Technique

All cases were done by two cornea surgeons, (SJ, HJ) under peribulbar anaesthesia with supplementary intravenous sedation whenever required. Cryopreserved AM was washed with Balanced Salt Solution three times, to reduce any possibility of contamination.[6] . Excision of the infected cornea leaving behind a rim of the healthy noninfected cornea was done. Exudates on & behind the iris were removed carefully, sacrificing infiltrate-laden non-viable iris, if needed. A core vitrectomy was done if needed. The amniotic membrane was cut into appropriate, sized pieces &multiple layers (3-4) were placed onto the ulcer bed, with fibrin glue between each layer. Then a piece of AM was trimmed to adequately cover the ulcer bed, placed epithelial side up & sutured with 10-0 nylon interrupted sutures. Lastly, a large piece of AM was used to cover the entire cornea and secured with interrupted sutures placed (Sandwich Technique) and BCL was placed [7].

Postoperatively, patients were continued on topical antifungals, prophylactic antibiotics, antiglaucoma & tear substitute drops.

At each postoperative visit, the following were monitored:1) Epithelisation 2) Localisation of the infiltrates (location, size, depth) 3) Resolution of infection 4) Need for TPK

Figure 1C: Post healing- adherent leucoma
Figure 1D: Post-Optical Keratoplasty

Figure 2 – Case 5
Figure 2A:Perforated fungal ulcer
Figure 2B: Post multi-layered AMG

Table 1-Clinical findings & outcome of AMT in case series of 9 patients

AM can reduce tissue damage & promote wound healing. [4]. Although in the past there were concerns about the recurrence of infection with AM transplantation, recent reports show that cryopreserved AM with intrinsic anti-infective properties has been used successfully in the treatment of non-healing corneal ulcers. [7,8]. It has been used in non-healing bacterial ulcers, [9]. also in acanthamoeba & HSV necrotising stromal keratitis.[10,5]. It has been used in Aspergillus, Fusarium & other persistent fungal infections [10,11]. with very low and treatable recurrence of infection even in active fungal keratitis [11]. In our case series too, there was no reinfection. AM is used as a single-layer inlay or overlay, multi-layered inlay or sandwich technique depending on the depth of the ulcer. [7,10].

Add what new this study adds to existing knowledge under the separate heading.

Newer Insights: In many cases reporting the use of AMG for nonhealing ulcers, keratitis was in the form of persistent epithelial defect with early sterile stromal melt.in these cases, a temporary AM as a patch, either sutured or self-retained (PROKERA ) resulted in surface healing [7,10]. In contrast, all our cases were infective melts or perforations. So a single-layer AM graft would have melted or dissolved due to overwhelming infection & inflammation. There are reports of the use of AMT for frank infections too, but those were central or paracentral small and superficial ulcers.[8,10]. unlike our series where all cases were severe progressive, limbus reaching or perforated ulcers. AMT has been used quite effectively for bacterial, acanthamoeba & herpes simplex keratitis, [5,7]. but in very few fungal keratitis cases, unlike our series where the majority were fungal. Another difference in the technique of AMG is most case series report the use of a single-layer overlay, or multi-layered inlay technique [8,11,12]. whereas we have used a combination or sandwich technique and method of using several pieces of AM as an inlay with the use of fibrin glue &onlay patch with sutures probably worked like a tectonic patch graft.

As all our cases were very severe keratitis, a single layer of AM would have melted within a few days. The use of multi-layered AM in ulcers with marginal residual stromal tissue, prevented aqueous leak & anterior chamber collapse, whereas, in perforated ulcers, it provided some tectonic support, possibly