Amniotic membrane transplantation in entropion surgery

Umbilical Amniotic Tissue Graft as an Alternative Approach for Eyelid Reconstruction After Necrotizing Fasciitis Debridement

A 54-year-old female with myelodysplastic syndrome on chemotherapy presented with 10 days of periocular erythema and edema worsening on oral antibiotics. Computed Tomography scan showed periorbital soft tissue swelling without postseptal extension or abscess. Intravenous broad-spectrum antibiotics were administered. However, she developed necrosis of the upper eyelid requiring aggressive debridement. Nine days after debridement, the defect measuring 5.5 × 3 cm was covered using an umbilical amniotic tissue graft (AmnioGuard, BioTissue, Miami, FL). At postoperative week 4, 5-fluorouracil was injected to prevent the shortening of anterior lamella. At postoperative week 20, the graft had dissolved and been replaced by regenerated skin. Final eyelid exam demonstrated normal eyelid elevation and minimal lagophthalmos. Herein, we present a case of umbilical amniotic membrane as a substrate graft to support the healing of the eyelid defect by secondary intention.

Mucous membrane grafting for cicatricial entropion repair: review of surgical techniques and outcomes

Mucous membrane graft (MMG) is used for moderate-to-severe cicatricial entropion repair either in primary or recurrent cases. We conducted a review to comprehensively summarize the various surgical techniques, outcomes, and complications of using MMG for cicatricial entropion. Though the comparison between different techniques is limited by multiple factors like small numbers of cicatricial entgropion patients, variable severity and success criteria across studies, and different underlying cicatricial entropion etiologies, the author has brought forth the nuances of the use of MMG for cicatricial entropion repair along with its outcomes and complications. MMG use in moderate-to-severe cicatricial entropion gives favourable outcomes. The shortened tarsoconjunctiva is lengthened using MMG, which is used either with terminal tarsal rotation or anterior lamellar recession (ALR) or tarsotomy alone. Non-trachomatous entropion has poor outcomes compared to trachomatous entropion. The most common source of MMG is labial or buccal mucosa and the exact size of MMG harvested is variable according to the defect, and very few prefer oversizing the graft by 10-30%. The outcomes of ALR+MMG appear similar to tarsal rotation and MMG for severe cicatricial entropion. The recurrences of trichiasis or entropion can occur for up to one year after surgery, irrespective of the technique used. Factors affecting the outcomes of cicatricial entropion repair are not well known. There is a non-uniformity in data reporting across literature; hence, future studies with details on severity of entropion, ocular surface changes, forniceal depth and ocular surface inflammation, and the degree of dry eye disease would be informative.

The current alternative for ocular surface and anophthalmic socket reconstruction, cryopreserved umbilical amniotic membrane (cUAM)

PURPOSE

This report presents the results of using cryopreserved umbilical amniotic membrane (cUAM) as an alternative mucosal graft for ocular surface reconstruction in cases of anophthalmic socket contracture (ASC), cicatricial entropion (CE), and conjunctival-scleral defects.

METHODS

The study included patients who underwent non-commercial implantation of cUAM grafts (prepared by corneal banking methods) for ASC, CE, conjunctival defect, and scleral melting. The main success criteria for this study were the comfortable fitting of the ocular prosthesis in ASC patients, the natural eyelid position in CE patients, and the degree of conjunctivalisation in melting patients.

RESULTS

cUAM transplantation was performed in 2 patients who could not use a prosthetic eye due to conjunctival contracture, 2 patients with CE, and 1 patient with conjunctival defect and 1 patient with conjunctival-scleral melting. The primary outcome was achieved in 83.3% (5/6) of patients. In one patient with CE, partial healing was achieved due to the persistence of CE in the medial upper eyelid.

CONCLUSIONS

cUAM is a viable alternative to mucosal grafting for reconstructing the bulbar and palpebral conjunctival surface, fornix, and orbit, with reduced donor morbidity and shorter surgical time. Its regenerative ability allows for tissue defect healing and improves cosmetic appearance through epithelialization within weeks.

