Amniotic membrane graft after excision of widespread conjunctival concretions / Enxerto de membrana amniótica após remoção de concreções conjuntivais

ABSTRACT Conjunctival concretions are single or clustered lesions frequently found on the palpebral conjunctiva. They are commonly present in older individuals, despite being rarely symptomatic. This case report describes an 83-year-old man with multiple conjunctival concretions, which were surgically treated. The patient was symptomatic on presentation and did not respond to conservative treatment. For this reason, a surgical approach was considered. After wide excision of the conjunctival lesions, a piece of amniotic membrane was fitted using fibrin glue. During follow-up, a markedly improvement in patient's symptoms was observed, along with nearly complete absence of conjunctival concretions. This is the first case report addressing extensive conjunctival concretions with a surgical approach using amniotic membrane. The authors conceived the technique described after noticing the limited clinical options in the literature. This technique was easily performed and achieved satisfactory results.

RESUMO As concreções conjuntivais representam lesões amareladas, simples ou múltiplas, frequentemente encontradas na conjuntiva palpebral. São mais prevalentes em idades avançadas e raramente sintomáticas. Este relato de caso descreve o quadro clínico de um paciente de 83 anos com múltiplas concreções conjuntivais, cirurgicamente tratadas. Por se tratar de um paciente sintomático com resposta insuficiente ao tratamento conservador, foi considerada a abordagem cirúrgica. Após remoção das lesões, foi aplicado um enxerto de membrana amniótica, adaptado com cola de fibrina. No acompanhamento pós-operatório, verificou-se melhoria significativa dos sintomas, com desaparecimento quase total das concreções conjuntivais. Este é o primeiro caso que descreve uma abordagem cirúrgica com utilização de membrana amniótica na resolução desse tipo de lesões. A técnica, de fácil execução e com resultados muito favoráveis, foi desenvolvida pelos autores após constatarem a escassez de alternativas na literatura.

Amniotic membrane transplantation in ocular surface diseases / Transplante de membrana amniótica em doenças da superfície ocular

Abstract Objective: To evaluate the clinical effectiveness of amniotic membrane transplantation for ocular surface reconstruction. Methods: Prospective study including 23 eyes of 21 patients who underwent amniotic membrane transplantation at Hospital de Clínicas da Universidade Federal do Paraná (HC-UFPR) and at Cirurgia e Diagnose em Oftalmologia do Paraná (CDOP) clinic, located in Curitiba, PR, Brazil, from may 2015 to july 2019. The amniotic membrane was collected from elective and term cesarean delivery, and conserved in preservation medium and glycerol 1:1, stored at -80° Celsius. The membrane was fixed on the ocular surface with 10-0 nylon, 8-0 vicryl, biological glue or a combination of these materials. Results: The ocular surface reconstruction was successful in 22 eyes (95.6%). Failure was observed only in 1 case (bullous keratopathy) in which the condition was maintained postoperatively. Patients' age ranged from 11-82 years, with a mean age of 37.4 years. There was a higher incidence in males (66.6%). A difference was perceived in the distribution of the affected eye (which was greater in the right eye - 65.2%). As for the previous ophthalmic surgery history, 12 of the 23 eyes had a positive history (52.2%). It was observed that all patients who had preoperative visual acuity assessed showed improvement or maintenance of corrected visual acuity. In the postoperative period, complications associated with the underlying disease were observed, although not particularly related to the amniotic membrane transplantation. There were not any cases of postoperative infection. Conclusions: There was an improvement in the general state of the ocular surface in almost all of the cases in which the transplant was performed. Therefore, the amniotic membrane can be considered a good alternative for reconstructing the ocular surface, as a single or supporting treatment.

Resumo Objetivo: Avaliar a eficácia clínica do transplante de membrana amniótica na reconstrução da superfície ocular. Métodos: Estudo prospectivo incluiu 23 olhos de 21 pacientes que realizaram transplante de membrana amniótica no Hospital de Clínicas da Universidade Federal do Paraná (UFPR) e na clínica de Cirurgia e Diagnose em Oftalmologia do Paraná (CDOP), localizados em Curitiba, PR, Brasil, no período de maio de 2015 a julho de 2019. A membrana amniótica foi captada a partir de parto cesárea eletivo e a termo, conservada em meio de preservação e glicerol 1:1 e armazenada a -80° Celsius. A membrana foi fixada na superfície ocular com fio nylon 10-0 ou vicryl 8-0 e/ou cola biológica. Resultados: A idade dos pacientes variou de 11-82 anos, com média de 37,4 anos. Houve maior incidência no sexo masculino (66,6%). Ocorreu diferença na distribuição do olho acometido (maior no olho direito - 65,2%). Quanto à história de cirurgia oftalmológica prévia, 12 dos 23 olhos tinham história positiva (52,2%). Observamos que nos pacientes em que foi possível a avaliação da acuidade visual pré-operatória, todos apresentaram melhora ou manutenção da acuidade visual. No pós-operatório foi observado complicações associadas à doença de base e não propriamente ao transplante de membrana amniótica. Não foram registrados casos de infecção pós-operatória. Conclusão: Houve melhora do estado geral da superfície ocular em quase totalidade dos casos em que o transplante foi realizado. Portanto, a membrana amniótica pode ser considerada uma boa alternativa para reconstrução da superfície ocular, como tratamento único ou coadjuvante.

