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Sarah N. Mirza, Ashley Kingham, Amin Alousi, Stella K. Kim; The Amniotic Membrane in Acute Stage IV Ocular Graft versus Host Disease; Case Report and Review of the Literature. Invest. Ophthalmol. Vis. Sci. 2012;53(14):1254.
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To describe the first case in the literature of amniotic membrane tissue to treat acute stage IV ocular graft-versus-host (GVHD) disease.
Case report and a literature search.
A 61 year-old male treated for chronic myelomonocytic leukemia with matched unrelated donor stem cell transplant with severe stage IV skin and GI GVHD and on post-transplant day 43 was noted to have extensive bilateral corneal epithelial sloughing and dense conjunctival pseudomembranes. Viral cultures were negative. Patient was being treated as an inpatient for steroid refractive systemic GVHD, requiring multiple immunomodulators and photopheresis. The corneal epithelial defects were slow to heal despite pseudomembrane debridement, aggressive lubrication and topical steroid therapy. Amniotic membrane in the form of Prokera® amniotic membrane device was inserted into the left eye at the bedside, which had a slightly larger defect than the right eye. During the first 24 hours after insertion of Prokera® amniotic membrane tissue device into the left eye, the circular corneal epithelial defect showed approximately 50 % reduction in the left eye as compared to approximately 10 % improvement in the right eye, which was treated with conjunctival pseudomembrane debridement, aggressive lubrication and topical steroids alone. The conjunctival injection also appeared improved in the left eye with the amniotic membrane compared to the right eye which received the same dose of topical medication without the amniotic membrane. 1 day later, Prokera® amniotic membrane device was place in the right eye. The corneal epithelial defect healed completely in 5 days in the right eye. The left eye continued to form extensive pseudomembrane/ membrane, suggesting the presence of worse ocular GVHD in the left eye. With continued debridement, topical steroid, and Prokera®, the corneal epithelial defect also healed in 8 days in the left eye. The patient had improved vision during his hospitalization, but unfortunately did not survive Grade IV systemic GVHD and died in 2 months. There is paucity of published data regarding intervention of acute stage IV ocular GVHD.
This is the first time the use of amniotic membrane tissue suspended in a forniceal ring (Prokera®) to promote corneal epithelial healing in acute stage IV ocular GVHD has been reported. In this case, the use of Prokera® was particularly beneficial in that the device was easily placed at the bedside in an immunosuppressed patient whose systemic illness precluded a trip to the operating room. Prokera® amniotic membrane tissue device can be used to enhance corneal epithelial healing in acute stage IV ocular GVHD. A larger series is needed for further studies.
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