[Show abstract][Hide abstract] ABSTRACT: Purpose:
To evaluate the clinical efficacy of self-retained cryopreserved amniotic membrane in treating dry eye disease.
Retrospective review of 10 patients treated with self-retained cryopreserved amniotic membrane (PROKERA® Slim [PKS], Bio-Tissue, Miami, FL) for moderate-to-severe dry eye refractory to conventional maximal medical treatments. Patients' symptoms, use of medications, conjunctival inflammation, corneal staining, and visual acuity were compared before and after treatment.
PKS was placed in 15 eyes of the 10 patients for 4.9 ± 1.5 days. All patients experienced symptomatic relief for a period of 4.2 ± 4.7 months (p<.001). Such improvement was accompanied by reduction of OSDI scores (p<.001), use of topical medications (p<.001), conjunctival hyperemia (p<.001), corneal staining (p<.001), and improvement of the visual acuity (p=.06). Linear regression analysis estimated that the optimal duration of PKS placement was 5 days to achieve an average symptom-free duration of 4 months in patients with dry eye. Surprisingly, PKS placement also generated improvement in the contralateral eyes.
This pilot study suggests that self-retained cryopreserved amniotic membrane via PKS can be used to treat moderate dry eye diseases and warrants further prospective controlled studies.
[Show abstract][Hide abstract] ABSTRACT: Postoperative adhesions after strabismus surgery may influence surgical outcome. Different techniques have been used with varying success to reduce these adhesions. We describe a novel surgical technique in which amniotic membrane is used to wrap the extraocular muscles.
No preview · Article · Nov 2008 · Journal of AAPOS: the official publication of the American Association for Pediatric Ophthalmology and Strabismus / American Association for Pediatric Ophthalmology and Strabismus
[Show abstract][Hide abstract] ABSTRACT: To evaluate the clinical outcome of a new sutureless approach for a temporary amniotic membrane patch (ProKera; Bio-Tissue, Inc, Miami, Florida) in eyes with acute burns.
Retrospective review of 5 eyes of 5 patients with grades I to III acute alkaline burns, receiving ProKera insertion within 8 days of injury.
These eyes had either total (2 cases) or extensive (60%-75%, 3 cases) corneal epithelial defects with limbal (120 degrees -360 degrees ) and conjunctival (30%-60%) epithelial defects. ProKera was inserted within a mean (SD) of 3.7 (3.1) days after burn and repeated 1 to 3 times for 3 cases. Conjunctival defects reepithelialized in 8.2 (5) days (range, 5-17 days), while limbal and corneal defects healed in 13.6 (8.3) days (range, 5-25 days). The latter was completed with circumferential closure of limbal defects followed by centripetal healing of corneal defects. In 3 eyes, early peripheral corneal neovascularization was followed by marked regression on completion of healing. During 16.8 (10.8) months of follow-up, all eyes retained a stable surface with improved corneal clarity, and without limbal deficiency or symblepharon.
This sutureless application of an amniotic membrane patch allows for early delivery of its biologic actions, which may help preserve remaining limbal stem cells for rapid expansion and prevent late cicatricial complications in eyes with mild and moderate acute alkaline burns.
Full-text · Article · Sep 2008 · Archives of ophthalmology
[Show abstract][Hide abstract] ABSTRACT: To identify surgical strategies of fornix reconstruction for symblepharon graded according to the length from the limbus to the lid margin, to the width, and to associated inflammation.
Retrospective, comparative, interventional case series.
In 61 eyes with symblepharon, cicatrix lysis and amniotic membrane transplantation (AMT) were performed with sutures (n = 34) or fibrin glue (n = 27) together with (n = 47) or without (n = 14) intraoperative mitomycin C (MMC), plus fornix reconstruction using anchoring sutures without (n = 30) or with (n = 7) oral mucosal graft or with conjunctival autograft (n = 4). Overall, success was defined as an outcome of complete success (restoration of an anatomically deep fornix) or partial success (focal recurrence of scar), and failure was defined as the return of symblepharon.
