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The key steps in sutureless The demodex patient discussed reservoir restoration are: “...chronic lid margin disease here used the towelettes as directed From Dry Eye to • inject 2% lidocaine infi ltrated for six weeks after his initial ad- with epinephrine (for hemostasis and infl ammation lead to vanced treatment, which signifi cantly and to separate tissue planes) reduced his eyelid infl ammation, • resect redundant conjunctiva ocular surface infl ammation.” ocular surface infl ammation and red- • remove unhealthy Tenon’s cap- ness and discomfort (see Figure 6). Lid Margin Diseases: sule from scleral bed In addition to demodex, Cliradex® • cauterize any prolapsed fat cedure. They are among the most complaint was bilateral ocular irrita- is also indicated for managing symp- so it shrinks back behind the satisfi ed patients in my practice. tion, and he had been experiencing toms associated with meibomian fornix and the edge of remain- They come in miserable from their redness and recurrent chalazia gland dysfunction, rosacea blepha- Promoting Quality Healing Through ing Tenon’s symptoms, desperate for a solution, for approximately a year (see ritis, dry eye, chalazia and other • with a small amount of fi brin and leave thrilled with the results of Figure 4). He had been diagnosed lid margin diseases, making it a Evidence-Based Therapies glue, secure a small piece of this procedure, which takes 10 to with chronic blepharoconjunctivitis, very useful addition to the treatment AmnioGraft® biologic ocular 12 minutes on average to perform. but his condition had limited re- options I can offer my lid margin/ transplantation graft to cover the sponse to hot compresses, lid scrubs, ocular surface disease patients. inferior rectus muscle insertion topical antibiotics/steroids, lubricants 1. Tan EK, Cooke M, Mandrycky C, et al. Structural (to replace Tenon’s in that area DEALING WITH LID and oral doxycycline. and biological comparison of cryopreserved and discomfort/irritation, as well as ® uring a recent industry meeting, four corneal specialists came and to prevent restriction and MARGIN AND OCULAR Examining this type of patient, Figure 6. Reduced infl ammation and redness following treatment for demodex with Cliradex and fresh amniotic membrane tissues. J Biomaterials and vision-threatening complications Cliradex® Complete. Tissue Engineering 2014;4:379-388. together to discuss how innovative corneal wound-healing and potential diplopia) SURFACE DISEASE ISSUES with chronic symptoms and no 2. Cooke M, Tan EK, Mandrycky C, He H, et al. such as scarring and haze. Thus, • using minimal glue, secure a Preeya K. Gupta, MD relief from the usual therapies, it’s Comparison of cryopreserved amniotic mem- hygiene solutions have changed the way they approach a wide effective control of infl ammation is ® brane and umbilical cord tissue with dehydrated D second piece of AmnioGraft important to consider the full range to examine the base of the eyelashes fective at low concentrations, which amniotic membrane/chorion tissue. J Wound Care. range of ocular surface and eyelid margin diseases and disorders, an important strategy for promoting (cut larger than the defect) over As knowledge about ocular sur- of potential causes, such as meibo- for cylindrical dandruff (see Figure is important in terms of patient 2014;23(10):465-74, 476. including dry eye, epithelial defects, conjunctivochalasis, blepharitis quality healing and minimizing the 3. Data on fi le, Bio-Tissue. the entire defect (overshoot the face disease has advanced, it mian gland dysfunction associated 5), which is pathognomonic for comfort and tolerability. 4. Carson CF, Hammer A, Riley TV. Melaleuca and demodex. They shared their experiences with Bio-Tissue Inc.’s risk of scar and haze. ® edges when pulling the graft into has become clear that chronic lid with rosacea, chronic conjunctivi- demodex. When this is observed, The kit also includes 24 Cliradex alternifolia (tea tree) oil: a review of antimicrobial ® ® Biologic corneal bandages can and other medicinal properties. Clin Microbiol Rev. PROKERA biologic corneal bandage, AmnioGraft biologic ocular ® place), tucking the edges a mini- margin disease and infl ammation tis, toxicity issues, mucous fi shing a few eyelashes should be plucked lid, lash and facial cleanser tow- 2006;19(1):50-62. transplantation graft and Cliradex lid, lash and facial cleanser. High- promote quality healing because mum of 1 mm under the conjunc- lead to ocular surface infl amma- syndromes, lid apposition problems and closely examined for the pres- elettes for patients to use at home. 5. Gao Y-Y, Di Pascuale MA, Li W, et al. In vitro and they modulate infl ammation (see in vivo killing of ocular Demodex by tea tree oil. Br J lights from their discussion follow. tiva on the sides (as if tucking a tion. Without proper management and, in this particular case, based ence of the demodex mites (see Like the gel, the towelettes are Ophthalmol. 