Surgical Treatment of 32 Cases of Long-term Atopic Keratoconjunctivitis Using the Amniotic Membrane

J Yang; F-h Yang; C-H Peng; D Erol; S H Tsang; X-r Li

Disclosures

Eye. 2013;27(11):1254-1262. 

In This Article

Abstract and Introduction

Abstract

Purpose To evaluate the use of surgical treatment with amniotic membrane for long-term atopic keratoconjunctivitis. Damaged corneas were repaired with various techniques: amniotic membrane transplantations, amniotic membrane coverings, amniotic membrane fillings (AMFs), and amniotic membrane inlay fillings, the latter of which were combined with glycerol-preserved corneal transplants.

Methods This retrospective study was conducted on 37 eyes belonging to 37 patients with atopic keratoconjunctivitis. Thirty-two patients were classified into four groups according to surgical technique. Five patients undergoing medical management served as controls. Surgical outcome was measured by recovery time and long-term visual improvement.

Results In all surgical eyes, integrity of ocular tissues was effectively restored and symptoms were reduced at 24.4±13 days post recovery. Mean best-corrected visual acuity improved from 0.6±0.2 to 0.198±0.16 logarithm of the minimum angle of resolution (P<0.001). There were no intraoperative or postoperative complications, with the exception of two recurring cases, both controlled by medication. Recovery time of the control groups lasted 52±16 days. In controls, mean best-corrected visual acuity improved from 0.74±0.15 to 0.54±0.29 logarithm of the minimum angle of resolution (P≤0.05). The vision improvement has significant difference for surgical treatment vs medical. (Mann–Whitney U-test, U=119, P<0.05, one tailed).Vision improvements remained stable during a mean follow-up period of 21.7±3.8 months.

Conclusion Patients suffering from severe chronic atopic keratoconjunctivitis and its complications can benefit from suitable surgical treatments: transplants, covers, fillings, or corneal graft surgeries supplemented with AMFs.

Introduction

Atopic keratoconjunctivitis (AKC) is a perennial, relatively serious form of allergic keratoconjunctivitis that is often observed in atopic individuals.[1] AKC is characterized by chronic inflammation of the conjunctiva and by various related corneal epithelial pathologies, including superficial punctate keratopathy, epithelial defects, shield ulcers, and even corneal perforations. When corneal lesions caused by AKC persist over time, complications develop, including scarring, corneal vascularization, amblyopia, and eventually reduced visual acuity.

AKC-related corneal lesions pose great challenges for treatment. These lesions are more resistant to therapy than other ocular allergies, especially as the condition advances and complications begin to appear. Potential treatments must be chosen with care; anti-allergic eye drops are the first line of treatment. If these are shown to be ineffective, then steroid eye drops are added. In addition, any development of atopic blepharitis may require immediate treatment with a prescription-strength oral steroid.[2] In its advanced form, the severe corneal lesions caused by the disease may require surgery.

Since the 1940s, the amniotic membrane had been discussed as a promising source of graft tissue for corneal and conjunctival reconstructive surgeries. The utility of amniotic tissue has been established by several clinical trials; it has proven useful in many clinical situations, including the treatment of acute burns, corneal epithelial defects, and conjunctival scarring. In these surgeries, the membrane is used as a graft or patch to cover and repair the cornea.[3] Amniotic tissue is thought to shorten healing time and promote re-epithelialization.

Corneal graft transplantation is another type of surgery commonly used to treat corneal ulcers or perforations, when these are serious enough that the cornea must be replaced. Corneal grafts have the ability to restore integrity of the eye and promote visual recovery.[4] However, over time, the nutrients in the tissue dwindle, and, in many cases, postoperative immunological rejection has been reported after corneal graft surgery.[5]

Corneal grafts can be improved by reducing inflammation and promoting integration of graft tissue in the eye. To this end, the amniotic membrane has established anti-inflammatory and anti-vascular properties and has been shown to facilitate the migration of epithelial cells.[3] However, amniotic tissues do no not provide sufficient structural support to be used by itself for many types of surgeries.[6] For this study, we combined the advantages of corneal graft and amniotic membrane graft surgeries in one subgroup of patients, using both methods to maximize surgical treatment of the cornea.

Not more than a few surgical attempts have been reported in the past to treat severe AKC. In this study, we performed a retrospective review of 37 cases (62 eyes) of AKC patients treated over the past 5 years. Thirty-two of these eyes were treated surgically with amniotic membrane transplantations (AMTs), coverings, or fillings, or with a combination of corneal path grafts and amniotic tissue fillings. To better describe how to treat AKC patients in need of surgical intervention, we present long-term outcomes of AKC patients who have been treated with amniotic grafts or preserved corneal path grafts. Patients were assigned to surgeries based on the features of their cases.

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