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Amniotic membrane transplantation as an

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burns
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Amniotic membrane transplantation as an

adjunct to medical therapy in acute ocular
burns
Radhika Tandon, Noopur Gupta, Mani Kalaivani, et al.
Br J Ophthalmol 2011 95: 199-204 originally published online July 31, 2010

doi: 10.1136/bjo.2009.173716

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Clinical science

Amniotic membrane transplantation as an adjunct

to medical therapy in acute ocular burns
Radhika Tandon,1 Noopur Gupta,1 Mani Kalaivani,2 Namrata Sharma,1
Jeewan S Titiyal,1 Rasik B Vajpayee1,3
1

Cornea & Refractive Surgery

Services, Dr Rajendra Prasad
Centre for Ophthalmic Sciences,
All India Institute of Medical
Sciences, New Delhi, India
2
Department of Biostatistics, All
India Institute of Medical
Sciences, New Delhi, India
3
Centre for Eye Research
Australia, University of
Melbourne, Melbourne,
Australia
Correspondence to
Dr Radhika Tandon, Cornea &
Refractive Surgery Services, Dr
Rajendra Prasad Centre for
Ophthalmic Sciences, All India
Institute of Medical Sciences,
New Delhi, India;
[email protected]
Accepted 23 April 2010
Published Online First
31 July 2010

ABSTRACT
Aims To evaluate the role of amniotic membrane
transplantation in patients with acute ocular burns.
Methods In a prospective, randomised, controlled
clinical trial, 100 patients with grade II to IV acute ocular
burns (Roper Hall Classification) were recruited. 50
patients with grade IIeIII burns were graded as
moderate burns, and 50 patients with grade IV burns
were graded as severe burns. Both groups were
individually randomised into control group (n25) and
study group (n25). The corresponding grade of ocular
surface burn by Dua classification was noted. The eyes in
the study group underwent amniotic membrane
transplantation in addition to conventional medical
therapy. In the control group, conventional medical
therapy along with mechanical release of early adhesions
as and when necessary was instituted. Rate of healing of
corneal epithelial defect, visual acuity, extent of corneal
vascularisation, corneal clarity and formation of
symblepharon were compared in both groups.
Results In patients with moderate ocular burns treated
with amniotic membrane transplantation, the rate of
epithelial healing was significantly better than the group
treated with standard medical therapy alone (p0.0004).
There was no overall difference in the final visual
outcome, symblepharon formation, corneal clarity and
vascularisation with or without amniotic membrane
transplantation.
Conclusions Amniotic membrane transplantation in
eyes with acute ocular burns promotes faster healing of
epithelial defect in patients with moderate grade burns.
There seems to be no definite long-term advantage of
amniotic membrane transplantation over medical therapy
and mechanical release of adhesions in terms of final
visual outcome, appearance of symblepharon and
corneal vascularisation when compared in a controlled
clinical setting.

INTRODUCTION
The main aim of management of acute ocular burns
(thermal or chemical) is to promote epithelial
healing, reduce inammation and prevent progressive tissue melting to minimise scarring sequelae and
severe visual loss with medical or surgical therapy, or
both.1 Various medical and surgical modalities are
available,2 of which medical management is
reasonably effective in controlling the disease in large
number of cases. The role of amniotic membrane
transplantation (AMT) in the management of acute
ocular burns has been studied by various authors,3e5
but no prospective controlled studies have been
reported except the results of the preliminary study,
which was carried out at our centre.6 AMT improves
Br J Ophthalmol 2011;95:199e204. doi:10.1136/bjo.2009.173716

corneal re-epithelialisation and hastens recovery

after chemical burns. Amniotic membrane is effective in reducing inammation and its consequences,
and may partially restore limbal stem cell function in
ocular burns.3 4 Autolimbal or allolimbal transplantation with or without amniotic membrane
transplantation, combined with systemic immunosuppression and topical instillation of autologous
serum, have all evolved from the better understanding of ocular surface regeneration.The efcacy
of AMTas an adjunct to medical therapy in cases of
acute ocular burns in a large, prospective, randomised controlled clinical trial and the utility of a new
classication system (Dua classication) which has
been acclaimed to aid in better management and
predictive outcome of ocular injuries were studied.