Comparação dos meios de preparação e preservação de membrana amniótica humana para uso no tratamento de doenças da superfície ocular / Comparison of the preparation and preservation techniques of amniotic membrane used in the treatment of ocular surface diseases

Resumo Atualmente a membra amniótica (MA) tem obtido importância devido à comprovada capacidade de reduzir inflamação, auxiliar a cicatrização e epitelização, possuindo propriedades antimicrobianas e antivirais, além de baixa imunogenicidade. As indicações de seu uso na oftalmologia têm aumentado muito nas duas últimas décadas. Objetivo: Descrever a estrutura básica e as propriedades biológicas da MA em relação aos componentes da sua matriz extracelular e fatores de crescimento, as consequências de diferentes técnicas empregadas na sua preservação e esterilização, métodos para remoção do epitélio e a comparação dos custos dos diferentes meios de conservação atualmente empregados. Métodos: Pesquisa nas bases de dados do Portal da Biblioteca Virtual em Saúde (BVS), Pubmed, Cochrane, Scielo e Lilacs com as palavras-chave: membrana amniótica, transplante, reconstrução da córnea, doenças da conjuntiva. Resultados: A literatura é vasta na descrição dos efeitos de diversos agentes e técnicas na preparação da MA, dentre elas sua preservação, esterilização e desepitelização. A membrana desnuda tem sido a escolha para a reconstrução da superfície ocular, pois facilita a cicatrização. Em relação aos agentes conservantes, o glicerol é o meio mais utilizado mundialmente pelo baixo custo e facilidade de manuseio. Conclusão: A comparação das diversas técnicas nos guia na elaboração de protocolos de preparo da MA para uso oftalmológico. A membrana desnuda facilita a cicatrização em relação a com células epiteliais. O glicerol é o meio de conservação mais utilizado pelo baixo custo e facilidade de manuseio.

Abstract Currently, the amniotic membrane (AM) has obtained importance due to its ability to reduce inflammation, helping in the healing and epithelialization processes, having antimicrobial and antiviral properties and low immunogenicity. Its indications in ophthalmology have increased considerably in the past two decades. Objective: To describe the basic structure and biological properties of the AM, the components of the extracellular matrix and growth factors, the consequences of different techniques used in its preservation, and sterilization methods for the epithelium removal. To compare the costs of the different preservation solutions currently employed. Study design: literature review. Methods: Research in BVS databases, PubMed, Cochrane, Scielo and Lilacs with keywords: amniotic membrane transplantation, corneal reconstruction, conjunctival diseases. Results: The literature is vast in describing the effects of different agents and techniques used in the preparation of MA, including its preservation, sterilization and desepithelization. The naked membrane is the choice to reconstruct the ocular surface, as it facilitates the healing course. Regarding the preservatives, glycerol is the most used worldwide due its low cost and easy handling. Conclusion: Comparing different techniques guides us in developing a MA preparation protocol for ophthalmic use. The naked membrane facilitates the healing process compared with the presence of epithelial cells. The glycerol is the most used preservation method because of its low cost and easy handling.

Effects of the application of the amniotic membrane in the healing process of skin wounds in rats

Abstract Purpose: To evaluate the efficacy of the application of the human amniotic membrane (HAM) on the inflammatory process, fibroblast proliferation, formation of collagenand reduction of skin wound areas in rats. Methods: Thirty six rats were submitted to a surgical injury induction and divided into two groups (n = 18): group C (control) and T (treated with the HAM). The macroscopic evolution in the wound area and the histological characteristics of the skin samples were evaluated. Results: The regression of the wound area was greater in group T. The histological analysis revealed a significant reduction (p < 0.05) in the inflammatory infiltrate in group T at all experimental periods compared with that in the control group. Furthermore, the group T presented a significant increase in the proliferation of fibroblasts at 14 and 21 days compared with group C (p < 0.05). Regarding the deposition of mature collagen fibers, there was an increase in the replacement of type III collagen by type I collagen in group T (p < 0.05). Conclusion: Treatment with the HAM reduced the healing time as well as the inflammatory responses, increased the proliferation of fibroblasts, and induced a higher concentration of mature collagen fibers.

Surgical amniotic membrane transplantation after conjunctival and limbal tumor excision / Transplante de membrane amniótica após excisão de tumor limbar e conjuntival

ABSTRACT Purpose: To evaluate the clinical results of patients treated by amniotic membrane transplantation (AMT) following excision of conjunctival and limbal tumors. Methods: A total of 14 eyes of 14 patients who underwent AMT after total lesion-free tumor excision and perilesional cryotherapy were evaluated. Results: The excised tumors comprised 7 conjunctival intraepithelial neoplasia, 5 conjunctival nevus, 1 primary acquired melanosis, and 1 squamous cell carcinoma. Limbus was involved in 10 cases, whereas cornea was involved in 6 cases. The average measurement of the tumor base was 14.8 mm (range 6-20 mm, SD 16 mm). The mean follow-up time period was 17.5 months (range 6 -60 months, SD 20 months). Complete healing occurred in eight eyes, but limbal cell deficiency developed in two eyes. Four cases had recurrence and were treated with the same surgical and medical procedures; during follow-up after recurrence, superficial peripheral vascularization and corneal scar were noted to have developed. Conclusions: AMT was effective for reconstruction of tissue defect after excision and cryotherapy of limbal and conjunctival tumors. In most of these cases, complete healing was achieved with a smooth, stable, and translucent surface.

