Key Insights on Using Mucosal Grafts with AmnioGuard® Cryopreserved Amniotic Membrane
In part 5 of a 6-part series, Dane Slentz, MD, of Spindel Eye; Alon Kahana, MD, PhD, of Kahana Oculoplastic & Orbital Surgery; Christine Nelson, MD, of the University of Michigan; and Karine Shebaclo, MD, MSc, of the Mayo Clinic in Florida, discuss “one of the most incredible advances in [the] field in decades.”
Dane Slentz, MD:
Dr. Kahana, I mean for purposes of the video, for people who have not done, say, buccal mucosal graft in combination with AmnioGuard, how would you describe that to your average oculoplastic surgeon on how they should combine the 2?
Alon Kahana, MD, PhD:
Well, the question is which is your favorite source of mucous membrane? I’m agnostic. Use whichever mucous membrane source you like. It could be hard palate, it could be buccal, it could be lip. If you like the nasal mucosa, use the nasal mucosa. I think in California, they probably combine all these things with a nose job anyway, so you have access to nasal mucosa.
But whatever it is, put it in the tissue where you have the defect and now you have residual defect, because whatever you harvested is not big enough. If it’s big enough, then you’re good. But if it’s not big enough and you have a residual, don’t do big conjunctival flaps and compromise the fornix. Just take AmnioGuard, switch everything into that residual defect, and whatever remains of the AmnioGuard, put it on top as a patch.
Dane Slentz, MD:
Cover the whole defect and mucosal grafts, too?
Alon Kahana, MD, PhD:
That’s correct. I’ll put it in there, I’ll cut it to shape and size, put it in the residual defect, and suture that typically with 8-0 Vicryl. Then I’ll take whatever remains and I will request the size of AmnioGuard that will allow me to have a little extra, so that they can then patch on top, layer it, and then suture that with bolsters, and that heals tremendously. I mean I’ve used that for Stevens-Johnson syndrome, for ocular cicatricial pemphigoid, for burn patients, for cancer patients.
I have a patient that I used it for after resection of conjunctival melanoma. I’ve done it with conjunctival squamous cell carcinoma where you have huge defects. The reconstruction, it’s a combination. You got to have the stem cells and the blood supply, and then all of the anti-inflammatory and pro-regenerative.
But, by the way, I just want to mention one thing that we have not talked about, which is that I have a very significant practice in corneal neurotization. Corneal neurotization in the literature seems to be pretty successful, better than 50% success.
But I go and I’m a visiting professor here or there, and I travel nationally and internationally. People will do it 2, 3, 4 times. They’ll try it. It doesn’t work. There are entire geographic areas in this country where the cornea surgeons believe that it doesn’t work, so they’ll not refer the patients.
I just want to make a little plug, which is that I’ve now done it in 29 patients. I have 3 patients that are under 6 months. All the other ones, with the exception of 1, have been successful. That means 25 out of 26 patients have stabilization of the ocular surface, improved, basically normalized, corneal epithelial homeostasis, many of them have really improved sensation, but some of them still have pretty poor sensation. But there is much better homeostasis.
The technique I use is you do a cooptation, you tunnel the fascicles. I do divide the fascicles to keep the ocular surface nice and smooth and flat. Why do I have good results? Well, I wrap the cooptation with AmnioGuard, which has pentraxin-3, which is being studied for spinal cord regeneration and post-stroke regeneration. Then after I do the fascicles and close conch, I put the residual amniotic membrane over the entire ocular surface, by the way, which is what allows me to code for it, because the wraparound the cooptation, there is no code for that. But the ocular surface reconstruction in these patients who have a disaster cornea, sometimes they come to me with bare Descemet’s membrane in an area that they’re about to perforate.
I put in the amniotic membrane, suture it, put it or leave it in for 4 weeks, and it’s spectacular. I mean I’ve been amazed by the results, and I attribute that, to a large extent, to having a pentraxin-3 molecular delivery device, biological device, that actively promotes axonal regeneration, Schwann cell proliferation, and reinnervation.
I think that if you’re going to do corneal neurotization, those are surgeries you’re going to do in a hospital anyway, use the AmnioGuard. That’s my plug for what I think is one of the most incredible advances in our field in decades. I think that AmnioGuard is an enormous contributor to the success of those patients.
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