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Amniotic Membrane: A Game-changer?

This treatment modality for recurrent corneal erosion might be the alternative you have been looking for.
By Joseph P. Shovlin, OD

3/15/2017

Perhaps no corneal condition is more vexing than recurrent corneal erosion (RCE). While the causes vary, the treatment options have remained virtually unchanged for quite some time, at least until recently. Today, amniotic membranes have gained popularity as an alternate treatment for RCE.

The Problem

In RCE, disturbance to the underlying layers of the epithelium result in faulty hemidesmosome attachment of the epithelium to the basement membrane, and the loosely attached overlying epithelium easily erodes. Clinicians can gently pass a dry cellulose sponge over the suspected loose area of epithelium to look for epithelial movement.1

RCE can be the result of damage following trauma, known corneal dystrophy of the anterior cornea, corneal degeneration or surgical procedures such as refractive surgery, corneal transplants or even cataract surgery. Diabetes is also a well-known confounding factor.

The Tried-and-true

Traditional therapy for acute episodes includes antibiotic ointment to prevent infection, cycloplegia and proper lubrication. Once the epithelium closes, a hyperosmotic agent may aid in proper adhesion. For large abrasions, clinicians can use bandage lens therapy and pressure patching, but should avoid patching for contact lens wearers. Oral analgesics are often helpful as well.

When recurrent episodes are frequent, epithelial debridement, anterior stromal puncture, diamond burr polishing, excimer laser phototherapeutic keratectomy or extended bandage lens wear may be required. The key to minimizing recurrence is applying debridement and polishing beyond where the pathology appears to exist.

Due to its matrix metalloproteinase-9 inhibition, oral doxycycline 50mg BID with (and sometimes without) topical corticosteroid use for two to four weeks may be beneficial for some patients.

Often patients who have failed on other treatments do well with autologous serum tears as an adjunctive therapy. These affect the final phases of wound healing by supplying growth factors and extracellular matrix components that activate keratocytes.1 Always remember, medical treatment is aimed at minimizing inflammatory activity and managing meibomian gland disease.

The New Player

Amniotic membranes can create a so-called biological bandage and work as a temporary dressing, providing much-needed anti-inflammatory and anti-scarring effects. These membranes contain both antimicrobial properties and neurotrophic factors with low immunogenicity. They also inhibit angiogenesis.2,3

But new treatments always come with a host of unknowns: does the use of amniotic membrane after epithelial debridement and polishing significantly enhance healing to minimize recurrence? If so, how does this affect the overall healing time? Should we use this modality on most of our patients? At what point does it make the most sense? There’s not much information available to answer these questions, although a small series of retrospective reports show less recurrence with amniotic membrane use following diamond burr polishing.

Eye care providers still debate whether to use cryopreserved tissue or a dehydration preparation. While research shows fresh amniotic membrane is effective in clinical applications, it presents a significant risk of disease transmission, highlighting the importance of the processing methods that preserve biological effectiveness while ensuring safety.2

To complicate this new treatment further, some wonder if amniotic drops will eventually supplant the use of membrane tissue. So far, research shows morselized amniotic tissue is helpful in treating non-healing corneal defects.2

We all await a prospective, controlled study comparing bandage contact lenses with amniotic membrane application following debridement and polishing in patients who suffer from RCE. In the meantime, we must continue to use good judgment in caring for patients who are desperate for relief from the pain and inconvenience associated with erosive syndromes—which just might include applying an amniotic membrane to the cornea.

1. Albert D, Miller J, Azar D. Recurrent corneal epithelial erosion. Albert & Jakobiec’s Principles and Practice of Ophthalmology. Philadelphia: Saunders/Elsivier; 2008.
2. Stokkermans, Gupta PJ, Sayegh RR. A hands-on approach to band keratopathy. Rev. of Optom. 2017 Jan;154(1):36-8.
3. Huang Y, Sheha H, Tseng S. Self-retained amniotic membrane for recurrent corneal erosion. J Clin Exp Ophthalmol. 2013;4(2):272.


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