The following transcript has been edited for clarity:
Lisa Feulner MD: Welcome to AAO 2025 Orlando. I’m Dr. Lisa Feulner, chief medical editor of Ophthalmology Management, and I have the honor and privilege of two guests with me today: Dr. Mark Milner and Dr. Brandon Ayres. We’re going to be talking about an interesting topic in our offices, and some technology that not everyone is using, and why it’s important to incorporate these into our practices—specifically, amniotic membranes.
Gentlemen, can you talk to me about where, when, and how you use amniotic membranes in your practice, and what kind of amniotic membrane? I think a lot of people are familiar with some that are decellularized, some that are already moist, wet membranes. Why do you use one versus another, and in what patients? In what setting?
Brandon Ayres, MD: This is an easy one for me. I mean, this is teed up [for me] as a cornea specialist; we treat cornea disease all the time. So, office procedures like superficial ectomies, EDTA cations, I mean, anytime we remove the epithelium, it’s nice to add something after that procedure to try and boost healing, decrease discomfort, decrease additional scarring on the cornea. So that’s where the AMT [amniotic membrane transfer] comes in. Now, which “flavor” you want—whether you want cryopreserved or dried—I guess that depends a little bit on the practice and your practice pattern. We’ll actually use both [in my practice]. There’s plenty of times that I’m looking for a cryopreserved AMT; those will come on a thermoplastic ring, and they work great. Not every patient loves that thermoplastic ring, and we use a lot of the dried or the triple-layer AMT, which a little bit flatter and fits underneath the contact lens or a patch. And I think that significantly improves the healing process, with less haze after the procedure. So, we actually will use both. It just kind of depends on the patient.
Mark Milner, MD: The first question is where do we use it in our practice? First thing you have to understand is the theory behind amniotic membrane: it has these complexes in it that help with what’s called regenerative healing. So, there’s a lot of great cytokines and a lot of great growth factors, but there’s also this HC‐HA/PTX3, which is heavy chain, and all 3 are found in our bodies—but they’re only found together in the fetus, the placenta, and the amniotic membrane. It’s that complex that has been shown to cause this regenerative healing, meaning anti-angiogenesis, anti-scarring. The purpose of using these are for people who either don’t heal or [for whom] you want to limit scar tissue when you’re doing epithelial keratectomy. We use it for corneal ulcers that are not healing, neurotrophic keratitis, and neurotrophic ulcers.
But we started using it even earlier in these advanced corneal disease [cases]—things like dry eye, where we know that we want to regenerate some of those nerves. They become neurotrophic, and we use them for, like you said, epithelial ectomies, because it’s good business in your practice to take care of patients who have Saltzmann [nodual] degeneration or mapped-out fingerprint dystrophy. Especially if you want to do cataract surgery and you want to maximize your IOL calculations and make the surface healthier, you’re going to do an epithelial keratectomy, you’re going to remove those nodules, and we always put amniotic membrane on after that to help the healing and hopefully help get that back to its original state.
Dr. Ayres: I’d add one thing to that. Very often, we’re troubleshooting for other community doctors. We have a referral service. I can’t tell you how many times a week somebody comes in unhappy with their cataract surgery—they’ve got double vision; the vision’s not as crisp as they’d like. We do a topography and, sure enough, there’s mapped-out fingerprint or BM dystrophy all over the place. So now we have a specialty visit, we’re going to schedule another procedure, we’re likely going to use an AMT to help them heal and minimize scarring on the cornea. And that all could have been avoided. Specialty visits, additional testing, additional everything. If you just think beforehand, “You know what? There’s some corneal disease here. If I treat this preoperatively, we’ll get a better result afterwards. Happier patients.” [Patients needing fewer] followups and specialty visits is a huge [win] for a practice.
Dr. Feulner: Brandon, you bring up such a good point, because not everyone listening today is a cornea specialist like you guys, and they want to bring this technology into their offices and are wondering, how do I do that? Where does that fit into my practice and how can I take this patient who wants a premium lens, who has some changes on their corneal surface, and which membrane should I choose, or how do I get them there? We were talking earlier about how we can get more patients to choose premium lenses or maybe become candidates for premium lenses if we treat their ocular surface. Amniotic membrane is such a good tool to help us get those patients to their end goal.
Dr. Milner: There are a lot of options for amniotic membranes. We talked about what you said, decellularized or dehydrated, and then there’s cryopreserved of the wet kind. I know you talked about [how] some people don’t like the ring. The ring can be uncomfortable in some people. Now there’s a cryopreserved version that’s just called Camp 360, where you would put a collagen shield on and it’s like putting a dehydrated on, except you’re using the cryopreserved with a collagen shield and that eliminates that ring issue. So you have a lot of options coming down the road. There are going to be potentially amniotic drops that we may be able to use, or umbilical cord tissue, which will be a really high level of those fetal complexes. So, that’s coming down the road and we are excited about that because anything that you can do to help the surfaces [is good].
Dr. Ayres: So, Lisa, I’d make one more comment. I firmly believe that a superficial keratectomy—which is just debriding the epithelium—doesn’t need to be a cornea specialist procedure. It’s very straightforward. And whether you choose a dried amtAA or a cryopreserved amtA, I don’t know that it matters which one you choose. Just choose one and get good at that technique, because they all are a little bit different. AA layer probably works better with a patch; you might need one. You might need to use a contact lens with CAM 360, and, of course, you have your self-retaining, so get comfortable with the procedure, get comfortable with 1 AMT that you like. Then you may branch out into other versions down the road.
Dr. Feulner: For people who are just starting to consider using amniotic membranes in their practice, can you give a pearl or 2 about how they can fit it in an efficient way? Do they need to have a separate clinic? Can they fit it in their practice? How long does it take to actually use these membranes in their practice if they’re just treating ocular surface disease, dry eye neurotrophic?
Dr. Milner: I try to do it on the fly… My staff’s pretty versed at this, and when I’ll say, “I’m going to put in an amni-cryopreserved with a ring,” [they know] that it really takes me 2 seconds to put in. The key, though, is to rinse it thoroughly, because it will burn a little bit if you don’t rinse. But if I’m putting in either a CAM 360 or a dry, I’ll go into another room and see another patient while my staff gets that all set up, gets the consent, and then it takes about 3 to 5 minutes to put it in. It doesn’t take long.
Dr. Ayres: We typically are doing things at the end of a procedure. So, we already have the procedure set up and my technicians will already have the AMT in the room for me. The actual placement of the [ring] and the technique we’re going to use afterwards—temporary tarsorrhaphy, patch shield, or whatever it’s going to be—that doesn’t take long. But what does take some time is gaining the knowledge of how to screen and properly assess your patients to then know they should have an AMT. So, there is some thought, but the actual physical action of placing the lens is really quite simple.
Dr. Feulner: Thank you guys so much for being here with us today and talking about this very important treatment and technology. As you mentioned, there are some things coming down the road that’ll make it easier for us to engage in some growth factors and treating our neurotrophic keratitis patients, some drops that are going to become available. And hopefully you’ll come back next year and join us again and we’ll have a discussion talking about yet more new things to help our practices treat our patients. OM