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Comparison of Amniotic Membrane Transplantation and Umbilical Cord Serum in Acute Ocular Chemical Burns: A Randomized Controlled Trial
Accepted Manuscript Comparison of Amniotic Membrane Transplantation and Umbilical Cord Serum in Acute Ocular Chemical Burns: A Randomized Controlled Trial Namrata Sharma, Divya Singh, Prafulla K. Maharana, Alka Kriplani, Thirumurthy Velpandian, Ravindra Mohan Pandey, Rasik B. Vajpayee PII:
S0002-9394(16)30221-5
DOI:
10.1016/j.ajo.2016.05.010
Reference:
AJOPHT 9745
To appear in:
American Journal of Ophthalmology
Received Date: 19 November 2015 Revised Date:
9 May 2016
Accepted Date: 11 May 2016
Please cite this article as: Sharma N, Singh D, Maharana PK, Kriplani A, Velpandian T, Pandey RM, Vajpayee RB, Comparison of Amniotic Membrane Transplantation and Umbilical Cord Serum in Acute Ocular Chemical Burns: A Randomized Controlled Trial, American Journal of Ophthalmology (2016), doi: 10.1016/j.ajo.2016.05.010. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Abstract Purpose To compare the efficacy of topical umbilical cord serum drops (UCS) and amniotic membrane transplantation (AMT) in acute ocular chemical burns. Design: Randomized Controlled Trial Methods Setting: Tertiary care hospital. Study Population: 45 eyes with acute chemical burns of grade III, IV and V (Dua’s classification) presenting within the first week of injury were randomized into 3 groups (15 each). Patients with perforation/impending corneal perforation were excluded from the study. Intervention: Group1, 2 and 3 received UCS with medical therapy (MT), AMT with MT and MT alone respectively. Main Outcome Measure: Time to complete epithelialization. Results: The mean time to complete epithelialization was 56.7 ± 14.9, 22.0 ± 10.2, and 22.9 ± 10.1 days in MT, AMT, and UCS groups respectively, with a significant difference between MT and AMT (p= 0.001); between MT and UCS (p=0.001), but not between UCS and AMT (p=0.9). Improvement in pain score was better with UCS than AMT (p value; 0.012, 0.002, and 0.012 on day 7, 14, and 21 respectively). Corneal clarity was better in the UCS group at 21 (p=0.008) and 30 days (p=0.002), but not at 3 months (p=0.9). By month 3,visual outcome, symblepharon, tear film status and lid abnormalities were comparable between the 3 groups. Conclusions: UCS and AMT, as an adjuvant to standard medical therapy in acute chemical injury, are equally efficacious. UCS has the advantage of faster improvement in corneal clarity, better pain control and avoidance of surgery in an inflamed eye.
ACCEPTED MANUSCRIPT Comparison of Amniotic Membrane Transplantation and Umbilical Cord Serum in Acute Ocular Chemical Burns: A Randomized Controlled Trial Authors Namrata Sharma1
Prafulla K. Maharana1 Alka Kriplani2 Thirumurthy. Velpandian1
Rasik B.Vajpayee4
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Ravindra Mohan Pandey 3
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Divya Singh1
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1- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi 2- Department of Obstetrics & Gynaecology, All India Institute of Medical Sciences, New Delhi 3- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi 4- Vision Eye Institute, Royal Victorian Eye and Ear Hospital, North West Academic Centre, University of Melbourne, Australia
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Short title: Cord serum and Amniotic Membrane in Ocular Chemical Burns Address for correspondence: Namrata Sharma, MD
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Professor of Ophthalmology, Cornea & Refractive Surgery Services, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Ansari Nagar, New Delhi – 110029, India
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Email: [email protected], Fax: 91-11-26588919
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ACCEPTED MANUSCRIPT Introduction
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Ocular chemical burns are true emergencies that require rapid assessment and initiation of treatment. Chemical injuries of the eyes cause damage to the ocular surface epithelium, cornea and anterior segment. Thus, immediate and effective treatment influences the final outcome favorably. The primary goals of therapy in ocular chemical burns include restoration of an intact ocular epithelium, control of inflammatory reaction, prevention of infection, support of reparative processes and prevention of complications.1
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Standard medical therapy comprises of topical steroids, topical antibiotics, mydriatics and cycloplegics, topical or oral antiglaucoma therapy, and topical citrate and ascorbate. Various newer treatment modalities have been tried during the acute phase to minimize the damage to the ocular surface, enhance the ongoing healing process and prevent long-term sequelae. These newer modalities include; oxygen therapy,2 amniotic membrane extract,3 amniotic membrane transplantation (AMT),4-8 and umbilical cord serum (UCS) eye drops.9 Both UCS and amniotic membrane are rich in growth factors like EGF, NGF, FGF, TGF-β, vitamin A, fibronectin, and serum antiproteases like α2-macroglobulin.4-9 Both have shown efficacy in acute ocular thermal burns.4-9, 14-16 In this prospective randomised study, we compared the efficacy of AMT with UCS drops in the management of acute ocular chemical burns.
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Materials and methods A prospective randomized controlled clinical trial was planned and approval from the institutional review board (IRB)/Ethics Committee of Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India was taken. The research adhered to the tenets of the Declaration of Helsinki. The study has been registered under the Clinical Trials Registry, India (CTRI/2014/09/005067), National Institute of Medical Statistics, ICMR New Delhi (www.ctri.nic.in). We included patients who presented with acute ocular chemical burns (grade III, IV and V according to Dua’s classification 18 presenting within 2 weeks of injury and willing to participate in the study between the period of 01.06.2013 to 01.10.2014. So we evaluated both the limbal involvement and the conjunctival involvement and later calculated the analogue score as has been described by Dua’s classification. Hence, no separate mention has been made about the perilimbal ischemia in concordance with the Dua’s classification. Informed consent was obtained from all the patients. Patients with grade I, II, and VI injury, those with perforation/impending corneal perforation or not willing to participate in the study were excluded from the study. A total of 51 eyes (30 patients, with 21 bilateral and 9 unilateral involvement) were recruited for the study. Three patients (with bilateral involvement) refused to participate in the study hence excluded. A written informed consent was obtained, and the patients were randomized into three groups using a random numbers table.. Group I (n=15) received conventional medical therapy (control group), group II (n=15) received AMT with conventional medical therapy, and group III (n=15) received 20% UCS drops along with conventional medical therapy. In bilateral cases, each eye was randomized separately. Appropriate first-aid therapy in the form of irrigation with normal saline to achieve a neutral pH and removal of any particulate matter from the ocular surface was done in all cases. Group-I (Medical treatment) cases received conventional medical therapy, which included topical moxifloxacin hydrochloride 0.5% (Vigamox; Alcon, Texas, 2
