Scientific Online Resource System

Scripta Scientifica Medica

Amniotic membrane transplantation - analysis of structural characteristics in amniotic membrane transplant and corneal ulcers

Yana Manolova, Zarka Stoycheva, Yordan Yordanov, Christina Grupcheva


AIM: To analyze the structural characteristics in the cornea and the amniotic membrane (AM) with the help of laser scanning in-vivo confocal microscopy (IVCM) and to evaluate the morphometric changes in the cornea and the integration pattern of amniotic membrane into the host tissue using anterior-segment optical coherence tomography (AS-OCT) in patients with persistent corneal defect treated with amniotic membrane transplantation (AMT).

MATERIALS AND METHODS: Nine eyes of six consecutive patients (mean age 44.9 ± 8.7 years) with corneal defects and stromal thinning unresponsive to topical treatment were enrolled in this study. Transplantation of cryopreserved amniotic membrane was performed. The time of healing of the corneal defect, morphometric analysis of the cornea and transplanted amniotic membrane using AS-OCT and the structural characteristics in the amniotic membrane grafts and corneal ulcers assessed by in vivo confocal microscopy were evaluated.

RESULTS: Successful results after amniotic membrane transplantation (AMT) were observed in 8 of the 9 eyes (91.2%). On the 2nd day after transplantation, IVCM showed that under the amniotic membrane a new epithelium with large, flat, immature cells of the superficial corneal epithelium with an average density of 598.4 ± 66.38cells/mm2 was observed. The basal cells also showed immaturity and their average density was 1804 ± 93.32cells/mm2. In the corneal stroma edema and activated corneal cells were visualized. The average corneal epithelium thickness increased to 24.60 ± 2.07μm, the average density of epithelial cells increased to 657.6 ± 78.41cells/mm2, while the mean basal epithelium cells density was 2541 ± 540.13 cells/mm2. AS-OCT showed that the preoperative corneal thickness at the ulcer was 418.91 ± 96.56 μm. On the 2nd day after the surgery, the amniotic membrane (AM) thickness was measured to be 268 ±105 μm. On the 8th day it was two times smaller and was measured to be 123 ±39 μm. On the 25th day post-surgery the corneal thickness was measured at 494.03 ± 67.35 μm. In two of the cases integration of AM was found.

CONCLUSIONS: AMT leads to recovery of corneal defects unresponsive to conservative treatment. The amniotic membrane graft is effective in promoting re-epithelization, nonetheless, it can also integrate into the host corneal tissue which results in an increase in corneal thickness, stabilization of the epithelium and reduction of the subjective signs. The integration of amniotic membrane into the damaged cornea proves that AMT is an effective and irreplaceable procedure for difficult-to-treat anterior ocular surface diseases.


amniotic membrane, corneal ulcer, AS-OCT, IVCM, integration

Full Text


van Herendael BJ, Oberti C, Brosens I. Microanatomy of the human amniotic membranes. A light microscopic, transmission, and scanning electron microscopic study. Am J Obstet Gynecol. 1978 Aug 15;131(8):872-80.

Gheorghe A, Pop M, Burcea M, Serban M. New clinical application of amniotic membrane trans plant for ocular surface disease. J Med Life. 2016;9(2):177-9.

Akle CA, Adinolfi M, Welsh KI, Leibowitz S, Mc- Coll I. Immunogenicity of human amniotic epithelial cells after transplantation into volunteers. Lancet Lond Engl. 1981 Nov 7;2(8254):1003-5.

Silini AR, Cargnoni A, Magatti M, Pianta S, Parolini O. The Long Path of Human Placenta, and Its Derivatives, in Regenerative Medicine. Front Bioeng Biotechnol [Internet]. 2015 Oct 19 [cited 2017 Jan 30];3.

Park WC, Tseng SC. Modulation of acute inflammation and keratocyte death by suturing, blood, and amniotic membrane in PRK. Invest Ophthalmol Vis Sci. 2000 Sep;41(10):2906-14.

Li W, He H, Chen Y-T, Hayashida Y, Tseng SCG. Reversal of Myofibroblasts by Amniotic Membrane Stromal Extract. J Cell Physiol. 2008 Jun;215(3):657-647. Talmi YP, Sigler L, Inge E, Finkelstein Y, Zohar Y. Antibacterial properties of human amniotic membranes. Placenta. 1991 Jun;12(3):285-8.

Hao Y, Ma DH, Hwang DG, Kim WS, Zhang F. Identification of antiangiogenic and antiinflammatory proteins in human amniotic membrane. Cornea. 2000 May;19(3):348-52

Grueterich M, Espana EM, Tseng SCG. Ex vivo expansion of limbal epithelial stem cells: amniotic membrane serving as a stem cell niche. Surv Ophthalmol. 2003 Dec;48(6):631-46.

Kawakita T, Espana EM, He H, Smiddy R, Parel J-M, Liu C-Y, et al. Preservation and Expansion of the Primate Keratocyte Phenotype by Downregulating TGF-β Signaling in a Low-Calcium, Serum- Free Medium. Invest Ophthalmol Vis Sci. 2006 May;47(5):1918-27.