2005;89:1468-1473. Figure 1) and in my experience, they bed sheet under a pillow). of the infl ammation, patients are at on the chronic chalazia, sebaceous Figure 5 inset). The mites, which preservative-free and contain 6. Tighe S, Gao Y-Y, Tseng SCG. Terpinen-4-ol is the have made a big difference—in most active ingredient of tea tree oil to kill Demodex • “squeegee” excess glue (anteri- increased risk for impaired vision, cell carcinoma. It is also important are present on everyone’s skin but 4-Terpineol. My patients fi nd them mites. Trans Vis Sci Tech. 2013;2(7):2. HEALING healing of the ocular surface, more both easy and recalcitrant cases. In ® orly or laterally, never posteriorly) infection and subop- usually do not cause problems, live easy to use, which improves compli- PROKERA®, AmnioGraft® and Cliradex® EPITHELIAL DEFECTS tissue damage, chronic pain and fact, PROKERA products provide and excise excess tissue. timal cataract and in the glands and feed on meibum. ance. The gel contains approximate- are registered trademarks of Bio-Tissue Inc. Eric Donnenfeld, MD ® Most of my patients who have refractive surgical When they become a source of in- ly double the concentration of the CryoTek is a registered trademark of Tissue-Tek. Controlling the Wound Healing Cascade had sutureless reservoir restora- outcomes. fl ammation, they require treatment. towelettes and therefore serves as a Restasis® is a registered trademark of To obtain and sustain the best ® tion with an AmnioGraft biologic Demodex blepha- In this case, we treated the loading dose when applied in-offi ce. Allergan Inc. possible outcomes for patients, Injury to Host Tissue ocular transplantation graft begin to ritis is a common, but patient in-offi ce with the Cliradex® cornea specialists strive to achieve feel relief within 24 hours of the pro- frequently overlooked Complete Advanced Lid Hygiene quality healing of the ocular sur- cause of lid margin Kit, which includes a gel solution Eric Donnenfeld, MD, Neel R. Desai, MD, face. What is quality healing of the Normal Wound Healing +Cryopreserved Amniotic Membrane disease. It can exac- and an applicator brush that is is founding partner of specializes in cornea, cataract ocular surface? It’s the reproduction erbate pre-existing used to loosen debris at the eyelash Ophthalmic Consultants and refractive surgery and of quality cells on the ocular sur- Immune Response Regenerative Wound Healing conditions such as dry base and lid margin so it can be of Long Island and clinical is the medical director of the face, or the regeneration of healthy eye and pterygium, cleaned away. The lashes and lid professor of Ophthalmology International Sight Restoration tissue, rather than the need for Sustained Inflammation Selective Immune Respons and it has been impli- margin should be “combed” and at New York University. Eye Bank. repair with granulation tissue to re- cated as a contributor cleaned for no more than one to Brandon D. Ayres, MD, Preeya K. Gupta, MD, store normal tissue function. Visual Uncontrolled Angiogenesis Suppressed Inflammation to rosacea. It can also two minutes. The gel is all natural acuity, quality of life, comfort and is part of the Cornea Service is a corneal specialist at Duke make patients quite and preservative-free. It contains cosmetic appearance all depend Fibrotic Tissue Formation at Wills Eye Institute, where he Eye Center in North Carolina. Inhibited Angiogenesis uncomfortable, as it 4-Terpineol, the component of on quality healing; needless to say, serves as an assistant surgeon. Her clinical interests include did for a 49-year-old antimicrobial and anti-infl ammatory it is quite important. Disorganized Scar Tissue Remodeled Host Tissue He is also an instructor at corneal transplantation as well as patient who recently tea tree oil4,5 that has been shown Infl ammation is the fi rst step in Jefferson Medical College, cataract and refractive surgery. Figure 1:PROKERA® biologic corneal bandages, AmnioGraft® biologic ocular transplantation graft and Amnio- presented in my Figure 5. Cylindrical dandruff at the eyelash bases is a strong indica- to be the most effective component wound healing, but uncontrolled ® Figure 4. Chronically red eye prior to diagnosis Thomas Jefferson University. Guard biologic glaucoma shunt tube graft are the only amniotic membrane tissue products cleared by the FDA of demodex blepharitis. tion that demodex mites are the cause of lid margin and ocular surface 6 practice. His chief infl ammation. Inset: Demodex mites found on a patient’s eyelashes. for killing demodex mites. It is ef- infl ammation can cause delayed for reducing infl ammation and promoting regenerative healing of the ocular surface. SM-135, Rev 1

5 Review of Ophthalmology | March 2015 6 Review of Ophthalmology | March 2015 1 Review of Ophthalmology | March 2015