Patients and methods

The study was approved by the Ethics Committee
of the All India Institute of Medical Sciences
(AIIMS), New Delhi, India. The study was
conducted as a prospective, randomised controlled
clinical trial and was retrospectively registered with
Clinical Trials RegistrydIndia (CTRI) with the
registration number CTRI/2009/091/001018. The
sample size of 100 cases was calculated based on
the expected number of patients who we could
recruit during a 2-year study period as anticipated
from our past clinic and emergency records.

Patients
Patients presenting with acute chemical or thermal
ocular burns (Roper-Hall Grade IIeIV) at Rajendra
Prasad Centre for Ophthalmic Sciences, AIIMS
were included in the study. The study included 100
eyes of 100 patients with acute ocular burns treated
at a tertiary care hospital from October 2003 to
December 2005. Grades II and III burns were classied as a moderate burns group, while Grade IV
burns was taken as a severe burns group. An equal
number of patients (50 patients each) were
recruited with moderate and severe burns. Stratied
randomisation was done in patients with moderate
and severe burns respectively into a control group
(n25) and study group (n25). Patients in the
control group were treated with conventional
medical therapy including mechanical release of
any adhesions if necessary, while patients
comprising the study group were treated with
AMT in addition to the conventional therapy.
A detailed ophthalmic workup included a thorough history with special emphasis on the nature,
situation and causative agent of the injury. The
preliminary treatment and any delay in rst-aid
treatment were noted in all patients. All patients
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Clinical science
were initially subjected to rst aid therapy, which included
copious irrigation with normal saline for a minimum of 30 min
or as appropriate to normalise the ocular surface pH and removal
of any particulate matter or debris from the fornices.
After obtaining informed consent, the patients were randomised using a treatment assignment list prepared with the help
of a table of random numbers. A stratied randomisation system
was followed (gure 1). Serial numbers were given to the cases,
and concealed randomisation using sealed envelopes was
followed to decide whether a subject would receive either AMT
combined with conventional medical therapy (study group) or
conventional medical therapy alone (control group). Patients
with bilateral involvement were randomised as individuals, and
the right eye was randomised.

Medical treatment
All patients included in the study were started on conventional
medical therapy, which included topical prednisolone acetate
(1%) every 6 h; ooxacin(0.3%) every 6 h; sodium ascorbate
(10%) every 4 h, sodium citrate (10%) every 4 h and preservative-free tear substitutes every 2 h; homatropine (2%) twice
daily and oral vitamin C (500 mg) every 6 h for 2e4 weeks.
Antiglaucoma therapy including timolol maleate 0.5% drops
and/or oral acetazolamide was prescribed if required. Medications were self-administered by the patients except in cases
where symblepharon release was required. Patients in the study
group received medical therapy in addition to amniotic
membrane transplantation while the control group received
medical therapy alone.

Preparation of amniotic membrane and surgical method

The method of amniotic membrane preparation and preservation has been described previously.6 Amniotic membrane was
obtained under sterile conditions after Caesarian section delivery
from a seronegative donor (HIV, hepatitis B surface antigen,

hepatitis C virus, syphilis) after obtaining informed consent.

The membranes (amnion and chorion) were separated from the
placenta under strict asepsis and then cleaned, processed and
preserved. The amniotic membrane was cut into pieces and
wrapped onto the nitrocellulose paper discs (5 mm in diameter)
The pieces were stored in a 1:1 mixture of glycerol and Dulbecco
modied Eagle medium at 708C.
AMTwas performed by a single surgeon (RT) within 2 days of
presentation to the hospital. The amniotic membrane was
thawed before proceeding to transplantation in eyes with ocular
burns. The membrane was transferred onto the entire ocular
surface with the epithelial side facing up and stromal side of the
membrane touching the surface of the eye. Perilimbal, interrupted 8-0 Vicryl sutures (Ethicon, Johnson & Johnson, Ahmedabad, India) were applied to anchor the underlying conjunctiva
and episclera to the membrane. Additional vicryl sutures were
applied along the lid margins for further anchorage and stability.
Hence, the amniotic membrane was spread fully on the ocular
surface up to the fornices, so as to serve as a patch for the entire
ocular surface.