A Review of Current Uses of Amniotic Membrane Transplantation in Ophthalmic Plastic and Reconstructive Surgery

PURPOSE

To review and summarize the existing literature on the clinical applications of amniotic membrane transplantation (AMT) in ophthalmic plastic and reconstructive surgery.

METHODS

A literature review was conducted on the PubMed database using the following search terms: "amniotic membrane" and "eyelid" or "orbit" or "fornix" or "socket" or "lacrimal".

RESULTS

In total 516 articles resulted from the search, of which 62 were included. Numerous cases and case series have been published on the use of amniotic membrane transplantation for ocular surface reconstruction, eyelid and forniceal reconstruction, and cicatricial eyelid abnormalities. Surgical methods of securing the graft vary. Few comparative studies exist; some show a similar or improved result when compared to oral mucous membrane grafting for certain indications.

CONCLUSIONS

Amniotic membrane transplantation can be a useful tool for the oculoplastic surgeon when faced with a case requiring reconstruction of the posterior lamellae, particularly in patients without other graft donor sites available, and uses of AMT continue to expand. Additional studies directly comparing AMT to other reconstructive techniques would be helpful in choosing between the available surgical techniques and standardizing best practices.

The prevention and management of postoperative trachomatous trichiasis: A systematic review

Among ocular infections, trachoma is the main cause of blindness. Repeated conjunctival Chlamydia trachomatis infections lead to trichiasis, corneal opacification, and visual impairment. Surgery is often needed to relieve discomfort and preserve vision; however, a high postoperative trachomatous trichiasis (PTT) rate has been observed in various settings. We wanted to know why, whether PTT rates could be reduced, and how to manage the PTT that occurs. We performed a search of the literature. Of 217 papers screened, 59 studies were identified for inclusion as potentially relevant, the majority having been excluded for not directly concerning PTT in humans. Preventing PTT is a major challenge. Only one published trial, the STAR trial in Ethiopia, has reported a cumulative PTT rate <10% one year after surgery. The literature on the management of PTT is sparse. Though no PTT management guidelines are available, high-quality surgery with a low rate of unfavorable outcomes for PTT patients is likely to require enhanced training of a smaller group of highly-skilled surgeons. Based on the surgical complexity and the authors' own experience, the pathway for patients suffering from PTT should be studied further for improvement.

Modified Anterior Lamellar Recession for All Grades of Upper Eyelid Trachomatous Cicatricial Entropion

Purpose

This study aims to assess the combination of anterior lamellar recession (ALR) with blepharoplasty, suprasternal fixation, and internal eyelash bulb extirpation of aberrant lashes posteriorly located in patients with any grade of upper eyelid trachomatous cicatricial entropion.

Patients and Methods

We reviewed the clinical data of eighty-six patients (143 eyelids) including age, gender, systemic medical illnesses, and comprehensive ophthalmological assessment. Eyelid evaluation was recorded, including laterality, previous surgical technique used, possible trichiasis etiology, abnormality of the lid margin, tarsal plate consistency (shrinkage or loosening), skin fold overhanging, laxity of the pretarsal skin, margin reflex distance 1 (MRD1), lagophthalmos, and lid retraction. The success rate was assessed at 3, 6, 9, and 12 months postoperative.

Results

The success rate was 97.2% in the third month, which decreased significantly to 92.3% in the 6th month and 90.2% in the 9th month (P = 0.01, and 0.001 respectively). In the 9th month, we had fourteen failed cases. All of them were submitted for a second intervention. Three underwent electrolysis, four cases underwent re-internal bulb extirpation, four cases underwent the same procedure, and three cases underwent epilation. The success of the failed cases after the second intervention was significantly associated with the type of reintervention (P = 0.03), in which all of them succeed except two cases that underwent epilation. Kaplan-Meier analysis showed that the mean recurrence time in our study was 6.8 months (95% CI = 5.8-7.7 months).

