1. Clinical Outcome Of Amniotic Membrane Grafting For Ocular Surface Reconstruction Presenting author : M.V ANATHI MD 1 Contributing Authors : A Panda MD 1 Radhika Tandon MD 1, 2 1 Cornea Services, 2 Officer In – Charge National Eye Bank Dr R P Centre for Ophthalmic Sciences All India Institute of Medical Sciences, New Delhi, INDIA vanathi_g@yahoo.com Authors have no financial interest in the subject matter or any product mentioned in this study Acknowledgements: Department of Obstetrics & Gynaecology, AIIMS Department of Ocular Pharmacology, RPC, AIIMS Ms Meena Verma, Ophthalmic Technical Staff, Cornea lab, RPC, AIIMS

2. Introduction Wound healing characteristics of amniotic membrane 1 AM provides a new basement membrane, which forms a substrate for enhancing adhesion and growth of epithelial progenitor cells, including stem cells. AM exerts an antiinflammatory effect suppressing expression of 1L-1  and 1L-1  AM stromal matrix has a direct anti-scarring secondary to its suppression of TFG-  signaling and myofibroblast differentiation. All these act in combination to restore the micro-environmental conditions conducive to the growth of the epithelial progenitor cells. AM is also thought to promote nerve regeneration by maintaining nerve growth factor signalling 1.Tseng et. How does amniotic membrane work? The Ocular Surface 2004; 2, 177-187. Clinical Outcome Of Amniotic Membrane Grafting For Ocular Surface Reconstruction

3. A. AMT in the presence of stem cell deficiency Ocular chemical injury B. AMT in the absence of stem cell deficiency Corneal epithelial defects Corneal/Corneoscleral ulcers Bullous keratopathy C. AMT for conjunctival reconstructions Pterygium Conjunctivochalasis OSSN Limbal Dermoid Symblepharon Conjunctival lesions Leaking blebs D. AMT in ocular cicatricial diseases Toxic epidermal necrolysis Ocular cicatricial pemphigoid Oculopalpebral and reconstructive surgery E. Other indications of AM use Stem cell cultures Introduction Common Indications 2 Clinical Outcome Of Amniotic Membrane Grafting For Ocular Surface Reconstruction 2. Bouchard CS, John T. Amniotic membrane transplantation in the management of severe ocular surface disease: indications and outcomes. Ocul Surf. 2004 Jul;2(3):201-11.

4. Methods Retrospective analysis of case records of AMG for ocular surface reconstruction of a single surgeon (MV) from January 2006 – September 2009. Parameters noted: Age / sex Indication Time taken for complete ocular surface epithelialisation Complications Improvement in tear film stability Success in achieving optimal ocular surface reconstruction Purpose Despite widespread use of amniotic membrane grafting (AMG) in various procedures, standardization of the use of AM and of outcome measures is still lacking. Herein, we report, our results of AMG in ocular surface reconstruction. Clinical Outcome Of Amniotic Membrane Grafting For Ocular Surface Reconstruction (Successful outcome was defined as the healing of an epithelial defect (corneal or conjunctival) over a specified time period and the lack of induced motility disturbance)

5. Introduction Surgical Technique 3 Schematic diagram (sagittal view) showing multilayered amniotic membrane lining the entire ocular surface Double armed 6-0 silk fornix retaining sutures tied over rubber pegs 10-0 monofilament nylon sutures / human fibrin glue of AMG to lid margins Clinical Outcome Of Amniotic Membrane Grafting For Ocular Surface Reconstruction 4.Sangwan et al. Amniotic membrane transplantation: A review of current indications in the management of various ophthalmic disorders. Indian J Ophthalmol 2007; 55: 251 – 60. AMGs done include 4 : Inlay AMG (graft technique) Multilayered Onlay AMG ( Patch technique) Multilayered Inlay + Onlay AMG (layered technique) 3.Augusto Azuara-Blanco, C T Pillai and Harminder S Dua. Amniotic membrane transplantation for ocular surface reconstruction. Br J Ophthalmol 1999 83: 399-402

6. Clinical Outcome Of Amniotic Membrane Grafting For Ocular Surface Reconstruction Multilayered Inlay + Onlay AMG in acute chemical injury Multilayered Inlay + Onlay AMG in neurotrophic ulceration Symblepharon release + AMG with Fibrin glue Multilayered AMG with suture fixation with symblepharon shell insitu Multilayered AMG after OSSN resection Healed neurotrophic ulcer after AMG

7. Results Clinical Outcome Of Amniotic Membrane Grafting For Ocular Surface Reconstruction INDICATIONS No of eyes Time to epithelialisation Success AMT in the presence of stem cell deficiency (Alkali -3, acid -1, molten aluminium – 3) 7 3 – 6 weeks (3.39 + 2.71) 85.7% (6 eyes) AMT in the absence of stem cell deficiency Post-PK non-healing PED Viral keratitis Neurotrophic keratopathy Shields ulcer Moorens ulcer 13 2 3 4 3 1 1- 3 weeks (1.9 + 1.12) 100% AMT for conjunctival reconstructions post chemical injury symblepharon dermoid excision ocular surface squamous neoplasia 19 13 4 2 1- 6 weeks (3.91 + 2.18) 89.4% (17 eyes)

8. Results Successful ocular surface stabilization was achieved in 36 eyes (91%). The remaining 3 eyes required multiple interventions to achieve ocular surface reconstruction. Time to complete ocular surface epithelialisation varies in various indications. Prolonged postoperative topical lubricant and anti-inflammatory therapy is mandatory. Clinical Outcome Of Amniotic Membrane Grafting For Ocular Surface Reconstruction

9. Ocular surface reconstruction for acute chemical injuries and post chemical injury symblepharon was the leading indication for amniotic membrane grafting. Ocular surface stability can be successfully achieved by use of amniotic membrane grafting techniques. Conclusion Clinical Outcome Of Amniotic Membrane Grafting For Ocular Surface Reconstruction

10. Our findings concur with that of Kheirkhah et al 5. The complete success is more likely in less severe grades of symblepharon and with use of anchoring sutures Recurrence is more likely in younger age groups and with higher grades of chemical injury, canthal involvement Discussion Clinical Outcome Of Amniotic Membrane Grafting For Ocular Surface Reconstruction 5.Kheirkhah A, Blanco G, Casas V, Hayashida Y, Raju VK, Tseng SC. Surgical strategies for fornix reconstruction based on symblepharon severity. Am J Ophthalmol. 2008 Aug;146(2):266-275. Epub 2008 Jun 2.