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Annals of Medicine and Medical Sciences
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  2. Vol. 05, No. 06, (2026)
  3. Clinical Spectrum of Amniotic Membrane Transplantation in Ocular Surfa…
Original Article Open Access

Clinical Spectrum of Amniotic Membrane Transplantation in Ocular Surface Disorders at a Tertiary Care Hospital

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Annals of Medicine and Medical SciencesVol. 05, No. 06, (2026) June 21, 2026pp. 856 - 860
73 53
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Abstract

Purpose: To study the clinical spectrum of amniotic membrane transplantation in ocular surface disorders at a tertiary care hospital in Kashmir. Materials and Methods: This was a hospital based observational study with prospective recruitment of cases conducted in Post graduate Department of Ophthalmology GMC Srinagar. Patients with various ocular surface disorders were included. Results: A total of 96 patients underwent amniotic membrane transplantation and were followed up for a period of 18 months. 59 (62%) patients were male and 37(38%) were females, with a mean age group of 41.33 years.64.58% patients belonging to the rural population and 35.42% to the urban population. Right eye was affected in 57 (59.37%) patients while left eye was affected in 39 (40.63%) patients. The most common indication for AMT was seen as pterygium (25%) followed by OSSN (22.91%). Surgery was uneventful in all cases. 91 patients (94.79%) showed no pain and 88 patients (91.66%) showed no signs of inflammation & vascularization post-operatively. In cases of OSSN, limbal dermoid, conjunctival nevus, conjunctival cyst, rapid healing occured in all the patients and there was no case of recurrence up to 12 weeks that the patients were followed. Re epithelialization started as early as 8 days after the transplant. Failure to re-epithelialize was seen in two eyes, one with sterile corneal melt and another with severe neurotrphic ulcer. As such failure was seen in 3 cases with non healing of severe neurotrophic ulcer with persistent epithelial defects in two. Also one patient with recurrent pterygium showed recurrence following AMT. Visual acuity was improved in vast majority of cases 92 eyes (95.83%). Conclusion: Our study demonstrates that AMT is a safe and effective procedure in reconstructing the ocular surface defects by promoting epithelial healing, reducing surface inflammation, increasing patient comfort and reducing severity of vascularization and scarring in various ocular surface disorders.

Keywords

Ocular Surface Disorders Amniotic Membrane Transplantation OSSN Neutrophic Ulcer Pterygium.

Introduction

Common factors leading to the breakdown of ocular surface include infections, trauma, chemical injuries and dry eye. In this study we have shown that amniotic membrane transplantation has a great role in various ocular surface disorders that are refractory to medical treatment. AMT ameliorates photophobia and pain, facilitates rapid epithelialization, reduces vascularisation [1,3] restores a normal corneal epithelial surface and also improves the final visual acuity.

Amniotic basement membrane is an ideal substrate for promoting the growth of epithelial progenitor cells by prolonging their life span and maintaining clonogenicity [2], facilitating migration of epithelial cells and reinforcing the adhesion of basal epithelial cells.

Materials and Methods

A prospective analysis of 96 patients with various ocular surface disorders who underwent amniotic membrane transplantation at Govt Medical College and SMHS hospital was done. It included all the patients with various ocular surface disorders attending the cornea clinic of Post Graduate Department of Ophthalmology. There was no exclusion criteria.

Treatment Strategy

Cryopreserved amniotic membrane obtained in sterile vials containing 10% DMSO (Dimethyl sulfoxide) medium was used. Pterygium excision was done in a total of 24 patients out of which AMG was secured with 8-0 vicryl /fibrin glue. Same procedure was done in patients of recurrent pterygium(n=18) but in case of recurrent pterygium, fibrin glue was used to fix the amniotic membrane. In cases of pseudopterygium with symblepharon(n=4), pseudopterygium excision was done, symblepharon was released and amniotic membrane was placed over the bare sclera and fornices to act as a barrier and secured with fibrin glue and sutures.

In patients with ocular surface squamous neoplasia(OSSN)-n=22, patients were managed with excisional biopsy of the lesion with 4mm of clear conjunctiva and 2mm of clear cornea, cryotherapy and corneal epitheliectomy using absolute alcohol was done in cases where cornea was involved. Ocular surface reconstruction was done with cryopreserved amniotic membrane transplantation depending upon the size and extent of lesion (single layer/multi-layer and inlay/overlay or patch-graft). After surgery the bandage contact lens was put in place and discontinued after epithelialization.