Conclusion

This study showed the combination of ALR with blepharoplasty, suprasternal fixation, and cauterization or internal bulb extirpation of posteriorly located lashes procedure resulted in a high success rate in patients with any form of UCE with no increase in incidence or degree of lagophthalmos associated with UCE.

Preparation of human amniotic membrane for transplantation in different application areas

The human amniotic membrane (hAM) is the inner layer of the placenta and plays protective and nutritional roles for the fetus during pregnancy. It contains multiple growth factors and proteins that mediate unique regenerative properties and enhance wound healing in tissue regeneration. Due to these characteristics hAM has been successfully utilized in ophthalmology for many decades. This material has also found application in a variety of additional therapeutic areas. Particularly noteworthy are the extraordinary effects in the healing of chronic wounds and in the treatment of burns. But hAM has also been used successfully in gynecology, oral medicine, and plastic surgery and as a scaffold for in vitro cell culture approaches. This review aims to summarize the different graft preparation, preservation and storage techniques that are used and to present advantages and disadvantages of these methods. It shows the characteristics of the hAM according to the processing and storage methods used. The paper provides an overview of the currently mainly used application areas and raises new application possibilities. In addition, further preparation types like extracts, homogenates, and the resulting treatment alternatives are described.

Amniotic Membrane Transplantation in Ophthalmology: An Updated Perspective

Aim

The aim of this paper is to provide a succinct literature review of the different clinical applications for AMT usage in an ophthalmic setting, ranging from commonly used applications to less mainstream approaches. The hope is that this review enables the reader to have a better understanding of the biological properties of amnion as well as the indications and scenarios in which AMT can be used, whilst presenting relevant evidence from within the literature which may be of interest. We also provide an update on the methods of preservation of amniotic membrane and the application methodologies.

Methods

Literature search. A PubMed search was performed using the search terms “amniotic membrane transplant”, “amnion AND cornea”, amnion AND ophthalmology”, “amnion AND ocular surface” and “Amnion AND eye”. A full review of the literature using the PubMed database was conducted up until 01/05/20. The articles used were written in English, with all articles accessed in full. Both review articles and original articles were used for this review. All full publications related to ophthalmology were considered.

The Use of Umbilical Amnion for Conjunctival Socket, Fornix, and Eyelid Margin Reconstruction

PURPOSE

To describe outcomes using umbilical amnion for conjunctival fornix, socket, and eyelid margin reconstruction.

METHODS

A medical record review was performed to identify patients who had received umbilical amnion over a 2-year period in their department. Patient demographics, disease etiology, and data regarding surgical outcomes were collected. The primary outcome was the success rate of the surgical intervention.

RESULTS

Twenty-one patients received umbilical amnion for anophthalmic socket contracture (n = 16), orbital implant exposure (n = 3), ocular surface burn (n = 1), and cicatricial entropion repair (n = 1). The primary outcome was met in 76% of patients overall. In anophthalmic socket contracture, the primary outcome was met in 86% and 0% of patients with acquired and congenital anophthalmia, respectively. The primary outcome was met in all cases of orbital implant exposure and cicatricial entropion. The primary outcome was not met in a Roper-Hall grade IV ocular surface burn.

CONCLUSIONS

Umbilical amnion is an ideal substrate graft for reconstruction of the conjunctival fornix, socket, and eyelid margin. Umbilical amnion appears to be efficacious for the management of socket contracture in acquired anophthalmia, orbital implant exposure, and cicatricial entropion. Further experience is needed to determine the efficacy of umbilical amnion in ocular surface burns.

Anterior lamellar recession, blepharoplasty, and supratarsal fixation for cicatricial upper eyelid entropion without lagophthalmos

PURPOSE

To assess the results of anterior lamellar recession, blepharoplasty, and supratarsal fixation procedure in patients with upper eyelid cicatricial entropion without lagophthalmos.

