Vol 2, No 4 (2017)
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Published online: 2018-03-30

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Amniotic membrane application in complex cases of penetrating keratoplasty surgery

Andrea Passani, Angela Tindara Sframeli, Iacopo Franchini, Rosario Denaro, Mario D. Toro1, Chiara Posarelli
Ophthalmol J 2017;2(4):101-104.


INTRODUCTION. The aim of the study is to investigate the ability of an amniotic membrane implant combined with penetrating keratoplasty to reduce early and mid-term complications in complex cases such as penetrating burns, infective ulcers, keratitis, or corneal graft failure.

MATERIALS AND METHODS. Fifty patients: 12 with keratitis, 24 with infective ulcers, 10 with penetrating trauma, and four with a history of corneal graft failure, were divided into two groups. The first group of 25 patients (Group A) underwent penetrating keratoplasty alone, while the second group of 25 patients (Group B) received penetrating keratoplasty associated with an amniotic membrane implant. Amniotic membrane implantation was performed in a ‘patch modality’, and the membrane was sewn to the graft with the epithelium/basement membrane side facing inwards. All patients were evaluated, respectively, 3, 15, 30, 90, and 180 days after surgery. At each visit a slit-lamp examination was performed together with corneal thickness and endothelial cell count assessment. All the data were subjected to statistical analysis with Student’s t-test.

RESULTS. At the slit-lamp examination in Group A 48% of patients showed Descemet folds at one and three months, respectively, while 80% of patients of Group B did not show any Descemet folds. In Group A we registered two cases of early graft failure and two cases of shallow anterior chamber, while none of these complications appeared in Group B. In Group A the average corneal thickness at 15, 30, 90, and 180 days post-operatively was, respectively, 695 ± 43 μm, 658 ± 31 μm, 588 ± 12 μm, and 518 ± 20 μm, while in Group B it was found to be, respectively, 667 ± 12 μm, 632 ± 17 μm, 562 ± 16 μm, and 516 ± 10 μm. Differences in corneal thickness between Group A and Group B were found to be statistically significant (p = 0.05). Endothelial cell count was in Group A 2582 c/mm2 at 15 days, 2500 c/mm2 at one month, 2335 c/mm2 at three months, and 2111 c/mm2 at six months, while the average count for Group B patients was 2607 c/mm2, 2503 c/mm2, 2299 c/mm2, and 2086 c/mm2, respectively. Differences in endothelial cell count between the two groups did not show any statistical significance (p > 0.05).

CONCLUSIONS. Amniotic membrane implantation associated with penetrating keratoplasty reduces early and mid-term complications of corneal grafts in patients with high risk of failure. This positive effect may be due to the anti-inflammatory, neurotrophic, and anti-angiogenetic properties of the amniotic membrane. Longer observation and larger case series can be useful in evaluation of the functional outcome of grafts in these patients.