In patients with limbal dermoid(n=10), anterior segment B-scan was done to rule out posterior segment involvement. The border of the lesion was marked using a surgical marker. A conjunctival peritomy around the lesion was done and lamellar dissection of limbal dermoid was carried out. Ocular surface reconstruction was done using single layered amniotic membrane, which was secured with fibrin glue.

In patients with conjunctival cyst(n=4) and conjunctival nevus(n=4), lesions were excised along with 2mm of the healthy tissue and AM was placed by inlay technique and secured with sutures/fibrin glue.

In patients of neurotrophic ulcer with persistent epithelial defects(n=4), the base of the ulcer was debrided with a crescent blade and loose epithelium adjacent to the edge of the ulcer was removed. Corneal surface was covered with amniotic membrane. Bandage contact lens was put in place and removed after epithelialization. One case out of the 4 required repeat AMT.

In cases of corneal melt(n=4), the entire cornea was covered by amniotic membrane in a multi-layered patch graft fashion and secured with fibrin glue. Out of the 4 cases, AMT had to be repeated in one case who had Sjogren’s syndrome with graft melt and the size of the melt was very large -3*4mm.

In patients with bullous keratopathy(n=2) loose epithelium was removed with a microsponge .and cryopreserved amniotic membrane was applied and secured with fibrin glue.

Post -operative care consisted of antibiotic steroid eye drops four times a day and preservative free lubricating drops tapered off within 1 month. Sutures were removed after 4 weeks.

Patients were evaluated for: final visual outcome, re-epithelization corneal clarity, and degree of neo vascularization on 2nd week 4th week and 6th week. Patients were followed up for a mean period of 12 weeks.

Failure of cases was defined as those not achieving the desired results for which AM was used.

  • Non healing of ulceration in cases of neurotrophic ulcer

  • Non sealing of perforations

  • Non relief of pain, re-appearance of corneal haze/significant scarring and worsening of final visual acuity in cases of Bullous keratopathy

  • Recurrence in cases of pterygium and pseudopterygium

Results

The various indications of AMT in patients with Ocular surface disorders were categorised as under.

Table 1 Indications
Indications No of patients Percentage
1. Pterygium 24 25%
2. OSSN 22 22.91%
3. Limbal dermoid 10 10.41%
4. Neurotrophic ulcer with PED 4 4.16%
5.Pseudopterygium with symblepharon 4 4.16%
6. Sterile perforations/graft melt 4 4.16%
7. Recurrent pterygium 18 18.75%
8. Conjunctival nevus 4 4.16%
9. Conjunctival cyst 4 4.16%
10. Bullous keratopathy 2 2.08%
Total 96 100%

Table 1 showing indications of amniotic membrane transplantation in patients with ocular surface disorder

Table 2
Pre op pain No of pts %age Post op pain (12 week) No of pts %age
No pain 0 0 No pain 91 94.79%
Mild 39 40.63% Mild 5 5.21%
Moderate 37 38.54% Moderate 0 0
Severe 20 20.83% Severe 0 0
TOTAL 96 100% Total 96 100%

Table 2 showing pre and post op comparison of pain of patients who underwent amniotic membrane transplantation in our study.

Patients showed significant improvement in pain relief (p value=0.001 which is statistically significant using Fisher’s exact test).

Table 3 Inflammation (Pre op vs post op)
Pre op inflammation No of pts % age Post op inflammation (12th week) No of pts % age
Absent 0 0 Absent 88 91.66%
<3 clock hrs 25 26.04% <3 clock hrs 8 8.34%
3-6 clock hrs 45 46.88% 3-6 clock hrs 0 0
>6 clock hrs 26 27.08% >6 clock hrs 0 0
TOTAL 96 100% TOTAL 96 100%

Table 3 showing pre and post op inflammation of patients who underwent amniotic membrane transplantation in our study with 91.66% patients having no post-op inflammation post-op

Table 4 SCARRING (Pre op vs post op)
Pre op scarring No of pts % age Post op scarring No of pts % age
None 9 9.37% None 91 94.79%
Nebular(mild) 43 44.8% Nebular(mild) 2 2.08%
Macular(moderate) 23 23.95% Macular(moderate) 1 1.04%
Leucomatous(severe) 21 21.88% Leucomatous(severe) 2 2.08%
Total 96   Total 96 100%

Table 4 showing pre and post op scarring of patients who underwent amniotic membrane transplantation in our study with 94.79% patients having no post op. scarring.