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USA) 4 times per day; sodium ascorbate (10%) and sodium citrate (10%) every 2 hours, preservative free lubricants and topical prednisolone acetate 1% (Predforte; Allergan, Bangalore, India) every 2 hours; homatropine sulphate (2%) four times per day and oral vitamin C (500 mg) four times a day for two to four weeks. Antiglaucoma therapy in the form of timolol maleate (0.5%) two times per day and oral acetazolamide (250 mg) three times per day was given, when required. Group II cases received AMT with conventional therapy. Amniotic membrane was collected from seronegative donors (Human Immuno deficiency Virus (HIV), hepatitis B, hepatitis C, and syphilis) with uncomplicated caesarean section after obtaining informed consent. The amniotic membrane preparation was done using the standard technique which has been previously described.5 AMT was done using the onlay technique. Surgery was performed under peribulbar or general anaesthesia (if required) in adults and general anaesthesia in children. After transferring the amniotic membrane onto the operative field, peeling off the nitrocellulose membrane was done and the amniotic membrane was spread to cover the entire ocular surface with the stromal side touching the ocular surface. Interrupted 8-0 Vicryl sutures (Ethicon, Johnson & Johnson, Ahmedabad, India) were used to anchor the underlying conjunctiva and the episclera to the amniotic membrane around the limbus.5 A symblepharon ring was then put to uniformly spread the membrane and to flatten it against the ocular surface, especially in the fornices and along the palpebral conjunctiva. Additionally, interrupted Vicryl sutures were also applied to anchor the membrane along the lid margins. The eyes were bandaged after the surgery and the topical medications were continued in the postoperative period. Group-III cases received 20% UCS drops along with conventional medical therapy. The umbilical cord blood was collected from seronegative donors (hepatitis B, hepatitis C, HIV and syphilis) with uncomplicated caesarean deliveries after obtaining informed consent. Screening for parenterally transmitted diseases was done at the time of antenatal care registration and further repeated at the time of cord blood collection and three months after the cord blood collection. Cord blood serum was prepared according to the standard technique which has been previously described.9 Serum bottles were stored at −20°C before opening a nd at 4°C after opening. Patients were instructed to use serum vials within 7 days and to come back for a fresh vial after that. The patients were also instructed to look for the presence of any threadlike floating objects in the serum before instilling the drops and to discard the same vial if such contaminants were seen. The UCS eye drops (20%) were instilled 10 times per day until complete epithelialization was noted. Baseline evaluation included a comprehensive history with reference to the nature of chemical causing the damage to the ocular surface, duration of exposure to the chemical causing the injury, initial treatment received, and the time elapsed between exposure to the chemical and presentation at our centre. Best-corrected visual acuity (BCVA) was recorded using the logarithm of the minimum angle of resolution (logMAR) chart. Slit-lamp (Haag-Streit AG, Koeniz, Switzerland) examination was done. Other parameters noted at the initial visit included grade of chemical injury,18 corneal clarity,9 pain score,19 epithelial defect diameter (EDD) and the extent of limbal involvement. Additionally, epithelial defect area (EDA) was calculated as the product of the largest diameter and the diameter perpendicular to it.20 Tear film status, was assessed using the Schirmer test and tear break up time (TBUT), intraocular pressure and any other anterior segment or fundus abnormalities were noted. Patients were followed up on days 3, 7, 14, 21 and at the end of 1, 2 and 3 months. The parameters evaluated were time to epithelialization, size of the
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epithelial defect, corneal clarity grading, corneal vascularization, symblepharon formation, tear film status, lid abnormalities, limbal involvement, pain score, and visual acuity. Clinical photographs were recorded at each visit. The pain scoring was done using a numeric pain rating scale19 as summarised in table-1. Statistical analysis Keeping the power of study as 0.8 and the level of significance at 0.05, with the primary outcome measure being the mean time for complete epithelialization, a minimum sample size of 15 eyes was required in each group. All patients completed the scheduled follow-up. The statistical analysis was done using SPSS software for Windows. Time of epithelial healing was analyzed using Kaplan–Meier analysis. The χ2 test and Fischer exact test were used for comparing qualitative data; for parametric quantitative data, one-way analysis of variance (ANOVA) was used to compare intergroup means and Bonferroni correction was used to analyse post-test results; Kruskal–Wallis and Mann–Whitney tests were used for non-parametric quantitative data. For descriptive purposes, non parametric data have been expressed as median (range), parametric qualitative data has been expressed as a percentage and quantitative data has been expressed as mean ± standard deviation (SD). Results A total of 45 eyes with acute chemical burns were included and followed up for a period of 3 months. All patients completed the follow-up. The baseline characteristics such as; age, time between exposure and presentation, nature of chemical causing injury, treatment received initially, and Dua’s grading at presentation were comparable between the three groups (Table-2). Alkali burns were the most common, occurring in 24 eyes (53.3%), and acid burns occurred in 21 eyes (46.7%). The groups were comparable with regard to the nature of chemical exposure (p = 0.765). According to Dua’s classification, 23 eyes had a grade III injury, 9 eyes had a grade IV injury and 13 eyes had a grade V injury. The distribution was comparable across the groups (p = 0.548) [Table-2]. The epithelial defect had healed in all eyes in the UCS group, 14 of 15 eyes in AMT group, and 10 of 15 eyes in the medical therapy group at 3 months follow-up. The mean time to complete epithelialization was 56.7 ± 14.9, 22.0 ± 10.2, and 22.9 ± 10.1 days in medical therapy, AMT, and UCS groups respectively. The mean time for complete absorption of the amniotic membrane was 21 ± 3 days. The minimum and maximum time of healing being 28 and 91 days in medical therapy, 14 and 56 days in AMT, and 7 and 56 days in UCS groups. The difference was statistically significant between medical therapy and AMT groups (p= 0.001), and also between medical therapy and UCS groups (p=0.001) but no difference was found between UCS and AMT group (p=0.9). Kaplan–Meier survival analysis revealed that the differences in time of corneal epithelialization between the three groups were statistically significant (Figure 1, p = 0.001). The mean EDD at presentation was 5.6 ± 1.9, 6.0 ± 2.2, and 5.2 ± 2.4 mm in medical therapy, AMT, and UCS groups, respectively which were comparable (p = 0.696) [Table-3]. By the end of 21 days, EDD was 2.6 ± 1.3, 0.2 ± 0.6, and 0.2 ± 0.4 mm in medical therapy, AMT and UCS groups respectively. A significant difference was seen between medical therapy and AMT groups, and medical therapy and UCS groups at all follow-ups, but no significant difference was seen between AMT and UCS group at any follow-up as shown in table-3. The mean EDA at presentation was 32.6 ± 20.6, 37.9 ± 22.1, and 30.5 ± 22.7 mm2 in medical therapy, AMT, and UCS groups, respectively which was comparable
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(p = 0.690). By the end of 21 days the epithelial defect area was 6.8 ± 7.5, 0.4 ± 1.2, and 0.3 ± 1.0 mm2 in medical therapy, AMT, and UCS groups respectively with significant differences between medical therapy and AMT (p= 0.001), and medical therapy and UCS (p=0.001) groups but not between AMT and UCS group (p=0.90). At the time of presentation the median values for pain scores were 6, 6, and 5 in medical therapy, AMT, and UCS groups, respectively which were comparable in the three groups (p=0.101), and which decreased to the median values of 4, 5, and 5 in medical therapy, AMT, and UCS groups by day 7. A significant difference was seen between MT and AMT at day 7 (p=0.025) but not on subsequent follow up as shown in table-4. A significant difference was seen between MT and UCS groups only at 1 month follow-up (p= 0.043). However, UCS was better than AMT at all the follow-up as shown in table-4.
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The limbal involvement (in clock hours) at the time of presentation was 5.8 ± 2.5, 7.3 ± 2.5, and 6.1 ± 2.6 in MT, AMT, and UCS groups respectively which was comparable in the three groups (p = 0.123). The number of clock hours of limbus involved at the end of three months in the MT, AMT, and the UCS group were 3.7± 3.2, 1.5 ±1.9, and 0.9 ±1.2 respectively. This difference was found to be significantly different in the AMT group (p=0.015) and UCS group (p=0.001) when compared to the MT group alone. At the end of three months, the percentage decrease in limbal involvement was 44.2 ± 23.8, 84.7 ± 18.9, and 83.9 ± 18.4 in medical therapy, AMT, and UCS groups, respectively, which was significantly different amongst the MT and AMT groups (p = 0.001), and MT and UCS groups (p = 0.001) but no difference was seen between the UCS and AMT group (p=0.9). There was no need for repeat AMT or tarsorrhaphy in any of the patients.