RESUMO Objetivo: Avaliar os resultados clínicos de pacientes tratados com transplante de membrana amniótica (TMA) após a excisão de tumores conjuntival e limbar. Métodos: Foram avaliados 14 olhos de 14 pacientes submetidos a transplante de membrana amniótica após excisão total de tumor e crioterapia perilesional. Resultados: Os tumores que foram excisados podem ser classificados como neoplasia intraepitelial conjuntival em 7, nevus conjuntival em 5, melanose adquirida primária e carcinoma espinocelular em 1 caso cada. O limbo foi envolvido em 10 casos e a córnea foi envolvida em 6 casos. A medida média da base do tumor foi de 14,8 mm (6-20, DP 16). O tempo médio de seguimento foi de 17,5 meses (6-60, DP 20). A cicatrização completa ocorreu em 8 olhos e deficiência de células limbares ocorreu em 2 olhos. A recorrência foi diagnosticada em 4 casos e tratada com o mesmo procedimento cirúrgico e médico e, após essa recorrência, a vascularização periférica superficial e a cicatriz corneana desenvolveram-se em 4 casos durante o seguimento. Conclusões: O transplante de membrana amniótica é um método eficaz para a reconstrução do defeito do tecido após a excisão de tumores limbares e conjuntivais com a combinação de crioterapia. Na maioria destes casos, a cicatrização completa pode ser conseguida com uma superfície lisa, estável e transparente.

Epitelização de enxertos cutâneos em feridas recentes de coelhos tratados com membrana amniótica canina e/ou laserterapia / Skin graft epithelialization in rabbit fresh wounds treated with amniotic membrane and/or laser therapy

A enxertia cutânea é uma técnica cirúrgica simples e bastante útil para o reparo de feridas, principalmente aquelas onde existe dificuldade da aplicação do fechamento primário ou de outras técnicas reconstrutivas. Entretanto, para a sobrevivência do enxerto, é necessário que o leito da ferida esteja saudável e com presença de tecido de granulação exuberante. O objetivo do presente trabalho foi avaliar a aplicação da membrana amniótica e da laserterapia como potenciais estimulantes da cicatrização em enxertos aplicados em feridas sem tecido de granulação. Foram utilizados 42 coelhos, divididos em quatro grupos: grupo controle (GC), grupo membrana (GM), grupo laser (GL) e grupo membrana e laser (GML), submetidos a avaliações macro e microscópicas. Na avaliação macroscópica, foi possível notar que os pacientes dos grupos nos quais a membrana amniótica foi utilizada (GM e GML) apresentaram evidências associadas à acentuada reação inflamatória, à falha de integração do enxerto e à consequente necrose dele. Já os pacientes do GL apresentaram melhor aspecto do enxerto no último dia de avaliação. Na análise microscópica, observou-se intensa integração do enxerto à derme, reepitelização acentuada e escassas células inflamatórias no local do enxerto no GL. O contrário foi observado nos pacientes do GM e GML, nos quais aparentemente houve rejeição da membrana. A formação de colágeno não se correlacionou com outros fatores, como inflamação e necrose, em nenhum dos grupos de tratamento. Dessa forma, é possível afirmar que a laserterapia mostrou ser efetiva, contribuindo para o processo cicatricial e a integração do enxerto. Já a membrana amniótica canina não deve ser utilizada para esse fim, pois provoca intensa reação inflamatória, além de impedir a nutrição do enxerto.(AU)

Skin grafting is a simple surgical technique and useful to repair wounds, especially those where there is a difficulty to apply primary closure skin or other reconstructive techniques. However, for graft survival a healthy wound bed and the presence of an exuberant granulation tissue are necessary. This study aimed to evaluate the application of amniotic membrane and laser therapy as potential healing stimulants in grafts applied in wounds without granulation tissue. For this, we used 42 rabbits divided into four treatment groups, control group (CG), membrane group (MG), laser group (LG) and membrane and laser group (MLG), submitted to macroscopic and microscopic evaluation. The macroscopic examination showed that the patients of the groups where the amniotic membrane was used in order to stimulate re-epithelialization (MG and MLG) presented evidences associated with severe inflammatory reaction, graft integration failure and consequent necrosis. LG patients apparently had the best graph aspect in the last valuation date. Microscopic examination showed intense integration of the graft to the dermis, high re-epithelialization level, and scarce inflammatory cells in the graft site of LG patients. The opposite was observed in patients in the MG and MLG groups, where a rejection of the membrane was observed. Finally, collagen formation was not correlated with other factors such as inflammation and necrosis in any of the treatment groups. We can conclude that laser therapy was effective, contributing to the healing process and integration of the graft. Thus, canine amniotic membrane should not be used for this purpose because it causes intense inflammatory reaction besides avoiding graft nutrition.(AU)

Amniotic membrane as an option for treatment of acute Achilles tendon injury in rats

Abstract Purpose: To evaluate the effect of human amniotic membrane (hAM) fragment on inflammatory response, proliferation of fibroblast and organization of collagen fibers in injured tendon. Methods: Sixty rats were divided into 3 groups: C - surgical procedures without tendon lesion and with simulation of hAM application; I - surgical procedures, tendon injury and simulation of hAM application; T - surgical procedures, tendon injury and hAM application. These groups were subdivided into four experimental times (3, 7, 14 and 28 days). The samples underwent histological analysis and ATR-FTIR spectroscopy. Results: Histological analysis at 14 days, the T group showed collagen fibers with better alignment. At 28 days, the I group presented the characteristics described for the T group at 14 days, while this group presented aspects of a mature connective tissue. FT-IR analysis showed a clear distinction among the three groups at all experimental times and groups T and I presented more similarities to each other than to group C. Conclusion: Acute injury of tendon treated with human amniotic membrane fragment showed a faster healing process, reduction in inflammatory response, intense proliferation of fibroblasts and organization of collagen fibers.