Discussion

In our study, a total of 96 patients underwent amniotic membrane transplantation and were followed up for a period of 12 weeks. 59 patients were male and 37 were females. Right eye was affected in 57 (59.37%) patients while left eye was affected in 39 (40.63%) patients. Surgery was uneventful in all cases. 91 patients (94.79%) showed no pain and 88 patients (91.66%) showed no signs of inflammation & vascularization post-operatively. Re epithelialization started as early as 8 days after the transplant.

Failure to re-epithelialize was seen in two eyes, one with sterile corneal melt and another with severe neurotrophic ulcer.

PTERYGIUM & RECURRENT PTERYGIUM

In our study 24 patients (25%) with primary pterygium underwent amniotic membrane transplantation. In 6 patients AMG was secured with glue, while in the rest 18 AMG was secured with 8-0 vicryl sutures. Complete epithelialization was seen in all the patients as early as 8 days post-transplant and no complication or recurrence was observed in case of primary pterygium.

18 patients (18.75%) with recurrent pterygium underwent AMT and in all the cases AMG was secured with fibrin glue. Complete epithelialization was seen in all the patients. However recurrence was seen in one patient (5.5%)12 weeks post-transplant.

In our study, the recurrence rate following amniotic membrane graft for primary pterygium excision was nil over a 12 weeks follow-up period which was almost consistent with the study of Asadollah Katbaab et al., [4], that reported successful outcome of AMT after pterygium excision with recurrence in only two eyes out of 50 eyes with primary pterygium. In cases of recurrent pterygia, recurrence was seen in one patient (5.5%) which is consistent with the previous studies by:

Fallah et al.,[5] where conjunctival limbal autograft with AMT appeared to be more effective than intraoperative MMC with AMT for treatment of recurrent pterygia.

Ma et al.,[6] in a comparative study showed that amniotic membrane graft alone is an effective adjunctive treatment for recurrent pterygia and the addition of intraoperative mitomycin C did not further reduce recurrence rates [7].

LIMBAL DERMOID

10 patients (10.41%) underwent amniotic membrane transplantation following excision of limbal dermoid. This surgical technique achieved rapid postoperative corneal re-epithelialization, reduced postoperative pain, and diminished postoperative scarring in all ten patients. Existing preoperative astigmatism remained unchanged in 2 patients throughout the follow-up period, rest of the 8 patients achieved 6/6 vision post-transplant. No intraoperative or postoperative complications were noted.

Findings were consistent with the study of AMIR PIROUZIAN, KEVIN MERRIL RATEHALLI SUDESH (2011)[8] where they found that in the management of paediatric limbal dermoid (grade I), surgical excision combined with sutureless multi-layered amniotic membrane transplantation eliminates painful postoperative recovery and corneal neovascularization, and can achieve an improved long-term ocular surface cosmesis.

BULLOUS KERATOPATHY

It is a disorder caused by corneal endothelial decompensation and is characterized by corneal stromal edema with or without epithelial bullae, which may result in pain.

In our study, 2 patients (2.08%) with pseudophakic bullous keratopathy underwent amniotic membrane transplantation. During a mean follow-up of 12 weeks pain relief, epithelial healing, and visual changes were analysed. Amniotic membrane provided significant relief in pain and bullae were resolved with significant improvement in surface integrity. However vision remained same in both the cases because of significant pre-op scarring. Results were consistent with studies by:

Edgar M Espana 1, Martin Grueterich, Helga Sandoval, Abraham Solomon, Eduardo Alfonso, Carol L Karp, Francisco Fantes, Scheffer C G Tseng (2003) [9] reported pain relief obtained in 88% of patients with PBK.

Renato T.F. Pires, Scheffer C.G. Tseng, Pinnita Prabhasawat et al., (1999) [10] reported successful pain relief in 43 out of 48 eyes with symptomatic bullous keratopathy after AMT.

