- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT01926535
Amniotic Membrane Graft In Syntomathic Bullous Keratopathy (AMBUK)
Comparative Analysis of Human Amniotic Membrane Graft Versus Contact Lenses in Syntomathic Bullous Keratopathy
The amniotic membrane (AM) is an avascular structure derived from fetus, which is a good choice for regenerative medicine and effective treatment in eye surface pathologies such as bullous keratopathy (BK). This disease generates a chronic corneal edema evolving to the production of vesicles and bullae, chronic eye pain and visual acuity decrease.
Definitive treatment for those patients is corneal transplant; however, donation is not always available and thus requires long waiting times. The currently available palliative treatment consists in the use of contact lenses to prevent the corneal epithelium from falling. However, this may be associated with corneal neovascularization, lens displacement or loss, infections, and discomfort for the patient.
The objective of this work was to compare the use of amniotic membrane grafts versus contact lenses in patients suffering from BK awaiting a corneal transplant.
A randomized clinical trial assay was performed with patients with a clinical diagnosis of BK. Twenty patients were randomized into 2 groups: amniotic membrane and therapeutic contact lenses. Eye pain intensity (Analog visual scale), visual acuity (Snellen questioner), bullae and corneal epithelial defects presence, as well as corneal neovascularization and complications (biomicroscopy) were compared during 6 months.
Study Overview
Status
Conditions
Intervention / Treatment
Detailed Description
INTRODUCTION Handling of patients with severe eye surface injuries has always been challenging in the field of ophthalmology. One of the most significant pathologies causing severe injuries is Bullous Keratopathy (BK). This disorder is caused by a failure in corneal endothelial pump (Na+/K+/ATPase) characterized by chronic stromal edema, and it tends to evolve to the production of corneal vesicles and bullae due to the drainage of fluid to the anterior corneal layers as a consequence of intraocular pressure(1). Most common causes of BK are intraocular surgical procedures including those related to cataract surgery(2). This entity conforms the first cause for corneal transplant in the USA (from 26 to 50%) and the second in Europe(3,4,5).
Clinically, BK is characterized by chronic ocular pain, which is secondary to recurrent epithelial defects, ocular surface inflammation and visual sharpness decrease(1). Definitive treatment for patients with BK with remaining visual potential is corneal transplant. However, donor grafts are not always available and they often require long waiting times. For those reasons, medical and surgical palliative measures should be temporarily used to relief ocular pain. Among others, the use of therapeutic contact lenses stands out as one of the best alternatives due to its contribution to the prevention of epithelial falling and ulceration, acting as a mechanical bandage(6,7,8). These contact lenses do not improve visual sharpness neither contribute to the resolution of the problem that originated corneal edema. Besides, prolonged use of contact lenses may be associated to potential complications such as ocular disturbance, superficial neovascularization, inflammation and corneal infections, together with the economical expenses that patients have to deal with(6).
In 1940, De Roth described for the first time the use of human amniotic membrane (AM) in ophthalmology, and since that date, multiple studies guaranteed its application as an efficient treatment for ocular surface diseases(9,10, 11), including BK(12,13,14,15,16,17,18). AM is a thin membrane covering the foetal side of the placenta, and it consists of the external chorion (maternal origin) and the internal amnion (foetal origin). Histologically, it is composed of three layers: epithelium, basal membrane and stroma(19).
The therapeutic effect of the AM involves three basic synergistic actions on the ocular surface: 1) induction of growth and proliferation of new epithelia on the tissues (cornea and/or conjunctiva), 2) control of the inflammation of the tissues under the implant and 3) inhibition of fibrosis and neovascularization of the corneal stroma(19). For all these reasons AM might be an effective treatment to ameliorate disturbances generated by BK. In addition, human amniotic epithelial cells do not express HLA surface antigens, which justifies the absence of graft rejection in this type of transplants(20,21) and makes it a highly safe procedure.
In the present work, we describe the results of a randomized clinical trial in which the AM grafting technique was compared with the use of therapeutic contact lenses for the management of symptomatic bullous keratopathy in patients waiting for a corneal transplant at Carlos Van Buren Hospital from Valparaiso, Chile.