METHODS

In a prospective interventional case series, 52 eyelids (32 patients) were included (April 2009-December 2010). Excluded were patients with previous eyelid surgeries, lagophthalmos, and <12 months of follow-up. Using a microscope, after recessing anterior lamella 3-4 mm above the eyelid margin, it was fixed with 4-5 interrupted 6-0 vicryl sutures. Excess anterior lamella was then excised (blepharoplasty), supratarsal fixation sutures (6-0 vicryl) were put and the skin was closed with 6-0 nylon sutures. Success and failure defined based upon eyelash-globe touch on the last follow-up visit (at least 12 months), respectively.

RESULTS

There were 21 females (65.6%) and 11 males (34.4%) with a mean age of 69.7 years (SD=6.9) and mean follow-up of 21.06 months (SD=8.26). Success was observed in 39 (75%) and failure in 13 (25%). Mean time of failure was 4.5 months (SD=3). Although re-treatment with radio-frequency electrolysis (eight eyelids) and re-anterior lamellar recession (two eyelids) resulted in success in 12 eyelids with failure, two patients (three eyelids) declined further procedure. Except for thickened eyelid margin, no complications were observed.

CONCLUSION

Anterior lamellar recession, blepharoplasty, and supratarsal fixation procedure is an effective and safe technique for the treatment of the upper eyelid cicatricial entropion without lagophthalmos.

Shared buccal mucosal graft for simultaneous repair of severe upper and lower eyelid cicatricial entropion

PURPOSE

Cicatricial entropion is typically an acquired condition that can affect the upper and lower eyelids. The purpose of this prospective study is to examine the effect of shared buccal mucosal grafts for simultaneous repair of severe upper and lower eyelid cicatricial entropion on eyelid position.

METHODS

Patients at the University of Texas-Southwestern Medical Center Aston Ophthalmology clinic were identified who were diagnosed with cicatricial entropion. Patients found to have severe upper and lower eyelid cicatricial entropion were included in the study if they had undergone or were scheduled to undergo simultaneous upper and lower eyelid repair through the use of a shared mucosal graft. Pre-operative exams which included pre-operative photos and description of eyelid position were performed. Shared mucosal graft surgery was performed. At post-operative week 1, the patients had splitting of their shared mucosal grafts. Post-operative photos as well as post-operative description of eyelid position were made at 6 weeks, 3 months, and 6 months.

RESULTS

At 6 months after surgical repair of severe upper and lower eyelid cicatricial entropion by shared mucosal grafts, patients were found to have resolution of entropic eyelid position as well improvement in ocular surface irritation. No adverse events were found and no graft failures occurred.

CONCLUSIONS

The use of a shared mucosal graft for the repair of severe upper and lower eyelid entropion, when sufficient tarsal structural support is present, is effective for the correction of eyelid malpositions and ocular surface irritation.

Human amniotic membrane transplantation: Different modalities of its use in ophthalmology

The amniotic membrane (AM) is the inner layer of the fetal membranes and consist of 3 different layers: the epithelium, basement membrane and stroma which further consists of three contiguous but distinct layers: the inner compact layer, middle fibroblast layer and the outermost spongy layer. The AM has been shown to have anti-inflammatory, anti-fibrotic, anti-angiogenic as well as anti-microbial properties. Also because of its transparent structure, lack of immunogenicity and the ability to provide an excellent substrate for growth, migration and adhesion of epithelial corneal and conjunctival cells, it is being used increasingly for ocular surface reconstruction in a variety of ocular pathologies including corneal disorders associated with limbal stem cell deficiency, surgeries for conjunctival reconstruction, as a carrier for ex vivo expansion of limbal epithelial cells, glaucoma surgeries and sceral melts and perforations. However indiscriminate use of human AM needs to be discouraged as complications though infrequent can occur. These include risk of transmission of bacterial, viral or fungal infections to the recipient if the donors are not adequately screened for communicable diseases, if the membrane is not processed under sterile conditions or if storage is improper. Optimal outcomes can be achieved only with meticulous case selection. This review explores the ever expanding ophthalmological indications for the use of human AM.

