Amniotic Membrane Graft with Fibrin Glue to Ocular Surface

The procedure in the video demonstrates repair of the bulbar conjunctiva post Mohs Micrographic surgery with an amniotic membrane graft and fibrin glue

Procedure: The procedure in the video demonstrates repair of the bulbar conjunctiva post Mohs Micrographic surgery with an amniotic membrane graft and fibrin glue. Introduction: Any damage to the ocular surface, whether from intrinsic or extrinsic insults, can lead to ocular dysfunction. Various types of grafts can be used to repair these defects, and the amniotic membrane graft with fibrin glue can be used as an effective option. Indications: Current indications for amniotic graft use include conjunctival surface reconstruction including pterygium removal, Mohs reconstruction, and Steven Johnson Syndrome (SJS) repair, corneal surface defects with and without limbal stem cell deficiency, treatment of scleral perforations, and additional ocular surface reconstructions. Contraindications: The recipient is at risk for fungal, viral, or bacterial infection if the donor is not screened for communicable disease. Materials: A standard surgical eye instrumentation kit, amniotic membrane graft, and fibrin glue. Results: In most cases, reconstruction of the ocular surface is achieved without complications. Follow-up should monitor for microbial infection, graft retraction, and corneal revascularization. Conclusion: Amniotic membrane grafts with fibrin glue can be used to repair ocular surfaces.
The health of the ocular surface is critical for proper eye function. Any insult, whether from intrinsic factors that lead to extreme dry eye, such as Stevens Johnson Syndrome, or extrinsic factors such chemical injuries from alkalis or acids, can damage this extremely dynamic and sensitive region of the eye, and lead to ocular dysfunction as a whole. Many different tissues have been used to repair the ocular surface, ranging from mucous membrane grafts to rabbit peritoneum. Amniotic membrane grafts started to gain popularity in the early 1990s, after it was used in conjunctival repair by Batlle et al. The amniotic membrane is the innermost layer of the fetal membrane, interior to the outer chorion. It is composed of three layers: the epithelium, the basement membrane, and the stroma. It has anti-microbial, anti-inflammatory, anti-angiogenic, and anti-fibrotic properties. It furthermore promotes epithelialization, which along with its lack of immunogenicity and clear structure, make it the perfect substrate for ocular surface reconstruction. Amniotic membrane grafts are commercially available from a number of companies. There are two main type of amniotic membrane grafts: dehydrated and cryopreserved. They are available in sizes ranging from approximately 1.0 X 1.75 cm to 3.5 X3.5 cm. Thickness varies from 50 microns to greater than 300 microns.  Cryopreserved amniotic membranes are stored in the -80C freezer and should be brought to room temperature before use. Dehydrated amniotic membranes are created in a vacuum. They are stored at room temperature but must be rehydrated before surgery. Shelf life of amniotic membrane grafts differ from company to company but are usually about 2 years from the date of manufacture. Tissue adhesives such as fibrin glue can be used in ocular procedures to limit post-operative leaks, inflammation and post-operative infection. Compared to other surgical adhesives like cyanoacrylate, fibrin glues have less toxic and inflammatory reactions, but have less tensile strength. They are composed of two main components: fibrinogen and thrombin which are mixed together to polymerize and form the final insoluble glue.
Materials: A standard surgical eye instrumentation kit, amniotic membrane graft, and fibrin glue. The amniotic membrane graft should be thawed at room temperature for at least 5-10 minutes in its unopened package. The fibrin glue should be prepared according to the manufacturer’s instructions. Pre-operative workup: A thorough history and eye exam with slit lamp biomicroscopy should be performed. The surgeon should give special attention to the ocular surface, looking for symblephara and conjunctival scarring. Anatomy and landmarks: Knowledge of the eyelid and ocular surface anatomy is critical. Detailed steps: The eyelid should be opened to expose the ocular surface with either sutures or a lid speculum. The surface is examined for symblephara and identified symblephara are lysed with scissors. The recipient bed is created, inspected, measured, and dried with cellulose eye spears. The amniotic membrane graft is then placed with its inner paper backing to the sterile field. The graft is cut to the appropriate size with scissors. It is then peeled away from the underlying paper and placed on the desired area of the ocular surface. Ensure that the membrane is unrolled and flush against the eye, covering the desired area of the conjunctival defect. Attention is the turned to the fibrin glue. Fibrin glue includes two syringes: Thrombin and Fibrinogen (along with other components). Thrombin is first applied to the desired area followed by fibrinogen. The coagulation starts in 1-2 minutes, and the polymerization is complete by 3 minutes. Some surgeons prefer placement of the first layer of thrombin under the amniotic membrane graft. Ensure that the graft has remained in proper position and remove any excess glue taking care to not pull the amniotic membrane graft from its location.
Amniotic membrane grafts with fibrin glue can be used in many ocular procedures, including the repair of conjunctival defects after tumor removal. In most cases, reconstruction of the ocular surface is achieved without complications. Complications to monitor include corneal vascularization, microbial infection, recurrence of primary disease, and graft retraction.
Ocular surface reconstruction is necessary for proper ocular health. The use of amniotic membrane grafts is one of several methods to repair ocular surface defects. The main steps of this procedure involve creation of the recipient bed, proper sizing and placement of the amniotic membrane graft, and finally application of fibrin glue to the ocular surface. Amniotic membrane grafts are favorable for reconstruction due to their anti-inflammatory, anti-fibrotic, anti-angiogenic and enhanced epithelialization effects. They have several advantages over other existing techniques such as buccal mucosa grafts and conjunctival flaps. They avoid donor site morbidity, unsatisfactory cosmetic results from thick mucosal grafts, and have no limitations in utilizable tissue.
1. Batlle, J.P.F., Placental membranes as a conjunctival substitute. Ophthalmol., 1993. 100:A107. 2. Guhan, S., et al., Surgical adhesives in ophthalmology: history and current trends. Br J Ophthalmol, 2018. 3. Malhotra, C. and A.K. Jain, Human amniotic membrane transplantation: Different modalities of its use in ophthalmology. World J Transplant, 2014. 4(2): p. 111-21. 4. McGaughy, A. and P. Gupta, In-Office Use of Amniotic Membrane. Ophthalmic Pearls in the American Academy of Ophthalmology 2015. 5. Meller, D., et al., Amniotic membrane transplantation in the human eye. Dtsch Arztebl Int, 2011. 108(14): p. 243-8. 6. Murri, M.S., et al., Amniotic membrane extract and eye drops: a review of literature and clinical application. Clin Ophthalmol, 2018. 12: p. 1105-1112. 7. Panda, A., et al., Fibrin glue in ophthalmology. Indian J Ophthalmol, 2009. 57(5): p. 371-9. 8. Shanbhag, S.S., J. Chodosh, and H.N. Saeed, Sutureless amniotic membrane transplantation with cyanoacrylate glue for acute Stevens-Johnson syndrome/toxic epidermal necrolysis. Ocul Surf, 2019.

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