Spark Imagewise 17 – Cornea

Amniotic membrane transplantation in an eye with failed posterior lamellar keratoplasty

Dr Samyak Gupta, Dr Prabhat Nangia, Dr Sarang Lambat, Dr Vinay Nangia 
559, Suraj Eye Institute, Nagpur.

Case Description
A female, 54 years of age, came with a complaint of diminution of vision with pain in the right eye since 9 months. She had a history of right eye Descemet stripping endothelial keratoplasty (DSEK) performed elsewhere 9 months prior. She had no perception of light in the right eye (OD) & her best corrected visual acuity(BCVA) was 6/6, N6 in left eye (OS). . Intraocular pressure recorded by Goldmann applanation tonometer was 22 mmHg in OD and 16 mmHg in OS. Left eye fundus was normal.

Figure 1a: Slit Lamp photograph of right eye showing presence of failed DSEK graft in situ(Black arrows) with epithelial irregularity (Yellow arrow), bullae & 3 sutures in situ temporally 
Figure 1b: Slit Lamp photograph of right eye using fluorescein stain with cobalt blue filter for illumination showing surface irregularities with ruptured bullae (Red arrows)

Patient was clearly explained that there was no visual prognosis in right eye. She was keen on pain relief, and she underwent amniotic membrane grafting(AMG) in the right eye where inlay technique was used. A partial thickness groove was created all around in the peripheral cornea at 9 mm diameter & amniotic membrane graft was placed stromal side down. The membrane was tucked into the groove and sutured with 10-0 nylon sutures, and bandage contact lens was placed.
She was reviewed 1 week postoperatively which showed the AMG in situ(Fig 2a, yellow arrow) with sutures(Fig 2a, white arrows) and an epithelial defect over the AMG (Fig. 2b, yellow arrows).

Figure 2a: Slit Lamp photograph at 1 week post-op showing AMG in situ(Yellow arrow) with sutures(White arrows) 
Figure 2b: Slit Lamp photograph of right eye using fluorescein stain with cobalt blue filter for illumination showing an epithelial defect over the AMG (Yellow arrows)

At 2 weeks postoperatively OD showed AMG as before (Fig. 3a) with healing epithelial defect (Fig 3b, yellow arrow).

Figure 3 a: Slit Lamp photograph at 2 weeks showing Amniotic membrane graft 
Figure 3 b: Slit Lamp photograph of right eye using fluorescein stain with cobalt blue filter for illumination showing a healing epithelial defect (Yellow arrow)

At 1 month follow up, anterior segment examination of right eye showed AMG in situ (Fig. 4a)and minimal epithelial irregularities, significantly reduced as compared to the initial presentation (Fig. 4b, yellow arrow). Patient was symptomatically much better. Patient was asked to follow up after 3 months.

Figure 4a: Slit Lamp photograph at 1 month follow-up showing AMG in situ 
Figure 4b: Slit Lamp photograph of right eye using fluorescein stain with cobalt blue filter for illumination showing minimal epithelial irregularities, significantly reduced as compared to the initial presentation (Yellow arrows)

Discussion

In Bullous keratopathy (BK) cornea becomes swollen due to non-functioning corneal endothelial cells. The edematous cornea may subsequently develop bullae. These bullae, epithelial defects and the uneven surface causes discomfort such as pain, tearing, or foreign body sensation. Rupture of epithelial bullae causes symptoms of severe ocular pain, photophobia and lacrimation with an increased risk of microbial infection1. The definitive treatment for BK is a corneal graft procedure1. However, in eyes with poor visual potential and severe pain, therapies other than keratoplasty might avoid the unnecessary risks of open-eye surgery and the use of precious corneal tissue2
Management strategies for relieving pain & restoring corneal epithelial integrity include bandage contact lenses in patients who are able to tolerate them, stromal micropuncture, conjunctival flaps, or phototherapeutic keratectomy3.
These treatments are limited in their therapeutic effect for a variety of reasons: application of bandage contact lens predisposes to bacterial keratitis and corneal neovascularization requiring follow up and observation, conjunctival flaps may be cosmetically unsatisfactory, and phototherapeutic keratectomy is an expensive procedure carrying the risk of epithelial breakdown, neurotrophic ulceration, and infection3.
Amniotic membrane transplantation is considered as a safe & effective alternative to other therapies in cases of symptomatic BK as its properties are observed to alleviate symptoms of pain & cause healing of persistent corneal epithelial defects while reducing inflammation, scarring & vascularisation3,4. AMG facilitates re-epithelialisation by providing a suitable substrate and normal basement membrane, and promoting epithelial cell migration and adhesion. By performing the inlay technique, with AMG being placed stromal side down, the peripheral epithelial cells of the host cornea are provided with an opportunity to grow across the basement membrane of the AMG which then becomes the new basement membrane of the epithelial layer of the cornea. This decreases significantly the amount of fluid that enters the intercellular spaces thereby decreasing the number of bullae & providing symptomatic relief. AMG is also believed to produce several growth factors that support epithelial cells and has anti-inflammatory and anti-angiogenic properties making it an ideal tissue for reconstruction of ocular surfaces1,3.
Espana et al observed AMG to be an effective treatment modality for the relief of intractable pain and the restoration of epithelial integrity associated with chronic bullous keratopathy in eyes with poor visual potential2. In our case patient had poor visual potential and the amniotic membrane grafting was primarily done for symptomatic relief along with healing of the corneal epithelial defect.

ReadWise 

  1. dos Santos Paris F, Gonçalves ED, de Queiroz Campos MS, Sato ÉH, Dua HS, Gomes JÁ. Amniotic membrane transplantation versus anterior stromal puncture in bullous keratopathy: a comparative study. British Journal of Ophthalmology. 2013 Aug 1;97(8):980-4. http://dx.doi.org/10.1136/bjophthalmol-2013-303081 
  2. Espana EM, Grueterich M, Sandoval H, Solomon A, Alfonso E, Karp CL, Fantes F, Tseng SC. Amniotic membrane transplantation for bullous keratopathy in eyes with poor visual potential. Journal of Cataract & Refractive Surgery. 2003 Feb 1;29(2):279-84. https://doi.org/10.1016/S0886-3350(02)01525-0 
  3. Srinivas S, Mavrikakis E, Jenkins C. Amniotic membrane transplantation for painful bullous keratopathy. European journal of ophthalmology. 2007 Jan;17(1):7-10. https://doi.org/10.1177%2F112067210701700102 
  4. Pires RTF, Tseng SCG, Prabhasawat P, et al. Amniotic Membrane Transplantation for Symptomatic Bullous Keratopathy. Arch Ophthalmol. 1999;117(10):1291–1297. doi:10.1001/archopht.117.10.1291

Correspondence 

Dr Prabhat Nangia
DNB, FICO, FMRF, FAICO
Consultant  
Department of Cornea and Ocular Surface
Suraj eye Institute
Email – education@surajeye.org

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