0315_Biotissue_final.indd 1 2/20/15 3:12 PM faster and more effective healing of Case 1: Epithelial Defect reduces infl ammation quickly and treatment results, after one week the cornea with less pain, scarring Caused by Corneal Collagen allows simultaneous use of topical of use. Of the patients surveyed, “...the biologic ocular and infl ammation, leading to clear Cross-Linking antibiotics and steroids if needed. 95 percent reported that based on corneas and improved clinical Following epithelium-off collagen their doctor’s feedback, the biologic transplantation graft can be outcomes. That’s because cryopre- crosslinking to treat keratoconus, corneal bandage healed their eye.3 served amniotic membrane tissue this 25-year-old male had a 6-mm MANAGING CORNEAL When asked how their eye felt after precisely placed and tucked retains important biologic compo- epithelial defect that did not re- INFLAMMATION AND treatment compared with before, nents that reduce infl ammation and solve after use of a bandage con- DRY EYE 93 percent reported the eye felt simultaneously promote regenerative tact lens for three days and one Brandon D. Ayres, MD better. In addition, 75 percent of where it is needed during healing of the ocular surface. day of pressure patching. When patients responded that the biologic The proprietary method by he presented to our practice, we As the Dry Eye WorkShop dry corneal bandage alleviated the pain surgery.” which cryopreserved amniotic placed a PROKERA® biologic cor- eye severity grading scheme indi- associated with dry eye, and 92 membrane tissue is processed and neal bandage to promote healing cates, patients categorized as percent responded that they would stored contributes to its effective- and prevent development of haze abhaving Level 3 or Level 4 disease request the same treatment if their disease stemming from chronic While Dr. Tseng prefers to 3 ® ness. Cryopreservation has been Figure 2. Placement of PROKERA® Slim to (see Figure 2). The cornea healed can be profoundly affected by their symptoms returned. exposure to elevated levels of suture the AmnioGraft down promote healing of epithelial defect following Figure 3. Non-healing SPK and dry eye prior to cataract surgery (a). Placement of PROKERA® shown to be the method that best corneal collagen crosslinking. completely within 48 hours. symptoms. Their daily activities I participated in the survey, matrix metalloproteinases, a as part of his procedure, I have retains the native architecture of Slim to promote healing of epithelial defect following corneal collagen crosslinking (b). may be curtailed, sometimes to the and the overall results match my chronic infl ammatory process. developed a version of reservoir the amniotic membrane extracel- now considered an option in the Case 2: Epithelial point of reduced work capacity or a personal experience using this Dissolution of the Tenon’s fascia restoration that is sutureless. lular matrix and the quantity and full spectrum of ocular surface Defect Caused by This interferes with keratometry face in a variety of clinical psychological condition such as de- treatment option. With its ability occurs over time, which causes This approach evolved from my activity of key biological signals and corneal conditions. Cryopre- Lamellar Keratectomy and therefore predictable IOL situations. It fi ts nicely with my pression. To provide them with the to quiet the ocular surface disease the overlying conjunctiva to sutureless pterygium technique present including HC-HA/PTX3 served amniotic tissue has made A 55-year-old male underwent power calculation and accurate approach to any corneal condi- relief they seek, we must restore the process, I have seen patients become loose and redundant. in which I reconstruct the semi- complex—that modulate the in- a substantial difference in our chelation to address a dense cor- astigmatism management. Often, tion that involves infl ammation, ocular surface to a normal homeo- improve from Level 3 or 4 dry eye Furthermore, CCh not only ob- lunar fold and seal the potential fl ammatory immune response and ability to reduce infl ammation and neal scar and band keratopathy, as in this case, even if the areas which is to treat aggressively static stage so that tissue healing to Level 1, which is manageable structs the tear meniscus, it leads space between the conjunctiva promote regenerative healing.1,2 In promote healing in diffi cult, recal- but both recurred. We performed of SPK are not large they do not from the start and taper rapidly can ensue and further damage can with more mild treatments such as to foreshortening of the inferior and Tenon’s fascia. For sutureless dehydrated amniotic membrane, citrant cases. It has also allowed a lamellar keratectomy with a resolve with conservative treat- rather than settle for incremental be prevented. This requires diminish- punctal plugs, Restasis® or pulsed fornix thereby obliterating the reservoir restoration for CCh, the crucial HC-HA/PTX3 complex us to elevate outcomes in routine femtosecond laser to remove ments such as drops, ointments improvement. For non-healing ing factors that incite or promote topical steroids. If symptoms tear reservoir. Once the anatomy AmnioGraft®serves as an ideal is degraded or completely absent.2 cases by improving the health of the scar tissue, leaving an 8-mm or cyclosporine ophthalmic emul- epithelial defects in particular, infl ammation or other pathologies. recur beyond that level, I do not of the reservoir is altered, the Tenon’s replacement. Preserved PROKERA® is designed to be the ocular surface and reducing epithelial defect. Three days after sion 0.05% (Restasis®, Allergan). I follow these three primary When that is accomplished, regen- hesitate to use