Eyeworld

62 | EYEWORLD | WINTER 2025 C ORNEA References 1. Desai NR, Adams B. Cryopreserved amniotic membrane using the TissueTuck technique: a sutureless approach for pterygium surgery. Cornea. 2023:42:181–185. 2. Hovanesian JA. The THINK Study: testing hypoesthesia and the incidence of neurotrophic keratopathy in cataract patients with dry eye. Clin Ophthalmol. 2024;18:3627–3633. extracellular matrix proteins and cytokines more efficiently provide a matrix scaffold and promote rapid production of growth factors and anti-inflammatory cytokines that support an enhanced cell-mediated response, letting the recipient's healing process begin without delay. When to use these products Dr. Desai considers amniotic membranes in any circumstance where faster functional healing is desired and passive wound coverage may be insufficient. He previously used cryopreserved membranes exclusively because he didn't see the same clinical results with conventional de- hydrated membranes. But in the past year or so, he has begun to use the decellularized basement membrane. "I'm impressed that the results seem to be equivalent to the cryopreserved mem- branes for both clinical and surgical applica- tions," he said, adding that he's seeing slightly faster healing and greater patient comfort. The decellularized basement membrane has no ring because it's multi-layered, laminated, and bi-directional. It adheres to the cornea or to an epithelial defect quite well without the use of glue or a contact lens. In discussing how to choose when to use amniotic membrane, Dr. Desai noted what he called his "unified theory of ocular surface diseases." What makes some of these ocular surface diseases distinct is the severity and the longevity of the inflammatory degenerative pro- cess. You can see some of the continuity among different dry eye diseases on the spectrum, he said, mentioning things like keratitis, epithelial basement membrane disease, the development of Salzmann's nodules, and the development of recurrent erosion syndrome. Further on the spectrum, there is pterygium growth and recur- rences, conjunctivochalasis, and neurotrophic keratitis. All of these conditions are potential in- dications for the use of an amniotic membrane, Dr. Desai said. With dry eye disease, these patients typical- ly have a relatively mild condition that could be progressive. "We want to provide some anti-in- flammatory benefit to them right away and get them some relief," he said. "But at the same time, we don't want to add more discomfort by putting something in that has a ring on it." Using the cryopreserved Prokera (BioTis- sue), the benefit is that it has an initial anti-in- flammatory boost, so it's going to be soothing. "It puts the inflammatory fire out and buys time to let conventional therapies work," he said, adding that the downside is it has a ring. CAM360 (BioTissue), a gamma-irradiated mem- brane, which requires a contact lens or collagen shield for retention, could be used for greater comfort. Dr. Desai expressed concerns that the most severe dry eye patients he sees, where the benefits of amniotic membrane products might be most applicable, are inherently more prone to infections, especially under contact lens- es. Therefore, he prefers other interventional approaches to mild and moderate dry eye as first-line therapy in addition to immunomodu- latory therapies and lubricants before utilizing amniotic membrane products. For the most severe cases, Dr. Desai has begun using decel- lularized basement membrane, which avoids these potential risks. "We usually place the Biovance 3L Ocular membrane and a pressure patch that the patient can remove themselves at day 3. The decellularized basement membrane remains self-retained without significant risk of slippage, dissolving over the course of 3–7 days on its own," Dr. Desai said. The decellularized Biovance 3L Ocular works well for things like basement membrane disease, Salzmann's nodules, and recurrent erosion syndrome, Dr. Desai said. These are conditions where we create an epithelial de- fect by debriding the cornea, leaving an open wound that we want to heal quickly. In the case of recurrent erosion syndrome, there is a wound that's not healing at all, and those cells are not adherent to a healthy basement membrane any- more. "For this particular category, I think this is the ideal place to be using the decellularized, multi-layer graft because of the greater cellular adherence, the better viability of those cells, and the faster healing, as well as the comfort." For surgical indications like pterygium and conjunctivochalasis, Dr. Desai said he has pub- lished on pterygium techniques, specifically the Tissue Tuck technique he developed, using cryo- preserved amniotic membranes. His study on the Tissue Tuck technique showed just a 0.7% recurrence rate in primary pterygia without the use of MMC and an average case time of just under 14 minutes. 1 "I've been experimenting with the Biovance 3L Ocular decellularized basement membrane for these surgical cases and indications. The continued from page 61

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