Long-term effects of human amniotic membrane in a rat model of biliary fibrosis

Liver fibrosis is the most common outcome of chronic liver diseases, and its progression to cirrhosis can only be effectively treated with liver transplantation. The amniotic membrane (AM) has been studied as an alternative therapy for fibrosis diseases mainly for its favorable properties, including anti-inflammatory, anti-scaring and immunomodulatory properties. It was recently demonstrated that the AM reduces the progression of biliary fibrosis to its advanced stage, cirrhosis, when applied on the liver for 6 weeks after fibrosis induction. Here, we investigated the effects of AM on rat fibrotic liver, during a prolonged period of time. Fibrosis was induced by bile duct ligation (BDL), and at the same time, a fragment of AM was applied around the liver. After 1, 3, 6, and 9 weeks, the degree of fibrosis was assessed by qualitative Knodell scoring, and by quantitative image analysis to quantify the area of collagen deposition in hepatic tissue. While fibrosis progressed rapidly in untreated BDL animals, leading to cirrhosis within 6 weeks, AM-treated livers showed confined fibrosis at the periportal area with few and thin fibrotic septa, but without cirrhosis. In addition, collagen deposition was reduced to about 36 and 55% of levels observed in BDL at 6 and 9 weeks after BDL, respectively, which shows that the longer the period of AM application, the lower the collagen deposition. These results suggested that AM applied as a patch onto the liver surface for longer periods attenuated the severity of biliary fibrosis and protected against liver degeneration caused by excessive collagen deposition.

Excisão, crioterapia e mitomicina C no tratamento da neoplasia intraepitelial córneo-conjuntival / Excision, cryotherapy and mitomycin c for the treatment of conjunctival-corneal intraepithelial neoplasia

RESUMO Objetivo: Avaliar a segurança e eficácia de três técnicas distintas para o tratamento de neoplasia intraepitelial córneo-conjuntival. Métodos: Vinte e seis pacientes, 11 mulheres e 15 homens, com idade entre 32 e 88 anos (média 64,84 anos), atendidos entre 1999 e 2014, foram incluídos neste estudo. Todos os pacientes foram submetidos à exérese da lesão com margem de segurança de 4mm e crioterapia a 2mm do limbo. Conforme o tratamento complementar, os pacientes foram divididos em três grupos: Grupo 1 (8 olhos): recobrimento conjuntival e 2 ciclos de mitomicina C 0,02% (MMC) 4x/dia por 10 dias, com intervalo de 30 dias entre os ciclos. Grupo 2 (9 olhos): recobrimento com membrana amniótica e 3 ciclos de MMC 3x/dia por 10 dias, com intervalo de 10 dias entre o 1º e o 2º ciclo e 30 dias entre 2º e o 3º ciclo. Grupo 3 (9 olhos): recobrimento com membrana amniótica sem o uso de MMC. O acompanhamento dos pacientes variou de 3 meses a 14 anos (média: 4 anos). Resultados: Vinte e três pacientes apresentaram erradicação da lesão com um único tratamento. Três pacientes do Grupo 3 apresentaram recidiva da lesão após 3 meses, 6 meses e 1 ano do tratamento. Dois deles foram retratados pela técnica 1, sem nova recidiva após seguimento de 3 e 4 anos; o outro paciente foi submetido à enucleação. Não foram observados efeitos colaterais relacionados ao uso da mitomicina C durante o seguimento. Conclusão: Após exérese da lesão e crioterapia, os pacientes tratados com recobrimento conjuntival ou membrana amniótica associado à mitomicina C mostraram tendência a resultados mais eficazes.

ABSTRACT Purpose: To evaluate the safety and efficacy of three different techniques for the treatment of conjunctival-corneal intraepithelial neoplasia. Methods: Twenty-six eyes of 26 patients, 11 women and 15 men were included in a nonrandomized, retrospective, observational case series. Mean patient age was 64 years (range, 32-88 years).All patients were treated from 1999 to 2014. Mean postoperative follow-up was 4 years (range, 3 months to 14 years). All patients underwent excision of the lesion with a 4-mm safety margin and a 2-mm from the limbus cryotherapy. As further treatment the patients were divided into three groups: Group 1 (8 eyes): conjunctival autograft and 2 cycles of mitomycin C 0.02% (MMC) eye drops, four times daily for 10 days with an interval of 30 days between cycles. Group 2 (9 eyes): amniotic membrane (AM) graft and 3 cycles of MMC eye drops, three times daily for 10 days with an interval of 10 days between the 1st and 2nd cycle and 30 days between the 2nd and 3rd cycle. Group 3 (9 eyes): AM graft without MMC eye drops. Results: After a single treatment, the lesions were eradicated in twenty-three patients. Recurrence was noted in three patients from Group 3 at 3 months, 6 months and 1 year after treatment. Two of them were retreated by the technique used in Group 1 without further recurrence; the other patient underwent enucleation. No adverse effects related to the use of mitomycin C were observed during. There were no side effects related to the use of mitomycin C during follow-up. Conclusion: After surgical excision and cryotherapy, patients treated with conjunctival or amniotic membrane graft associated with mitomycin C, showed a tendency to more effective results.