PSEUDOPTERYGIUM WITH SYMBLEPHARON: 4 cases (4.16%) of pseudopterygium with symblepharon and restriction of extra-ocular movements were undertaken for AMT. AM proved substantially beneficial in its role, with the release of symblepharon, closure of the epithelial defect and reconstruction of conjunctival mucosal surface, restoration of extra-ocular movements. No complications or recurrence were seen. Shimzaki et al.,[11] reported successful use of amniotic membrane to treat four patients with recurrent pterygium with symblepharon.

OCULAR SURFACE SQUAMOUS NEOPLASIA (OSSN)

In our study amniotic membrane transplantation proved successful in reconstructing large conjunctival defects created during surgical removal of large lesions like OSSN n=22 (22.91%) with rapid healing, pain relief, decrease in vascularisation and scarring and vast improvement in final visual acuity In our study, no surgical complications were observed. The postoperative period of mild discomfort and inflammation was short and effectively managed with topical steroids. Successful ocular surface reconstruction and complete epithelialization of the amniotic membrane were achieved in all eyes. No recurrence was observed in any eyes. Our findings are consistent with earlier reported results of several case series of AMT after conjunctival tumor excision.

M Palamar, E Kaya, T Akalin, S Egrilmez and A Yagci(2014) [12] reported successful ocular surface reconstruction with AMT after OSSN excision in 21 patients.

Tseng et al reported successful use of amniotic membrane to reconstruct the conjunctival defects after removal of large lesions or symblepharon lysis.

Asoklis RS, Damijonaityte A, Butkiene L, Makselis A, Petroska D, Pajaujis M et al.,[13] reported successful ocular surface reconstruction using amniotic membrane following excision of conjunctival limbal tumors. Same findings were consistent with other studies like:

Tseng SCG, Prabhasawat P, Lee SH. (1997), Am J Ophthalmol Dua SH, Azuara Blanco (1999), Espana EM, Prabhasawat P, Grueterich M, Solomon A, Tseng SCG in Br J Ophthalmol (2002) [14]

Gu¨ndu¨ z K, Ucakhan OO, Kanpolat A, Gunalp I [15] used non-preserved human amniotic membrane for reconstruction of ocular surfaces after removal of large conjunctival tumors.

CONJUNCTIVAL CYST AND CONJUNCTIVAL NEVUS

Conjunctival nevi are usually benign pigmented tumorous lesions located in the bulbar conjunctiva. These lesions are to be removed mostly for cosmetic reasons, but excisional biopsies are best for suspicious malignancy. 4 eyes (4.16%) with conjunctival nevus were taken for AMT. Nevus excision was done after marking the lesion with surgical marker and the bare sclera was covered with amniotic membrane graft. No surgical complications were observed. Postoperatively, the amniotic membrane covered the surgical defect of the ocular surface in all cases. Post-operatively, the patients did not report any complications associated with the surgery and were satisfied with the cosmetic appearance. Epithelialization was seen as early as 1st week post-transplant with rapid relief in pain and inflammation. No recurrence was reported up to 12 weeks of follow up.

Results were consistent with the case report published by Tobias Rock Hans, Christian Bosmuller, Carl Ulrich Bartz-Schmidt of a 26 year old man in whom surgical excision combined with reconstruction via amniotic membrane transplantation was seen to be effective and economical for the treatment of large bulbar conjunctival nevus of the right eye.

In our study 4 patients with conjunctival cysts underwent conjunctival cyst excision with amniotic membrane transplantation. Rapid healing, pain relief, re-epithelialization was seen almost immediately post -operatively with no recurrence after 12 weeks.