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The pretreatment corneal clarity was comparable between the three groups (p = 0.774) [Table-5]. Although a significant difference was seen between AMT and UCS groups at the end of 21 days (p = 0.008) and 1 month (p = 0.002), but no significant difference was seen in corneal clarity between the three groups at the last follow-up (p = 0.069) as shown in table-5. In the medical therapy group, 11 eyes had 1 quadrant, 1 eye had 2 quadrants, 1 eye had 3 quadrants, and 2 eyes had 4 quadrants of vascularization. In the AMT group, a total of 3 eyes had 1 quadrant, 3 eyes had 2 quadrants, and 1 eye had 3 quadrants of vascularization. In the UCS group, 7 eyes developed 1 quadrant and 1 eye developed 2 quadrants of vascularization. The difference was found to be significantly different between medical therapy and AMT groups (p=0.001), and medical therapy and UCS groups (p=0.006), but no difference was seen between the AMT and UCS group at last follow-up (p=0.3). At the end of three months, no significant difference was seen in the final visual outcome (p = 0.086), symblepharon formation (p = 0.185), TBUT (p = 0.343), Schirmer test reading (p = 0.056), and lid abnormalities (p = 0.572) between the three groups (Table-6). Various modalities have been described previously like AS eye drops, UCS eye drops, AMT and limbal stem cell transplantation for management of acute ocular chemical burns.4-9, 20-23 There has been a renewed interest in the AMT with a large number of studies documenting enhanced epithelial growth rates in cases of moderate to severe acute chemical burns. Umbilical cord serum has previously been used for the management of dry eye, recurrent corneal erosions, neurotrophic
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keratitis and persistent corneal epithelial defects with favourable outcomes.14-17 In 2011, we, in a randomised controlled trial, demonstrated that UCS is superior to both autologous serum and conventional therapy for the management of acute ocular chemical burns.9 In another randomised trial in 2005, it was shown that epithelialization was faster with AMT compared with the conventional therapy in mild to moderate acute chemical burns (Grades II–IV, Roper–Hall classification).20 In one of our earlier retrospective study, we found that both UCS and AMT are useful in acute chemical burns, but UCS therapy may be a better alternative to AMT as it avoids surgical manoeuvre in already inflamed eyes.24 To the best of our knowledge this is the first prospective study to compare these different treatment modalities. We did not find any significant difference between UCS eye drops and AMT in the healing of the epithelial defect, however both of them are superior to conventional medical management. Our experience on chemical injury suggests that epithelial defect may take beyond three months to heal, especially in cases where the limbal stem cells have not recovered completely. This could be attributed to the recurrent epithelial breakdown which prevented complete epithelialization.Hence, the patients were treated on the designated therapy. Our results corroborate the findings of previous studies that both UCS and AMT are beneficial adjuncts to conventional medical management in ocular chemical burns. Both UCS and amniotic membrane are rich in a variety of growth factors like EGF, NGF, FGF, TGF-β, vitamin A, fibronectin and serum antiproteases like α2-macroglobulin.10-17 These stimulate proliferation of corneal epithelium and increase the tensile strength of wounds. We did not find any correlation between the visual recovery and the time to epithelialization as the visual outcome following the healing of an acute case of chemical injury depends upon several other factors such as the presence of conjunctivalisation, vascularization, corneal haze and other co-morbidities in these patients such as glaucoma and posterior segment pathologies. Furthermore, we found that UCS has certain advantages over AMT, such as early reduction of pain scores and faster improvement in corneal clarity. The higher concentration of growth factors in UCS is the main reason which may lead to faster healing. However, it may be possible that the AMT group had a higher number of cases with severe grades of injury which itself can lead to a lower pain score at baseline due to associated damage to the nerve fibers and a consequent poor pain control compared to UCS. Numeric pain score depends upon the subjective response of the patient. Pain scores were higher at 21 days in the MT group owing to the slower epithelial healing however in the AMT group higher pain scores were attributed to the surgical intervention and the placement of sutures to anchor the graft to host bed. Lastly, UCS group showed better epithelial healing and there was no associated surgical intervention which could have resulted in the lesser pain score in this group. The other advantage of UCS is that large amount of sample can be withdrawn from the umbilical vein at the time of delivery and the serum can be supplied to many patients. As UCS drops can be prepared in advance, patients don’t need to wait for additional preparations. Further the patients do not need to undergo a surgery in acutely inflamed eye. UCS is also useful in cases where the patient is too debilitated to undergo surgery due to anaesthetic indications or refuses surgery. Similarly, in pediatric chemical injuries unnecessary general anaesthesia can be avoided by using UCS. The use of UCS therapy has the potential drawback of availability compared to AMT, as the facility for the procurement of cord serum may not be available at all centres since it is not commercially available. However, since cord serum may not be available at peripheral centres, AMT may be more
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appropriate in these situations. In our study we did not come across any complications such as infection, suture related problems in AMT group or severe inflammation. However, infectious keratitis is a likely possibility with the use of UCS and another study with larger sample size might be needed to further evaluate the associated complications. Even though both UCS and AMT are beneficial for the management of ocular chemical burns, it is important to remember a few facts regarding their use; firstly both of these modalities carry a risk for the transmission of parenteral diseases and serological testing at least twice to account for the window period of infections is essential to minimize this risk. Secondly, preparation of both requires expensive processing and preservation facilities, which are often scarce in developing countries. Moreover, legal and ethical issues might crop up when using these modalities. There are certain limitations to the study. First of all a close observation of the groups suggests a higher proportion of cases with severe grade of chemical burns in AMT group. Even though the three groups were comparable at baseline, which may be due to a small sample, it could have resulted in a better outcome in the UCS group in parameters such as corneal clarity and pain score. Secondly, all cases enrolled had received some sort of treatment before being referred to us and it cannot be ruled out that the initial treatment could have influenced the outcomes in the three groups.
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Thus, to conclude cord serum therapy and amniotic membrane transplantation as an adjuvant to standard medical therapy improves the final outcome in cases of acute chemical injury. Depending upon their availability and the patients condition either can be used in moderate grades of acute chemical burns. Our study did not include grade I, II and VI chemical burns, thus a larger study including all grades of chemical burns may be useful to evaluate the role of these adjuvants especially in grade VI where the prognosis is often grim.
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ACCEPTED MANUSCRIPT References
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1. Wagoner MD. Chemical injuries of the eye: current concepts in pathophysiology and therapy. Surv Ophthalmol 1997;41(4):275-313. 2. Sharifipour F, Baradaran-Rafii A, Idani E, Zamani M, Jabbarpoor Bonyadi MH. Oxygen therapy for acute ocular chemical or thermal burns: a pilot study. Am J Ophthalmol 2011;151(5):823-828. 3. Liang L, Li W, Ling S, et al. Amniotic membrane extraction solution for ocular chemical burns. Clin Experiment Ophthalmol 2009;37(9):855-863. 4. Tejwani S, Kolari RS, Sangwan VS, Rao GN. Role of amniotic membrane graft for ocular chemical and thermal injuries. Cornea 2007;26(1):21–26. 5. Tandon R, Gupta N, Kalaivani M, Sharma N, Titiyal JS, Vajpayee RB. Amniotic membrane transplantation as an adjunct to medical therapy in acute ocular burns. Br J Ophthalmol 2011;95(2):199–204. 6. Prabhasawat P, Tesavibul N, Prakairungthong N, Booranapong W. Efficacy of amniotic membrane patching for acute chemical and thermal ocular burns. J Med Assoc Thai 2007;90(2):319–326. 7. Meller D, Pires RT, Mack RJ, et al. Amniotic membrane transplantation for acute chemical or thermal burns. Ophthalmology 2000;107(5):980–989. 8. Kobayashi A, Shirao Y, Yoshita T, et al. Temporary amniotic membrane patching for acute chemical burns. Eye (Lond) 2003;17(2):149–158. 9. Sharma N, Goel M, Velpandian T, Titiyal JS, Tandon R, Vajpayee RB. Evaluation of umbilical cord serum therapy in acute ocular chemical burns. Invest Ophthalmol Vis Sci 2011;52(2):1087–1092. 10. Koizumi NJ, Inatomi TJ, Sotozono CJ, Fullwood NJ, Quantock AJ, Kinoshita S. Growth factor mRNA and protein in preserved human amniotic membrane. Curr Eye Res 2000;20(3):173–177. 11. Tseng SCG, Espana EM, Kawakita T, et al. How does amniotic membrane work? Ocul Surf 2004;2(3):177–187. 12. Touhami A, Grueterich M, Tseng SCG. The role of NGF signaling in human limbal epithelium expanded by amniotic membrane culture. Invest Ophthalmol Vis Sci 2002;43(4):987–994. 13. Lee SB, Li DQ, Tan DT, Meller DC, Tseng SC. Suppression of TGF-beta signaling in both normal conjunctival fibroblasts and pterygial body fibroblasts by amniotic membrane. Curr Eye Res 2000;20(4):325–334. 14. Yoon KC, Heo H, Jeong IY, Park YG. Therapeutic effect of umbilical cord serum eyedrops for persistent corneal epithelial defect. Korean J Ophthalmol 2005;19(3):174–178. 15. Yoon KC, Im SK, Park YG, Jung YD, Yang SY, Choi J. Application of umbilical cord serum eyedrops for the treatment of dry eye syndrome. Cornea 2006;25(3):268–272. 16. Yoon KC, You IC, Im SK, Jeong TS, Park YG, Choi J. Application of umbilical cord serum eyedrops for the treatment of neurotrophic keratitis. Ophthalmology 2007;114(9):1637–1642. 17. Yoon KC, Choi W, You IC, Choi J. Application of umbilical cord serum eyedrops for recurrent corneal erosions. Cornea 2011;30(7):744–748. 18. Dua HS, King AJ, Joseph A. A new classification of ocular surface burns. Br J Ophthalmol 2001;85(11):1379–1383. 19. McCaffery M. Using the 0-to-10 pain rating scale. Am J Nurs 2001;101(10):81-82.