Limbal transplantation at a tertiary hospital in Brazil: a retrospective study / Transplante de limbo em hospital terciário no Brasil: estudo retrospectivo

ABSTRACTPurpose:Epidemiological analysis of limbal transplantation surgeries performed in the Ophthalmologic Hospital of Sorocaba.Methods:Retrospective medical records review of 30 patients who underwent limbal stem cell transplants between January 2003 and March 2008. Cases involving conjunctival limbal autograft were classified as group I, and those involving conjunctival limbal allograft as group II.Results:Two patients were excluded due to incomplete data during postoperative follow-up. Of the total sample of 28 patients, 53.6% constituted group I, whereas 46.4% were included in group II. Males were predominant (67.9%), and right eyes were the most prevalent (67.9%). The mean age was 40.3 years. Unilateral cases accounted for 60.7%. The most frequent pathology causing limbal system failure was chemical burns (53%). The mean length of time from diagnosis to surgery was 11.18 years. The limbal graft and amniotic membrane were associated in 75% of all cases, and tarsorrhaphy in 57.1%. The average follow-up period was 24.84 months. The uncorrected visual acuity improved in 38% of the cases, was unchanged in 28.5%, and deteriorated in 33.3%. There was no persistent epithelial defect in 75% of the patients. The conjunctivalization rate was similar between the groups (53.3% and 58.3%, respectively). The transparency improved in only 38.4% of the cases, and 28.5% of the surgeries performed were successful. The most prevalent complication was persistent epithelial defect, which occurred in 25% of the patients, followed by corneal melting in 14.2%. Other complications observed included infectious ulcers, limbal graft necrosis or ischemia, perforation, and descemetocele.Conclusion:Chemical burns remain the main cause of limbal stem cell deficiency. In these cases, limbal transplantation is the standard procedure to restore the ocular surface even though the success rate is low.

RESUMOObjetivo:Análise epidemiológica dos transplantes de limbo realizados no Hospital Oftalmológico de Sorocaba.Método:Foi realizada uma análise retrospectiva através de revisão de prontuário de trinta casos de transplante de limbo realizados no período de janeiro de 2003 a março de 2008. Casos de transplante de limbo autólogo foram classificados como grupo I e alogênicos como grupo II.Resultados:Dois pacientes foram excluídos da análise por insuficiência de dados nos registros. Da amostra completa de 28 pacientes, 53,6% constituíram o grupo I enquanto 46,4% o grupo II. O olho direito (68%) e o sexo masculino (68%) foram mais acometidos, com uma média de idade de 40,3 anos. Casos unilaterais contabilizaram 60,7%. A patologia de base causadora da deficiência límbica mais prevalente foi a queimadura química (53%). A média do tempo de doença até a cirurgia foi de 11,18 anos. Na maioria dos casos o transplante foi associado a membrana amniótica (75%) e tarsorrafia (57%). O tempo médio de seguimento foi de 24,84 meses. Foi observado melhora da acuidade visual não corrigida em 38% dos casos enquanto 28,5% permaneceram inalteradas e 33,3% pioraram. Evolução sem defeito epitelial persistente ocorreu em 75% dos pacientes. A taxa de conjuntivalização foi semelhante nos 2 grupos (53,3% e 58,3%). Em apenas 38% dos casos houve melhora da transparência. A taxa de sucesso foi de cerca de 28%. A complicação mais prevalente foi defeito epitelial persistente (25%) seguida de melting (14,2%). Outras complicações observadas foram úlceras infecciosas, necrose ou isquemia do enxerto, perfuração e descemetocele.Conclusões:A queimadura química permanece como principal patologia causadora de deficiência límbica. Nestes casos o transplante de limbo é atualmente a técnica de eleição para restauração da superfície ocular, porém com baixa taxa de sucesso.

Usos de membrana amniótica en patología ocular pediátrica / Use of amniotic membrane in childhood ocular disease

Introducción: La membrana amniótica (MA) posee varias propiedades clínicas que la hacen útil en el tratamiento de diferentes patologías. El principal efecto clínico es que permite la epitelización de los tejidos, favorece el crecimiento, adhesión y diferenciación de las células epiteliales, además de prevenir su apoptosis, reduciendo la cicatrización. Objetivo: Describir la utilidad de la membrana amniótica como alternativa en el tratamiento de la superficie ocular. Son abordados tópicos como las diferentes formas de obtención, preparación y conservación de la misma, así como sus mecanismos de acción y aplicaciones. Resultados: En el Servicio de Oftalmología del Hospital de Pediatría J. P. Garrahan se usaron 429 membranas amnióticas en 294 pacientes desde el año 2002 hasta octubre 2014 para el tratamiento de distintas patologías oculares. Los pacientes estudiados presentaron reducción de la inflamación, vascularización y mejor cicatrización. Conclusión: la MA es en la actualidad una alternativa en el tratamiento de patologías de difícil manejo que no responden a las terapias médicas convencionales. Sin embargo, su empleo deberá ser racional, para evitar falsas expectativas de considerarla como panacea en toda patología corneal o conjuntival (AU)