Burman S, Tejwani S, Vemuganti GK, Gopinathan U, Sangwan VS. Ophthalmic applications of preserved human amniotic membrane: a review of current indications. Cell Tissue Bank. 2004;5(3):161-75.

Lee SH, Tseng SC. Amniotic membrane transplantation for persistent epithelial defects with ulceration. Am J Ophthalmol. 1997 Mar;123(3):303-12

Shi W, Chen M, Xie L. Amniotic membrane transplantation combined with antiviral and steroid therapy for herpes necrotizing stromal keratitis. Ophthalmology. 2007 Aug;114(8):1476-81.

Prabhasawat P, Tesavibul N, Komolsuradej W. Single and multilayer amniotic membrane transplantation for persistent corneal epithelial defect with and without stromal thinning and perforation. Br J Ophthalmol. 2001 Dec;85(12):1455-63.

Seitz B, Resch MD, Schlötzer-Schrehardt U, Hofmann- Rummelt C, Sauer R, Kruse FE. Histopathology and ultrastructure of human corneas after amniotic membrane transplantation. Arch Ophthalmol Chic Ill 1960. 2006 Oct;124(10):1487-90.

DUA H. Amniotic membrane transplantation. Br J Ophthalmol. 1999 Jun;83(6):748-52.

Malhotra C, Jain AK. Human amniotic membrane transplantation: Different modalities of its use in ophthalmology. World J Transplant. 2014 Jun 24;4(2):111-21.

Manolova Y, Popov C, Grupcheva C. Amniotic membrane transplantation- excellent biological scaffold for anterior ocular surface reconstruction. Scr Sci Medica. 2016 Oct 3;48(3):65-72.

Luanratanakorn P, Ratanapakorn T, Suwan-Apichon O, Chuck RS. Randomised controlled study of conjunctival autograft versus amniotic membrane graft in pterygium excision. Br J Ophthalmol. 2006 Dec;90(12):1476-80.

Stephenson, Michelle. Treatment Options with Amniotic Membrane. Review of Ophthalmology;Nov2015, Vol. 22 Issue 11, p68

Nubile M, Dua HS, Lanzini M, Ciancaglini M, Calienno R, Said DG, et al. In Vivo Analysis of Stromal Integration of Multilayer Amniotic Membrane Transplantation in Corneal Ulcers. Am J Ophthalmol. 2011 May 1;151(5):809-822.e1.

Letko E, Stechschulte SU, Kenyon KR, Sadeq N, Romero TR, Samson CM, et al. Amniotic membrane inlay and overlay grafting for corneal epithelial defects and stromal ulcers. Arch Ophthalmol Chic Ill 1960. 2001 May;119(5):659-63.

Solomon A, Meller D, Prabhasawat P, John T, Espana EM, Steuhl K-P, et al. Amniotic membrane grafts for nontraumatic corneal perforations, descemetoceles, and deep ulcers. Ophthalmology. 2002 Apr;109(4):694-703.

Kruse FE, Rohrschneider K, Völcker HE. Multilayer amniotic membrane transplantation for reconstruction of deep corneal ulcers. Ophthalmology. 1999 Aug;106(8):1504-1510; discussion 1511.

Dua HS, Gomes JAP, King AJ, Maharajan VS. The amniotic membrane in ophthalmology. Surv Ophthalmol. 2004 Feb;49(1):51-77.

Resch MD, Schlötzer-Schrehardt U, Hofmann- Rummelt C, Sauer R, Kruse FE, Beckmann MW, et al. Integration patterns of cryopreserved amniotic membranes into the human cornea. Ophthalmology. 2006 Nov;113(11):1927-35.

Nubile M, Dua HS, Lanzini TE, et al. Amniotic membrane transplantation for the management of corneal epithelial defects: an in vivo confocal microscopic study. Br J Ophthalmol 2008;92(1):54-60.

Connon CJ, Doutch J, Chen B, Hopkinson A, Mehta JS, Nakamura T, et al. The variation in transparency of amniotic membrane used in ocular surface regeneration. Br J Ophthalmol. 2010 Aug;94(8):1057-61.

Lemp MA, Blackman HJ. Ocular surface defense mechanisms. Ann Ophthalmol. 1981 Jan;13(1):61-3.

Zakaria N, Ní Dhubhghaill S, Taal M, Berneman Z, Koppen C, Tassignon M-J. Optical Coherence Tomography in Cultivated Limbal Epithelial Stem Cell Transplantation Surgery. Asia-Pac J Ophthalmol Phila Pa. 2015 Dec;4(6):339-45.

About The Authors

Yana Manolova
Medical University of Varna

Department of Ophthalmology and Visual Sciences, Faculty of Medicine

Zarka Stoycheva
Medical University of Varna

Department of Ophthalmology and Visual Sciences, Faculty of Medicine

Yordan Yordanov
Specialized Eye Hospital - Varna

Christina Grupcheva
Medical University of Varna

Department of Ophthalmology and Visual Sciences, Faculty of Medicine

Font Size