[Surgical management of entropion]

Entropion is an inward folding malposition of the eyelid margin. As a result of persistent entropion and trichiasis severe complications of the conjunctiva and the cornea can occur, which can lead to loss of visual acuity. Conservative forms of therapy mostly provide only a temporary solution and are generally used in preoperative care or if surgical intervention is unfeasible. The main therapeutic means is surgery. Normally congenital entropion recedes throughout the first 12 months of life, so that surgery is not needed immediately. Spastic inflammatory entropion disappears with successful treatment of the inflammation. Senile entropion is caused by three different pathological mechanisms: loss of lid laxity, loss of tension of lower lid retractors and alterations to the musculus orbicularis. These can be corrected with the procedures developed by Wies and also by Quickert and Jones. The surgeon should be careful to avoid an overcorrection with iatrogenic ectropion. Finally, cicatricial entropion can occur as a consequence of persistent inflammation or injuries. In this case free mucosa grafts may be necessary.

Amniotic membrane transplantation for ocular surface reconstruction: indications and outcomes

BACKGROUND

The amniotic membrane is a useful tool in the management of several ocular surface diseases. Despite numerous studies, standardization of the use of the membrane and of outcome measures is lacking. Herein, the authors' results of amniotic membrane transplantation (AMT) in ocular surface reconstruction against defined outcome measures are reported.

METHODS

A retrospective case study of 74 consecutive procedures (58 patients) performed against predefined outcome measures. The cases were divided into three groups. Group A AMT in the presence of stem cell loss (32 procedures), Group B AMT without stem cell loss (24 procedures) and Group C AMT for conjunctival reconstruction (18 procedures). The outcomes were evaluated against defined criteria based on the purpose (patch or graft) and objective for use of the membrane. Results were analysed by defining the outcomes as success, partial success or failure.

RESULTS

Unequivocal success of the procedure was observed in 22% in Group A, 62.5% in Group B and 50% in Group C. AMT was significantly more successful in the presence of functioning stem cells (P = 0.01). In Group A acute and subacute cases (less than 3 months) needed more procedures compared with chronic cases (P = 0.02). In Group C, results were comparatively worse when AMT was used in progressive cicatrizing conditions.

CONCLUSION

Use of AMT can be associated with a significant number of failures. It provides a useful alternative for specific indications where its use should be encouraged. It is important to define criteria for success in order to accurately evaluate efficacy.

Reconstruction of Contracted Eye Socket With Amniotic Membrane Graft

PURPOSE

To investigate the use of amniotic membrane graft for socket reconstruction in cases in which forniceal shortening by scar or symblepharon formation has made it difficult to successfully wear an ocular prosthesis.

METHODS

A retrospective analysis of 20 contracted eye sockets that underwent forniceal reconstruction with amniotic membrane graft from 1997 to 2001.

RESULTS

There were 8 male and 12 female patients, with an age range between 2 and 66 years. Duration of forniceal shortening varied from 2 months to 48 years. The operation was performed in the lower fornix in 13 eyes, upper fornix in 1 eye, and both fornices in 6 eyes. The mean follow-up period was 13.6 months. Eighty percent of cases achieved successful prosthetic fitting after surgery. Four eyes had recurrent forniceal shortening after surgery in which a prosthesis could not be properly fitted. There were no serious complications, such as infection or graft rejection.

CONCLUSIONS

The use of amniotic membrane grafts can be a useful option in forniceal reconstruction with a high success rate, a low rate of complications, and without discomfort of donor sites.

Amniotic Membrane Transplantation for Ocular Surface Reconstruction

The amniotic membrane, composed of 3 layers, the epithelium, basement membrane, and the stroma, was first used along with the chorion as a biologic membrane to promote healing of skin burns in 1910. In ophthalmology, it was used in 1940 in the management of conjunctival defects. Its revival in the 1990s was due to its ability to reduce ocular surface inflammation and scarring, promote rapid epithelialization due to the presence of growth factors, and antimicrobial properties. This has resulted in its application in several ocular disorders. A review of the literature shows that amniotic membrane is definitely beneficial in some but not all pathology. The future of amniotic membrane transplantation is very exciting, especially in the field of limbal stem cell research. However, further work is needed to elucidate whether it functions merely as a biologic contact lens or whether it has additional benefits.