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20. Mukerji N, Vajpayee RB, Sharma N. Technique of area measurement of epithelial defects. Cornea 2003;22(6):549–551. 21. Tamhane A, Vajpayee RB, Biswas NR, et al. Evaluation of amniotic membrane transplantation as an adjunct to medical therapy as compared with medical therapy alone in acute ocular burns. Ophthalmology 2005;112(11):1963–1969. 22. Sridhar MS, Bansal AK, Sangwan VS, Rao GN. Amniotic membrane transplantation in acute chemical and thermal injury. Am J Ophthalmol 2000;130(1):134–137. 23. Kheirkhah A, Johnson DA, Paranjpe DR, Raju VK, Casas V, Tseng SC. Temporary sutureless amniotic membrane patch for acute alkaline burns. Arch Ophthalmol 2008;126(8):1059–1066. 24. Sharma N, Lathi SS, Sehra SV, et al. Comparison of umbilical cord serum and amniotic membrane transplantation in acute ocular chemical burns. Br J Ophthalmol 2015;99(5):669-673.
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ACCEPTED MANUSCRIPT Figure Legends Figure 1: Kaplan-Meier survival analysis showing time to epithelialisation in medical therapy, amniotic membrane transplant, and umbilical cord serum groups in acute
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ocular chemical burns.
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Grade Severity No pain 0 1 Mild pain 2 3 4 Moderate pain 5 6 7 8 Severe pain 9 10 Footnotes: mild, moderate, or severe is purely based on patient’s description of pain
ACCEPTED MANUSCRIPT Table 2: Comparison of Pretreatment variables between medical therapy, amniotic membrane transplant, and umbilical cord serum groups in acute ocular chemical burns Baseline variables
Standard treatment group
Amniotic membrane group
Cord blood serum group
(n=15)
(n=15)
22.9 ± 17.4
p value
a
(n =15) 18.1 ± 11.3
Time between exposure and presentation in days, mean ± SD
4.2 ± 1.4
3.9 ± 1.5
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21.9 ± 13.9
4.0 ± 1.2
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Age in years, b mean ± SD
0.953
Nature of chemical 8(53.3%)
7(46.7%)
Alkali
7(46.7%)
8(53.3%)
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Acid
6(40.0%) 9(60.0%)
0.765
Initial treatment received 8(53.3%)
No
7(46.7%)
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Yes
8(53.3%)
6(40.0%)
7(46.7%)
9(60.0%)
0.701
Dua’s Grading
10(66.7%)
5(33.3%)
8(53.3%)
Grade IV
2(13.3%)
4(26.7%)
3(20.0%)
6(40.0%)
4(26.7%)
3(20.0%)
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Grade V
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Grade III
Footnotes; a n= number of eyes, bSD= standard deviation
0.548
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Table-3: Comparison of Epithelial defect diameter (in mm) between medical therapy, amniotic membrane transplant, and umbilical cord serum groups in acute ocular chemical burns GROUP Day 0 Day 21 Month 1 Month 2 Month 3 MT: Median(Min,Max) 5.6(3,8) 2(1,5) 1.2(0,4) 0(0,2.8) 0(0,2.8) 5.6±1.9 2.6±1.3 1.4±0.9 0.6±0.9 0.5±0.8 Mean±SDa AMT: Median(Min,Max) 7(2.6,8) 0(0,2) 0(0,2) 0(0,2) 0(0,2) Mean±SD 6.0±2.2 0.2±0.6 0.2±0.5 0.1±0.5 0.1±0.5 UCS: Median(Min,Max) 5.8(2,8) 0(0,2) 0(0,1) 0(0,0) 0(0,0) Mean±SD 5.2±2.4 0.2±0.4 0.1±0.3 0.0±0.0 0.0±0.0 p-value overall 0.696 0.001 0.001 0.007 0.008 b c p-value: MT vs AMT 0.900 0.001 0.001 0.043 0.046 p-value: MT vs UCSd 0.900 0.001 0.001 0.007 0.007 p-value: AMT vs UCS 0.900 0.900 0.550 0.317 0.317 a b c Footnotes: SD= standard deviation, MT= medical therapy, AMT= amniotic membrane transplant, d UCS= umbilical cord serum
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Table-4: Comparison of pain scores between medical therapy, amniotic membrane transplant, and umbilical cord serum groups in acute ocular chemical burns Pain Scores Day 0 Day 7 Day 14 Day 21 Day 30 MT: Median(Min,Max) 6(4,8) 4(3,8) 3(2,8) 3(2,7) 2(0,6) Mean ± SDa 5.8±1.1 4.7±1.8 3.8±1.8 3.1±1.6 2.2±1.5 AMT: Median(Min,Max) 6(5,8) 5(4,7) 4(2,6) 4(1,6) 3(0,5) Mean ± SD 6.4±1.1 5.4±1.1 4.5±1.3 3.4±1.6 2.4±1.3 UCS: Median(Min,Max) 5(1,9) 5(1,6) 3(1,4) 2(0,3) 1(0,3) Mean ± SD 5.3±1.8 4.1±1.6 2.9±1.0 1.9±1.0 1.2±0.9 p-value overall 0.101 0.040 0.011 0.028 0.021 b c p-value : MT vs AMT 0.025 0.076 0.495 0.469 p-value : MT vs UCSd 0.865 0.389 0.052 0.043 p-value : AMT vs UCS 0.012 0.002 0.012 0.008 Footnotes: a SD= standard deviation, b MT= medical therapy, c AMT= amniotic membrane transplant, d UCS= umbilical cord serum
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Day 0
Day 21 Month 1 Month 2 Month 3
2.3±0.8 2.5±0.9
2.7±0.8
2.7±0.8
2.9±0.9
AMT : Mean±SD
2.2±0.9 1.9±0.6
2.1±0.6
2.5±0.7
3.0±1.1
UCS : Mean±SD
2.4±0.6 2.7±0.5
2.9±0.5
3.1±0.6
3.7±0.6
0.083
0.069
0.943
0.900
0.630
0.109
0.081
0.168
0.774
0.007
0.001
p-value : MTa vs AMTb
0.900
0.062
0.018
p-value : MT vs UCSc
0.900
0.900
0.900
p-value : AMT vs UCS
0.900
0.008
0.002
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p-value overall
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MT : Mean±SD
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Footnotes: a MT= medical therapy, b AMT= amniotic membrane transplant, c UCS= umbilical cord serum.
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Table-6: Comparison of outcome variables at the end of three months between medical therapy, amniotic membrane transplant, and umbilical cord serum groups in acute ocular chemical burns Lid Mean Mean Groups Percentage Symblepharon improvement formation at 3 abnormalities schirmer TBUT in visual months (number of test readings acuity at 3 (number of eyes) reading (in months eyes) (mm) seconds) MT 52.2 ±11.8 10 6 18.0 ± 10.3±3.8 4.0 AMT 66.1 ±26.2 5 3 21.2 ± 10.7±1.8 2.1 UCS 66.0 ±16.9 8 2 20.5 ± 11.5±2.7 3.9 p0.086 0.185 0.572 0.056 0.343 value Footnotes: MT= medical therapy, AMT= amniotic membrane transplant, UCS= umbilical cord serum, TBUT= tear break up time.