Examinations
Baseline evaluation
Visual acuity was recorded using Snellen charts and was
converted into decimals and equivalent values on a log scale.
Detailed ophthalmic examination was performed with the aid of
a slit lamp, noting the extent of the burn, limbal ischaemia in
clock hours and the presence or absence of symblepharon. The
conjunctival involvement was estimated by dividing the bulbar
and fornicial conjunctiva into quadrants and determining the
area of involvement; palpebral conjunctiva was not included in
calculation.
Cornea was examined for extent of haze, grade of clarity, size of
epithelial defect and corneal vascularisation.Corneal clarity was
given a value from 0 to 4 according to the standard classication.

Figure 1 Consolidated Standards of

Reporting Trials diagram showing the
randomisation and flow of participants
through each stage of the randomised
trial.

200

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Clinical science
For the purpose of nal analysis, we have reversed the corneal
clarity grading to the corneal haze grading by subtracting the
corneal clarity grading number from 4, such that we obtained
a modied classication on the basis of corneal haze (table 1).
The size of the epithelial defect was measured on the slit lamp
aided by uorescein staining (Haag-Streit AG, Koeniz,
Switzerland), and the area of the epithelial defect was obtained
by the product of the dimensions of the largest diameter and the
diameter perpendicular to it. Anterior segment uorescein
angiography was carried out whenever possible.
The classication of injury severity was done by the Roper
Hall Classication (RHC) system.7 Disease severity was also
done simultaneously by a new, modied classication system
proposed by Dua et al,8 which takes into account the extent of
limbal involvement in clock hours, the percentage of conjunctival involvement and subsequently tabulating an analogue scale
for recording the clinical status and grade of ocular surface burn.

Follow-up
The patients were examined at day 1, day 7, weekly until
1 month, biweekly until 3 months and monthly thereafter. The
patients were called for follow-up more frequently, if the
condition of the eye so required. The patients were carefully
examined at each follow-up visit for complications such as
symblepharon and suture granuloma, which were then eventually treated. Visual acuity, status of transplanted membrane,
ocular surface, size of corneal epithelial defect, extent of corneal
vascularisation and anterior chamber inammation were
assessed at each visit.
Digital photographs at each visit were obtained and stored for
independent comparative assessment by masked observers.
Epithelial defect size was calculated independently using imageanalysis software (Image-Pro Plus, version 4.5, Media Cybernetics, Silver Spring, Maryland). In patients with the amniotic
membrane in situ, margins of the epithelial defect, if discernible
under the membrane, were measured and recorded. Percentage
reduction in the size of epithelial defect as compared with the
baseline measurements was computed.
Primary outcome measure:
a. rate of healing of epithelial defect.
Secondary outcome measures:
a. visual outcome;
b. corneal clarity and vascularisation, if any;
c. prevention of symblepharon.

Statistical analysis
Data analysis was carried out using STATA 9.0 (College Station,
Texas). Data were described as number (%) or median (range).
Continuous response variables were compared between the
groups using the Wilcoxon ranksum test, since the data were nonnormal. Categorical response variables were analysed between
the groups using the c2 test/Fisher exact test as appropriate. A p
value less than 0.05 was considered statistically signicant.
Table 1 Modified grading of corneal clarity on the basis
of corneal haze
Grade

Characteristic

0
1
2

No corneal haze
Iris details visible
Pupillary margin visible, iris details not
visible
Pupillary margin not visible
Cornea totally opaque

