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. 2001 Dec;85(12):1455–1463. doi: 10.1136/bjo.85.12.1455

Single and multilayer amniotic membrane transplantation for persistent corneal epithelial defect with and without stromal thinning and perforation

P Prabhasawat 1, N Tesavibul 1, W Komolsuradej 1
PMCID: PMC1723817  PMID: 11734521

Abstract

AIMS—To evaluate the efficacy of amniotic membrane transplantation (AMT) in persistent corneal epithelial defect with or without stromal thinning and corneal perforation.
METHODS—28 patients (28 eyes) with persistent corneal epithelial defect unresponsive to medical treatment were given preserved human amniotic membrane transplants. The patients were divided into three groups: group A, persistent corneal epithelial defect 10 eyes; group B, epithelial defect with stromal thinning 13 eyes; and group C, corneal perforation five eyes. AMT was performed using one layer in group A and multilayers in group B and C. The causes of persistent epithelial defect were neurotrophic keratopathy (24 eyes), limbal deficiency (six eyes), exposure keratopathy (four eyes), and Mooren's ulcer (one eye).
RESULTS—Success was noted in 82.1% (23/28 eyes) in all groups, with 80% (8/10 eyes), 84.6% (11/13 eyes), and 80% (4/5 eyes) in groups A, B, and C respectively, with a mean follow up of 10.9 months (1-30 months). The mean epithelialisation time after AMT was 2.1 weeks. The healing times of groups B and C are also significantly shorter than group A (p=0.017 and 0.018, respectively). Corneal stromal thickness was significantly increased in all cases in groups B and C (p=0.006). Those with corneal perforation in group C were completely healed by multilayer AMT. There was no difference in the epithelialisation time between successful cases treated by a single operation (17 eyes) or repeated operation (six eyes). Vision improved in 18.9% (8/28 eyes) and worsened as a result of cataract formation in 2.3% (1/28 eyes). Failure was noted in 17.9% (5/28 eyes), because of corneal infection (two eyes), neurotrophic keratopathy with and without limbal deficiency (two eyes), and intractable corneal perforation (one eye). No patient developed major immediate postoperative complications or graft rejection.
CONCLUSION—Amniotic membrane can successfully treat refractory corneal epithelial defect by promoting epithelial healing and thus prevent corneal perforation. It can be used as a treatment for corneal perforation by restoring corneal stromal thickness so that emergency penetrating keratoplasty can be avoided.



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Figure 1  .

Figure 1  

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Group A. A patient with rhabdomyosarcoma (A) of the eyelid who underwent tumour removal surgery and radiation resulting in upper eyelid defect, with exposure keratopathy and a persistent epithelial defect. Two weeks after AMT and nasal tarsorrhaphy, part of the membrane started to dissolve and the epithelium healed completely (B). A patient with a history of recurrent herpes simplex keratitis (C) and post phacoemulsification, developed a persistent corneal epithelial defect over 1 year. After single layer AMT, the epithelial defect healed completely in 8 weeks but recurred after the amniotic membrane partially dissolved (arrows). A single layer AMT combined with an amniotic membrane patch and tarsorrhaphy were performed (D). One week after AMT, part of the patch dissolved (E). Complete epithelial healing as shown by fluorescein staining (F), which remained stable 5 months thereafter, until optical PKP was performed.

Figure 2  .

Figure 2  

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Group B. A patient developed a descemetocele from exposure keratopathy after wide excision of a squamous cell carcinoma of the lower eyelid. Appearance at 7 days after multilayer AMT revealed no epithelial defect (A). One month after surgery, the eye showed an increased stromal thickness and a marked reduction of ocular inflammation (B). Surface integrity was maintained up to 9 months before advanced recurrent tumours developed which required exenteration. A patient with Mooren's ulcer developed a corneal perforation (C). Immunosuppressive treatment and glue were used to restore the globe integrity and reduce inflammation (D). Because of the irritative symptoms and glue toxicity, which induced chronic inflammation and prevented tissue healing, the glue was removed and a descemetocele developed which required a multilayer AMT. Complete epithelialisation after 7 postoperative days with a partially dissolved membrane (arrow) (E). Four months after surgery, the eye showed an increased stromal thickness with no inflammation (F).

Figure 3  .

Figure 3  

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Group C. A patient with a history of recurrent herpes simplex virus keratitis developed a corneal perforation (A, arrow). A multilayer AMT was performed (B) with an amniotic patch on top (C). Four months postoperatively, a membrane completely dissolved revealing a fully restored stromal thickness with no epithelial defect (D). The corneal pannus resulted from a previous inflammation induced by herpes. A 3 mm corneal perforation in an eye with herpetic keratitis superimposed by bacterial corneal ulcer was managed by glue and multilayer AMT (E). The membrane dissolved totally after 1 month (F). The exposed glue induced corneal vascularisation and interfered with corneal healing. Removal of glue and repeated multilayer AMT decreased the corneal vascularisation and increased stromal thickness to normal (G). Five months later, PKP was performed which improved the vision from counting fingers to 20/50. A pathological section revealed a normal stromal thickness with abundant keratocytes and a residual part of the membrane in the area of perforation (H).

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