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S0002-9394(16)30221-5
DOI:
10.1016/j.ajo.2016.05.010
Reference:
AJOPHT 9745
To appear in:
American Journal of Ophthalmology
Received Date: 19 November 2015 Revised Date:
9 May 2016
Accepted Date: 11 May 2016
Please cite this article as: Sharma N, Singh D, Maharana PK, Kriplani A, Velpandian T, Pandey RM, Vajpayee RB, Comparison of Amniotic Membrane Transplantation and Umbilical Cord Serum in Acute Ocular Chemical Burns: A Randomized Controlled Trial, American Journal of Ophthalmology (2016), doi: 10.1016/j.ajo.2016.05.010. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Abstract Purpose To compare the efficacy of topical umbilical cord serum drops (UCS) and amniotic membrane transplantation (AMT) in acute ocular chemical burns. Design: Randomized Controlled Trial Methods Setting: Tertiary care hospital. Study Population: 45 eyes with acute chemical burns of grade III, IV and V (Dua’s classification) presenting within the first week of injury were randomized into 3 groups (15 each). Patients with perforation/impending corneal perforation were excluded from the study. Intervention: Group1, 2 and 3 received UCS with medical therapy (MT), AMT with MT and MT alone respectively. Main Outcome Measure: Time to complete epithelialization. Results: The mean time to complete epithelialization was 56.7 ± 14.9, 22.0 ± 10.2, and 22.9 ± 10.1 days in MT, AMT, and UCS groups respectively, with a significant difference between MT and AMT (p= 0.001); between MT and UCS (p=0.001), but not between UCS and AMT (p=0.9). Improvement in pain score was better with UCS than AMT (p value; 0.012, 0.002, and 0.012 on day 7, 14, and 21 respectively). Corneal clarity was better in the UCS group at 21 (p=0.008) and 30 days (p=0.002), but not at 3 months (p=0.9). By month 3,visual outcome, symblepharon, tear film status and lid abnormalities were comparable between the 3 groups. Conclusions: UCS and AMT, as an adjuvant to standard medical therapy in acute chemical injury, are equally efficacious. UCS has the advantage of faster improvement in corneal clarity, better pain control and avoidance of surgery in an inflamed eye.
ACCEPTED MANUSCRIPT Comparison of Amniotic Membrane Transplantation and Umbilical Cord Serum in Acute Ocular Chemical Burns: A Randomized Controlled Trial Authors Namrata Sharma1
Prafulla K. Maharana1 Alka Kriplani2 Thirumurthy. Velpandian1
Rasik B.Vajpayee4
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Ravindra Mohan Pandey 3
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Divya Singh1
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1- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi 2- Department of Obstetrics & Gynaecology, All India Institute of Medical Sciences, New Delhi 3- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi 4- Vision Eye Institute, Royal Victorian Eye and Ear Hospital, North West Academic Centre, University of Melbourne, Australia
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Short title: Cord serum and Amniotic Membrane in Ocular Chemical Burns Address for correspondence: Namrata Sharma, MD
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Professor of Ophthalmology, Cornea & Refractive Surgery Services, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Ansari Nagar, New Delhi – 110029, India
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Email: [email protected], Fax: 91-11-26588919
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Ocular chemical burns are true emergencies that require rapid assessment and initiation of treatment. Chemical injuries of the eyes cause damage to the ocular surface epithelium, cornea and anterior segment. Thus, immediate and effective treatment influences the final outcome favorably. The primary goals of therapy in ocular chemical burns include restoration of an intact ocular epithelium, control of inflammatory reaction, prevention of infection, support of reparative processes and prevention of complications.1
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Standard medical therapy comprises of topical steroids, topical antibiotics, mydriatics and cycloplegics, topical or oral antiglaucoma therapy, and topical citrate and ascorbate. Various newer treatment modalities have been tried during the acute phase to minimize the damage to the ocular surface, enhance the ongoing healing process and prevent long-term sequelae. These newer modalities include; oxygen therapy,2 amniotic membrane extract,3 amniotic membrane transplantation (AMT),4-8 and umbilical cord serum (UCS) eye drops.9 Both UCS and amniotic membrane are rich in growth factors like EGF, NGF, FGF, TGF-β, vitamin A, fibronectin, and serum antiproteases like α2-macroglobulin.4-9 Both have shown efficacy in acute ocular thermal burns.4-9, 14-16 In this prospective randomised study, we compared the efficacy of AMT with UCS drops in the management of acute ocular chemical burns.
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Materials and methods A prospective randomized controlled clinical trial was planned and approval from the institutional review board (IRB)/Ethics Committee of Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India was taken. The research adhered to the tenets of the Declaration of Helsinki. The study has been registered under the Clinical Trials Registry, India (CTRI/2014/09/005067), National Institute of Medical Statistics, ICMR New Delhi (www.ctri.nic.in). We included patients who presented with acute ocular chemical burns (grade III, IV and V according to Dua’s classification 18 presenting within 2 weeks of injury and willing to participate in the study between the period of 01.06.2013 to 01.10.2014. So we evaluated both the limbal involvement and the conjunctival involvement and later calculated the analogue score as has been described by Dua’s classification. Hence, no separate mention has been made about the perilimbal ischemia in concordance with the Dua’s classification. Informed consent was obtained from all the patients. Patients with grade I, II, and VI injury, those with perforation/impending corneal perforation or not willing to participate in the study were excluded from the study. A total of 51 eyes (30 patients, with 21 bilateral and 9 unilateral involvement) were recruited for the study. Three patients (with bilateral involvement) refused to participate in the study hence excluded. A written informed consent was obtained, and the patients were randomized into three groups using a random numbers table.. Group I (n=15) received conventional medical therapy (control group), group II (n=15) received AMT with conventional medical therapy, and group III (n=15) received 20% UCS drops along with conventional medical therapy. In bilateral cases, each eye was randomized separately. Appropriate first-aid therapy in the form of irrigation with normal saline to achieve a neutral pH and removal of any particulate matter from the ocular surface was done in all cases. Group-I (Medical treatment) cases received conventional medical therapy, which included topical moxifloxacin hydrochloride 0.5% (Vigamox; Alcon, Texas, 2
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USA) 4 times per day; sodium ascorbate (10%) and sodium citrate (10%) every 2 hours, preservative free lubricants and topical prednisolone acetate 1% (Predforte; Allergan, Bangalore, India) every 2 hours; homatropine sulphate (2%) four times per day and oral vitamin C (500 mg) four times a day for two to four weeks. Antiglaucoma therapy in the form of timolol maleate (0.5%) two times per day and oral acetazolamide (250 mg) three times per day was given, when required. Group II cases received AMT with conventional therapy. Amniotic membrane was collected from seronegative donors (Human Immuno deficiency Virus (HIV), hepatitis B, hepatitis C, and syphilis) with uncomplicated caesarean section after obtaining informed consent. The amniotic membrane preparation was done using the standard technique which has been previously described.5 AMT was done using the onlay technique. Surgery was performed under peribulbar or general anaesthesia (if required) in adults and general anaesthesia in children. After transferring the amniotic membrane onto the operative field, peeling off the nitrocellulose membrane was done and the amniotic membrane was spread to cover the entire ocular surface with the stromal side touching the ocular