Sutureless Amniotic Membrane Transplantation for Partial Limbal Stem Cell Deficiency

Abstract

PURPOSE-To evaluate the results of sutureless amniotic membrane (AM) transplantation using fibrin glue for reconstructing corneal surfaces with partial limbal stem cell deficiency (LSCD). DESIGN-Retrospective noncomparative interventional case series.METHODS-Eleven eyes of nine patients that had LSCD with 120 degrees to almost 360 degrees of limbal involvement underwent superficial keratectomy to remove the conjunctivalized pannus followed by AM transplantation using fibrin glue. Additional sutureless AM patch (ProKera; BioTissue, Inc, Miami, Florida, USA) was used in seven patients, and mitomycin C was applied on the cornea in four eyes and during fornix reconstruction in seven eyes. The surgery was repeated in three eyes for residual pannus.RESULTS-During a mean follow-up of 14.2 ± 7.7 months (range, six to 26 months), all eyes maintained a smooth and stable corneal epithelial surface without recurrent erosion or persistent epithelial defect, and showed less stromal cloudiness and vascularization. Best-corrected visual acuity improved in nine eyes (81.8%). Corneal epithelialization proceeded by epithelial growth over AM (n = 4), accompanied by dissolution of AM (n = 4) or a combination of both (n = 3). No complication was noted regarding initial or repeated uses of fibrin glue.CONCLUSION-AM transplantation using fibrin glue appears to be a safe and effective method of restoring a stable corneal epithelium for cases with partial LSCD. This approach avoids the need of transplanting limbal epithelial stem cells. THE MAINTENANCE OF A HEALTHY CORNEAL EPITHElium under both normal and traumatic conditions is provided by a unique subpopulation of stem cells located at the limbus. 1,2 When limbal epithelial stem cells are destroyed and/or their supporting stromal environment becomes dysfunctional, a pathological state known as limbal stem cell deficiency (LSCD) develops (for review; see Reference 3 ). LSCD carries the cytologic evidence of conjunctivalization of the corneal surface by a goblet cell-containing conjunctival epithelium. 4 Pathologically, limbal-deficient corneas exhibit destruction of the basement membrane, superficial neovascularization, chronic inflammation, scarring, and poor epithelial integrity (for reviews; see References 3 and 5 ). Clinically, LSCD is a major cause of corneal blindness unable to be corrected by traditional corneal transplantation alone.For eyes inflicted with partial LSCD, where a part of the limbus is damaged, the corneal surface can be reconstructed by debridement of conjunctivalized epithelium with 6-8 or without 9 transplantation of amniotic membrane (AM). Several studies have shown that in eyes with partial LSCD, AM promotes expansion of remaining limbal epithelial stem cells. [6][7][8]10 NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author Manuscript these studies, sutures were used to secure AM to the cornea following the removal of conjunctivalized pannus from the corneal surface. Recent findings suggest that epithelialization may occur both over and unde...

Tissue adhesives in ocular surgery

“…Kheirkhah and coinvestigators utilized fibrin glue-assisted AMT in patients with partial limbal cell deficiency and conjunctivochalasis. They were able to circumvent limbal epithelial stem cell transplantation, demonstrating the efficacy of fibrin glue-assisted AMT in successfully inducing corneal epithelial growth, leading to complete coverage of the AM [88]. In the conjunctivochalasis study, they reported effective attachment of the AM to bare sclera and development of a smooth conjunctival surface [89].…”

Sealing Penetrating Eye Injuries with Photoactivated Bonding

“…Although fibrin glue has been used for sealing amnion to the ocular surface 26,27 and is used for lowtension applications, clinical experience indicates that it has insufficient bonding strength required for large lacerations and stellate lacerations. The results of this study using a V-shaped incision mimicking a large irregular laceration support this experience.…”

Surgical Reconstruction of Ocular Surface Tumors Using Fibrin Sealant Tissue Adhesive

“…Amniotic membrane transplantation has been used successfully in conjunctival surface reconstruction due to its anti-inflammatory property and minimal scar formation [7,12,13]. Fibrin tissue adhesive has been widely applied in various medical fields, including ophthalmic surgery such as vitreoretinal, glaucoma, ocular surface, cataract and refractive surgery [3,4,5,6,7,8,9,13,14,15,16,17,18].…”

“…When wide excisions are necessary for tumor surgery, autologous graft or labial mucosa can be used for surface reconstruction [1]. An alternative is the use of amniotic membrane graft, which has been used in ocular surface reconstruction in surgical scarring diseases of the cornea and conjunctiva [2,3,4,5,6,7,8]. The amniotic membrane is the innermost layer of the placenta and is a thick basal membrane with an avascular stroma [1].…”

“…Its use has been described for closure of the conjunctiva [3,4,5], glaucoma surgery [9], trophic ulcer or perforated cornea [10], closure of corneal and scleral tunnel, setting of autologous conjunctiva in pterygium surgery [3,4,11], fixation of amniotic membrane to the sclera and cornea [6], lamellar keratoplasty, limbal transplantation [7] and ocular surface reconstruction, but there are still few reports regarding its use in ocular surface tumor surgeries [5]. This study aims to evaluate the surgical outcomes of surface reconstruction in ocular surface tumors using fibrin sealant tissue adhesive.…”