NEUROTROPHIC ULCER WITH PERSISTENT EPITHELIAL DEFECTS

Non infective ulcers or ulcers rendered sterile after pharmacotherapy can fail to epithelialize leading to progressive stromal melting. Various surgical procedures are used in such situations like tarsorrhaphy, adhesives, Gunderson’s flap or a combination of these techniques. AMT can be used as an alternative, being less invasive than keratoplasties. The amniotic membrane graft is attached to entire corneal surface(overlay) using fibrin glue. This patch graft allows proliferation of the epithelium underneath the membrane. Alternately it can also be used as a patch graft to cover epithelial defect only as a substrate graft. In our study 4 eyes (4.16%) with neurotrophic ulcer and persistent epithelial defects received amniotic membrane transplantation secured with fibrin glue. All the four eyes had underlying viral keratitis. Depending on the depth of stromal ulceration the, ulcer was covered by one or more than one layer of amniotic membrane and the basement membrane side of the graft was congruent with the patient’s exposed surface. Except for one eye, all the other 3 eyes healed rapidly with significant decrease in corneal edema and rapid re-epithelialization. In one eye in which the patient had severe diabetes mellitus, the ulcer had healed on first follow up i.e. after two weeks, however on second follow up, the patient presented with recurrence of epithelial defects and had to undergo AMT again. However on subsequent follow ups, the patient presented with superadded infection. The second attempt at AMT was performed without success.

During the follow up period of 12 weeks, visual acuity was improved in rest of the 3 eyes from hand movement to counting fingers-6m(case 1) and finger counting 2m and 3 m to 6/60 (BCVA) in the other two eyes.

Our report shows that AMT can be considered as effective measure for treating severe neurotrophic corneal ulcer and the findings were consistent with various studies like

Kruse et al, (1999)[16] who successfully treated nine out of 11 eyes with neurotrophic corneal ulcers with multi-layered AMT.

Hong-Jeng Chen, Renato T F Pires, ScheVer C G Tseng (2000)[17] reported successful use of amniotic membrane transplantation in 16 eyes for persistent neurotrophic corneal ulcers. All but four (76.4%) achieved rapid epithelialization in 16.6 days.

Lee and Tseng (1997)[18] used amniotic membrane to treat persistent epithelial defects where epithelialization occured in 10 out of 11 consecutive patients. Also Tseng et al [7] used AMT for successful reconstruction of ocular surface in partial limbal stem cell deficiency (LSCD).

STERILE PERFORATIONS AND GRAFT MELT

In our study 4 patients (4.16%) with sterile corneal melt underwent amniotic membrane transplantation. Except for one eye, the other 3 showed significant improvement in pain, inflammation, vascularisation and epithelial integrity post - operatively. Epithelialization was slow and total re-epithelialization was seen on second follow up i.e. after 4 weeks. We attempted multi-layer AMT in a case of Sjogren’s syndrome with a graft melt of 3.5*4mm areadue to non-availability of corneal graft in covid times. However on first follow at 2 weeks AM failed to provide adequate tectonic support.

This was consistent with a study by Augusto Azuara-Blanco [19] in 1999 on the efficacy of amniotic membrane transplantation for ocular surface reconstruction.

Summary

  • 96 patients with various types of ocular surface disorders that underwent amniotic membrane transplantation were included in our study, among which were 61.45% males and 38.55% were females.

  • Amniotic membrane transplantation was done in 25% of patients with primary pterygium followed by 22.91% of patients with ocular surface squamous neoplasia, followed by limbal dermoid (10.41%) with 100% success in these disorders.

  • It also proved substantially beneficial in conjunctival reconstruction in conjunctival nevus, conjunctival cyst and symblepharon release with no scarring or recurrence.

  • However its role as a tectonic support in case of large perforations, corneal melts is debatable and needs further research.

  • In majority of the patient’s fibrin glue was used to secure the graft (n=61/ 63.5%), while in 35 (36.45%) patients’ suture (8-0 vicryl) was used to secure the graft. Fibrin glue proved way superior than sutures with less surgical time, no foreign body sensation post-operatively and rapid healing, pain relief and decrease in neovascularization and foreign body sensation.

  • Re-epithelialization was seen as early as 8th day post-operatively with maximum time of 2 weeks

  • Significant improvement in scarring and final visual acuity was seen in 92(95.83%) patients

  • Failure was seen in 3 patients (3.12%) in the form of:

  • Recurrence of pterygium

  • Failure of re-epithelization

  • Non sealing of perforation

Conclusion

AMT is a safe and effective procedure in reconstructing the ocular surface defects by promoting epithelial healing, reducing surface inflammation, increasing patient comfort and reducing severity of vascularization and scarring in various ocular surface disorders.

Declarations

Financial support and sponsorship

Nil

Conflicts of interest

The authors declare that there are no conflicts of interests of this paper

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