PATIENTS AND METHODS Study design Randomized clinical trial. Patients The universe of this clinical trial are all patients with clinical diagnosis of symptomatic bullous keratopathy (corneal bullae, recurrent eye pain, foreign body sensation and photophobia), diagnosed at the Department of Ophthalmology Hospital Carlos Van Buren, Valparaiso, Chile, who were on the waiting list for corneal transplant from January 2008 to October 2011. Excluded patients were those with medical contraindication to undergo surgery with topical anesthesia, patients with severe systemic conditions and patients with corneal infections.
Twenty patients, corresponding to universe of patients during this period, accepted to participate in this study and were included in this clinical trial. All patients provided written consent to participate in this study, and the trial was approved by the Ethics Committee of the Faculty of Medicine, Universidad de Valparaiso (Nº 10/2011). Patients were randomized on a simple random basis from a prefabricated list and divided into two groups: study group (N=10), with the implant of the AM, and control group (N=10), in which contact lenses were used.
Clinical data and variables considered for the study were: demography, etiology of BK, ocular pain (evaluated by using a visual analogue scale ranging from 0 to 10) and visual acuity (Snellen scale). By using a bio-microscope we evaluated the presence of bullae and epithelial defects per quadrant (with fluorescein test) and neovascularization. After treatment, the same equipment was used to check for presence of traces of AM and complications (infection, wound dehiscence, etc) through serial controls performed over a period of 6 months.
Interventions Human AM was prepared and preserved in the Biomedical Research Centre using a method previously described by Lee and Tseng (1995). In the study group, amniotic membrane (AM) grafts were implanted in the affected eyes using topical anesthesia. Each graft was sutured to the bulbar conjunctive tissue using 10-0 nylon sutures and a reinforcement stitch was applied at the cornea (Figure 1).
Therapeutic contact lenses were applied in all patients included in the control group and the lenses were replaced every two months according to the pre-established gold standard for this procedure.
Clinical follow-up examination was performed on days 1, 7, 30, and then monthly until 6 months for both groups. Both groups were managed with topical gentamicin each 4 hours during the first week after surgery.
Statistical analysis. Data were analysed with Stata SE 12.0 software. Results corresponding to continuous variables were described by medians and interquartile range (IQR) and categorical medians were described by percentages and frequencies. Mann-Whitney statistical test was used to detect statistical differences between two continuous variables, and Fisher exact test was used for categorical variables. Association between quantitative variables was established by Kendal's tau correlation test. For all analysis, a value of p<0.05 was considered statistically significant and all analyses were carried out double tailed.
Study Type
Enrollment (Actual)
Phase
- Phase 2
Contacts and Locations
Study Locations
-
-
-
Valparaíso, Chile
- Universidad de Valparaiso
-
-
Participation Criteria
Eligibility Criteria
Ages Eligible for Study
- Child
- Adult
- Older Adult
Accepts Healthy Volunteers
Genders Eligible for Study
Description
Inclusion Criteria:
All patients with clinical diagnosis of symptomatic bullous keratopathy (corneal bullae, recurrent eye pain, foreign body sensation and photophobia), diagnosed at the Department of Ophthalmology Hospital Carlos Van Buren, Valparaiso, Chile, who were on the waiting list for corneal transplant from January 2008 to October 2011
Exclusion Criteria:
Excluded patients were those with medical contraindication to undergo surgery with topical anesthesia, patients with severe systemic conditions and patients with corneal infections.
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Treatment
- Allocation: Randomized
- Interventional Model: Parallel Assignment
- Masking: Double
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
Experimental: Implant of amniotic membrane grafts
Amniotic membrane grafts were implanted in the affected eyes using topical anesthesia.
Each graft was sutured to the bulbar conjunctive tissue using 10-0 nylon sutures and a reinforcement stitch was applied at the cornea
|
Amniotic membrane grafts were implanted in the affected eyes using topical anesthesia.
Each graft was sutured to the bulbar conjunctive tissue using 10-0 nylon sutures and a reinforcement stitch was applied at the cornea
|
Active Comparator: Therapeutic contact lenses
Therapeutic contact lenses were applied in all patients and the lenses were replaced every two months according to the pre-established gold standard for this procedure.
|
Therapeutic contact lenses were applied in all patients included in the control group and the lenses were replaced every two months according to the pre-established gold standard for this procedure.