a biologic corneal problems cannot be fi xed by through Bio-Tissue’s CryoTek® self-retaining in the eye. This cryo- the risk of scarring, haze and ir- placement of the PROKERA® Therefore, to expedite the heal- principles: erative healing can take place. I bandage again. Unlike other topical therapies or punctal occlu- process, the AmnioGraft® bio- biologic corneal bandage, the ing process for this patient and 1. Discontinue topical drops have seen a clear difference in the treatments for dry eye, which can sion. Surgery is the only solution. logic ocular transplantation graft defect healed. The corneal surface smooth the ocular surface, we that may be impeding the healing effi cacy of cryopreserved tissue take substantial time to work or Several techniques for surgically maintains the high molecular “Cryopreserved amniotic tissue was smooth, and visual acuity placed a PROKERA® Slim in the process, such as those that have over autologous serum eye drops may not work at all, this biologic treating CCh, such as cautery or weight proteins and HC-HA/PTX3 was markedly improved. affected eye. As we have come a thick vehicle capable of causing for delivering quality healing of the treatment option allows me to “paste, pinch and snip,” have complexes that are present in the has made a substantial For this case, we chose to expect, this led to rapid heal- problems, especially under a con- ocular surface. achieve excellent results for dry been tried and tend to worsen the fetal wound-healing environment. PROKERA® Plus due to the severity ing (see Figure 3b). tact lens, and replace with milder Bio-Tissue recently conducted a eye patients quickly. condition rather than cure it. Dr. These crucial growth factors, difference in our ability to of the infl ammation and the resis- Importantly, the cornea re- options if necessary. survey of multiple physicians and Scheffer C. G. Tseng developed cytokines and proteins are ren- tance to healing. The PROKERA® sumed normal shape in 24 hours, 2. Prescribe oral doxycycline, 295 patients to assess the effective- a successful technique called res- dered ineffective when membrane reduce infl ammation and Plus contains a thicker membrane allowing us to perform accurate starting at 100 mg bid for the anti- ness of the PROKERA® Slim bio- SUTURELESS RESERVOIR ervoir restoration, which restores is preserved by dehydration. that remains present in the eye to en- preoperative measurements and collagenolytic effect. logic corneal bandage in treating RESTORATION FOR the function of the anatomical tear In addition to the benefi ts of its promote healing...” hance the durability of the treatment. ensuring that the patient had an 3. Place a PROKERA® cryopre- dry eye.4 The survey focused on CONJUNCTIVOCHALASIS reservoir (fornix) by: mechanism of action and anti- uneventful postoperative healing served biologic corneal bandage, qualitative feedback, such as patient DRY EYE 1. removing deteriorated Tenon’s infl ammatory effects, AmnioGraft® preserved amniotic membrane is regular healing. Case 3: Non-healing course. If we had used a dehy- which, unlike pressure patching, lifestyle factors and satisfaction with Neel R. Desai, MD capsule maintains the structural integrity fastened to an ophthalmic con- Persistent epithelial defects, Superfi cial Punctate drated membrane with a BCL, 2. rearranging conjunctiva of the tissue histologically, giving former, which is placed between recurrent corneal erosion, fi la- Keratitis and Dry Eye Prior we would likely have needed to “...we must restore the Among the misconceptions that and/or removing conjunctiva it intraoperative workability. This the eyeball and the eyelid. This mentary keratitis, herpetic ulcers, to Cataract Surgery wait for up to four weeks for the exist about the condition known if necessary means, in contrast to the more delivery system is revolution- neurotrophic corneas are several It is common for cataract cornea to stabilize for biometry. as conjunctivochalasis are that 3. deepening the fornix brittle dehydrated tissue, the ary and has made it possible of the clinical situations in which surgery patients, such as this Cryopreserved amniotic ocular surface to a normal it is a disease of the conjunctiva 4. using multiple-layer cryopre- biologic ocular transplantation for amniotic membrane therapy a biologic corneal bandage has 55-year-old female (see Figure membrane tissue provides that only affects the tear meniscus served amniotic membrane to graft can be precisely placed and to be used in-offi ce for many been very helpful for us and our 3a), to have superfi cial punctate anterior segment surgeons with homeostatic stage so that tissue and can be managed in the same replace the Tenon’s and con- tucked where it is needed during applications. In our practice, patients, as illustrated by the keratitis and the dry eye that a welcome additional resource way as aqueous tear defi ciency. junctiva to help prevent recur- surgery. It also, of course, elimi- cryopreserved amniotic tissue is following three cases. accompanies it preoperatively. for managing the ocular sur- healing can ensue...” The truth is, CCh is a Tenon’s rence and expedite recovery. nates the need for an autograft.