Polytetrafluoroethylene as a Spacer Graft for the Correction of Lower Eyelid Retraction

PURPOSE

To evaluate the efficacy of porous expanded polytetrafluoroethylene (e-PTFE, Goretex) containing large pores made with a 21-gauge needle as a graft for the correction of lower lid retraction.

METHODS

e-PTFE grafts were implanted between the tarsus and lower lid retractor via a transconjunctival approach with/without amniotic membrane transplantation, or via a transcutaneous approach. Rabbits were examined and assessed for comeal and conjunctival complications and for e-PTFE graft status. Rabbits were sacrificed for a histological study at 8 weeks postoperatively.

RESULTS

e-PTFE grafts were uniformly extruded 3 weeks postoperatively in eyelids operated on via the transconjunctival approach. However, rabbits operated on via the transcutaneous approach demonstrated e-PTFE graft retention; in addition, dense fibrovascular ingrowths into the large pores of e-PTFE were observed histologically.

CONCLUSIONS

e-PTFE is a good substitute for other graft materials as a spacer in lower lid retraction operations, especially as an interpositional graft using a transcutaneous approach.

Multilayer Amniotic Membrane Transplantation in the Treatment of Corneal Perforations

PURPOSE

To determine if multilayer amniotic membrane transplantation (AMT) is useful in the treatment of corneal perforations, and in particular to assess to what extent efficacy is affected by perforation size.

METHODS

Fifteen patients (15 eyes) with corneal perforations of different sizes were divided into 3 groups: group A (microperforation, 6 eyes), group B (0.5-1.5 mm, 4 eyes), and group C (>1.5 mm, 5 eyes). The corneal perforation was caused by autoimmunity-related ulcer (3 eyes), neurotrophic ulcer (9 eyes), infectious keratitis (1 eye), or postkeratoplasty ulcer (2 eyes). Two layers of AM (for microperforations) or 3-4 layers (for the other groups) were trimmed to the size of the ulcer and sutured in place with interrupted 10-0 nylon sutures. In all cases, a bandage contact lens was then applied.

RESULTS

Mean epithelialization time was 3.7 weeks (range 2-6). Mean time to recovery of corneal stroma thickness was 10.1 weeks (range 7-15). In all cases, ocular inflammation subsided within 2-5 weeks. The treatment was judged successful in 73% (11/15) of eyes. Three of the 4 unsuccessful treatments were of perforations 3 mm or more in diameter; of the 5 eyes with perforations of more than 1.5 mm in diameter, only 2 were treated successfully.

CONCLUSIONS

These results suggest that multilayer AMT is effective for treating corneal perforations with diameter less than 1.5 mm. The technique may be a good alternative to penetrating keratoplasty, especially in acute cases in which graft rejection risk is high.

Amniotic Membrane Transplantation in the Management of Severe Ocular Surface Disease: Indications and Outcomes

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

The Results of Amniotic Membrane Transplantation for Primary Pterygium Compared with Conjunctival Autograft

PURPOSE

To study the efficacy and safety of amniotic membrane transplantation as an adjunctive therapy after surgical excision of primary pterygium and to compare the clinical outcome with that of conjunctival autograft.

METHODS

Eighty-six eyes of 78 patients with primary pterygium were operated on by a single surgeon (N.T.). All patients were randomized to undergo amniotic membrane or conjunctival autograft transplantation as an adjuvant therapy after pterygium excision. Forty-four eyes in 39 patients were treated with amniotic membrane transplantation (AM group), and 42 eyes of 41 patients were treated with conjunctival autograft (CG group). Patients were followed up at 1 week, 1, 3, 6, and 12 months postoperation. The main outcome measurement was a recurrence rate after surgery.

