Easy-to-use modality offers exciting benefits for patients.
An amniotic membrane has long been used to promote faster healing on the eye postoperatively or for treatment of diabetic corneal ulcers. The membrane fosters cellular regeneration, provides collagen scaffolds for stem cell growth, and reduces inflammation and scarring. As a treatment option in eye care, it has evolved and expanded areas for use. The result is a modality that not only has significant clinical advantages but is an easy, comfortable prospect for optometrists and their patients.
The amniotic membrane meets patients’ essential goals of getting back to work and resuming activities without worrying about inflammation, infection, or losing quality of vision to scarring. From the optometrist’s perspective, the current products are easy to use, affordable, and have a stable shelf life. The amniotic membrane is an effective treatment for many conditions we treat every day, such as corneal erosions, abrasions, and severe dry eye disease (DED), among others. As a result, it is moving from a treatment of last resort to a primary or secondary treatment, particularly for conditions that cause significant discomfort or sight-threatening possibilities for patients.
Early versions of amniotic membranes had few applications for optometrists, given the storage requirements and costs. When cryopreserved amniotic membrane was introduced (Prokera; BioTissue), it became more accessible to optometrists. Although there was not a standard of care or a clear treatment path for using it, some clinicians, including myself, were open to trying it because we saw the benefits of epithelial healing. Soon, we not only felt comfortable using the membrane, but we also saw more potential opportunities to manage cornea-related disorders for patients.
The challenges of a cryopreserved amniotic membrane can be patient discomfort from the graft’s integrated ring, as well as cost and reimbursement. As a result, many optometrists left treatment as a last option for more severe or recalcitrant cases.
With the introduction of an acellular, air-dried amniotic membrane (AcellFX; Thea Pharma), this treatment option can be considered easier to apply and can be more comfortable for patients because it has no ring. Unlike other amniotic membranes, the epithelium and chorion layers have been removed in this technology, rendering it acellular to reduce immune response and eliminating the need for us to orient to a “correct side” during placement. I have received greater advantages with less work and reduced patient discomfort. Furthermore, the air-dried form has a long shelf life with no need for refrigeration or special storage, and it can be used right out of the package.
The amniotic membrane is a phenomenal therapy for a range of inflammatory conditions where patients benefit from active, expedited healing, rather than a more passive approach that relies on natural healing without intervention. I started using amniotic membranes for corneal erosions, but once I saw it initiate active healing and cellular regeneration, I started to identify different applications and feel comfortable pursuing them:
» Abrasions and recurrent erosions: The current standard of care is to patch the eye or use a bandage contact lens and allow the eye to heal. I choose to use an amniotic membrane as a first-line treatment for managing abrasions or recurrent erosions. Abrasions require straightforward healing, where this modality excels. But patients with recurrent erosions gain even greater benefit because as the membrane facilitates healing, it fortifies the epithelial tissue, reducing the potential for erosions to recur.
» DED: DED is chronic, progressive, and inflammatory, which slows management. When a patient with DED has significant staining and inflammation, I use an amniotic membrane to reduce inflammation, facilitate healing, and allow the patient to restore homeostasis faster.
» Other conditions: There is a growing list of other areas where optometrists can use an amniotic membrane. For example, it is an excellent choice for herpes zoster or simplex ulcers, which have significant potential for interstitial inflammation and corneal scarring. I sometimes use it for postsurgical patients with slower-than-average healing, neurotrophic keratitis, corneal damage due to Sjögren syndrome, or soft contact lens-associated hypoxia. In some cases, I use amniotic membrane to stabilize conditions that I previously referred out, such as an alkali burn on the cornea, bacterial ulcer, or corneal infiltrates.
The placement of the cryopreserved amniotic membrane is accomplished by having the patient look down and placing the tissue under the upper lid; by then having them look up, you can pull the lower lid over the bottom of the ring. It is important to make sure the amniotic membrane is not hitting the limbus as this may induce further discomfort.
Comparatively, there are 2 simple ways to place a dry amniotic membrane. The first is to instill an anesthetic drop, have the patient look down, and then place the membrane in the lower fornice. I ask these patients to use a patch or disposable shield (SleepTite/SleepRite; Ophthalmic Resources Partners) for a few days. They can remove it if needed for any reason. The second method is to use a bandage contact lens with a dry membrane. Because dry likes dry, you need to dry the inside of the contact lens, gently place the graft inside with forceps, and then place it on the eye.
After placement, patients with cryopreserved membranes come back in 3 to 5 days for follow-up examination and ring removal. Patients whom I have use a dry membrane return in 5 to 7 days, at which point the membrane has been absorbed and I remove the contact lens if one was used. Although we anticipate the inflammatory condition or corneal issue to be improved at this visit, the amniotic membrane’s effects continue after initial insertion. I always see the patients back in a month or a few weeks to ensure that the tissue has had a positive effect on the condition I was treating.
As the elevation of the amniotic membrane as a first- and second-tier therapy continues, I think optometrists can expect to see more applications for this exceptional modality. It is a change driven by the benefits for our patients, made easier by the evolution of this technology toward increased convenience and simplicity in use, while providing patient comfort during healing.