Introduction: Amniotic membrane has several clinical properties rendering it useful in different pathologies. Its main clinical effect is the epithelization of tissue, favoring growth, adhesion and differentiation of epithelial cells as well as prevention of apoptosis and reduction of scarring. Objective: To determine the usefulness of amniotic membrane as an alternative for ocular surface treatment. Issues such harvesting techniques, preparation, and storage of the amniotic membrane, as well as mechanisms of action and use are discussed. Results: At the Department of Ophthalmology of the Pediatric Hospital J. P. Garrahan 429 amniotic membranes were used in 294 patients between 2002 and October 2014 for the treatment of different eye pathologies. The patients studied presented with reduced inflammation and better vascularisation and scarring. Conclusion: Amniotic membrane is currently a treatment option in difficult-to-treat pathologies that do not respond to conventional therapies. Nevertheless, it should be used rationally to avoid unrealistic expectations considering it the panacea for all corneal or conjunctival pathologies (AU)

Deep Anterior Lamellar Keratoplasty Using Irradiated Acellular Cornea with Amniotic Membrane Transplantation for Intractable Ocular Surface Diseases

PURPOSE: To report the clinical outcomes of deep anterior lamellar keratoplasty (DALK) when sterile gamma-irradiated acellular corneal tissues (VisionGraft) are used in combination with amniotic membrane transplantation (AMT) for intractable ocular surface diseases. METHODS: The medical records of fifteen patients who had DALK with AMT were retrospectively reviewed. Indications for surgery included ocular burn, bacterial keratitis, herpes simplex virus keratitis, corneal opacity with Stevens-Johnson syndrome, Mooren's ulcer, idiopathic myxoid degeneration of corneal stroma, and recurrent band keratopathy. DALK was performed using partial-thickness acellular corneal tissue and a temporary amniotic membrane patch was added at the end of the operation. RESULTS: All cases that underwent DALK with AMT became epithelialized within 2 postoperative weeks. Twelve patients showed favorable outcomes without graft rejection, corneal opacification, or neovascularization. The other three grafts developed corneal opacification and neovascularization, and required additional penetrating keratoplasty (PK). Unlike the results of previous PKs, there were no graft rejections and the graft clarity was well-maintained in these three cases for at least 8 months after PK. CONCLUSIONS: DALK using sterile acellular corneal tissues in combination with AMT may be a good therapeutic strategy for treating intractable ocular surface diseases because of lowered immune rejection, fibroblast activation, and facilitation of epithelialization. Furthermore, DALK can help stabilize the ocular surface, prolong graft survival, and may allow better outcomes when combined with subsequent PK.

Amniotic Membrane Transplantation for Repair of a Large Intraoperative Conjunctival Defect during Trabeculectomy

No abstract available.

Ultrasound biomicroscopy after palliative surgical procedures for bullous keratopathy: a descriptive comparative study / Biomicroscopia ultrassônica após procedimentos cirúrgicos paliativos na ceratopatia bolhosa: estudo comparativo descritivo

Purpose: To describe quantitative and qualitative features of eyes with advanced bullous keratopathy assessed using ultrasound biomicroscopy, before and after anterior stromal puncture (ASP) or amniotic membrane transplantation (AMT) procedures to relieve chronic pain. Methods: The present descriptive comparative study included 40 eyes of 40 patients with chronic intermittent pain due to bullous keratopathy who were randomly assigned to one of the two treatments (AMT or ASP). Ultrasound biomicroscopy (Humphrey, UBM 840, 50 MHz transducer, immersion technique) was used, and a questionnaire about pain intensity was completed preoperatively and postoperatively at days 90 and 180, respectively. Exclusion criteria were age<18 years, presence of concurrent infection, ocular hypertension, and absence of pain. Results: In a 180-day follow-up, the AMT group exhibited mean central corneal thickness (CCT), 899.4 µm preoperatively and 1122.5 µm postoperatively (p<0.001); mean epithelial thickness (ET), 156.4 µm preoperatively and 247.8 µm postoperatively (p<0.001); and mean stromal thickness (ST), 742.9 µm preoperatively and 826.3 µm postoperatively (p=0.005). The ASP group exhibited mean CCT, 756.7 µm preoperatively and 914.8 µm postoperatively (p<0.001); mean ET, 102.1 µm preoperatively and 245.2 µm postoperatively (p<0.001); and mean ST, 654.6 µm preoperatively and 681.5 µm postoperatively (p<0.999). Correlations between CCT and pain intensity in the AMT group (p=0.209 pre- and postoperatively) and the ASP group (p=0.157 preoperatively and p=0.426 at the 180-day follow-up) were not statistically significant. Epithelial and stromal edema, Descemet’s membrane folds, epithelial bullae, and the presence of interface fluid were frequently observed qualitative features. Conclusion: CCT increased over time in both groups. The magnitude of CCT did not correlate with pain intensity in the sample studied. The presence of interface ...