2 Review of Ophthalmology | March 2015 3 Review of Ophthalmology | March 2015 4 Review of Ophthalmology | March 2015

0315_Biotissue_final.indd 2 2/20/15 3:12 PM faster and more effective healing of Case 1: Epithelial Defect reduces infl ammation quickly and treatment results, after one week the cornea with less pain, scarring Caused by Corneal Collagen allows simultaneous use of topical of use. Of the patients surveyed, “...the biologic ocular and infl ammation, leading to clear Cross-Linking antibiotics and steroids if needed. 95 percent reported that based on corneas and improved clinical Following epithelium-off collagen their doctor’s feedback, the biologic transplantation graft can be outcomes. That’s because cryopre- crosslinking to treat keratoconus, corneal bandage healed their eye.3 served amniotic membrane tissue this 25-year-old male had a 6-mm MANAGING CORNEAL When asked how their eye felt after precisely placed and tucked retains important biologic compo- epithelial defect that did not re- INFLAMMATION AND treatment compared with before, nents that reduce infl ammation and solve after use of a bandage con- DRY EYE 93 percent reported the eye felt simultaneously promote regenerative tact lens for three days and one Brandon D. Ayres, MD better. In addition, 75 percent of where it is needed during healing of the ocular surface. day of pressure patching. When patients responded that the biologic The proprietary method by he presented to our practice, we As the Dry Eye WorkShop dry corneal bandage alleviated the pain surgery.” which cryopreserved amniotic placed a PROKERA® biologic cor- eye severity grading scheme indi- associated with dry eye, and 92 membrane tissue is processed and neal bandage to promote healing cates, patients categorized as percent responded that they would stored contributes to its effective- and prevent development of haze abhaving Level 3 or Level 4 disease request the same treatment if their disease stemming from chronic While Dr. Tseng prefers to 3 ® ness. Cryopreservation has been Figure 2. Placement of PROKERA® Slim to (see Figure 2). The cornea healed can be profoundly affected by their symptoms returned. exposure to elevated levels of suture the AmnioGraft down promote healing of epithelial defect following Figure 3. Non-healing SPK and dry eye prior to cataract surgery (a). Placement of PROKERA® shown to be the method that best corneal collagen crosslinking. completely within 48 hours. symptoms. Their daily activities I participated in the survey, matrix metalloproteinases, a as part of his procedure, I have retains the native architecture of Slim to promote healing of epithelial defect following corneal collagen crosslinking (b). may be curtailed, sometimes to the and the overall results match my chronic infl ammatory process. developed a version of reservoir the amniotic membrane extracel- now considered an option in the Case 2: Epithelial point of reduced work capacity or a personal experience using this Dissolution of the Tenon’s fascia restoration that is sutureless. lular matrix and the quantity and full spectrum of ocular surface Defect Caused by This interferes with keratometry face in a variety of clinical psychological condition such as de- treatment option. With its ability occurs over time, which causes This approach evolved from my activity of key biological signals and corneal conditions. Cryopre- Lamellar Keratectomy and therefore predictable IOL situations. It fi ts nicely with my pression. To provide them with the to quiet the ocular surface disease the overlying conjunctiva to sutureless pterygium technique present including HC-HA/PTX3 served amniotic tissue has made A 55-year-old male underwent power calculation and accurate approach to any corneal condi- relief they seek, we must restore the process, I have seen patients become loose and redundant. in which I reconstruct the semi- complex—that modulate the in- a substantial difference in our chelation to address a dense cor- astigmatism management. Often, tion that involves infl ammation, ocular surface to a normal homeo- improve from Level 3 or 4 dry eye Furthermore, CCh not only ob- lunar fold and seal the potential fl ammatory immune response and ability to reduce infl ammation and neal scar and band keratopathy, as in this case, even if the areas which is to treat aggressively static stage so that tissue healing to Level 1, which is manageable structs the tear meniscus, it leads space between the conjunctiva promote regenerative healing.1,2 In promote healing in diffi cult, recal- but both recurred. We performed of SPK are not large they do not from the start and taper rapidly can ensue and further damage can with more mild treatments such as to foreshortening of the inferior and Tenon’s fascia. For sutureless dehydrated amniotic membrane, citrant cases. It has also allowed a lamellar keratectomy with a resolve with conservative treat- rather than settle for incremental be prevented. This requires diminish- punctal plugs, Restasis® or pulsed fornix thereby obliterating the reservoir restoration for CCh, the crucial HC-HA/PTX3 complex us to elevate outcomes in routine femtosecond laser to remove ments such as drops, ointments improvement. For non-healing ing factors that incite or promote topical steroids. If symptoms tear reservoir. Once the anatomy AmnioGraft®serves as an ideal is degraded or completely absent.2 cases by improving the health of the scar tissue, leaving an 8-mm or cyclosporine ophthalmic emul- epithelial defects in particular, infl