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23 EW NEWS & OPINION October 2014 by Lauren Lipuma EyeWorld Staff Writer a steep learning curve, according to Dr. Salinger. "You do not have to be a cornea specialist to perform this proce- dure," he said. "If you have done pterygium surgery with conjunctival transplant, the techniques in this surgery are very similar." The procedure involves 4 major steps. First, the surgeon must ag- gressively remove the deteriorated Tenon's fascia. "If you leave Tenon's fascia behind, it continues to interfere with the proper ana- tomical anchoring of the rearranged conjunctiva and the amniotic membrane," Dr. Salinger said. Second, the surgeon must rearrange the remaining conjunc- tiva, removing as little as possible, taking care to avoid the limbal stem cell population. Third, the surgeon deepens the fornix and uses the remaining conjunctiva to reform the inferior cul-de-sac, restoring the proper anatomy of the tear reservoir. In the fourth and final step, the surgeon uses multiple layers of cryo- preserved amniotic membrane to replace the degraded Tenon's fascia and conjunctiva. Surgeons use biological tissue adhesive to attach the amniotic membrane to the ocular surface, but some, including Dr. Salinger, use sutures as well. "The glue in many cases is just not enough to hold the membrane in proper position in these patients," he said. "The last thing I want to do is go back for a repeat surgery in the same location. I also want to know that I have reformed that inferior cul-de-sac in the best way possible." Surgical videos of both methods —with sutures and without—and other resources are available from Bio-Tissue to help surgeons become more comfortable with the evalu- ation, diagnosis, and medical and surgical treatment of the disease. For a more in-depth review of the technique, visit the Ocular Surface Research and Education Foundation website at www.osref.org. EW Editors' note: Dr. Salinger has financial interests with Bio-Tissue. Contact information Salinger: drsalinger@comcast.net ability to facilitate epithelialization and reduce inflammation, vascula - ization, and scarring. Using amni- otic membrane as an ocular surface graft was first introduced in 1940, but the method did not take hold until 1995, when cryopreservation methods had advanced enough to retain the biological properties of the tissue. The Reservoir Restoration Procedure is superior to alternative surgical procedures because it ad- dresses the nasal and temporal areas of redundant conjunctiva as well as the obliterated tear reservoir that is unable to be appreciated, hidden by the lower lid in the area of the inferior cul-de-sac, according to Dr. Salinger. Additionally, the use of cryopreserved amniotic membrane promotes healing, inhibits further MMP degradation of the Tenon's fas- cia, and expedites patient recovery. "I'm a strong believer in using the cryopreserved Bio-Tissue amni- otic membrane because it has been shown that the cryopreserved meth- od helps the tissue to maintain the anti-inflammato y properties, as well as better retain the growth factors, the nutrients, the proteins necessary for regenerative healing, to suppress pain and achieve superior symptom- atic and cosmetic results," he said. The procedure The Reservoir Restoration Procedure is straightforward and does not have to dry eye symptoms may or may not be significant. "Clinicians understand [dry eye] is related to 4 factors to some varying degree—exposure to the en- vironment, inflammation, quantity of tear production, and the quality of the tear," Dr. Salinger said. "Conjunctivochalasis is a fifth component or contributing factor in many of our patients," he said. "The only way to determine whether it's minor, moderate, or significant is to treat and remove all the other factors from the equation." Ocular surface repair If medical treatment of dry eye is ineffective and symptoms persist, Dr. Salinger turns to surgical treat- ment to address the conjunctivo- chalasis and reestablish a normal ocular surface environment. The Reservoir Restoration Procedure uses AmnioGraft (Bio-Tissue, Doral, Fla.) cryopreserved amniotic membrane to replace the degraded conjunctiva and Tenon's fascia and to restore the natural tear reservoir. Amniotic membrane is harvested from the placenta during Cesarean section, then processed and preserved under sterile condi- tions until the time of transplant. It is an ideal tissue for ocular surface grafts because of its composition- al similarity to the conjunctiva. Additionally, its cells have character- istics of multipotent stem cells—the New procedure uses cryopreserved amniotic membrane to treat conjunctivochalasis I n the last 20 years, amniotic membrane transplantation has revolutionized ocular surface reconstruction. The uses for this versatile tissue continue to ex- pand and evolve, from treatment for corneal ulcers and chemical burns to conjunctival defects and limbal stem cell deficienc . One of the latest advances is a new procedure developed by oph- thalmic surgeons to treat conjuncti- vochalasis dry eye. In this procedure, surgeons use amniotic membrane to replace degraded conjunctiva and Tenon's fascia and to restore the nat- ural tear reservoir. Clifford Salinger, MD, medical director, Cornea and Refractive Consultants of the Palm Beaches and V.I.P Laser Eye Center, Palm Beach Gardens, Fla., discussed the advantages of this new proce- dure and the benefits of amniotic membrane transplantation in ocular surface repair. Conjunctivochalasis Conjunctivochalasis presents as loosened and wrinkled conjunctiva with many redundant folds just above the inferior lid margin, usual- ly apparent nasally and temporally. It occurs as a result of degeneration of the underlying Tenon's fascia that connects the conjunctiva to the sclera. As the Tenon's fascia degen- erates, the conjunctiva becomes significantly loosened and non-a - herent to the sclera, creating redun- dant folds and pulling up out of the inferior fornix, diminishing or oblit- erating the natural tear reservoir. Without the ability to replenish the tear meniscus from the reservoir and hydrate the ocular surface, patients often experience dry eye symptoms, epiphora, foreign body sensation, pain, and irritation. Degeneration of the Tenon's fascia is felt to be inflammato y and related to matrix metalloprotein- ase (MMP) activity, but the exact etiology is unknown. The condition can also be related to factors such as eye rubbing or allergies, Dr. Salinger said. While conjunctivochalasis may be clinically present, its contribution A new use for amniotic membrane transplantation in ocular surface repair Fluorescein with yellow filter befo e (two photos above) and after (two photos below) amniotic membrane transplantation Source: Clifford Salinger, MD