Objetivo: Descrever as características quantitativas e qualitativas da biomicroscopia ultrassônica (UBM) em olhos com ceratopatia bolhosa avançada, antes e após os procedimentos de punção estromal anterior (ASP) ou transplante de membrana amniótica (AMT) para alívio de dor crônica. Métodos: Estudo comparativo descritivo incluindo 40 olhos de 40 pacientes com dor crônica intermitente devido a ceratopatia bolhosa, randomizados em duas modalidades de tratamento (AMT e ASP). Biomicroscopia ultrassônica (Humphrey, UBM 840, transdutor de 50 MHz, técnica de imersão) foi utilizada, e um questionário de avaliação da intensidade da dor foi aplicado no pré-operatório, e após 90 e 180 dias de pós-operatório. Critérios de exclusão foram: idade abaixo de 18 anos, presença de infecção, hipertensão ocular, e ausência de dor. Resultados: No seguimento de 180 dias, o grupo Transplante de membrana amniótica apresentou: média da espessura corneana central (CCT): 899,4 µm (pré), 1.122,5 µm (pós-operatório) (p<0,001); média da espessura epitelial (ET): 156,4 µm (pré), 247,8 µm (pós-operatório) (p<0,001); média da espessura estromal (ST): 742,9 µm (pré), 826,3 µm (pós-operatório) (p=0,005), e, grupo ASP apresentou: CCT média: 756.7 µm (pré), 914,8µm (pós-operatório) (p<0,001); ET média: 102,1 µm (pré), 245,2 µm (pós-operatório) (p<0,001); ST média: 654,6 µm (pré), 681.5 µm (pós-operatório) (p<0,999). A correlação entre intensidade da dor e espessura corneana central no grupo AMT (p=0,209 pré e pós-operatórios) e no grupo ASP (p=0,157 pré-operatório e p=0,426 aos 180 dias de seguimento) não foi significativa. Edema epitelial e estromal, dobras na membrana de Descemet, bolhas epiteliais, e presença de fluido na interface foram características qualitativas frequentemente observadas. Conclusão: A espessura corneana central aumentou ao longo do tempo em ambos os grupos. A magnitude da espessura corneana central não interfere na intensidade da dor ...

Autoinjerto limboconjuntival con membrana amniótica en la insuficiencia límbica total unilateral / Limbal-conjunctival autograft with amniotic membrane to treat total unilateral limbal stem cell deficiency

Se presentan tres ojos de tres pacientes con insuficiencia límbica total por quemadura alcalina grave (n= 2), con enfermedad de Coats y antecedentes de cirugía de desprendimiento de retina (n= 1). Los casos uno y dos tenían una evolución de las quemaduras de 2 años y 8 meses respectivamente, y el caso tres de 8 meses. A todos los pacientes se les realizó la misma técnica quirúrgica: peritomía a 360º, extirpación de la membrana corneal fibrovascular, autoinjerto limboconjuntival (donante del ojo homólogo sano) y la implantación de membrana amniótica. El caso 1, con agudeza visual corregida preoperatoria de percepción de luz y sentido cromático en el ojo derecho, alcanzó a los 12 meses una agudeza visual corregida de 0,3 y a los 13 años, con +1,50-0,50 x 90º, una visión de 0,9. El caso 2, con agudeza visual preoperatoria de bultos a 20 centímetros, logró a los dos años una agudeza visual de 0,6; y el caso 3, con visión preoperatoria de percepción de luz, alcanzó una visión de 0,05 (20/500). En todos los casos el autoinjerto limbo-conjuntival del ojo homólogo sano con implantación de membrana amniótica constituyó una excelente alternativa para la mejoría visual y la rehabilitación laboral de los dos primeros pacientes. En el caso uno se logró un resultado extraordinario. El caso 3 logró una reepitelización corneal total y una evidente mejoría de la transparencia corneal, pero por la enfermedad de base la agudeza visual solo mejoró discretamente.

Three eyes of three patients with grave alkali burns (n-2) and with Coats disease after retinal detachment surgery (n-1). All of the cases presented a total limbal stem cells deficiency. Cases 1 and 2 had an burning evolution of 2 years and 8 months respectively, and the case 3 an evolution of 8 months before surgery. All patients underwent the same operation: Peritomy 360º, keratectomy of corneal fibrovascular membrane, limbo-conjuntival autograft from the healthy fellow eye and implantation of amniotic membrane. Case number 1 with preoperatory visual acuity of light perception and projection improved to 0,3 his visual acuity after 12 months and with +1,50-0,50 x 90 a visual acuity 0,9 after 12 years. Case 2 with preoperatory visual acuity of counter finger at 20 centimeters improved his visual acuity 0,6 after two years, and case 3 with preoperatory visual acuity of light perception improved to 0,05 (20/500). In all cases, limbal-conjunctival autograft of the healthy fellow eye with amniotic membrane transplantation resulted an excellent option for improving visual acuity and laborer rehabilitation in cases 1 and 2 (achieving case 1 excellent visual acuity). Case 3 had a total corneal epithelization and an evident improvement in corneal transparency, but visual acuity had a little improvement due to base disease.

Application of Human Amniotic Membrane in Canine Penile Tunica Albuginea Defect: First Step toward an Innovating New Method for Treatment of Peyronie?s Disease

Purposes To evaluate the efficacy of human amniotic membrane (AM) grafting in the canine penile tunica albuginea defect; we developed an animal model as the first step toward an innovating new method for the treatment of Peyronie’s disease, penile cancers, and congenital deformities of the penis. Material and Methods From August to September 2011, ten healthy male dogs were selected. A rhomboid incision about 3x2cm over the tunica albuginea and its overlying squamous epithelium was made and then excised. The amniotic membrane was folded twice on itself and grafted on the defect. After 8 weeks, artificial erection was made for 5 dogs and for the other 5 dogs after 12 weeks. After artificial erection, partial penectomy was done and histopathological evaluation was performed on the grafts. Results Artificial erection performed successfully in all of the dogs. No infection or any other complication was seen. Histopathological examination showed complete re-epithelialization with squamous epithelium and collagen fiber deposition. Also, no dysplasia was seen. Conclusions The amniotic membrane can be used as a suitable substitution for tunica albuginea. It is safe, inexpensive, biodegradable, and available and may be used for the treatment of Peyronie’s disease, penile cancers, congenital penile deformities, and penile reconstructive surgery. .