3
4

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RESULTS
The baseline demographic and clinical characteristics of the
patients in the control and study group are outlined in table 2.
The age of the patients varied from 4 to 52 years in the moderate
burns group and from 3 to 61 years in the severe burns group.
The majority of the patients presenting with ocular burns were
young adults and below 40 years of age (96% in the moderate
burns group and 92% in the severe burns group). Thirteen
females (two with moderate burns and 11 with severe burns) and
87 males participated in the study. Alkali burn was the
commonest type of chemical injury (72 of 100 eyes) followed by
acid injury (20 of 100 eyes) and thermal injury (eight of 100 eyes).
The ocular surface burn was also graded into six grades
according to a classication system described by Dua et al,
essentially subclassifying RHC Grade IV into Dua 4, 5 and 6
grades. There were 24 and 26 patients, respectively (table 3), in
Grade II and III ocular burns in both Dua and RHC. Grade IV
ocular burn by RHC comprised a total of 50 patients, who were
subdivided into three grades under Dua classication system
(Figure 2). There were 12, 16 and 22 patients in Grade 4, 5 and 6
by Dua Classication respectively.
In patients with moderate burns, the primary outcome variable of healing of the epithelial defect in the control group
(0.8 mm2/day; range0.43e5.1 mm2/day) and in the study
group (2.45 mm2/day; range0.48e5.8 mm2/day) was statistically signicant (p0.0004). Hence, patients of ocular burns
who were treated with amniotic membrane transplantation
showed a faster healing rate than patients who were treated
with conventional medical therapy alone in the moderate burns
group.
In patients with moderate burns, the average time taken for
the epithelial defect to heal was 21 days in the control group and
15 days in the study group. The difference was not statistically
signicant (p0.56). In the severe burns group, the time taken
for healing of the epithelial defect in controls ranged from 14 to
90 days, the average being 60 days. In the study group, the time
taken by the epithelial defect for complete healing ranged from
12 to 90 days, the average being 30 days. The difference was not
statistically signicant (p0.219).
At the nal follow-up, secondary outcome variables (table 4)
such as visual acuity, corneal clarity and vascularisation, and
development of symblepharon were also compared between the
two groups, and the difference was not statistically signicant.
Corneal vascularisation was measured according to the
number of quadrants involved. The outcome in terms of corneal
vascularisation was also studied in the different grades of burns.
It was found that with increasing grade of ocular burn, the
number of quadrants of corneal vascularisation also increased.
The difference was statistically signicant (p0.001).
Corneal vascularisation was not evident in any case at
presentation. At the nal follow-up visit, it was absent in 25
patients (12 in control group and 13 in AMT group) with
moderate burns. It was present in one quadrant in 15 patients
(30%), in two quadrants in nine patients (18%) and circumferentially (four quadrants) in one patient (2%), with moderate
burns. Corneal vascularisation was characteristically present in
all patients with severe burns (100%) at the nal follow-up visit.
It was present in one quadrant in ve patients (10%), in two
quadrants in eight patients (16%), in three quadrants in six
patients (12%) and in all four quadrants in 31 patients (62%),
with severe burns.
In the moderate burns group, two patients of the study group
had to undergo a procedure other than amniotic membrane

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Clinical science
Table 2 Baseline characteristics in the two groups
Moderate
Baseline variables

Control
(n[25)

Severe
Amniotic membrane
transplantation (n[25)

Control
(n[25)

Amniotic membrane
transplantation (n[25)

Agey

25 (4e45)

18 (5e52)

14 (3e61)

13 (6e60)

Sex*
Male
Female

23 (92.00)
2 (8.00)

25 (100.00)
0 (0.00)

21 (84.00)
4 (16.00)

18 (72.00)
7 (28.00)

Mode of injury*
Alkali
Acid
Thermal

18 (72.00)
6 (24.00)
1 (4.00)

17 (68.00)
4 (16.00)
4 (16.00)

18 (72.00)
4 (16.00)
3 (12.00)

19 (76.00)
6 (24.00)
0 (0.00)

3 (0e14)

6 (1e15)

7 (1e15)

7 (1e15)

2 (0.3e4)

3 (0.2e4)

