In part 3 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 the use of cryopreserved amniotic membrane products in real-world challenging patient cases.
Dane Slentz, MD:
Some of the more challenging cases I’ve had with it recently, I’ve treated a couple of patients with cicatricial entropion in the setting of OCP.
Karine Shebaclo, MD, MSc:
Yeah.
Dane Slentz, MD:
I think trying to get the optimal time when their disease is overall well managed, but their symptoms are pretty bad, it’s something to balance. I’ve had pretty good results with resolution of the entropion. But I mean, these patients oftentimes are needing more work done. I’ve used it both as a spacer graft if I was doing an anterior lamellar recession, but also to release some blepharon as well and reconstruct. Anyone else have really difficult cases that they’re using on with lid reconstruction?
Alon Kahana, MD, PhD:
Oh, yeah, absolutely. Dr. published for cicatricial entropion as well. I think that was the original paper.
Christine Nelson, MD:
Burns, I don’t know if you guys all see many of the burns, but burn patients as well, because they need lots of help and don’t have much tissue.
Alon Kahana, MD, PhD:
Yeah. You and I shared a very severe burn patient whose eyelids were saved by the use of ultra thick amniotic membrane. I got a picture from her and her parents not long ago, and she has eyelids. Her eyes are great. She’s getting surgery to reconstruct, to rebuild, a nose for her. But, oh my God.
Dane Slentz, MD:
For those burn patients like that, are you using it both as advantage? Would you release the lids and then literally just place the suture right over the whole eye? Or how are you using it in those severe cases?
Alon Kahana, MD, PhD:
I use it as a skin substitute. The issue with these burn patients is if you take skin grafts and put them on highly inflamed burned tissue, the skin graft is not going to take, is going to contract. You’re using up whatever little skin you have to try to calm things down. Remember, every surgery causes inflammation and scarring. Every time that you do anything, you are causing some iatrogenic damage. The first step for me is to try to calm down the inflammation. It could be systemic steroids, topical steroids, and ultra-thick amniotic membrane to bring down the inflammation. Once the inflammation, 5-fluorouracil, I’ll use 5-fluorouracil, especially if there are cicatricial changes, or the pre-cicatricial process, and then once the tissues are a lot less inflamed and angry, that’s when you need to look at a final treatment, a real reconstruction. Doing the reconstruction prematurely ends up actually causing more harm than good. The umbilical cord is a great way to buy you and the patient time while the inflammation subsides.
Christine Nelson, MD:
I think you have to jump in early. I think you can’t just wait and watch until you have the cicatricial component on these burn patients. You really have to jump in… If you even think there’s a hint of lag, do tarsorrhaphies, as Alon says, quiet things down, follow them like a hawk, put in some 5-FU on the dressing changes. They’re very time-consuming but rewarding in the end, because they do very well, if you can stay with them early on, and counter that contraction that he’s talking about.
Karine Shebaclo, MD, MSc:
We had a very challenging case that was referred up from D.C. up to Philly. It was a 25-year-old guy who was in the military. He was playing with fireworks and it was just a terrible burn patient. He lost 1 eye and the second eye had complete conjunctivilization of his ocular surface. What I did, with our cornea colleagues, we did basically a superficial keratectomy. It was his only eye. His retina was intact. We basically just debrided all that conch tissue off the cornea. Did layered AMT with the AmnioGuard, placed a symblepharon ring, and then I recreated the fornix, which was amazing. The key is it took twice, because the first time was the symblepharon ring actually adhered. The second time you have to be very careful when you’re reconstructing your fornix. But the second time we were able to really recreate that deep fornix. He went from basically count fingers, hand motion to seeing 20/200, which we gave him some vision back.
Alon Kahana, MD, PhD:
That’s useful vision. He can make himself a cup of coffee in the morning, can see people come to him, can see his children, grandchildren. Did you use any mucous membrane grafting?
Karine Shebaclo, MD, MSc:
That was the mistake. The first time I did not. The second time, I did. I think that’s the key.
Alon Kahana, MD, PhD:
That’s the stem cells, because you have a patient who’s burned his stem cell niches, and you can provide all the matrix you want. It’s always a race between the fibroblasts and the stem cells. If the stem cells win, you get nice tissue. If the fibroblasts win, you have scar tissue. That’s the role of the heavy chain hyaluronic acid, is to block the collagen deposition and the fibroblast proliferation. The role of the pentraxin-3 is to promote stem cell proliferation and migration. That’s what you’re using here in bringing in a biological such as the umbilical cord membrane.
Karine Shebaclo, MD, MSc:
A lot of people…
Alon Kahana, MD, PhD:
Great example. That’s great.
Karine Shebaclo, MD, MSc:
What’s interesting is, and I think all of you have touched on it in the discussion, is that it’s important to have healthy epithelial tissue that can regenerate. If the tissue is necrotic, ischemic, you really have to get down to that tissue that bleeds. I had another patient who was a high-pressure diesel injury to the orbit. He lost the eye. We did place an ocular orbital implant that was then extruding, and then used it as a skin substitute. In order to place the implant back in, I actually wrapped it with the AmnioGuard, then found some residual sclera. The extraocular muscles sort of pushed it back, closed it up, and then used more amniotic membrane to let the conch kind of grow on top of it. That worked. But the key that did not work was as a skin substitute, because everything was just dead from the diesel. It’s about patient selection is key, I guess.
Alon Kahana, MD, PhD:
I’ve used though AmnioGuard as a skin substitute. But you have to have good skin to surround the area. I’ve also combined it with skin grafting. But again, you got to have good blood supply. Actually, we published a few cases of using it as a skin substitute. Now, in skin substitutes, there are many options. There are actually many options for these matrices. Some of them are much hardier than the umbilical cord membrane. I think that each one of them has a niche for where they have some superiority, but none of them have the anti-inflammatory, pro-regenerative capabilities of amniotic membrane.
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