In part 1 of a 6-part series, 4 oculoplastic specialists discuss the use of regenerative medicine in the field, particularly the role of cryopreserved and dehydrated amniotic membrane products for different surgical applications.
Dane Slentz, MD:
My name is Dane Slentz. I’m an oculoplastic surgeon and I’m here representing Ophthalmology 360 with my group of colleagues here. We’re going to talk about the use of amniotic membrane in oculoplastic surgery.
Alon Kahana, MD, PhD:
My name is Alon Kahana. I am an oculoplastic and orbital surgeon. I have a practice, Kahana Oculoplastic & Orbital Surgery based in southeast Michigan. I’m a professor and vice chair for academic affairs at the Beaumont University ophthalmology department.
Christine Nelson, MD:
I’m Christine Olson and I’m a professor of ophthalmology and visual sciences, as well as the department of surgery in the section of plastic surgery at the University of Michigan and the Kellogg Eye Center and have been practicing oculoplastics for over 40 years.
Karine Shebaclo, MD, MSc:
I’m Karine Shebaclo. I’m an oculoplastic surgeon in Philadelphia, recent graduate from fellowship at Wills Eye Hospital where I’ve been practicing for a year. I’m actually going to be starting at the Mayo Clinic next month.
Dane Slentz, MD:
Thanks all for joining with us tonight. I’m just go through the topics that were presented. Again, hopefully let’s have a good conversation about each one of those areas. The first topic to discuss was reviewing the oculoplastic use of amniotic membrane product in general for surgery. I thought we’d initially talk about the difference between cryopreserved amniotic membrane and dehydrated products, and really what you feel the real benefits are for each one of them and the differences between how they handle during certain applications.
A couple of things that I thought of was obviously dehydrated product, you lose a lot of the growth factors. It’s structurally not as competent as cryopreserved, but one of the benefits that it could have is more cost-effective. If you are using it frequently for, say, if you have a patient with frequent burns who needed some kind of coverage, it might be an option. However, in those same patients, we want to use something that has really good growth factors in it so cryopreserved is probably a better and more superior product. I feel personally that cryopreserved product is easier to handle than dehydrated products. But I was interested to see what everyone else thought as well.
Christine Nelson, MD:
I must say I agree. I almost only exclusively use the cryopreserved for the amniotic membrane than other products.
Alon Kahana, MD, PhD:
I see amniotic membrane as having 2 sides to its use. One is as a matrix in which cells can grow. For that purpose, I don’t think that there is a huge difference between cryopreservation and dehydration. The dehydrated matrix works, you may need to add new matrix more frequently because the body will go through the matrix, it won’t survive for as long. But it works in order to guide stem cells as they’re proliferating and migrating into the tissue that you’re trying to reconstruct or repair. But the other, and I think most important part of amniotic membrane that makes it superior to other matrix type of products, decellularized dermis and all sorts of things like that, is that it has regenerative growth molecules and, there, more is better. There’s no question that cryopreservation retains a higher proportion of the natural growth factors that are in amniotic and umbilical cord membranes.
Then the question is whether those factors are important for what you’re using? For what I’m using, the whole point for me is regenerative medicine to help the body heal itself, I think that this is critical. I believe strongly in the adage that you never have a second chance to do it right the first time. If you do the surgery properly the first time, if you manage the burn patient, the trauma patient, the cancer patient, the involutional patient correctly the first time, most cost-effective is to do a good job the first time that you’re doing anything and that avoids the complications and having to redo surgeries. That’s where I think that medicine becomes really expensive and not cost-effective. For me, the best product the first time is what I’d like to do.
Dane Slentz, MD:
Great.
Alon Kahana, MD, PhD:
What do you think, Christine? You have the same kind of practice that I do, cancer and trauma and burns, and actually you’re the person who taught me to use the ultra thick as opposed to the standard amniotic membrane.
Christine Nelson, MD:
I agree with you completely. I think that there is the cost issue, but as you said, if you’re going to have to use it multiple times then you’ve negated the cost issue and you’ve already, now, I don’t know exactly what the spread is, but then you’ve used 2 of the cheaper product and you should have just used the right thing in the first place. I agree.
Alon Kahana, MD, PhD:
Also, I think that there’s too much made of it being expensive, because in reality it’s not expensive. If you compare it to its competitors, and there are many competitors that have acellular matrices as well as one product that has embryonic stem cells, all of them are at least as expensive. In the context of a surgery where you have a facility fee, an anesthesia fee, inpatient admission fees, consultant fees, surgeons’ fees, the cost of this little pro-regenerative molecular delivery system is fairly trivial. I would not want to compromise a 10 or 20 or $100,000 medical process in order to save a few hundred dollars. That’s what we’re talking about is a few hundred dollars. I would say use what you would use if this was your parent, your sibling, your child.
Dane Slentz, MD:
Part of that too, what I’ve noticed is different surgery centers will have in stock different types of products. I remember fondly in my time at the VA in Ann Arbor, they only had dehydrated products, they did not carry and they would not carry cryopreserved. I was forced a couple of times to specifically use the dehydrated, which helped me appreciate the cryopreserved a lot more. But it still worked and it still served its purpose too. But anyway, I think in general, in my hands, I do like the cryopreserved product more.
Karine Shebaclo, MD, MSc:
We were discussing about the cost prohibitiveness of using the graft. In the office we actually stock the AmnioGuard or the umbilical cord membrane, and we actually started stocking the 3 by 4 centimeter membrane, cutting it in half so you actually get 2 membranes for the cost of one. Again, it’s not prohibitive and we probably keep about 10 in stock at a time. It took some time for our ASC in the hospital and at an academic center to get it all stocked, but in the meantime we were using the 65779 for in-office surgery. It actually covered the cost of the suture, of the graft, of our time, the patient didn’t have to pay the facility fee or the anesthesia fee. It’s not prohibitive, it’s just learning how to code effectively, proficiently, and as Dr. Kahana was saying, reaching out and learning from one another in our field.
Alon Kahana, MD, PhD:
Well, I think that the evidence is clear that the cryopreserved contains 5 to 10 times the molecular content of pentraxin-3 and heavy chain hyaluronic acid, so the anti-inflammatory and pro-regenerative molecules. Amniotic membrane is amniotic membrane.
Dane Slentz, MD:
Correct.
Alon Kahana, MD, PhD:
The question is how do you get it from the placenta to the patient and all the proprietary knowledge and skill for the biotech company is in this process.
Karine Shebaclo, MD, MSc:
I think the important thing is we’re talking about cryopreserved in the US versus outside in Europe and with our Asian colleagues. I reviewed a paper recently of a group in France that was using dehydrated amniotic membrane, so when you compare their outcomes to the outcomes that Dr. Slentz and Dr. Nelson discussed in their papers as well as the paper that we’re working on right now with the cryopreserved membrane, you can’t even compare them. The dehydrated membrane doesn’t have the PTX3, which is really the most important growth factor that helps polarize the macrophages and inhibit the lymphocytes. Really we’re talking about regenerative capacity here.
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