Duration at presentationy (days)

Visual acuityy
Logmar

0.8 (0.13e4)

0.5 (0e3)

Lid involvement*
0 (absent)
1 (present)

9 (45.00)
11 (55.00)

5 (27.78)
13 (72.22)

9 (36.00)
16 (64.00)

12 (48.00)
13 (52.00)

Symblepharon*
0 (absent)
1 (present)

25 (100.00)
0 (0.00)

24 (96.00)
1 (4.00)

20 (80.00)
5 (20.00)

20 (80.00)
5 (20.00)

Conjunctival involvementy (%)

Size of epithelial defect (mm2)y
Corneal hazey (%)
Grade of corneal clarityy
Corneal vascularisation
Limbal ischaemiay (clock hours)

0
22.8
20
1
0
2

(0e25)
(4e144)
(0e100)
(0e4)
(1e6)

20
42
20
1
0
5

(0e50)
(3.4e100)
(0e80)
(0e2)
(2e6)

25
144
80
3
0
10

(0e100)
(16e144)
(20e100)
(1e4)

25
144
77.5
3
0
9

(7e12)

(0e100)
(25e144)
(50e100)
(0e4)
(7e12)

*Data presented as number (%).

yData presented as median (range).

transplantation which included granuloma excision and repeat

amniotic membrane grafting. One patient of the control group
underwent a large-diameter lamellar keratoplasty. The difference
was not statistically signicant (p0.39). In the severe burns
group, 19 patients of the control group and 18 patients of the
study group had to undergo further procedures. These procedures mainly included limbal stem cell transplantation and large
diameter lamellar keratoplasty.The difference was not statistically signicant (p0.89)
At the nal follow-up, symblepharon was present in one patient
of the study group and three patients of the control group as
a consequence of the moderate ocular burn. The difference was
not statistically signicant (p0.29). In the severe burns group,
17 patients of the study group and 16 patients of the control group
developed symblepharon as a consequence of the ocular burn.
The difference was not statistically signicant (p0.89).
The average follow-up of patients with acute ocular burns
was 13.263.8 months. No complications were encountered in
any patient during the period of the study.

moderate and severe ocular burns and to compare the results

with a control group.
This was a follow-on study, and we aimed to eliminate the
fallacies of the preliminary trial conducted at our centre.6 The
present study involved a larger number of patients with a longer
follow-up period. In the preliminary trial, some of the baseline
variables were signicantly worse in the AMT group compared
with controls. This fallacy was attributed to the small sample
size and the randomisation strategy which was followed.6 A
stratied random sampling method was used in the follow-on
study, which ensured that equal numbers of patients with
moderate and severe burns could be recruited. Moreover, all
baseline parameters in the control and study group were
comparable and similar for all grades of ocular burns. Additionally, Dua classication was also used to ensure a more
detailed subclassication of grade IV burns based on the exact
extent of limbal ischaemia and conjunctival involvement to
prognosticate outcome in various degrees of severe burns.
Table 3

DISCUSSION
Amniotic membrane transplantation has been used for ocular
surface reconstruction in acute chemical and thermal injury and
reported to be effective in a number of studies,9e11 but
a controlled, prospective study involving a large number of
patients is lacking.6 The present study was designed to assess
the potential efcacy of AMT involving 100 patients with
202

