Eyeworld

63 EW CORNEA July 2017 CCh, despite its name, is not a disease of the conjunctiva but a disease of the Tenon's, and thus has to be treated as such. The treat- ment technique using amniotic membrane is similar to that of his pterygium tuck. During the Q&A portion of the webinar, Dr. Desai explained how he'll use mitomycin-C with his Tissue Tuck technique in Hispanic or African patients who have aggressive pterygia and who are prone to re- occurrence. He said he doesn't treat the scleral bed and only allows 20 seconds of exposure time. Dr. John pointed out that in some cases, like those with signif- icant inflammation, more than one amniotic membrane treatment might be needed. Similarly, Dr. Desai said in these cases, Prokera Plus, a thicker, dual layer amniotic mem- brane, or using an amniotic mem- brane sandwich technique could provide a longer-lasting effect. A recording of this webinar and supplemental materials can be found on the ASCRS Center for Learning at ascrs.org/center-for-learning. EW References 1. John T, et al. Amniotic membrane in the surgical management of acute toxic epidermal necrolysis. Ophthalmology. 2002;109:351– 360. 2. John T, et al. Corneal nerve regeneration after self-retained amniotic membrane for dry-eye disease. 2017 ASCRS•ASOA Sympo- sium & Congress. Editors' note: Dr. John has financial interests with Bio-Tissue, TissueTech (Doral, Florida), and others. Dr. Yeu has financial interests with Bio-Tis- sue and Ocular Science. Dr. Desai has financial interests with Bio-Tissue, TearScience, and others. Contact information Desai: desaivision@hotmail.com John: tjcornea@gmail.com Yeu: eyeulin@gmail.com Dr. Yeu's second case was a 67-year-old woman with complaints of fluctuating vision but no pain, irritation, or redness. Upon slit lamp examination, significant basement membrane dystrophy was observed along with a 3+ nuclear cataract in her right eye (her left eye was pseudophakic but had best corrected distance visual acuity of 20/30). Dr. Yeu performed superficial keratecto- my with Prokera postop. Preop, the patient's average K value was 43.26 with 6.6 D of astigmatism; postop, her average K was 46.56 with 0.71 D of astigmatism. After 6, weeks, Dr. Yeu said, the patient's spherical equivalent was –0.25 D. "This demonstrates that it can completely change the power of the cornea, having the presence of that irregular epithelium," Dr. Yeu said. Her third case was a Sjögren's patient with a history of depression and intolerance to cyclosporine and pilocarpine. After trying various therapies, including LipiFlow (Tear- Science, Morrisville, North Carolina), Dr. Yeu tried the patient on amniotic cytokine extract, Genesis (Ocular Sci- ence, Manhattan Beach, California). Within 2 months of using the drops, which have growth factors and anti-inflammatory molecules, the patient's dryness score was reduced, and she went from artificial tears eight times a day to only twice daily, as needed. Dr. Desai discussed his tech- niques involving amniotic mem- brane for pterygium and conjuncti- val chalasis (CCh). His Tissue Tuck pterygium technique is a less than 12-minute, sutureless procedure with a less than 1% recurrence rate and a recovery time between 1 and 3 weeks. Dr. Desai described how the amniotic membrane, laid stromal side down, is pulled up and over the edge of a semilunar fold that you've created, similar to how you would pull a bed sheet over pillows, and then swept down underneath, effec- tively creating a double foldback and a lunar fold. He hasn't found a need for NSAIDs in the postop regimen. which includes Ambiodry2, Ambio5, and AmbioDisk, which are rehydrat- ed before application and require a bandage contact lens. Dr. Yeu presented several case examples of patients where amniotic membrane was found to be benefi- cial. One was the case of a 71-year- old physician's wife, looking for a refractive outcome, presenting with blurred vision and for cataract evalu- ation. This patient had been treated for dry eye by another doctor for more than a year and was frustrated with the continued delay in cataract surgery. She'd had Guillain-Barre syndrome in her distant past, which left her with some lagophthalmos in her right eye. Dr. Yeu said this patient was on several pain medica- tions within the narcotic family and furosemide, and had self-reported topical cyclosporine intolerance. Her SPEED score was 6, and she exhibited elevated osmolarity, low tear breakup time, meibomian gland dysfunction with telangiectasis, a poor blink rate, diffuse staining with corneal nerve vascularization, and anterior stromal scarring in the inferior periphery. Dr. Yeu started this patient on loteprednol ointment and very fre- quent lubrication. After 3 weeks, her condition was not much better, but Dr. Yeu said she'd already prepped the patient about the possibility of cryopreserved amniotic membrane therapy. After several days with Prokera therapy, Dr. Yeu said the patient's keratometry measurements were much better. "But the most important part here is that we need to consider the management of patient expecta- tions, and there is going to be chair time where we have to help pa- tients understand where the blurred vision is coming from," Dr. Yeu said, adding that cataract surgery can, at times, worsen dry eye symptoms in the months after, and especially in refractive cataract surgery cas- es, chronic dry eye therapy might be needed to maintain quality of vision. that facilitate regenerative healing. Dr. John pointed out the similarities between amniotic membrane epithe- lium and conjunctival epithelium in terms of hexagonal cell shape and microvilli. Amniotic membrane, Dr. John said, stabilizes the ocular surface, re- duces inflammation, promotes heal- ing without scarring, and supports stem cell expansion. In general, he said it can be used as a biological bandage for superficial epithelial defects or as a permanent graft for deeper defects. Expanded indica- tions include epithelial and stroma defects such as corneal PED, neuro- trophic keratopathy, post-infectious ulcers, recurrent erosions/endothe- lial basement membrane dystrophy, and corneal perforation less than 3 mm; inflammatory conditions, such as Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and chemical burns; ocular surface reconstruction, as in cases of pterygium, conjunctivochalasis, and conjunctival tumors, symbleph- aron repair, and limbal auto and allografts; post-surgical procedures, like superficial keratectomy, band keratopathy, anterior lamellar ker- atoplasty, penetrating keratoplasty, and Salzmann's nodular degenera- tion; and in glaucoma cases with a leaking bleb or exposed tube shunt. John et al. reported the first case of TEN treated with cryopreserved amniotic membrane with excellent results. 1 In a study presented by Dr. John at the 2017 ASCRS•ASOA Sym- posium & Congress, it was shown for the first time that in moderate to severe dry eye patients, cryopre- served amniotic membrane plays a role in corneal nerve regeneration and restores corneal nerve integrity. 2 There are two commercially available forms of amniotic mem- brane: the cryopreserved variety by Bio-Tissue (Doral, Florida), which includes AmnioGraft, AmnioGuard, Prokera, Prokera Slim, Prokera Clear, and Prokera Plus, and the dehy- drated variety by IOP Ophthalmics (Katena, Denville, New Jersey),

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