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Ocular pain
Time Frame: 6 months
|
Evaluated by using a visual analogue scale ranging from 0 to 10
|
6 months
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Visual acuity
Time Frame: 6 months
|
Snellen scale
|
6 months
|
Corneal Neovascularization
Time Frame: 6 months
|
Evaluation using a bio-microscope
|
6 months
|
Corneal epithelial defects
Time Frame: 6 months
|
Evaluation using a bio-microscope per quadrant with fluorescein test
|
6 months
|
Complications
Time Frame: 6 months
|
Evaluation using a bio-microscope
|
6 months
|
Other Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Age
Time Frame: At the enrolling moment
|
In years
|
At the enrolling moment
|
Sex
Time Frame: At the enrolling moment
|
Male or Female
|
At the enrolling moment
|
Affected eye
Time Frame: At the enrolling moment
|
left eye or right eye
|
At the enrolling moment
|
Collaborators and Investigators
Sponsor
Collaborators
Investigators
- Principal Investigator: L. Venegas, Ophthalmology Unit, Van Buren Hospital, Valparaiso, Chile.
- Principal Investigator: M. Hettich, Ophthalmology Unit, Van Buren Hospital, Valparaiso, Chile.
- Principal Investigator: J. Villena, Biomedical Research Centre, School of Medicine, Universidad de Valparaiso, Chile.
- Principal Investigator: R. Aris, Biomedical Research Centre, School of Medicine, Universidad de Valparaiso, Chile.
- Principal Investigator: M. Párraga, Biomedical Research Centre, School of Medicine, Universidad de Valparaiso, Chile.
- Principal Investigator: O. Parolini, Centro di Ricerca E. Menni, Fondazione Poliambulanza-Istituto Ospedaliero, Brescia, Italy.
- Principal Investigator: M. Alaminos, Department of Histology, University of Granada, Spain
- Principal Investigator: A. Campos, Biomedical Research Centre, School of Medicine, Universidad de Valparaiso, Chile.
- Study Director: S, San Martin, Biomedical Research Centre, School of Medicine, Universidad de Valparaiso, Chile.
Publications and helpful links
General Publications
- Pires RT, Tseng SC, Prabhasawat P, Puangsricharern V, Maskin SL, Kim JC, Tan DT. Amniotic membrane transplantation for symptomatic bullous keratopathy. Arch Ophthalmol. 1999 Oct;117(10):1291-7. doi: 10.1001/archopht.117.10.1291.
- Nishida T. Cornea: Fundamentals of cornea and external disease. St. Louis, Mosby. 1997; p. 3-27.
- Courtright P, Lewallen S, Holland SP, Wendt TM. Corneal decompensation after cataract surgery. An outbreak investigation in Asia. Ophthalmology. 1995 Oct;102(10):1461-5. doi: 10.1016/s0161-6420(95)30845-7.
- Canner JK, Javitt JC, McBean AM. National outcomes of cataract extraction. III. Corneal edema and transplant following inpatient surgery. Arch Ophthalmol. 1992 Aug;110(8):1137-42. doi: 10.1001/archopht.1992.01080200117038.
- Cosar CB, Sridhar MS, Cohen EJ, Held EL, Alvim Pde T, Rapuano CJ, Raber IM, Laibson PR. Indications for penetrating keratoplasty and associated procedures, 1996-2000. Cornea. 2002 Mar;21(2):148-51. doi: 10.1097/00003226-200203000-00003.
- Maeno A, Naor J, Lee HM, Hunter WS, Rootman DS. Three decades of corneal transplantation: indications and patient characteristics. Cornea. 2000 Jan;19(1):7-11. doi: 10.1097/00003226-200001000-00002.
- Jablonski J, Szafran B, Cichowska M. [Treatment of corneal complications after cataract surgery with soft contact lenses]. Klin Oczna. 1998;100(3):151-3. Polish.