For a follow-up of 25 +/- 10.8 months, the overall success was achieved by the first attempt in 52 eyes (85.2%) and failure resulted in nine eyes (14.8%); however, the success rate improved to 59 eyes (96.7%) with additional attempts. At the first attempt, AMT alone achieved overall successes in 92.8% of grade I eyes and in 100% of grade II eyes. Additional anchoring sutures achieved successes in 100% of grade I eyes, 70% of grade II eyes, and 71.4% of grade III/IV eyes. Additional oral mucosa or conjunctival autograft achieved successes in 100% of grade III/IV eyes. The complete success was correlated positively with lower grades of symblepharon or intraoperative use of MMC, but negatively correlated with younger ages, canthal involvement, or use of anchoring sutures. Anatomic improvement was accompanied by reduction of preoperative conjunctival inflammation (n = 40), improved visual acuity (n = 14), improved ocular motility (n = 18), improved eyelid closure (n = 3), and feasibility of contact lens wear (n = 10).
Successful outcome can be achieved by selectively deploying cicatrix lysis and AMT, intraoperative MMC, anchoring sutures, and oral mucosal or conjunctival autograft based on the severity of pathogenic symblepharon.
Full-text · Article · Jun 2008 · American Journal of Ophthalmology
[Show abstract][Hide abstract] ABSTRACT: To evaluate the results of sutureless amniotic membrane (AM) transplantation using fibrin glue for reconstructing corneal surfaces with partial limbal stem cell deficiency (LSCD).
Retrospective noncomparative interventional case series.
Eleven eyes of nine patients that had LSCD with 120 degrees to almost 360 degrees of limbal involvement underwent superficial keratectomy to remove the conjunctivalized pannus followed by AM transplantation using fibrin glue. Additional sutureless AM patch (ProKera; Bio-Tissue, Inc, Miami, Florida, USA) was used in seven patients, and mitomycin C was applied on the cornea in four eyes and during fornix reconstruction in seven eyes. The surgery was repeated in three eyes for residual pannus.
During a mean follow-up of 14.2 +/- 7.7 months (range, six to 26 months), all eyes maintained a smooth and stable corneal epithelial surface without recurrent erosion or persistent epithelial defect, and showed less stromal cloudiness and vascularization. Best-corrected visual acuity improved in nine eyes (81.8%). Corneal epithelialization proceeded by epithelial growth over AM (n = 4), accompanied by dissolution of AM (n = 4) or a combination of both (n = 3). No complication was noted regarding initial or repeated uses of fibrin glue.
AM transplantation using fibrin glue appears to be a safe and effective method of restoring a stable corneal epithelium for cases with partial LSCD. This approach avoids the need of transplanting limbal epithelial stem cells.
Full-text · Article · Jun 2008 · American Journal of Ophthalmology
[Show abstract][Hide abstract] ABSTRACT: To describe the combined use of tenonplasty, lamellar corneal patch graft, and amniotic membrane transplantation in managing scleral ischemia and/or melt by using sutures or fibrin glue.
We subjected five eyes of 4 patients with scleral ischemia and/or melt of diverse etiologies to debridement of all necrotic tissue, followed by a lamellar corneal graft (cases with melt, n = 3) or a cryopreserved amniotic membrane (cases without melt, n = 2), and a Tenon pedicle graft was used to cover the ischemic zone; surgery was completed by using a second layer of cryopreserved amniotic membrane. These procedures were performed by using either sutures or fibrin glue. Reduction of photophobia, facilitation of epithelialization, and correction of scleral ischemia and/or melt with preservation of the globe integrity were considered the main outcome measurements.
Surgical measures were effective to reduce or eliminate photophobia, facilitate epithelialization, halt scleral ischemia and/or melt, and preserve the globe integrity in all eyes except for 1 eye, in which a second attempt was needed to completely correct scleral ischemia. Complications included granuloma formation in 1 case and dellen formation and extreme gaze horizontal diplopia caused by a small symblepharon formation in another case.
The combination of tenonplasty and amniotic membrane transplantation with or without lamellar corneal patch grafting, by using sutures or fibrin glue, is a feasible alternative for treating scleral ischemia and/or melt.