ammation or other pathologies. recur beyond that level, I do not of the reservoir is altered, the Tenon’s replacement. Preserved PROKERA® is designed to be the ocular surface and reducing epithelial defect. Three days after sion 0.05% (Restasis®, Allergan). I follow these three primary When that is accomplished, regen- hesitate to use a biologic corneal problems cannot be fi xed by through Bio-Tissue’s CryoTek® self-retaining in the eye. This cryo- the risk of scarring, haze and ir- placement of the PROKERA® Therefore, to expedite the heal- principles: erative healing can take place. I bandage again. Unlike other topical therapies or punctal occlu- process, the AmnioGraft® bio- biologic corneal bandage, the ing process for this patient and 1. Discontinue topical drops have seen a clear difference in the treatments for dry eye, which can sion. Surgery is the only solution. logic ocular transplantation graft defect healed. The corneal surface smooth the ocular surface, we that may be impeding the healing effi cacy of cryopreserved tissue take substantial time to work or Several techniques for surgically maintains the high molecular “Cryopreserved amniotic tissue was smooth, and visual acuity placed a PROKERA® Slim in the process, such as those that have over autologous serum eye drops may not work at all, this biologic treating CCh, such as cautery or weight proteins and HC-HA/PTX3 was markedly improved. affected eye. As we have come a thick vehicle capable of causing for delivering quality healing of the treatment option allows me to “paste, pinch and snip,” have complexes that are present in the has made a substantial For this case, we chose to expect, this led to rapid heal- problems, especially under a con- ocular surface. achieve excellent results for dry been tried and tend to worsen the fetal wound-healing environment. PROKERA® Plus due to the severity ing (see Figure 3b). tact lens, and replace with milder Bio-Tissue recently conducted a eye patients quickly. condition rather than cure it. Dr. These crucial growth factors, difference in our ability to of the infl ammation and the resis- Importantly, the cornea re- options if necessary. survey of multiple physicians and Scheffer C. G. Tseng developed cytokines and proteins are ren- tance to healing. The PROKERA® sumed normal shape in 24 hours, 2. Prescribe oral doxycycline, 295 patients to assess the effective- a successful technique called res- dered ineffective when membrane reduce infl ammation and Plus contains a thicker membrane allowing us to perform accurate starting at 100 mg bid for the anti- ness of the PROKERA® Slim bio- SUTURELESS RESERVOIR ervoir restoration, which restores is preserved by dehydration. that remains present in the eye to en- preoperative measurements and collagenolytic effect. logic corneal bandage in treating RESTORATION FOR the function of the anatomical tear In addition to the benefi ts of its promote healing...” hance the durability of the treatment. ensuring that the patient had an 3. Place a PROKERA® cryopre- dry eye.4 The survey focused on CONJUNCTIVOCHALASIS reservoir (fornix) by: mechanism of action and anti- uneventful postoperative healing served biologic corneal bandage, qualitative feedback, such as patient DRY EYE 1. removing deteriorated Tenon’s infl ammatory effects, AmnioGraft® preserved amniotic membrane is regular healing. Case 3: Non-healing course. If we had used a dehy- which, unlike pressure patching, lifestyle factors and satisfaction with Neel R. Desai, MD capsule maintains the structural integrity fastened to an ophthalmic con- Persistent epithelial defects, Superfi cial Punctate drated membrane with a BCL, 2. rearranging conjunctiva of the tissue histologically, giving former, which is placed between recurrent corneal erosion, fi la- Keratitis and Dry Eye Prior we would likely have needed to “...we must restore the Among the misconceptions that and/or removing conjunctiva it intraoperative workability. This the eyeball and the eyelid. This mentary keratitis, herpetic ulcers, to Cataract Surgery wait for up to four weeks for the exist about the condition known if necessary means, in contrast to the more delivery system is revolution- neurotrophic corneas are several It is common for cataract cornea to stabilize for biometry. as conjunctivochalasis are that 3. deepening the fornix brittle dehydrated tissue, the ary and has made it possible of the clinical situations in which surgery patients, such as this Cryopreserved amniotic ocular surface to a normal it is a disease of the conjunctiva 4. using multiple-layer cryopre- biologic ocular transplantation for amniotic membrane therapy a biologic corneal bandage has 55-year-old female (see Figure membrane tissue provides that only affects the tear meniscus served amniotic membrane to graft can be precisely placed and to be used in-offi ce for many been very helpful for us and our 3a), to have superfi cial punctate anterior segment surgeons with homeostatic stage so that tissue and can be managed in the same replace the Tenon’s and con- tucked where it is needed during applications. In our practice, patients, as illustrated by the keratitis and the dry eye that a welcome additional resource way as aqueous tear defi ciency. junctiva to help prevent recur- surgery. It also, of course, elimi- cryopreserved amniotic tissue is following three cases. accompanies it preoperatively. for managing the ocular sur- healing can ensue...” The truth is, CCh is a Tenon’s rence and expedite recovery. nates the need for an autograft.