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  1. Jirsova K, Jones GLA. Amniotic membrane in ophthalmology: properties, preparation, storage and indications for grafting-a review. Cell Tissue Bank. 2017; 18(2): 193–204.
  2. Rahman I, Said DG, Maharajan VS, et al. Amniotic membrane in ophthalmology: indications and limitations. Eye (Lond). 2009; 23(10): 1954–1961.
  3. Gomes JAP, Romano A, Santos MS, et al. Amniotic membrane use in ophthalmology. Curr Opin Ophthalmol. 2005; 16(4): 233–240.
  4. Dua H, Gomes J, King A, et al. The amniotic membrane in ophthalmology. Surv Ophthalmol. 2004; 49(1): 51–77.
  5. Duchesne B, Mans B, Lavalleye B, et al. [Use of the cryopreserved human amniotic membrane for reconstruction of the ocular surface]. Bull Soc Belge Ophtalmol. 1998; 268: 73–77.
  6. Tseng S. Amniotic Membrane Transplantation With or Without Limbal Allografts for Corneal Surface Reconstruction in Patients With Limbal Stem Cell Deficiency. Archives of Ophthalmology. 1998; 116(4): 431.
  7. Amniotic membrane transplantation for severe neurotrophic corneal ulcers. Chen H-J, Pires RTF, Tseng SCG*(1). Br J Ophthalmol 2000;84:826-833. Am J Ophthalmol. 2001; 131(1): 155–156.
  8. Chen HJ, Pires RT, Tseng SC. Amniotic membrane transplantation for severe neurotrophic corneal ulcers. Br J Ophthalmol. 2000; 84(8): 826–833.
  9. Shimazaki J, Yang HY, Tsubota K. Amniotic membrane transplantation for ocular surface reconstruction in patients with chemical and thermal burns. Ophthalmology. 1997; 104(12): 2068–2076.
  10. Prabhasawat P, Tesavibul N, Komolsuradej W. Single and multilayer amniotic membrane transplantation for persistent corneal epithelial defect with and without stromal thinning and perforation. Br J Ophthalmol. 2001; 85(12): 1455–1463.
  11. Feiz V, Mannis MJ, Kandavel G, et al. Surface keratopathy after penetrating keratoplasty. Trans Am Ophthalmol Soc. 2001; 99: 159–168.
  12. Wagoner MD, Ba-Abbad R, Al-Mohaimeed M, et al. King Khaled Eye Specialist Hospital Corneal Transplant Study Group. Postoperative complications after primary adult optical penetrating keratoplasty: prevalence and impact on graft survival. Cornea. 2009; 28(4): 385–394.
  13. Stechschulte SU, Azar DT. Complications after penetrating keratoplasty. Int Ophthalmol Clin. 2000; 40(1): 27–43.
  14. Armitage WJ, Dick AD, Bourne WM. Predicting endothelial cell loss and long-term corneal graft survival. Invest Ophthalmol Vis Sci. 2003; 44(8): 3326–3331.
  15. Tseng S. Amniotic Membrane Transplantation With or Without Limbal Allografts for Corneal Surface Reconstruction in Patients With Limbal Stem Cell Deficiency. Archives of Ophthalmology. 1998; 116(4): 431–41.
  16. Seitz B, Das S, Sauer R, et al. Amniotic membrane transplantation for persistent corneal epithelial defects in eyes after penetrating keratoplasty. Eye (Lond). 2009; 23(4): 840–848.
  17. Koizumi N, Fullwood NJ, Bairaktaris G, et al. Cultivation of corneal epithelial cells on intact and denuded human amniotic membrane. Invest Ophthalmol Vis Sci. 2000; 41(9): 2506–2513.
  18. Khodadoust AA, Silverstein AM, Kenyon DR, et al. Adhesion of regenerating corneal epithelium. The role of basement membrane. Am J Ophthalmol. 1968; 65(3): 339–348.
  19. Kurpakus MA, Stock EL, Jones JC. The role of the basement membrane in differential expression of keratin proteins in epithelial cells. Dev Biol. 1992; 150(2): 243–255.
  20. Li DQ, Lee SB, Tseng SC. Differential expression and regulation of TGF-beta1, TGF-beta2, TGF-beta3, TGF-betaRI, TGF-betaRII and TGF-betaRIII in cultured human corneal, limbal, and conjunctival fibroblasts. Curr Eye Res. 1999; 19(2): 154–161.
  21. Li DQ, Tseng SC. Differential regulation of cytokine and receptor transcript expression in human corneal and limbal fibroblasts by epidermal growth factor, transforming growth factor-alpha, platelet-derived growth factor B, and interleukin-1 beta. Invest Ophthalmol Vis Sci. 1996; 37(10): 2068–2080.
  22. Li DQ, Tseng SC. Three patterns of cytokine expression potentially involved in epithelial-fibroblast interactions of human ocular surface. J Cell Physiol. 1995; 163(1): 61–79.