In part 2 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 cases in which they would use AmnioGuard and AmnioGraft amniotic membrane products.
Dane Slentz, MD:
I’m going to move on to the next topic, which is discussing AmnioGuard and AmnioGraft for surgical applications. Really, we’re trying to talk about product handling and surgical applications here.
Just as a background, AmnioGuard is derived from umbilical cord. Amnion is ultra-thick, anywhere from 500 to 900 microns. The benefit of this, as opposed to, say, AmnioGraft, is it can provide that bulk tensile strength to really help structurally fill the tissue if needed. Whereas AmnioGraft, it’s derived from the placental amnion and it’s thinner, about 50 to 100 microns, and that’s typically placed on the ocular surface itself.
There’s tons of literature about the use of both of these products in the ophthalmology literature. For oculoplastics, we often are using this as a biological dressing, for wound reconstruction, as a graft, and also for structural support.
Can we just talk a little bit about how we are each using this specifically in our practices for a variety of oculoplastics indications?
Christine Nelson, MD:
I can go first. Primarily, I would say, I use it a fair amount for sockets. That’s probably the biggest use for me, in contracted sockets, in congenital anomalies that are very small and has been very successful. I do it very similar to the way we originally described, with the exception of maybe how I had fixated and I guess I’ve changed that a little bit. But it’s been a real game changer for me in socket surgery.
Dane Slentz, MD:
How are you currently fixating? Are you using sutures? Are you using glue?
Christine Nelson, MD:
I really haven’t found I needed the glue. For a fornix, I do some deep suture fixation through either a retinal band or some pretty solid piece of material that I then remove, patch the inferior rim, it’s usually inferior, periosteum, and then put it over a bolster on the lid. Then I have, before I tie that tight, I will put some cardinal sutures. I don’t put a ton of sutures in because once you sort of have that in, and then if you’re putting in a conformer or some other prosthesis or something that’s going to hold that space, I found I don’t really need a lot of sutures.
The glue, I guess I’m not sure I’ve done the glue in the fornix so much because I worry a little bit when I tie my suture in that it might shift things. I guess it would shift with sutures too, but I’m interested to hear what you all do.
Dane Slentz, MD:
For sockets, I’m pretty similar to what we described in the initial papers as well, I’m using a 5-0 Prolene. It’s hard for me in my surgery center just to find a retinal band, because not a lot of people do retinal surgeries in the ASCs that I’m at these days. I actually found a red rubber catheter to use a couple of times for a change, and it’s worked great, and I’ll put a conformer in as well.
I personally have not been using much glue. Mostly in ASC, it’s also a cost-effective thing that they always are worried about, but it’d be interesting to see if anyone noticed more inflammatory effects by using sutures versus glue. But I personally don’t have much to compare it to because I’m usually using sutures.
Alon Kahana, MD, PhD:
Well, Prolene has no tissue reaction, and I also use Prolene. My approach is very similar to Dr. Nelson’s. It may be identical. I don’t typically use a bolster inside the fornix. The 5-0 or 4-0 Prolene are thick enough that if you tie it snug but not tight, it will hold. I’ll typically put 2 of them inferior, 2 of them superior. I may suture the very medial and lateral aspects.
I don’t use a fibrin sealant. By the way, I don’t like using the word “glue” because it has no adhesive properties. It doesn’t actually… People call it glue. There are things such as surgical glues, but this one is a sealant, so it’s just meant to fill the space. It doesn’t have real tensile strength. I’m a surgeon, I know how to suture. I like suturing. When I suture, it is exactly where it’s at. When you put a sealant, you hope that you know where it’s at. Dr. Nelson and I are old-fashioned in this way.
Christine Nelson, MD:
Alon, I would just ask you. I’m curious because I put in, and it doesn’t have to be a retinal banding, could easily be a retinal catheter, IV tubing. It could be anything really. I use the short-dated retinal bands that retina is about to not use and we’re going to throw out. They go, “I don’t understand. You use a different one every time.” I said, “It’s just the one with the shortest expiration date.”
But Alon, so do you notice… The reason I do that is because I was thinking between my sutures, it wouldn’t have the added pressure. Do you notice the fornix has deeper spots where you put your sutures or it’s really the same all the way across and maybe I’m doing it, I don’t need to?
Alon Kahana, MD, PhD:
I have not noticed it. Importantly, my ocularists have not noticed it. If there was an issue for the ocularists, they would’ve let me know. I’ve worked with 4 of them and that’s not been the issue.
Christine Nelson, MD:
Good to know.
Alon Kahana, MD, PhD:
One of my concerns, and it’s happened to me only once but never again, is I put something like that in the fornix and then it kind of got embedded in the socket, and then it’s a mess to try to get out. You don’t really need to get it out because it’s inert and all that, but I didn’t like it. I decided it was probably a technical problem on my end. It was many, many years ago, but I’ve had… Because we put in a conformer, it fills in whatever space. By the way, I always place a short suture as well. I think that that also helps to stretch the fornices over the conformer and smooth out the forniceal pressure tension.
Christine Nelson, MD:
Good point.
Alon Kahana, MD, PhD:
Yeah, I think that it’s been great for socket reconstruction in babies. It’s great because they have plenty of stem cells. You need to be careful in doing it in older patients who don’t have all the conjunctival stem cells. There, I have, and I’ve given lectures on this, I combine it with a buccal graft. Let’s say my defect or my need is big. I’ll take a small buccal graft. The mouth has tremendous amount of stem cells, even in an old adult and older.
As I get older, I don’t like the word “old.” I just like the word “older.” Experienced. That serves as the source of stem cells. It’s important to put it where there’s good blood supply because some of these sockets or fornices don’t have good blood supply, so you need to make sure that when you’re cutting, there’s blood. If you’re cutting in its scar, you need to remove the scar and you keep cutting until you get to an area that has good vascular supply. You put in the buccal graft and then you surround it and patch it with the ultra-thick amniotic membrane. Now, you have the stem cells, plus the matrix that will allow everything to grow.
Karine Shebaclo, MD, MSc:
I think it’s very nice to suture partial thickness through it as well. I know it sounds like you guys are mostly all using Prolene sutures. We tend to use 6-0 Vicryl instead. I’m curious, because it sounds like most of you are using it for anophthalmic socket reconstruction and contracture cases, but is anyone using it for cicatricial cases, lower eyelid reconstruction? I think that’s probably a majority of what I’ve been using it for, thyroid patients and post-blepharoplasty disasters.
Alon Kahana, MD, PhD:
Yes, all of the above.
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