[Show abstract][Hide abstract] ABSTRACT: To determine the clinical significance of postoperative conjunctival inflammation noted at the third or fourth week after intraoperative application of mitomycin C and amniotic membrane transplantation for pterygium.
This retrospective study included 27 eyes of 23 patients with primary (n = 12) or recurrent (n = 15) pterygia. All cases were operated by extensive removal of subconjunctival fibrovascular tissue and intraoperative application of 0.04% mitomycin C in the fornix, followed by amniotic membrane transplantation by using either fibrin glue (14 eyes) or sutures (13 eyes). Main outcome measures included development of conjunctival inflammation, pyogenic granuloma, and pterygium recurrence after surgery.
For a follow-up of 29.6 +/- 17.2 months (range, 6-56 months), 16 (59.3%) eyes without postoperative conjunctival inflammation resulted in favorable outcomes. Conjunctival inflammation around the surgical site was noted in the remaining 11 (40.7%) eyes and was significantly more common in eyes with sutures than those with fibrin glue (61.5% vs. 21.4%, respectively; P = 0.05). Among those with this inflammation, 7 eyes receiving subconjunctival injection of triamcinolone resulted in complete resolution and a good aesthetic outcome. Four eyes without this injection gradually developed conjunctival (n = 1) or corneal (n = 1) recurrence and/or pyogenic granuloma (n = 3).
Host conjunctival inflammation is still common after intraoperative application of mitomycin C and amniotic membrane transplantation, especially when sutures are used in pterygium surgery. If left untreated, persistent inflammation may lead to a poor surgical outcome.
[Show abstract][Hide abstract] ABSTRACT: To evaluate the feasibility of performing sutureless amniotic membrane transplantation (AMT) using fibrin glue for conjunctivochalasis.
Noncomparative interventional case series.
In 25 eyes of 16 patients with refractory conjunctivochalasis (CCh), AMT using fibrin glue was performed to cover the bare sclera.
The mean age was 55.2 +/- 18.5 years with nine patients (56.2%) younger than 60 years. The Tenon capsule was dissolved in all eyes. Fibrin glue was effective in securing the amniotic membrane to the sclera. For a mean follow-up of 10.6 +/- 4.3 months, all eyes achieved a smooth conjunctival surface with complete or significant improvement of symptoms in 44% and 56%, respectively. Complications included focal conjunctival inflammation in four eyes and pyogenic granuloma in one eye.
AMT using fibrin glue can be performed for refractory CCh resulting in alleviating its symptoms and signs.
Full-text · Article · Sep 2007 · American Journal of Ophthalmology
[Show abstract][Hide abstract] ABSTRACT: To show poor adhesion between the conjunctiva and the sclera in eyes with superior conjunctivochalasis (CCh) and to introduce a new surgical approach by reinforcing adhesion between the conjunctiva and the sclera for correcting this deficiency.
After conjunctival peritomy and removal of the loose Tenon remnants, "Tenon reinforcement" for conjunctival adhesion to the underlying sclera was achieved by transplantation of cryopreserved amniotic membrane with fibrin glue (group A, 9 eyes of 6 patients) or 10-0 nylon sutures (group B, 8 eyes of 6 patients) in 17 eyes of 12 patients with refractory superior CCh.
The mean age of patients was 68.2 +/- 9.8 years (range, 54-80 years). Superior CCh was associated with a superior limbic keratoconjunctivitis (SLK)-like clinical feature before surgery and found to exhibit dissolved Tenon capsule during surgery in all patients. During a mean follow-up of 3.7 +/- 1.9 months after surgery, all eyes achieved smooth conjunctival surface without any sign of CCh. Complete resolution of symptoms was seen in 9 eyes (52.9%) and significant resolution in 8 eyes (47.1%). There was no significant difference between groups A and B in improvement of symptoms and signs. No complications related to surgery were noted during follow-up.
We propose that loose and dissolved Tenon tissue is correlated with the development of superior CCh, which may result in an SLK-like appearance by blink-related microtrauma. Reinforcement of conjunctival adhesion onto the sclera by amniotic membrane with either fibrin glue or sutures is effective in alleviating symptoms and signs in eyes with superior CCh.