surface. Interrupted 8-0 Vicryl sutures (Ethicon, Johnson & Johnson, Ahmedabad, India) were used to anchor the underlying conjunctiva and the episclera to the amniotic membrane around the limbus.5 A symblepharon ring was then put to uniformly spread the membrane and to flatten it against the ocular surface, especially in the fornices and along the palpebral conjunctiva. Additionally, interrupted Vicryl sutures were also applied to anchor the membrane along the lid margins. The eyes were bandaged after the surgery and the topical medications were continued in the postoperative period. Group-III cases received 20% UCS drops along with conventional medical therapy. The umbilical cord blood was collected from seronegative donors (hepatitis B, hepatitis C, HIV and syphilis) with uncomplicated caesarean deliveries after obtaining informed consent. Screening for parenterally transmitted diseases was done at the time of antenatal care registration and further repeated at the time of cord blood collection and three months after the cord blood collection. Cord blood serum was prepared according to the standard technique which has been previously described.9 Serum bottles were stored at −20°C before opening a nd at 4°C after opening. Patients were instructed to use serum vials within 7 days and to come back for a fresh vial after that. The patients were also instructed to look for the presence of any threadlike floating objects in the serum before instilling the drops and to discard the same vial if such contaminants were seen. The UCS eye drops (20%) were instilled 10 times per day until complete epithelialization was noted. Baseline evaluation included a comprehensive history with reference to the nature of chemical causing the damage to the ocular surface, duration of exposure to the chemical causing the injury, initial treatment received, and the time elapsed between exposure to the chemical and presentation at our centre. Best-corrected visual acuity (BCVA) was recorded using the logarithm of the minimum angle of resolution (logMAR) chart. Slit-lamp (Haag-Streit AG, Koeniz, Switzerland) examination was done. Other parameters noted at the initial visit included grade of chemical injury,18 corneal clarity,9 pain score,19 epithelial defect diameter (EDD) and the extent of limbal involvement. Additionally, epithelial defect area (EDA) was calculated as the product of the largest diameter and the diameter perpendicular to it.20 Tear film status, was assessed using the Schirmer test and tear break up time (TBUT), intraocular pressure and any other anterior segment or fundus abnormalities were noted. Patients were followed up on days 3, 7, 14, 21 and at the end of 1, 2 and 3 months. The parameters evaluated were time to epithelialization, size of the
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epithelial defect, corneal clarity grading, corneal vascularization, symblepharon formation, tear film status, lid abnormalities, limbal involvement, pain score, and visual acuity. Clinical photographs were recorded at each visit. The pain scoring was done using a numeric pain rating scale19 as summarised in table-1. Statistical analysis Keeping the power of study as 0.8 and the level of significance at 0.05, with the primary outcome measure being the mean time for complete epithelialization, a minimum sample size of 15 eyes was required in each group. All patients completed the scheduled follow-up. The statistical analysis was done using SPSS software for Windows. Time of epithelial healing was analyzed using Kaplan–Meier analysis. The χ2 test and Fischer exact test were used for comparing qualitative data; for parametric quantitative data, one-way analysis of variance (ANOVA) was used to compare intergroup means and Bonferroni correction was used to analyse post-test results; Kruskal–Wallis and Mann–Whitney tests were used for non-parametric quantitative data. For descriptive purposes, non parametric data have been expressed as median (range), parametric qualitative data has been expressed as a percentage and quantitative data has been expressed as mean ± standard deviation (SD). Results A total of 45 eyes with acute chemical burns were included and followed up for a period of 3 months. All patients completed the follow-up. The baseline characteristics such as; age, time between exposure and presentation, nature of chemical causing injury, treatment received initially, and Dua’s grading at presentation were comparable between the three groups (Table-2). Alkali burns were the most common, occurring in 24 eyes (53.3%), and acid burns occurred in 21 eyes (46.7%). The groups were comparable with regard to the nature of chemical exposure (p = 0.765). According to Dua’s classification, 23 eyes had a grade III injury, 9 eyes had a grade IV injury and 13 eyes had a grade V injury. The distribution was comparable across the groups (p = 0.548) [Table-2]. The epithelial defect had healed in all eyes in the UCS group, 14 of 15 eyes in AMT group, and 10 of 15 eyes in the medical therapy group at 3 months follow-up. The mean time to complete epithelialization was 56.7 ± 14.9, 22.0 ± 10.2, and 22.9 ± 10.1 days in medical therapy, AMT, and UCS groups respectively. The mean time for complete absorption of the amniotic membrane was 21 ± 3 days. The minimum and maximum time of healing being 28 and 91 days in medical therapy, 14 and 56 days in AMT, and 7 and 56 days in UCS groups. The difference was statistically significant between medical therapy and AMT groups (p= 0.001), and also between medical therapy and UCS groups (p=0.001) but no difference was found between UCS and AMT group (p=0.9). Kaplan–Meier survival analysis revealed that the differences in time of corneal epithelialization between the three groups were statistically significant (Figure 1, p = 0.001). The mean EDD at presentation was 5.6 ± 1.9, 6.0 ± 2.2, and 5.2 ± 2.4 mm in medical therapy, AMT, and UCS groups, respectively which were comparable (p = 0.696) [Table-3]. By the end of 21 days, EDD was 2.6 ± 1.3, 0.2 ± 0.6, and 0.2 ± 0.4 mm in medical therapy, AMT and UCS groups respectively. A significant difference was seen between medical therapy and AMT groups, and medical therapy and UCS groups at all follow-ups, but no significant difference was seen between AMT and UCS group at any follow-up as shown in table-3. The mean EDA at presentation was 32.6 ± 20.6, 37.9 ± 22.1, and 30.5 ± 22.7 mm2 in medical therapy, AMT, and UCS groups, respectively which was comparable
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(p = 0.690). By the end of 21 days the epithelial defect area was 6.8 ± 7.5, 0.4 ± 1.2, and 0.3 ± 1.0 mm2 in medical therapy, AMT, and UCS groups respectively with significant differences between medical therapy and AMT (p= 0.001), and medical therapy and UCS (p=0.001) groups but not between AMT and UCS group (p=0.90). At the time of presentation the median values for pain scores were 6, 6, and 5 in medical therapy, AMT, and UCS groups, respectively which were comparable in the three groups (p=0.101), and which decreased to the median values of 4, 5, and 5 in medical therapy, AMT, and UCS groups by day 7. A significant difference was seen between MT and AMT at day 7 (p=0.025) but not on subsequent follow up as shown in table-4. A significant difference was seen between MT and UCS groups only at 1 month follow-up (p= 0.043). However, UCS was better than AMT at all the follow-up as shown in table-4.
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The limbal involvement (in clock hours) at the time of presentation was 5.8 ± 2.5, 7.3 ± 2.5, and 6.1 ± 2.6 in MT, AMT, and UCS groups respectively which was comparable in the three groups (p = 0.123). The number of clock hours of limbus involved at the end of three months in the MT, AMT, and the UCS group were 3.7± 3.2, 1.5 ±1.9, and 0.9 ±1.2 respectively. This difference was found to be significantly different in the AMT group (p=0.015) and UCS group (p=0.001) when compared to the MT group alone. At the end of three months, the percentage decrease in limbal involvement was 44.2 ± 23.8, 84.7 ± 18.9, and 83.9 ± 18.4 in medical therapy, AMT, and UCS groups, respectively, which was significantly different amongst the MT and AMT groups (p = 0.001), and MT and UCS groups (p = 0.001) but no difference was seen between the UCS and AMT group (p=0.9). There was no need for repeat AMT or tarsorrhaphy in any of the patients.
