Amniotic Membrane Transplantation for Ocular Surface Reconstruction

Major modes of using cryopreserved amniotic membrane

Cryopreserved amniotic membrane (Bio-tissue, Miami, FL www.biotissue.com) can be used either as a Permanent Graft, a Biologic Bandage, or both

	Permanent Graft	Biologic Bandage
What biologic action(s) are primarily delivered?	Anti-inflammatory, anti-scarring, anti-angiogenic, and growth promotion	Anti-inflammatory and growth promotion
Where does the epithelialization occur?	Over the membrane	Under the membrane
Will the membrane be integrated into the host tissue?	Yes (either conjunctiva or cornea)	No
Will the membrane be removed/dissolve?	No	Yes. After healing the tissue will dissolve or be removed. Rapid dissolution in less than one week suggests an “exposure” problem
How many layers are needed?	One or multiple layers to fill in stromal defects of any shape	One
Does the orientation matter?	Yes (stromal/sticky side down for the top layer)	No
Do I need to use sutures?	Fibrin glue or sutures can be used to secure the graft (if multiple layers are used, the top layer must be sutured)	10-0 nylon sutures by purse-string perilimbal or running otherwise

Differences in cryopreserved amniotic membrane delivery mechanisms

Differences in cryopreserved Amniotic Membrane Delivery Methods

Surgically Attached Layers (AmnioGraft ®)	Delivery Device (ProKera ®)
Mode of use	Permanent graft or biologic bandage	Biologic bandage only
Treated area	Cornea, conjunctiva or both	Cornia only
Depth of defect	Superficial or deep	Superficial only
Number of layers needed	Single or multiple	Single only
Sutures used?	Yes (sutures or fabrin glue needed)	No

Surgical handling of cryopreserved amniotic membrane

Surgical Handling of Cryopreserved Amniotic Membrane

Cryopreserved amniotic membrane is semi-transparent and is resilient to stretching or tearing. To help orient the membrane during clinical use, the tissue’s sticky stromal side is manufactured attached to the carrier paper. This carrier paper is enclosed in a dualpouch system (A) and shipped in a temperature controlled shipping container.

In the operating room, the circulating nurse peels open the foil pouch (B), while the scrub nurse retrieves a clear plastic bag from inside using sterile smooth forceps or gloves to remove the inner pouch containing the tissue (C). The clear inner pouch may be introduced to the sterile field. Using sterile scissors, cut below the sealed line of the inner pouch and remove the tissue and carrier paper using smooth sterile forceps (D).

Removing Cryopreserved Amniotic Membrane from the Carrier Paper

During surgery, the orientation of AmnioGraft® should be “the sticky stromal side down” if it is used as a permanent graft. If multiple layers are used, the orientation of the bottom layer(s) does not matter; only the orientation of the top membrane needs to be “sticky stromal side down”. The following methods can be used to ensure such an orientation.

If an assistant is available, the surgeon may use two 0.12 forceps to grab the two corners of the membrane while the assistant retrieves the backing support from the surgeon (E). By keeping the two forceps apart, the surgeon can ensure that the sticky stromal side (facing the backing support) is placed down on the area to be grafted.

If an assistant is not available, the surgeon may use one 0.12 forceps to grab the backing support while a dry surgical sponge or 0.12 forceps are used to peel off the membrane gradually from one side until 3 to 5 mm of the remaining membrane is still adhered to the backing support. The backing paper is then flipped so that the membrane is underneath and the semi-detached membrane is flattened on the eye. This ensures the sticky stromal side is facing down on the area to be grafted.

Confirming Amniotic Membrane Orientation

If the orientation becomes questionable, the following method can be used to verify the desired orientation:

Spread the membrane so that it is flat.
Take a dry surgical applicator and approach the membrane vertically from above.
If the tip catches the membrane, the sticky stromal side is UP (F).
If the tip does not catch the membrane, the sticky stromal side is DOWN (G).

Videos

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OSREF Introduction to ProKera Video