RESULTS

The mean follow-up was 14.40 +/- 5.4 months in the AM group and 12.35 +/- 3.13 months in the CG group. There were 18 recurrences (40.9%) in the AM group and two (4.76%) in the CG group, which was significantly different among both groups (P < 0.007). The cumulative proportion that were recurrence-free at 12 months was 0.6 +/- 0.15 for the AM group and 0.95 +/- 0.07 for the CG group (P = 0.0003, Log-rank test). The cumulative nonrecurrence rate at 6 and 12 months in all patients stratified by age and sex was not significantly different (P = 0.28 and P = 0.9, Log-rank test). No major complications were observed in either group.

CONCLUSION

The surgical results of primary pterygium excision followed by amniotic membrane and conjunctival autograft transplantation were compared. It was found that amniotic membrane transplantation for pterygium surgery has an unacceptably high recurrence rate.

The amniotic membrane in ophthalmology

The amniotic membrane is the innermost of the three layers forming the fetal membranes. It was first used in 1910 in skin transplantation. Thereafter it has been used in surgical procedures related to the genito-urinary tract, skin, brain, and head and neck, among others. The first documented ophthalmological application was in the 1940s when it was used in the treatment of ocular burns. Following initial reports, its use in ocular surgery abated until recently when it was re-discovered in the Soviet Union and South America. Its introduction to North America in the early 1990s heralded a massive surge in the ophthalmic applications of this membrane. The reintroduction of amniotic membrane in ophthalmic surgery holds great promise; however, although it has been shown to be a useful and viable alternative for some conditions, it is currently being used far in excess of its true useful potential. In many clinical situations it offers an alternative to existing management options without any distinct advantage over the others. Further studies will undoubtedly reveal the true potential of the membrane, its mechanism(s) of action, and the effective use of this tissue in ophthalmology.

Management of the Late Ocular Sequelae of Stevens-Johnson Syndrome

The acute conjunctivitis seen initially in Stevens-Johnson syndrome is followed by a cicatricial phase, which often leads to severe ocular surface disease and visual morbidity. Manifestations include keratinization of the conjunctiva, lid margins, and lacrimal and meibomian ducts, resulting in an unstable tear film and mechanical trauma to the conjunctiva and cornea with blinking. Limbal stem cell deficiency is the most vision-threatening sequela of Stevens-Johnson syndrome, as it causes corneal neovascularization, chronic corneal inflammation, and an irregular corneal epithelium. Management of late sequelae often requires a multipronged approach, including strategies for ocular surface protection, ocular surface support, and ocular surface reconstruction. In this review, established therapies, as well as new experimental therapies, are discussed.

Amniotic Membrane for Repair of Exposed Hydroxyapatite Orbital Implant

Exposure of a hydroxyapatite orbital implant measuring 10 x 3 mm developed in a 25-year-old man. The exposure was repaired with an amniotic membrane graft. Follow-up examinations at 5 days, 2 weeks, 2.5 months, and 5 months after surgery demonstrated closure of the conjunctival defect. The author concludes that amniotic membrane may be useful for the treatment of hydroxyapatite orbital implant exposures.

Management of primary and recurrent pterygium using amniotic membrane transplantation

This review discusses the relative merits of the various techniques used in pterygium surgery with particular reference to the growing interest in the use of amniotic membrane transplantation (AMT) because it is safe, effective, and may be employed in conjunction with other techniques, such as limbal transplantation. The efficacy of AMT is comparable to the established method of conjunctival autograft transplantation (CG) and it is especially indicated when there exists a very large conjunctival defect to cover as in primary double-headed pterygium, or in the context of preserving superior bulbar conjunctiva for future glaucoma surgeries. The authors explain how current management principles (eg, use of anti-inflammatory agents, adequate removal of fibrovascular tissue) are based on known differences in pathogenesis and clinical behavior between primary and recurrent pterygium.