Distribution of patients by Roper Hall and Dua Classification

Dua

Roper Hall

Total

II
III
IV
Total

24
e
e
24

e
26
e
26

e
e
12
12

e
e
16
16

e
e
22
22

24
26
50
100

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Clinical science

Figure 2 Representative photographs of patients with severe ocular surface burns (Grade 4 Roper Hall Classification and the equivalent Dua 4, 5, 6
ocular burn). The upper row shows the clinical pictures of the patients at presentation, and the lower row shows the corresponding slit-lamp
photographs of the same patient at final follow-up visit: AeD: Grade 4 chemical burns (6e9 clock hours of limbal ischaemia); EeH: Grade 5 chemical
burns (9e11 clock hours of limbal ischaemia); IeL: Grade 6 chemical burns (12 clock hours of limbal ischaemia); A, B, E, F, I, J: patients treated with
standard medical therapy; C, D, G, H, K, L: patients who underwent amniotic membrane transplantation.
The results of the current study have again demonstrated that
AMT promotes epithelial healing in patients with moderate
ocular burns in comparison with a control group, as reported
previously by us.6 The rate of epithelial healing in patients with
moderate burns was signicantly faster in patients who received
AMT. In patients with severe burns, the AMT-treated group had
a slightly faster healing rate of the epithelial defect, but the
difference was not statistically signicant. The role of AMT for
severe burns seems limited, because these burns are associated
with extensive limbal ischaemia and stem cell deciency. There
was no statistically signicant difference in outcome in patients
with severe burns who underwent AMT as compared with
patients who were managed conservatively on medical therapy.
This could be due to aggressive medical management on an
Table 4

inpatient basis under close observation, monitoring and use of

manual techniques to break and prevent any symblepharon. The
power of the study for the primary outcome variable in cases
of severe burns was found to be 21%. The prognosis of Dua
Grade 6 burns remains poor, as all of these patients had total
epithelial defect with 12 clock hours of limbal involvement
and 100% conjunctival involvement. Moreover, in such cases
the nal outcome should only be assessed after ocular surface
reconstruction procedures such as autolimbal or allolimbal
transplantation12e14 with15 or without amniotic membrane
transplantation16e18 combined with systemic immunosuppression. Another prospective controlled trial involving a larger
sample size of patients with severe ocular burns is recommended
to determine the efcacy of AMT in such patients.

Effect of therapy on outcome variables

Moderate

Severe

Response variable

Control (n[25)

AMT (n[25)

p Value

Control (n[25)

AMT (n[25)

p Value

Primary outcome variable

Epithelial healing ratey

0.8 (0.43 to 5.1)

2.45 (0.48 to 5.8)

0.0004z

2.4 (0.27 to 4.8)

2.8 (1 to 4.8)

0.275

Secondary outcome variables

Visual acuityy
LogMAR
Lid involvement*
Presence of symblepharon*
Corneal hazey (%)
Duration taken for epithelial healing (days)y
Corneal hazey

0.3 (0 to 2)
0 (0.00)
3 (12.00)
0 (0 to 100)
21 (7 to 90)
0 (0 to 2)

0.2 (0 to 1.8)
0 (0.00)
1 (4.00)
10 (0 to 50)
15 (7 to 70)
1 (0 to 3)

0.531
e
0.609
0.983
0.433
0.983

2 (0.2 to 4)
0 (0.00)
16 (64.00)
75 (0 to 100)
60 (14 to 90)
3 (0 to 4)

1.8 (0 to 4)
1 (4.00)
17 (68.00)
80 (50 to 100)
30 (12 to 90)
2 (0 to 4)

0.709
0.500
1.00
0.272
0.219
0.272

Grade of corneal haze*

0
1
2
3
4

13 (52.00)
9 (36.00)
3 (12.00)
0 (0.00)
0 (0.00)

12 (48.00)
10 (40.00)
2 (8.00)
1 (4.00)
0 (0.00)

0.706

2
4
6
8
5

2
4
8
9
2

0.538

Corneal vascularisation*
0
1
2
3
4

12 (48.00)
7 (28.00)
5 (20.00)
0 (0.00)
1 (4.00)

13 (52.00)
8 (32.00)
4 (16.00)
0 (0.00)
0 (0.00)

0.432

0 (0)
2 (8)
3 (12)
3 (12)
17 (68)

(8.00)
(16.00)
(24.00)
(32.00)
(20.00)

(8.00)
(16.00)
(32.00)
(36.00)
(8.00)

0 (0)
3 (12)
5 (20)
3 (12)
14 (56)

0.804

*Data presented as number (%).

yData presented as median (range).
zp<0.01, statistically significant.
AMT, amniotic membrane transplantation.