Melanoma conjuntival multifocal recidivado originado de nevus pigmentado preexistente / Recurrent multifocal conjunctival melanoma originated from preexisting pigmented nevus

O melanoma conjuntival multifocal recidivado originado de nevus preexistente é extremamente raro, ocorrendo em uma pessoa para cinco milhões de habitantes. Seu estudo é de extrema relevância, devido sua potencial letalidade. Este estudo objetiva descrever um caso de melanoma conjuntival multifocal recidivado proveniente de nevus pigmentado preexistente ocorrido em Patos de Minas, MG. Este é um estudo de caso com revisão de literatura. O diagnóstico histopatológico e o estadiamento precoce da lesão conjuntival é de fundamental importância para designar a conduta frente ao paciente. O procedimento terapêutico mais utilizado nos dias atuais é a excisão cirúrgica com crioterapia adjuvante associada à mitomicina C. O prognóstico do melanoma conjuntival multifocal recidivado originado de nevus preexistente é o pior dentre todos os melanomas oculares, apresentando alta taxa de mortalidade, 12% a 20% em 5 anos e 30% em 10 anos de desenvolvimento patológico.

Recurrent multifocal conjunctival melanoma originated from preexisting nevus is extremely rare: it occurs in one out of five million individuals. The investigation of this disease is extremely important due to its potential lethality. Thus, this study aims to describe a case of recurrent multifocal conjunctival melanoma originated from preexisting pigmented nevus, which occurred in the city of Patos de Minas, state of Minas Gerais. This is a case study and literature review. Histopathological diagnosis and early staging of the conjunctival lesion is a key element on how to approach the patient. The treatment procedure most commonly used today is surgical excision with adjuvant cryotherapy and mitomycin C. The prognosis of recurrent multifocal conjunctival melanoma originated from preexisting nevus is the worst of all ocular melanomas, with high mortality rate: 12% to 20% within 5 years and 30% within 10 years of pathological development.

Comparative evaluation of conventional medical treatment alone versus conventional medical treatment with amniotic membrane transplantation in infective corneal ulcer

To compare the effect of amniotic membrane transplantation along with conventional therapy and the conventional therapy alone for the treatment of infective corneal ulcer. This study was conducted at Ophthalmology Department, Hayatabad Medical Complex Peshawar. The duration of study was 6 months, i.e., from April 2010 to October 2010, in which a total of 68 patients were included using WHO software for sample size determination. They were divided into two equal groups of 34 each. Non probability purposive sampling technique was used. In this study, mean age was 50 +/- 0.24 years. Forty six [67.6%] patients were male while 32.4% [n=22] patients were female. Conventional Medical Treatment alone was effective in 87% [n=30] cases while Conventional Medical Treatment with Amniotic Membrane was effective in 96% [n=33] cases with a p-value of 0.03. This study showed encouraging results of amniotic membrane trans plantation along with conventional treatment in corneal ulcer in improving both symptoms and signs

Effect of Age and Early Intervention with a Systemic Steroid, Intravenous Immunoglobulin or Amniotic Membrane Transplantation on the Ocular Outcomes of Patients with Stevens-Johnson Syndrome

PURPOSE: This retrospective observational case series of fifty-one consecutive patients referred to the eye clinic with acute-stage Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN) from 1995 to 2011 examines the effect of early treatment with a systemic corticosteroid or intravenous immunoglobulin (IVIG) on the ocular outcomes in patients with SJS or TEN. METHODS: All patients were classified by age (18 years) and analyzed by treatment modality and early intervention with systemic corticosteroids (< or =5 days), IVIG (< or =6 days), or amniotic membrane graft transplantation (AMT) (< or =15 days). The main outcomes were best-corrected visual acuity (BCVA) in logarithm of the minimum angle of resolution (logMAR) and ocular involvement scores (OIS, 0-12), which were calculated based on the presence of superficial punctate keratitis, epithelial defect, conjunctivalization, neovascularization, corneal opacity, keratinization, hyperemia, symblepharon, trichiasis, mucocutaneous junction involvement, meibomian gland involvement, and punctal damage. RESULTS: The mean logMAR and OIS scores at the initial visit were not significantly different in the pediatric group (logMAR = 0.44, OIS = 2.76, n = 17) or the adult group (logMAR = 0.60, OIS = 2.21, n = 34). At the final follow-up, the logMAR and OIS had improved significantly in the adult group (p = 0.0002, p = 0.023, respectively), but not in the pediatric group. Early intervention with IVIG or corticosteroids significantly improved the mean BCVA and OIS in the adult group (p = 0.043 and p = 0.024, respectively for IVIG; p = 0.002 and p = 0.034, respectively for corticosteroid). AMT was found to be associated with a significantly improved BCVA or OIS in the late treatment group or the group with a better initial OIS (p = 0.043 and p = 0.043, respectively for BCVA; p = 0.042 and p = 0.041, respectively for OIS). CONCLUSIONS: Our findings suggest that patients with SJS or TEN who are aged 18 years or less have poorer ocular outcomes than older patients and that early treatment with steroid or immunoglobulin therapy improves ocular outcomes.