2 Review of Ophthalmology | March 2015 3 Review of Ophthalmology | March 2015 4 Review of Ophthalmology | March 2015

0315_Biotissue_final.indd 2 2/20/15 3:12 PM faster and more effective healing of Case 1: Epithelial Defect reduces infl ammation quickly and treatment results, after one week the cornea with less pain, scarring Caused by Corneal Collagen allows simultaneous use of topical of use. Of the patients surveyed, “...the biologic ocular and infl ammation, leading to clear Cross-Linking antibiotics and steroids if needed. 95 percent reported that based on corneas and improved clinical Following epithelium-off collagen their doctor’s feedback, the biologic transplantation graft can be outcomes. That’s because cryopre- crosslinking to treat keratoconus, corneal bandage healed their eye.3 served amniotic membrane tissue this 25-year-old male had a 6-mm MANAGING CORNEAL When asked how their eye felt after precisely placed and tucked retains important biologic compo- epithelial defect that did not re- INFLAMMATION AND treatment compared with before, nents that reduce infl ammation and solve after use of a bandage con- DRY EYE 93 percent reported the eye felt simultaneously promote regenerative tact lens for three days and one Brandon D. Ayres, MD better. In addition, 75 percent of where it is needed during healing of the ocular surface. day of pressure patching. When patients responded that the biologic The proprietary method by he presented to our practice, we As the Dry Eye WorkShop dry corneal bandage alleviated the pain surgery.” which cryopreserved amniotic placed a PROKERA® biologic cor- eye severity grading scheme indi- associated with dry eye, and 92 membrane tissue is processed and neal bandage to promote healing cates, patients categorized as percent responded that they would stored contributes to its effective- and prevent development of haze abhaving Level 3 or Level 4 disease request the same treatment if their disease stemming from chronic While Dr. Tseng prefers to 3 ® ness. Cryopreservation has been Figure 2. Placement of PROKERA® Slim to (see Figure 2). The cornea healed can be profoundly affected by their symptoms returned. exposure to elevated levels of suture the AmnioGraft down promote healing of epithelial defect following Figure 3. Non-healing SPK and dry eye prior to cataract surgery (a). Placement of PROKERA® shown to be the method that best corneal collagen crosslinking. completely within 48 hours. symptoms. Their daily activities I participated in the survey, matrix metalloproteinases, a as part of his procedure, I have retains the native architecture of Slim to promote healing of epithelial defect following corneal collagen crosslinking (b). may be curtailed, sometimes to the and the overall results match my chronic infl ammatory process. developed a version of reservoir the amniotic membrane extracel- now considered an option in the Case 2: Epithelial point of reduced work capacity or a personal experience using this Dissolution of the Tenon’s fascia restoration that is sutureless. lular matrix and the quantity and full spectrum of ocular surface Defect Caused by This interferes with keratometry face in a variety of clinical psychological condition such as de- treatment option. With its ability occurs over time, which causes This approach evolved from my activity of key biological signals and corneal conditions. Cryopre- Lamellar Keratectomy and therefore predictable IOL situations. It fi ts nicely with my pression. To provide them with the to quiet the ocular surface disease the overlying conjunctiva to sutureless pterygium technique present including HC-HA/PTX3 served amniotic tissue has made A 55-year-old male underwent power calculation and accurate approach to any corneal condi- relief they seek, we must restore the process, I have seen patients become loose and redundant. in which I reconstruct the semi- complex—that modulate the in- a substantial difference in our chelation to address a dense cor- astigmatism management. Often, tion that involves infl ammation, ocular surface to a normal homeo- improve from Level 3 or 4 dry eye Furthermore, CCh not only ob- lunar fold and seal the potential fl ammatory immune response and ability to reduce infl ammation and neal scar and band keratopathy, as in this case, even if the areas which is to treat aggressively static stage so that tissue healing to Level 1, which is manageable structs the tear meniscus, it leads space between the conjunctiva promote regenerative healing.1,2 In promote healing in diffi cult, recal- but both recurred. We performed of SPK are not large they do not from the start and taper rapidly can ensue and further damage can with more mild treatments such as to foreshortening of the inferior and Tenon’s fascia. For sutureless dehydrated amniotic membrane, citrant cases. It has also allowed a lamellar keratectomy with a resolve with conservative treat- rather than settle for