We have all heard and likely used an amniotic membrane for anterior segment disease management in practice at some point in our careers, and if you have yet to handle a membrane, what an intimidating and yet exhilarating experience it is to apply the very first one! Common indications for amniotic membrane use can range from dry eye management to various forms of keratitis, to moderate and severe recurrent erosions of the corneal epithelium, and beyond. I will not be going into extensive detail on what they are and the science behind them, or even the various options available, but instead, I want to share my personal experience of the first application, successes and failures, and an interesting case I recently saw which is relevant to the topic.

 

Working with Prokera for the very first time

Just like working with any new contact lenses, tools, types of technologies or devices, an amniotic membrane is quite intimidating and requires unique handling. There is the intricate packaging and lens storage, the slimy texture of the material, the size of the device and of course the dreaded peripheral ring. Gloves, forceps, and profuse lens irrigation are all required.

Prior to handling my first Prokera, I had seen multiple demonstrations, watched videos, read inserts and felt quite comfortable in my mind, but the physical nature of going through the steps, handling the device, and inserting it on an angry eye of a miserable patient is a whole new feeling. To my surprise, the first experience went very smoothly and was so gratifying when the patient expressed immediate relief (after the Proparacaine wore off). I think that having the right candidate, the confidence in your skills and knowledge of what the device can provide over some of the other considered treatment options, and having a helping set of hands were keys to the success.

Be organized, be prepared, and just pull the trigger. Really take the time to educate the patient on what an amniotic membrane is and why it will help, but most importantly, let them know how it will feel; let them ask questions. Of course, bill appropriately to medical insurance for the procedure with the appropriate diagnosis code – there is quite an extensive list.

A great case for Amniotic Membrane use

A middle-aged WF comes in s/p bilateral blepharoplasty of superior and inferior lids. Secondary to the procedure and complications, the patient developed cicatricial ectropion of inferior lids, with very significant inferior corneal exposure, severe pain and sensitivity to light in the left eye more than right, copious mucopurulent discharge, and was noncompliant with directed treatment – topical antibiotics, non-preserved artificial tears. The patient also reported abuse of topical steroids and anesthetics, how they were obtained is undisclosed.

In slit lamp examination, severe inferior staining of the corneal epithelium was noted 4-7o’clock, c mild stromal edema of both eyes. Lids were clear on eversion, but erythematous and edematous externally. The exposed conjunctiva was moderately inflamed.

Although the patient was in significant discomfort, the options of proposed treatment were presented and understanding was expressed. The amniotic membrane (with topical treatment) was presented as the first, and most promising option, likely offering the most significant subjective and objective improvement of condition. All pros/cons were addressed – the concern was the awareness and irritation due to the outer ring. The second option was autologous serum drops in both eyes, in addition to previously directed topical treatment – the concern: poor compliance secondary to unlikely immediate relief of symptoms. Third, partial lid closure (likely taping) with copious lubrication and appropriate topical antibiotics – the concern: poor compliance. The amniotic membrane was selected for the left eye, in combination with partial lid taping for the first 24 hours. A Prokera Slim was used in treatment and was seamlessly inserted and well tolerated. The right eye was to be treated with topical lubrication, antibiotics, and Muro 128 ointment.

The patient felt immediate relief, with some awareness of the device. She was directed to initiate frequent lubrication, and compliance of topical antibiotics was stressed. At the 24 hour follow-up, the patient was significantly more comfortable with some objective resolution of the condition. The lid was left untapped for the remainder of treatment. The right eye had some improvement in symptoms, with topical management. A Prokera Slim was also considered for the right eye, but concern was reduced visual acuity. Prokera Clear was not considered for either eye at any point in treatment, as some central staining was also noted. The patient was then seen for a four-day follow-up, the membrane was removed. Overall resolution of the staining was noted on the left eye, the patient was much more comfortable. A membrane was considered for the right eye, again, but due to a more mild presentation and reduction in symptoms, it was decided that the right eye would be managed with topical treatment for the short term. The patient will be scheduled for further eyelid repair.

All in all…

Having the opportunity to work with different tools is what keeps us on our toes. We are all well aware of the tools at our disposal, but sometimes hesitate to use them with the fear of failure. Trust yourself and your skill and do not hesitate to call on a colleague who can help or guide you through the process. The experience of “new” can be extremely exhilarating and gratifying to you as the practitioner, not to mention very beneficial to your patients.