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The results of the study should be interpreted, keeping in mind
that even patients on conventional medical therapy were carefully managed and closely monitored. The authors feel that there
was no difference in formation of symblepharon with or without
AMT, as patients on medical therapy alone were actively
managed, and symblepharon formation was prevented by manual
release and proper therapy modulation as and when required.
Ocular surface reconstruction procedures are being extensively
used in patients of ocular burns for rehabilitation and improving
visual outcome in such cases.11 With the advent of LSCT19 and
amniotic membrane grafting18 20 21 prognosis of less severe
grades of burns is enhanced. In our study, AMT was benecial in
patients with 50e75% limbal involvement and resulted in
improved outcome in Grade IV burns by Dua classication.
The prognosis of Dua Grade VI burns is poor, and the use of
AMT for Grade VI burns is limited. This may be due to the
presence of chronic ocular surface inammation in these cases
which could affect the success of AMT and limbal transplantation procedures. It is simply not enough to note the
healing of the epithelial defect, but to ascertain the nature and
morphology of the covering epithelium. Impression cytology is
a good method to monitor the inammatory status of the ocular
surface that is assessed by expression of the MHC class II
inammatory marker HLA-DR by the conjunctival epithelium,22
and also to assess whether the covering epithelium is corneal or
conjunctival in origin. There is a signicant upregulation of the
expression of HLA-DR in eyes with severe burns, and this affects
the nal outcome in patients with ocular surface burns.22
Published literature on the efcacy of AMT in acute ocular
burns is inadequate in terms of number of patients and
comparison with controls. Various studies reported varying
degrees of success, and a randomised, controlled trial was much
needed. A large number of retrospective reviews3 4 21 are available which report favourable outcome with AMT in acute ocular
burns. Prospective, non-controlled studies5 10 23 24 have also been
conducted and have reported that AMT can effectively reduce
the inammation of the cornea at the acute stage of burn injury
and prevent complications such as corneal ulcer and perforation.
Larger case series9 10 25 involving two to ve eyes have shown
contradictory results. A study by Joseph et al25 showed failure of
AMT in ocular burns because all patients had severe burns with
total epithelial defect and 100% limbal ischaemia.
AMT promoted healing of the ocular surface in all patients, as
complete epithelialisation was achieved in all cases. It helps in
corneal and conjunctival differentiation and regeneration. This
action of amniotic membrane is by virtue of the epithelial
basement membrane layer providing a mechanical support and
acting as an internal splint. In addition, the amniotic membrane
has benecial biological properties such as secretion of cytokines,
growth factors and protease inhibitors which decrease surface
inammation and prevent brosis and symblepharon formation.
AMT stabilises the ocular surface and provides a conducive
surface for further procedures such as auto-limbal and allolimbal transplantation, lamellar or penetrating keratoplasty.
AMT can be considered as a useful surgical option in moderate
chemical burns with non-healing epithelial defects. It may also
be used judiciously in severe cases where close monitoring and
follow-up are not possible, and compliance with medication is
not satisfactory.

204

Acknowledgements Thanks to the following: research associates who worked on

the project, including M Mehta, PM Nath, V Jhanjhi, H Kukreja and H Pundir;
Department of Obstetrics & Gynaecology, AIIMS, for procurement of the amniotic
membrane; and Department of Ocular Pharmacology, Dr Rajendra Prasad Centre for
Ophthalmic Sciences, AIIMS, for providing sodium ascorbate and citrate eye-drops.
Funding Indian Council of Medical Research, Ansari Nagar, New Delhi under
Grant-in-aid of Research Scheme (No I-389).The sponsor or funding organisation had
no role in the design or conduct of this research.
Competing interests None.
Patient consent Obtained.
Ethics approval Ethics approval was provided by the Ethics Committee of the All
India Institute of Medical Sciences (AIIMS), New Delhi, India.
Provenance and peer review Not commissioned; externally peer reviewed.

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Br J Ophthalmol 2011;95:199e204. doi:10.1136/bjo.2009.173716