1

Brett Levinson, MD

Presentation and Case studies

ASCRS

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Overview

1. Role of amniotic membrane in corneal surgery

2. Case studies1. Suture abscess in a corneal transplant

2. Chemical injury

3. Salzmann nodule removal

4. Anterior Basement Membrane Dystrophy

3. Surgical Technique

4. Bio-D Benefits

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Immune Privileged:• Amnion Epithelial Cells• Mesenchymal Stromal Cells

– No Expression of MHC Class II Antigens

Extracellular Matrix:• Type I, II, III, IV, V, VII

Collagen• Laminin & Fibronectin• Abundant Source of HC-HA

Angiogenic:• VEGF, PDGF

Anti-Microbial:• Ability To Produce β - Defensins

Anti-Inflammatory:• Suppression of IL – 1 α/β

Anti-Adhesion (Fibrosis Suppressant):• Down regulates TGF-β inhibiting fibroblast

production

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Amniotic Membrane

Basement membrane substitute

Anti-inflammatory effects/ anti scarring effects

Growth factors promote epithelial healing

Structural proteins (laminin and type VII collagen) – epitheliotrophic effects

Inhibition of TGF-β – anti-scarring effects

Pro-inflammatory cytokines

anti-inflammatory cytokines interluekin 10 &1RA

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INDICATIONS– Persistent Corneal Epithelial

Defects– Corneal Ulcers– Pterygium Surgeries– Conjunctival Surface

Reconstruction– Bullous Keratopathy– Chemical/Thermal Burns– Ocular Surface Reconstruction– SJS– Leaking Filtering Blebs after

Glaucoma Surgery– Cicatricial Entropion

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Table of Contents

1. Role of amniotic membrane in corneal surgery

2. Case studies

1. Suture abscess in a corneal transplant

2. Chemical injury

3. Salzmann nodule

4. Anterior basement membrane dystophy

3. Surgical technique

4. Bio-D benefits

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Case 1 - March 2013• 86 y/o woman, s/p PK x2• Suture abscess• Treated with ProKera x2• Fortified Vanco, Tobra• 2.5 weeks to heal• Very uncomfortable• Stinging with insertion

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Case 1- March 2014• 86 y/o woman, s/p PK x2• Another Suture abscess• Refused ProKera• “I’d rather go blind.”• Bio-D/BSCL placed• Fortified Vanco, Tobra• 2.5 weeks to heal• Much more comfortable

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Case 2- Chemical truama• 70 y/o man, severe pain,

photophobia• Used body lotion instead of

his glaucoma drops• Vision 20/60• Normal pH• Bio-D/BSCL placed• Vigamox, ProLensa

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Case 2- Chemical truama• 70 y/o man, severe pain,

photophobia• Used body lotion instead of

his glaucoma drops• Vision 20/60• Normal pH• Bio-D/BSCL placed• Vigamox, ProLensa

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Case 2- Chemical truama• 70 y/o man, severe pain,

photophobia• Used body lotion instead of

his glaucoma drops• Vision 20/60• Normal pH• Bio-D/BSCL placed• Vigamox, ProLensa• 2 days later • Epi defect healing• No pain

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Case 2- Chemical truama• 5 days later • Epithelial defect fully healed• Vision 20/20• No corneal inflammation

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Case 3- Salzmann’s nodules• Paracentral superior nodule

causing decreased quality vision• Plan: epithelial debridement with

nodule peeling and Bio-D AMT• Outcome: epi defect healed in 4

days. Bio-D dissolved by day 8• Vision quality improved

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Case 3- Salzmann’s nodules• Paracentral superior nodule

causing decreased quality vision• Plan: epithelial debridement with

nodule peeling and Bio-D AMT• Outcome: epi defect healed in 4

days. Bio-D dissolved by day 8• Vision quality improved

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Case 3- Salzmann’s nodules• Paracentral superior nodule

causing decreased quality vision• Plan: epithelial debridement with

nodule peeling and Bio-D AMT• Outcome: epi defect healed in 4

days. Bio-D dissolved by day 8• Vision quality improved

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Case 3- Salzmann’s nodules• Paracentral superior nodule

causing decreased quality vision• Plan: epithelial debridement with

nodule peeling and Bio-D AMT• Outcome: epi defect healed in 4

days. Bio-D dissolved by day 8• Vision quality improved

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Case 4- AMBD/ Map-Dot Dystrophy• Central irregular epithelium (ABMD)• Low quality vision OD (20/40)• Plan: epithelial debridement with Bio-D

AMT• Outcome: epi defect healed in 4 days.

Bio-D dissolved by day 17• Vision quality markedly improved

(20/20)

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Case 4- AMBD/ Map-Dot Dystrophy

Post Op Day 6

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Case 4- AMBD/ Map-Dot Dystrophy

Post Op Day 11

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Case 4- AMBD/ Map-Dot Dystrophy

Post Op Day 17

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Table of Contents

1. Role of amniotic membrane in corneal surgery

2. Case studies1. Suture abscess in a corneal transplant

2. Chemical injury

3. Salzmann nodule removal

4. Anterior Basement Membrane Dystrophy

3. Surgical Technique

4. Bio-D benefits

www.biodlogics.com22

Preference List• Merocel spears • 2.5 mm fine grit diamond burr• Titanium lid speculum• #3 jewelers forceps• Punctal plugs• 15 blade• Bio- D 12mm disk

• Plan: epithelial debridement with nodule peeling and Bio-D AMT• Outcome: epi defect healed in 4 days. Bio-D dissolved by day 8• Vision quality improved

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Surgical Pearls• Must maintain orientation (stromal side down)• Keep firm grip on tissue (positive pressure in OR)• Vision will be blurry until Bio-D absorption• Consent form for AMT

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Table of Contents

1. Role of amniotic membrane in corneal surgery

2. Case studies1. Suture abscess in a corneal transplant

2. Chemical injury

3. Salzmann nodule removal

4. Anterior Basement Membrane Dystrophy

3. Surgical tecnique

4. Bio-D benefits

www.biodlogics.com25

• Product Sizes– 12mm disc– 15mm disc– 1.5 x 2.0 cm2

– 2.5 x 3.0 cm2

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BENEFITS– AMT available in the office for corneal procedures– Very well tolerated

• Easy to place• No discomfort

– Store at room temperature for 2 years– Easy to prepare for staff– Safe and Efficacious– Cost– Excellent product support

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Questions