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The pretreatment corneal clarity was comparable between the three groups (p = 0.774) [Table-5]. Although a significant difference was seen between AMT and UCS groups at the end of 21 days (p = 0.008) and 1 month (p = 0.002), but no significant difference was seen in corneal clarity between the three groups at the last follow-up (p = 0.069) as shown in table-5. In the medical therapy group, 11 eyes had 1 quadrant, 1 eye had 2 quadrants, 1 eye had 3 quadrants, and 2 eyes had 4 quadrants of vascularization. In the AMT group, a total of 3 eyes had 1 quadrant, 3 eyes had 2 quadrants, and 1 eye had 3 quadrants of vascularization. In the UCS group, 7 eyes developed 1 quadrant and 1 eye developed 2 quadrants of vascularization. The difference was found to be significantly different between medical therapy and AMT groups (p=0.001), and medical therapy and UCS groups (p=0.006), but no difference was seen between the AMT and UCS group at last follow-up (p=0.3). At the end of three months, no significant difference was seen in the final visual outcome (p = 0.086), symblepharon formation (p = 0.185), TBUT (p = 0.343), Schirmer test reading (p = 0.056), and lid abnormalities (p = 0.572) between the three groups (Table-6). Various modalities have been described previously like AS eye drops, UCS eye drops, AMT and limbal stem cell transplantation for management of acute ocular chemical burns.4-9, 20-23 There has been a renewed interest in the AMT with a large number of studies documenting enhanced epithelial growth rates in cases of moderate to severe acute chemical burns. Umbilical cord serum has previously been used for the management of dry eye, recurrent corneal erosions, neurotrophic
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keratitis and persistent corneal epithelial defects with favourable outcomes.14-17 In 2011, we, in a randomised controlled trial, demonstrated that UCS is superior to both autologous serum and conventional therapy for the management of acute ocular chemical burns.9 In another randomised trial in 2005, it was shown that epithelialization was faster with AMT compared with the conventional therapy in mild to moderate acute chemical burns (Grades II–IV, Roper–Hall classification).20 In one of our earlier retrospective study, we found that both UCS and AMT are useful in acute chemical burns, but UCS therapy may be a better alternative to AMT as it avoids surgical manoeuvre in already inflamed eyes.24 To the best of our knowledge this is the first prospective study to compare these different treatment modalities. We did not find any significant difference between UCS eye drops and AMT in the healing of the epithelial defect, however both of them are superior to conventional medical management. Our experience on chemical injury suggests that epithelial defect may take beyond three months to heal, especially in cases where the limbal stem cells have not recovered completely. This could be attributed to the recurrent epithelial breakdown which prevented complete epithelialization.Hence, the patients were treated on the designated therapy. Our results corroborate the findings of previous studies that both UCS and AMT are beneficial adjuncts to conventional medical management in ocular chemical burns. Both UCS and amniotic membrane are rich in a variety of growth factors like EGF, NGF, FGF, TGF-β, vitamin A, fibronectin and serum antiproteases like α2-macroglobulin.10-17 These stimulate proliferation of corneal epithelium and increase the tensile strength of wounds. We did not find any correlation between the visual recovery and the time to epithelialization as the visual outcome following the healing of an acute case of chemical injury depends upon several other factors such as the presence of conjunctivalisation, vascularization, corneal haze and other co-morbidities in these patients such as glaucoma and posterior segment pathologies. Furthermore, we found that UCS has certain advantages over AMT, such as early reduction of pain scores and faster improvement in corneal clarity. The higher concentration of growth factors in UCS is the main reason which may lead to faster healing. However, it may be possible that the AMT group had a higher number of cases with severe grades of injury which itself can lead to a lower pain score at baseline due to associated damage to the nerve fibers and a consequent poor pain control compared to UCS. Numeric pain score depends upon the subjective response of the patient. Pain scores were higher at 21 days in the MT group owing to the slower epithelial healing however in the AMT group higher pain scores were attributed to the surgical intervention and the placement of sutures to anchor the graft to host bed. Lastly, UCS group showed better epithelial healing and there was no associated surgical intervention which could have resulted in the lesser pain score in this group. The other advantage of UCS is that large amount of sample can be withdrawn from the umbilical vein at the time of delivery and the serum can be supplied to many patients. As UCS drops can be prepared in advance, patients don’t need to wait for additional preparations. Further the patients do not need to undergo a surgery in acutely inflamed eye. UCS is also useful in cases where the patient is too debilitated to undergo surgery due to anaesthetic indications or refuses surgery. Similarly, in pediatric chemical injuries unnecessary general anaesthesia can be avoided by using UCS. The use of UCS therapy has the potential drawback of availability compared to AMT, as the facility for the procurement of cord serum may not be available at all centres since it is not commercially available. However, since cord serum may not be available at peripheral centres, AMT may be more
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appropriate in these situations. In our study we did not come across any complications such as infection, suture related problems in AMT group or severe inflammation. However, infectious keratitis is a likely possibility with the use of UCS and another study with larger sample size might be needed to further evaluate the associated complications. Even though both UCS and AMT are beneficial for the management of ocular chemical burns, it is important to remember a few facts regarding their use; firstly both of these modalities carry a risk for the transmission of parenteral diseases and serological testing at least twice to account for the window period of infections is essential to minimize this risk. Secondly, preparation of both requires expensive processing and preservation facilities, which are often scarce in developing countries. Moreover, legal and ethical issues might crop up when using these modalities. There are certain limitations to the study. First of all a close observation of the groups suggests a higher proportion of cases with severe grade of chemical burns in AMT group. Even though the three groups were comparable at baseline, which may be due to a small sample, it could have resulted in a better outcome in the UCS group in parameters such as corneal clarity and pain score. Secondly, all cases enrolled had received some sort of treatment before being referred to us and it cannot be ruled out that the initial treatment could have influenced the outcomes in the three groups.
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Thus, to conclude cord serum therapy and amniotic membrane transplantation as an adjuvant to standard medical therapy improves the final outcome in cases of acute chemical injury. Depending upon their availability and the patients condition either can be used in moderate grades of acute chemical burns. Our study did not include grade I, II and VI chemical burns, thus a larger study including all grades of chemical burns may be useful to evaluate the role of these adjuvants especially in grade VI where the prognosis is often grim.
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1. Wagoner MD. Chemical injuries of the eye: current concepts in pathophysiology and therapy. Surv Ophthalmol 1997;41(4):275-313. 2. Sharifipour F, Baradaran-Rafii A, Idani E, Zamani M, Jabbarpoor Bonyadi MH. Oxygen therapy for acute ocular chemical or thermal burns: a pilot study. Am J Ophthalmol 2011;151(5):823-828. 3. Liang L, Li W, Ling S, et al. Amniotic membrane extraction solution for ocular chemical burns. Clin Experiment Ophthalmol 2009;37(9):855-863. 4. Tejwani S, Kolari RS, Sangwan VS, Rao GN. Role of amniotic membrane graft for ocular chemical and thermal injuries. Cornea 2007;26(1):21–26. 5. Tandon R, Gupta N, Kalaivani M, Sharma N, Titiyal JS, Vajpayee RB. Amniotic membrane transplantation as an adjunct to medical therapy in acute ocular burns. Br J Ophthalmol 2011;95(2):199–204. 6. Prabhasawat P, Tesavibul N, Prakairungthong N, Booranapong W. Efficacy of amniotic membrane patching for acute chemical and thermal ocular burns. J Med Assoc Thai 2007;90(2):319–326. 7. Meller D, Pires RT, Mack RJ, et al. Amniotic membrane transplantation for acute chemical or thermal burns. Ophthalmology 2000;107(5):980–989. 8. Kobayashi A, Shirao Y, Yoshita T, et al. Temporary amniotic membrane patching for acute chemical burns. Eye (Lond) 2003;17(2):149–158. 9. Sharma N, Goel M, Velpandian T, Titiyal JS, Tandon R, Vajpayee RB. Evaluation of umbilical cord serum therapy in acute ocular chemical burns. Invest Ophthalmol Vis Sci 2011;52(2):1087–1092. 10. Koizumi NJ, Inatomi TJ, Sotozono CJ, Fullwood NJ, Quantock AJ, Kinoshita S. Growth factor mRNA and protein in preserved human amniotic membrane. Curr Eye Res 2000;20(3):173–177. 11. Tseng SCG, Espana EM, Kawakita T, et al. How does amniotic membrane work? Ocul Surf 2004;2(3):177–187. 12. Touhami A, Grueterich M, Tseng SCG. The role of NGF signaling in human limbal epithelium expanded by amniotic membrane culture. Invest Ophthalmol Vis Sci 2002;43(4):987–994. 13. Lee SB, Li DQ, Tan DT, Meller DC, Tseng SC. Suppression of TGF-beta signaling in both normal conjunctival fibroblasts and pterygial body fibroblasts by amniotic membrane. Curr Eye Res 2000;20(4):325–334. 14. Yoon KC, Heo H, Jeong IY, Park YG. Therapeutic effect of umbilical cord serum eyedrops for persistent corneal epithelial defect. Korean J Ophthalmol 2005;19(3):174–178. 15. Yoon KC, Im SK, Park YG, Jung YD, Yang SY, Choi J. Application of umbilical cord serum eyedrops for the treatment of dry eye syndrome. Cornea 2006;25(3):268–272. 16. Yoon KC, You IC, Im SK, Jeong TS, Park YG, Choi J. Application of umbilical cord serum eyedrops for the treatment of neurotrophic keratitis. Ophthalmology 2007;114(9):1637–1642. 17. Yoon KC, Choi W, You IC, Choi J. Application of umbilical cord serum eyedrops for recurrent corneal erosions. Cornea 2011;30(7):744–748. 18. Dua HS, King AJ, Joseph A. A new classification of ocular surface burns. Br J Ophthalmol 2001;85(11):1379–1383. 19. McCaffery M. Using the 0-to-10 pain rating scale. Am J Nurs 2001;101(10):81-82.