- Smiddy WE, Hamburg TR, Kracher GP, Gottsch JD, Stark WJ. Therapeutic contact lenses. Ophthalmology. 1990 Mar;97(3):291-5. doi: 10.1016/s0161-6420(90)32589-7.
- Leibowitz HM, Rosenthal P. Hydrophilic contact lenses in corneal disease. II. Bullous keratopathy. Arch Ophthalmol. 1971 Mar;85(3):283-5. doi: 10.1001/archopht.1971.00990050285006. No abstract available.
- Kim JC, Tseng SC. Transplantation of preserved human amniotic membrane for surface reconstruction in severely damaged rabbit corneas. Cornea. 1995 Sep;14(5):473-84.
- Kim JC, Tseng SC. The effects on inhibition of corneal neovascularization after human amniotic membrane transplantation in severely damaged rabbit corneas. Korean J Ophthalmol. 1995 Jun;9(1):32-46. doi: 10.3341/kjo.1995.9.1.32.
- Sangwan VS, Burman S, Tejwani S, Mahesh SP, Murthy R. Amniotic membrane transplantation: a review of current indications in the management of ophthalmic disorders. Indian J Ophthalmol. 2007 Jul-Aug;55(4):251-60. doi: 10.4103/0301-4738.33036.
- Georgiadis NS, Ziakas NG, Boboridis KG, Terzidou C, Mikropoulos DG. Cryopreserved amniotic membrane transplantation for the management of symptomatic bullous keratopathy. Clin Exp Ophthalmol. 2008 Mar;36(2):130-5. doi: 10.1111/j.1442-9071.2008.01696.x.
- Lee HI, Ha SW, Kim JC. A novel application of amniotic membrane in patients with bullous keratopathy. J Korean Med Sci. 2006 Apr;21(2):324-8. doi: 10.3346/jkms.2006.21.2.324.
- Lopez Ferrando N, Celis Sanchez J, Gonzalez Del Valle F, Lopez Mondejar E. [Monolayered amniotic membrane transplantation as a palliative treatment for bullous keratopathy]. Arch Soc Esp Oftalmol. 2004 Jan;79(1):27-31. doi: 10.4321/s0365-66912004000100007. Spanish.
- Espana EM, Grueterich M, Sandoval H, Solomon A, Alfonso E, Karp CL, Fantes F, Tseng SC. Amniotic membrane transplantation for bullous keratopathy in eyes with poor visual potential. J Cataract Refract Surg. 2003 Feb;29(2):279-84. doi: 10.1016/s0886-3350(02)01525-0.
- Panda A, Pangtey MS, Sony P. Response to symptomatic management of postoperative bullous keratopathy with nonpreserved human amniotic membrane. Cornea. 2003 Mar;22(2):187; author reply 187-8. doi: 10.1097/00003226-200303000-00024. No abstract available.
- Mejia LF, Santamaria JP, Acosta C. Symptomatic management of postoperative bullous keratopathy with nonpreserved human amniotic membrane. Cornea. 2002 May;21(4):342-5. doi: 10.1097/00003226-200205000-00002.
- Shimmura S, Shimazaki J, Ohashi Y, Tsubota K. Antiinflammatory effects of amniotic membrane transplantation in ocular surface disorders. Cornea. 2001 May;20(4):408-13. doi: 10.1097/00003226-200105000-00015.
- Adinolfi M, Akle CA, McColl I, Fensom AH, Tansley L, Connolly P, Hsi BL, Faulk WP, Travers P, Bodmer WF. Expression of HLA antigens, beta 2-microglobulin and enzymes by human amniotic epithelial cells. Nature. 1982 Jan 28;295(5847):325-7. doi: 10.1038/295325a0. No abstract available.
- Akle CA, Adinolfi M, Welsh KI, Leibowitz S, McColl I. Immunogenicity of human amniotic epithelial cells after transplantation into volunteers. Lancet. 1981 Nov 7;2(8254):1003-5. doi: 10.1016/s0140-6736(81)91212-5.
Study record dates
Study Major Dates
Study Start
Primary Completion (Actual)
Study Completion (Actual)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Estimate)
Study Record Updates
Last Update Posted (Estimate)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Additional Relevant MeSH Terms
Other Study ID Numbers
- RARIS-001
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