Eye of a human immunodeficiency virus–positive 10-year-old girl who had received amniotic membrane transplantation for a central corneal opacification with neovascularization (60th postoperative day). A, The amniotic membrane was fully reabsorbed without any adverse effect. B, After suture removal, the good corneal transparency achieved with mild ocular inflammation is apparent. Only a few residual vessels are observable on the inferior corneal sectors.
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Capozzi P, Morini C, Vadalà P. Amniotic Membrane Transplantation in Human Immunodeficiency Virus–Positive Children. Arch Ophthalmol. 2008;126(6):866–876. doi:10.1001/archopht.126.6.866
Amniotic membrane transplantation (AMT) is a beneficial and safe procedure in several ocular surface impairments.1 Reported adverse effects of AMT are pseudopterygium, postoperative bacterial ulcer, ocular discomfort, and fibrotic reaction.2,3 Goyal et al4 recently observed an organized amniotic membrane in a human immunodeficiency virus (HIV)–positive child after an AMT for symblepharon. We report a similar case of an HIV-positive patient treated with an AMT at our institution.
An HIV-positive 10-year-old girl with a history of herpetic keratitis and penetrating keratoplasty (January 2006) of the right eye was referred to our pediatric ophthalmology service in June 2006. At our examination, visual acuity was +1.7 logMAR (logarithm of minimum angle resolution) OD and 0.0 logMAR OS. The cornea had a central opacification that was deeply vascularized. A severe active corneal inflammation was present. Fundus examination in the right eye was not valuable. We treated the patient with an AMT to reduce the neovascularization before a second penetrating keratoplasty. The amniotic membrane was provided by the S. Giovanni Eye Bank, Rome, Italy. Preservation methods and transplantation followed the surgical technique described by Lee and Tseng,5 with the basement membrane facing down and assured by 8 interrupted nylon 10.0 sutures. Postoperative treatment included topical antibiotic and fluorometholone, 0.1%, eyedrops for 2 weeks. The patient underwent ocular examinations on a daily basis for the first 4 days and then once a week for 3 months. Suture removal was performed in August 2006.
The clinical course in this patient was successful, as it has been for other pediatric AMTs performed at our institution.
We observed a progressive reduction of the neovascularization and inflammation and a remarkable increase of the corneal transparency (Figure).
On the 40th postoperative day, the amniotic membrane was fully reabsorbed and visual acuity improved to 0.5 logMAR OD. Clinical conditions were stable in the follow-up period, and the patient is currently on a waiting list for a second penetrating keratoplasty.
In the reported case, AMT was effective in reducing the corneal neovascularization and surface inflammation and allowed for an improved corneal transparency, likely through a partial restoration of the limbal stem cell pool. These effects were important while planning a second corneal graft. In fact, chronic surface inflammation and corneal neovascularization are well-known risk factors for a keratoplasty rejection.6 Through the AMT, the reduction of these risk factors was achieved, avoiding long-term local and systemic steroidal therapies. Moreover, we did not see any adverse effect or unusual reaction, as observed by Goyal et al.4
In the article by Goyal and colleagues, a severe fibrotic reaction was observed after AMT in an HIV-positive child. The thickened membrane was removed. The investigators presumed that “the abnormal CD4+ T lymphocytes . . . were unable to recognize the amniotic membrane as foreign . . . , resulting in an abnormal immune reaction,” and they concluded that “its vision potential in patients with altered immune systems should be guarded, given our experience in 1 patient with HIV.”4 We assume that the difference in the pathogenesis of the diseases in these 2 children may explain the different reaction to the amniotic membrane. Indeed, given the satisfactory results observed in our case, we do not support their suggestion.
Correspondence: Dr Morini, Pediatric Ophthalmology Service, Ospedale Pediatrico Bambino Gesù, Piazza S. Onofrio 4, 00165 Rome, Italy (firstname.lastname@example.org).
Financial Disclosure: None reported.