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20. Mukerji N, Vajpayee RB, Sharma N. Technique of area measurement of epithelial defects. Cornea 2003;22(6):549–551. 21. Tamhane A, Vajpayee RB, Biswas NR, et al. Evaluation of amniotic membrane transplantation as an adjunct to medical therapy as compared with medical therapy alone in acute ocular burns. Ophthalmology 2005;112(11):1963–1969. 22. Sridhar MS, Bansal AK, Sangwan VS, Rao GN. Amniotic membrane transplantation in acute chemical and thermal injury. Am J Ophthalmol 2000;130(1):134–137. 23. Kheirkhah A, Johnson DA, Paranjpe DR, Raju VK, Casas V, Tseng SC. Temporary sutureless amniotic membrane patch for acute alkaline burns. Arch Ophthalmol 2008;126(8):1059–1066. 24. Sharma N, Lathi SS, Sehra SV, et al. Comparison of umbilical cord serum and amniotic membrane transplantation in acute ocular chemical burns. Br J Ophthalmol 2015;99(5):669-673.
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ACCEPTED MANUSCRIPT Figure Legends Figure 1: Kaplan-Meier survival analysis showing time to epithelialisation in medical therapy, amniotic membrane transplant, and umbilical cord serum groups in acute
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ocular chemical burns.
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Grade Severity No pain 0 1 Mild pain 2 3 4 Moderate pain 5 6 7 8 Severe pain 9 10 Footnotes: mild, moderate, or severe is purely based on patient’s description of pain
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Standard treatment group
Amniotic membrane group
Cord blood serum group
(n=15)
(n=15)
22.9 ± 17.4
p value
a
(n =15) 18.1 ± 11.3
Time between exposure and presentation in days, mean ± SD
4.2 ± 1.4
3.9 ± 1.5
0.739
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21.9 ± 13.9
4.0 ± 1.2
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Age in years, b mean ± SD
0.953
Nature of chemical 8(53.3%)
7(46.7%)
Alkali
7(46.7%)
8(53.3%)
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Acid
6(40.0%) 9(60.0%)
0.765
Initial treatment received 8(53.3%)
No
7(46.7%)
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Yes
8(53.3%)
6(40.0%)
7(46.7%)
9(60.0%)
0.701
Dua’s Grading
10(66.7%)
5(33.3%)
8(53.3%)
Grade IV
2(13.3%)
4(26.7%)
3(20.0%)
6(40.0%)
4(26.7%)
3(20.0%)
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Grade V
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Grade III
Footnotes; a n= number of eyes, bSD= standard deviation
0.548
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Table-3: Comparison of Epithelial defect diameter (in mm) between medical therapy, amniotic membrane transplant, and umbilical cord serum groups in acute ocular chemical burns GROUP Day 0 Day 21 Month 1 Month 2 Month 3 MT: Median(Min,Max) 5.6(3,8) 2(1,5) 1.2(0,4) 0(0,2.8) 0(0,2.8) 5.6±1.9 2.6±1.3 1.4±0.9 0.6±0.9 0.5±0.8 Mean±SDa AMT: Median(Min,Max) 7(2.6,8) 0(0,2) 0(0,2) 0(0,2) 0(0,2) Mean±SD 6.0±2.2 0.2±0.6 0.2±0.5 0.1±0.5 0.1±0.5 UCS: Median(Min,Max) 5.8(2,8) 0(0,2) 0(0,1) 0(0,0) 0(0,0) Mean±SD 5.2±2.4 0.2±0.4 0.1±0.3 0.0±0.0 0.0±0.0 p-value overall 0.696 0.001 0.001 0.007 0.008 b c p-value: MT vs AMT 0.900 0.001 0.001 0.043 0.046 p-value: MT vs UCSd 0.900 0.001 0.001 0.007 0.007 p-value: AMT vs UCS 0.900 0.900 0.550 0.317 0.317 a b c Footnotes: SD= standard deviation, MT= medical therapy, AMT= amniotic membrane transplant, d UCS= umbilical cord serum
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Table-4: Comparison of pain scores between medical therapy, amniotic membrane transplant, and umbilical cord serum groups in acute ocular chemical burns Pain Scores Day 0 Day 7 Day 14 Day 21 Day 30 MT: Median(Min,Max) 6(4,8) 4(3,8) 3(2,8) 3(2,7) 2(0,6) Mean ± SDa 5.8±1.1 4.7±1.8 3.8±1.8 3.1±1.6 2.2±1.5 AMT: Median(Min,Max) 6(5,8) 5(4,7) 4(2,6) 4(1,6) 3(0,5) Mean ± SD 6.4±1.1 5.4±1.1 4.5±1.3 3.4±1.6 2.4±1.3 UCS: Median(Min,Max) 5(1,9) 5(1,6) 3(1,4) 2(0,3) 1(0,3) Mean ± SD 5.3±1.8 4.1±1.6 2.9±1.0 1.9±1.0 1.2±0.9 p-value overall 0.101 0.040 0.011 0.028 0.021 b c p-value : MT vs AMT 0.025 0.076 0.495 0.469 p-value : MT vs UCSd 0.865 0.389 0.052 0.043 p-value : AMT vs UCS 0.012 0.002 0.012 0.008 Footnotes: a SD= standard deviation, b MT= medical therapy, c AMT= amniotic membrane transplant, d UCS= umbilical cord serum
ACCEPTED MANUSCRIPT Table-5: Comparison of corneal clarity between medical therapy, amniotic membrane transplant, and umbilical cord serum groups in acute ocular chemical burns Group
Day 0
Day 21 Month 1 Month 2 Month 3
2.3±0.8 2.5±0.9
2.7±0.8
2.7±0.8
2.9±0.9
AMT : Mean±SD
2.2±0.9 1.9±0.6
2.1±0.6
2.5±0.7
3.0±1.1
UCS : Mean±SD
2.4±0.6 2.7±0.5
2.9±0.5
3.1±0.6
3.7±0.6
0.083
0.069
0.943
0.900
0.630
0.109
0.081
0.168
0.774
0.007
0.001
p-value : MTa vs AMTb
0.900
0.062
0.018
p-value : MT vs UCSc
0.900
0.900
0.900
p-value : AMT vs UCS
0.900
0.008
0.002
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p-value overall
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MT : Mean±SD
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Footnotes: a MT= medical therapy, b AMT= amniotic membrane transplant, c UCS= umbilical cord serum.
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Table-6: Comparison of outcome variables at the end of three months between medical therapy, amniotic membrane transplant, and umbilical cord serum groups in acute ocular chemical burns Lid Mean Mean Groups Percentage Symblepharon improvement formation at 3 abnormalities schirmer TBUT in visual months (number of test readings acuity at 3 (number of eyes) reading (in months eyes) (mm) seconds) MT 52.2 ±11.8 10 6 18.0 ± 10.3±3.8 4.0 AMT 66.1 ±26.2 5 3 21.2 ± 10.7±1.8 2.1 UCS 66.0 ±16.9 8 2 20.5 ± 11.5±2.7 3.9 p0.086 0.185 0.572 0.056 0.343 value Footnotes: MT= medical therapy, AMT= amniotic membrane transplant, UCS= umbilical cord serum, TBUT= tear break up time.
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