Eyeworld

67 EW CORNEA July 2016 chronic flare-up with an AM are going to be few and far between," Dr. Desai said. "We don't want to treat with AM before the patient's been on topical steroids and topical cyclosporine 0.05% and before we've tried some of the newer topical ther- apies for OSD." Dr. Aldave has been referred cas- es where AM was used in the treat- ment of a persistent epithelial defect overlying active infectious keratitis or scleritis. In neither case is AM an appropriate treatment as it does not possess antimicrobial properties and obscures the underlying infectious process. Dr. Hovanesian has seen referral patients with AM for recurrent ero- sions—a sometimes inappropriate treatment. Using AM as a bandage for basement membrane dystrophy is reasonable, "but I don't think it has any significant advantage over a collagen bandage contact lens, which is a much more cost effective way to address that issue." Clinicians may think that using AM in the management of corneal limbal stem cell deficiency is appropriate, but "applying AM is not going to address the underlying problem as it is not a source of lim- bal stem cells," Dr. Aldave said. While no one thinks clinicians are intentionally misusing AM, "it comes down to misunderstanding what AM can and cannot do based on not being familiar with its bio- logic properties," Dr. Aldave said. Pearls for use "Don't wait to treat when there's a good indication to do it and pre- vent vision loss by using AM, but be cautious about overusing it in conditions that have a very loose indication," Dr. Desai said. Clinicians should note that the more inflammation there is, the fast- er the membrane is going to dissolve and release its biological factors. "With PROKERA, the mem- brane may dissolve after 2 to 3 days, particularly in a hot eye," Dr. Desai said. But since the removal of a global period of 10 days, if the patient will benefit from a second membrane, the surgeon can insert one "even at day 2 or 3." When AM is sutured to the cornea for management of per- sistent corneal epithelial defects, as it is very thin, it may not remain intact for the requisite period of time unless it's protected. Therefore, Dr. Aldave said, "I always place a bandage contact lens and perform a suture lateral tarsorrhaphy to help maintain the contact lens. At 1 month after surgery, I open the tar- sorrhaphy, take out the contact lens, and typically the epithelial defect has healed." Get patients invested in the process, Dr. Desai said. "So much of what we do is absolutely painless that patients have this preconceived notion that everything should be painless," he said. "We need to make sure that patients understand that it may be in their best interest to be a little bit uncomfortable for a day or 2 to give them the long-term best outcome with less scarring, less haze, better vision, faster healing, and fewer adverse events, like fungal keratitis, compared to just using a contact lens." When used properly, AM has amazing abilities, Dr. Hovanesian said. "AM and the whole biologics industry is a powerful tool in our armamentarium as cornea specialists and eyecare professionals that treat any variety of ocular surface diseas- es," Dr. Desai said. EW Editors' note: Dr. Aldave has no finan- cial interests related to his comments. Dr. Desai has financial interests with Bio-Tissue. Dr. Hovanesian has finan- cial interests with Katena (Denville, New Jersey). Contact information Aldave: aldave@jsei.ucla.edu Desai: desaivision@hotmail.com Hovanesian: jhovanesian@harvardeye.com But that doesn't mean its use is appropriate in all cases, Dr. Hovanesian added. "This is not a cure-all to be used for every possible cornea problem," Dr. Desai said. Too often, AM is used for indications for which it is not well suited, which, in turn, delays a more definitive and appropriate treat- ment, Dr. Aldave said. He cited cases of patients who had AM placed for significant corneal stromal thinning; in cases in which the AM does not stop the progression of thinning, the cornea may perforate, necessitating the placement of cyanoacrylate glue, "which is more difficult to perform after as opposed to before corneal perforation." Dr. Hovanesian thinks the biggest misperception about when to use AM is in cases of dry eye or epithelial basement membrane dys- trophy or "anytime you've got an ocular surface disease." "It's not wrong to use AM in dry eye, but it's a very rare case of dry eye that actually needs AM," he said. Using AM in just any dry eye patient "is not generally helpful." Inflammatory processes are in play with ocular surface disease (OSD), making it a chronic condi- tion with acute flare-ups. But "the number of instances where you might want to resolve an acute upon Amniotic membrane patch placed for management of a persistent epithelial defect Scleral melt inappropriately managed with amniotic membrane, seen at the limbus Source (all): Anthony Aldave, MD

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