION
• In this study, positive HSV antigen was easily detected in cases with a history
of dendritic episode
• For suspicious cases of superinfected HSV keratitis, appropriate antimicrobial
should
be considered
• Attention should be paid to debride the necrotizing tissue around and on the
ulcer base completely, otherwise inflammatory response from the replicating
CONCLUSION virus will damage basal membrane and disturb the repair of epithelial cells
Multilayer AMT comprises of
layers of inferior graft and superior patch
• In this study, an AM graft provides a healthy substrate, contributed to rapid
epithelialization, and significantly reduced ocular inflammation
• For cases with descemetocele, AMT is not advised because AM will dissolve or shed
before healing occurs and could not provide continuous basement for such type of
corneal ulcers

RS MATA BALI MANDARA. 2019.

 More updates on AMT…
RESULTS • For deeper corneal ulcer and even perforations, a single or multilayer AMT
cannot plug the defective zone. Moreover, surface reconstruction should
include filling of new collagen into the ulcer bed
• AM was rolled and plugged into defect zone of the cornea; then a bilayer
AM was was used to overlay and fix the amniotic roll, and finally a larger
AM was used to cover the whole cornea
• Purposefully, enough force was generated to resist the pressure of ante-
DISCUSSION rior
chamber and prevent any aqueous leakage and outward bulging of the
amniotic membrane roll (AMR) during post-op period
• When plug was employed, the aqueous could somehow still ooze along
the AMR due to anterior chamber pressure  resulting in disappearance
of AC
• Innovation was made using gas-solution interfacial tension to prevent the
CONCLUSION leaking mechanism
• C3F8 gas mixture is injected, which lasted relatively longer than injecting
sterile air bubbles, to prevent fluid oozing. Depth of AC could be main-
tained
• The technique was not practiced in for perforations/ulcers sized > 3mm in
diameter and with a thin basement, due to high-risk complications
• However, in related study for lesions < 3mm, in longer term follow-ups
that 2 months after intervention revealed successful fusion of AM rolls
with
corneal tissues which filled the lesion areas
RS MATA BALI MANDARA. 2019.
• Fan Conclusion: AMR
J., et al. 2016. Improvement combined
of Amniotic withformultilayer
Membrane Method amniotic
The Treatment of Corneal Perforation.membrane cover
Biomed Research Intl. is
doi: 10.1155/2016/1693815
 More updates on AMT…
RESULTS

DISCUSSION

CONCLUSION

RS MATA BALI MANDARA. 2019. Fan J., et al. 2016. Improvement of Amniotic Membrane Method for The Treatment of Corneal Perforation. Biomed Research Intl. doi: 10.1155/2016/1693815
 Topical corticosteroids can suppress immune response
RESULTS
• The Herpetic Eye Disease Study demonstrated that topical corticosteroid was effec-
tive in reducing the persistence/progression of stromal inflammation and shorten-
ing the
duration of the disease
• One of the eligibility criteria for stromal disease is epithelial defect < 1mm
• Because, by contrast, for epithelial keratitis caused by herpes, topical
DISCUSSION corticosteroids would worsen the prognosis due to high risk of corneal melting
• In this study, compromise of wound healing by corticosteroid was not ob-
served/seen

Antiviral agents are also indispensable

to the treatment of herpetic stromal keratitis

CONCLUSION • WITHOUT ULCERATION  topical CS + PROPHYLACTIC dose of antiviral

Prednisolone 1% 6-8x daily, tapered over greater than 10 weeks + Acyclovir 2 x
400 mg or Valacyclovir 1 x 500 mg or Famcyclovir 2 x 250 mg
• WITH ULCERATION  topical CS + THERAPEUTIC dose of antiviral
Prednisolone 1% twice daily + Acyclovir 800 mg 3-5x daily or Valacyclovir 1 g 3x
daily or Famcyclovir 500 mg 2x daily FOR 7 – 10 DAYS
• After 10 days, oral antiviral in necrotizing keratitis is reduced into prophylactic dose
andmaintained in both types as long as topical CS was still given. As disease is re-
solving, Prednisolone could be tapered slowly

RS MATA BALI MANDARA. 2019.

 More novel treatments on complicated HSV keratitis…
RESULTS • Management of corneal neovascularization: steroids, cauterization, surgery by
keratectomy, and argon laser
• Recent studies mentioning topical intra-stromal injection of anti-VEGF factors
(bevacizumab – Avastin) to be a promising treatment as it is effective and gen-
erally more well tolerated
• Effectiveness may vary depending on the extension of NV and possible delay of
treatment with the onset of neovessels
DISCUSSION
• Reconstruction of corneal surface after epithelial damage necessitates the migra-
tion and maturation of limbal stem cells
• In cases of LSCD (Limbal Stem Cells Deficiency), treatment is more complicated.
With partial LSCD, AMT might be adequate but in cases with total LSCD, stem cell
transplantation is considered a critical therapeutic option
• In unilateral LSCD case, stem cell transplant could be obtained from the con-
tralateral eye (autologous tissue)
CONCLUSION

• Cyclosporine-A is an immunomodulatory drug that was initially used to prevent

rejection of transplanted organs/tissues
• Ophthalmic use (suspension, 0,5 – 2%) of cyclosporine-A includes dry eye syn-
drome, vernal and atopic keratoconjunctivitis
• Supportive evidence that the use of cyclosporine-A suspension can restrict
corneal immune reaction in various ocular surface disorders, resulting in
enhancement of corneal thickening and epithelial regeneration
Kalegorepoulos, D. et al. 2017. New Therapeutic Perceptions in a Patient wih Complicated HSV-1 Keratitis: A Case Report and Review of the Literature.
RS MATA BALI MANDARA. 2019. Am J Case Rep; 18: 1382-89
 Significant improvement of
VA

RESULTS Ulcers rapidly healed

within 1 month

Anatomical integrity was

achieved
This study further indicated that
No recurrence observed AMT was a much better alterna-
tive compared to tectonic or opti-
No corneal NV cal
DISCUSSION observed
corneal transplantation

Specifically on viral etiology, AM holds antiviral and anti-inflammatory proper-

CONCLUSION
RS MATA BALI MANDARA. 2019.
ties
that contribute to the resolution of the disease. Paradowska et al reported that
human placenta contained endogenous tumor necrosis factors and interferons,
which
possibly gave non-specific antiviral immunity. AM also express cystatin E, a
novel
human cysteine proteinase inhibitor, to inhibit proteolytic cleavage required for
viral replication including HSV-1. In another study of a mouse model having HSV-
1
stromal keratitis, AMT was effective in promoting corneal wound healing which
may be related to the reduced expression of matrix metalloproteinases (MMP-8
and MMP-9) and increased expression of their tissue inhibitors (TIMP-1 and TIMP-
 RESULTS

The adjunctive use of antiviral and steroid therapy with

AMT should be recommended in the treatment of
DISCUSSION
herpes necrotizing stromal keratitis for its safety and effi-
cacy

It helps to promote epithelialization of corneal defects,

alleviate corneal scars, and restore useful visual acuity

CONCLUSION

RS MATA BALI MANDARA. 2019.