[Show abstract][Hide abstract] ABSTRACT: To show whether fluorescein dye helps detect and count Demodex embedded in cylindrical dandruff (CD) of epilated eyelashes from patients with blepharitis.
Two eyelashes with CD were removed from each lid of 10 consecutive patients with blepharitis and subjected to microscopic examination with and without fluorescein solution to detect and count Demodex mites.
Of 80 eyelashes examined, 36 (45%) lashes retained their CD after removal. Before addition of the fluorescein solution, the mean total Demodex count per patient was 14.9 +/- 10 and the mean Demodex count per lash was 3.1 +/- 2.5 and 0.8 +/- 0.7 in epilated eyelashes with and without retained CD, respectively (P < 0.0001). After addition of the fluorescein solution, opaque and compact CD instantly expanded to reveal embedded mites in a yellowish and semitransparent background. As a result, the mean total Demodex count per patient was significantly increased to 20.2 +/- 13.8 (P = 0.003), and the mean count per lash was significantly increased to 4.4 +/- 2.8 and 1 +/- 0.8 in eyelashes with and without retained CD (P < 0.0001 and P = 0.007), respectively. This new method yielded more mites in 8 of 10 patients and allowed mites to be detected in 3 lashes with retained CD and 1 lash without retained CD that had an initial count of zero.
Addition of fluorescein solution after mounting further increases the proficiency of detecting and counting mites embedded in CD of epilated eyelashes.
[Show abstract][Hide abstract] ABSTRACT: To report the corneal manifestations in eyes with Demodex infestation of the eyelids.
Noncomparative, interventional case series.
This retrospective review included six patients with Demodex blepharitis who also exhibited corneal abnormalities, which led to suspicion of limbal stem cell deficiency in three cases. All patients received weekly lid scrubs with 50% tea tree oil and a daily lid scrubs with tea tree shampoo for a minimum of six weeks. Improvement of symptoms and corneal and conjunctival signs were evaluated.
All six patients exhibited ocular irritation and conjunctival inflammation, while meibomian gland dysfunction (n = 5), rosacea (n = 4), and decreased vision (n = 3) also were noted despite prior treatments with oral tetracycline, topical steroids with antibiotics, and lid scrub with baby shampoo. These patients were proven to have Demodex folliculorum (n = 6) and Demodex brevis (n = 3) by microscopic examination of epilated lashes. Their corneal manifestation included superficial corneal vascularization (six eyes of five cases), marginal corneal infiltration (two eyes of two cases), phlyctenule-like lesion (one eye of one case), superficial corneal opacity (two eyes of two cases), and nodular corneal scar (two eyes of two cases). After treatment, the Demodex count was reduced from 6.8 +/- 2.8 to 1 +/- 0.9 (standard deviation; P = .001). All patients showed dramatic resolution of ocular irritation, conjunctival inflammation, and all inflammatory, but not scarred, corneal signs; three patients showed improved vision.
A variety of corneal pathologic features together with conjunctival inflammation, commonly noted in rosacea, can be found in patients with Demodex infestation of the eyelids. When conventional treatments for rosacea fail, one may consider lid scrub with tea tree oil to eradicate mites as a new treatment.
Full-text · Article · Jun 2007 · American Journal of Ophthalmology
[Show abstract][Hide abstract] ABSTRACT: Transplantation of cryopreserved amniotic membrane (AM) is a widely accepted surgical procedure to promote epithelial healing and to reduce inflammation, scarring and emerging neovascularization on the ocular surface. Clinical uses of AM for ocular surface reconstruction can be categorized either as a permanent graft or as a biological bandage. Permanent graft of AM has been used to replace the deficient or destroyed ocular surface tissue (cornea and/or conjunctiva) caused by disease or surgery and to promote regeneration, rather than repair, of the ocular surface. The main indication for using AM as a biological bandage is to suppress inflammation on the ocular surface caused by various diseases and insults, so as to promote epithelial healing with minimal or no scarring. Sutureless AM transplantation with fibrin glue or ProKera™ is a safe and easy method that avoids complications related to sutures and shortens the time of surgery.