Eyeworld

WINTER 2025 | EYEWORLD | 63 C Contact Desai: desaivision2020@gmail.com Hovanesian: DrHovanesian@harvardeye.com Relevant disclosures Desai: BioTissue, DefEYE Hovanesian: None Tissue Tuck technique was already an improve- ment over conjunctival autograft in terms of speed, efficiency, comfort, and healing. The decellularized membrane heals faster, is more comfortable, and has as low a recurrence rate as the cryopreserved membrane," he said. For neurotrophic keratitis, you can use either a cryopreserved option, like Prokera, or the decellularized basement membrane. For Dr. Desai, the choice depends on the stage of neuro- trophic keratitis. He noted that stage 1 is defined as either a punctate keratitis or a stage 1 with reduced corneal sensitivity; stage 2 NK is defined by a sterile epithelial defect but no stromal involve- ment. For both of these milder stages, he prefers the decellularized basement membrane. For stage 3 NK, you could have an epi- thelial defect but also a corneal ulcer or melt involved and some stromal dissolution because of this inflammatory effect. "That's a little bit more severe, and I want the added boost of a cryopreserved membrane," he said, adding that he'll also prescribe Oxervate (cenegermin-bkbj, Dompe) with this. "For stage 1 and 2, I'll use decellularized basement membrane while we wait for Oxer- vate to be delivered. For stage 3, I'll use Prokera or Prokera Plus, the multi-layer cryopreserved, and prescribe Oxervate," he said. Dr. Hovanesian published the THINK study, 2 which showed that a fairly large portion of patients presenting for cataract surgery with dry eye have early-stage neurotrophic keratitis. He said it's been known for decades that this type of material has powerful anti-inflammatory and anti-fibrotic properties, which makes it useful for promoting healthy healing in a diseased ocular surface. He noted its use in neurotroph- ic keratitis or any condition where there is an epithelial defect that is not prone to healing on its own. Pterygium surgery is another area where this is useful, he said. While pterygium surgery can be done without amniotic membrane, you can use it as a graft, and it's a little easier of a surgery to learn. However, he noted that recur- rence rates using amniotic membrane may be higher than with other pterygium techniques. Dr. Hovanesian also cautioned against the overuse of amniotic membranes. He noted that particularly in dry eye, you want to be careful you're not using amniotic membrane when it's not needed. You need to think about "what's the right science for my patient" first, he said. While these can be a good option, some patients might have a painful response to treatment with amniotic membrane because they don't actually need an amniotic membrane. "When we think about using amniotic membrane products of any kind in the context of things like ocular surface disease, dry eye disease, or anterior basement membrane dis- ease, I think it's important to realize that using … amniotic membranes is not a replacement for conventional therapies," Dr. Desai said. "We still will rely on our primary MDs and ODs to prescribe and utilize all of the conventional therapies for dry eye disease." He added that it's important to use things like immunomodulatory therapy, steroid thera- py, artificial tears, lid margin treatments, warm compresses, etc. Amniotic membrane products are not a replacement, but they are an adjuvant to accelerate treatment and healing in those cases. Oftentimes, conventional therapies will take weeks, if not months, to work, Dr. Desai said, noting that "applying an amniotic mem- brane becomes an interventional treatment that has 100% compliance because you know you've put it on. That buys us time to give the conven- tional treatments a chance to work." Editors' note: This is not an exhaustive discussion of all amniotic membrane products available in the U.S. It is limited to companies and products mentioned by the physician sources. " … applying an amniotic membrane becomes an interventional treatment that has 100% compliance because you know you've put it on. That buys us time to give the conventional treatments a chance to work." —Neel Desai, MD

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