incremental be prevented. This requires diminish- punctal plugs, Restasis® or pulsed fornix thereby obliterating the reservoir restoration for CCh, the crucial HC-HA/PTX3 complex us to elevate outcomes in routine femtosecond laser to remove ments such as drops, ointments improvement. For non-healing ing factors that incite or promote topical steroids. If symptoms tear reservoir. Once the anatomy AmnioGraft®serves as an ideal is degraded or completely absent.2 cases by improving the health of the scar tissue, leaving an 8-mm or cyclosporine ophthalmic emul- epithelial defects in particular, infl ammation or other pathologies. recur beyond that level, I do not of the reservoir is altered, the Tenon’s replacement. Preserved PROKERA® is designed to be the ocular surface and reducing epithelial defect. Three days after sion 0.05% (Restasis®, Allergan). I follow these three primary When that is accomplished, regen- hesitate to use a biologic corneal problems cannot be fi xed by through Bio-Tissue’s CryoTek® self-retaining in the eye. This cryo- the risk of scarring, haze and ir- placement of the PROKERA® Therefore, to expedite the heal- principles: erative healing can take place. I bandage again. Unlike other topical therapies or punctal occlu- process, the AmnioGraft® bio- biologic corneal bandage, the ing process for this patient and 1. Discontinue topical drops have seen a clear difference in the treatments for dry eye, which can sion. Surgery is the only solution. logic ocular transplantation graft defect healed. The corneal surface smooth the ocular surface, we that may be impeding the healing effi cacy of cryopreserved tissue take substantial time to work or Several techniques for surgically maintains the high molecular “Cryopreserved amniotic tissue was smooth, and visual acuity placed a PROKERA® Slim in the process, such as those that have over autologous serum eye drops may not work at all, this biologic treating CCh, such as cautery or weight proteins and HC-HA/PTX3 was markedly improved. affected eye. As we have come a thick vehicle capable of causing for delivering quality healing of the treatment option allows me to “paste, pinch and snip,” have complexes that are present in the has made a substantial For this case, we chose to expect, this led to rapid heal- problems, especially under a con- ocular surface. achieve excellent results for dry been tried and tend to worsen the fetal wound-healing environment. PROKERA® Plus due to the severity ing (see Figure 3b). tact lens, and replace with milder Bio-Tissue recently conducted a eye patients quickly. condition rather than cure it. Dr. These crucial growth factors, difference in our ability to of the infl ammation and the resis- Importantly, the cornea re- options if necessary. survey of multiple physicians and Scheffer C. G. Tseng developed cytokines and proteins are ren- tance to healing. The PROKERA® sumed normal shape in 24 hours, 2. Prescribe oral doxycycline, 295 patients to assess the effective- a successful technique called res- dered ineffective when membrane reduce infl ammation and Plus contains a thicker membrane allowing us to perform accurate starting at 100 mg bid for the anti- ness of the PROKERA® Slim bio- SUTURELESS RESERVOIR ervoir restoration, which restores is preserved by dehydration. that remains present in the eye to en- preoperative measurements and collagenolytic effect. logic corneal bandage in treating RESTORATION FOR the function of the anatomical tear In addition to the benefi ts of its promote healing...” hance the durability of the treatment. ensuring that the patient had an 3. Place a PROKERA® cryopre- dry eye.4 The survey focused on CONJUNCTIVOCHALASIS reservoir (fornix) by: mechanism of action and anti- uneventful postoperative healing served biologic corneal bandage, qualitative feedback, such as patient DRY EYE 1. removing deteriorated Tenon’s infl ammatory effects, AmnioGraft® preserved amniotic membrane is regular healing. Case 3: Non-healing course. If we had used a dehy- which, unlike pressure patching, lifestyle factors and satisfaction with Neel R. Desai, MD capsule maintains the structural integrity fastened to an ophthalmic con- Persistent epithelial defects, Superfi cial Punctate drated membrane with a BCL, 2. rearranging conjunctiva of the tissue histologically, giving former, which is placed between recurrent corneal erosion, fi la- Keratitis and Dry Eye Prior we would likely have needed to “...we must restore the Among the misconceptions that and/or removing conjunctiva it intraoperative workability. This the eyeball and the eyelid. This mentary keratitis, herpetic ulcers, to Cataract Surgery wait for up to four weeks for the exist about the condition known if necessary means, in contrast to the more delivery system is revolution- neurotrophic corneas are several It is common for cataract cornea to stabilize for biometry. as conjunctivochalasis are that 3. deepening the fornix brittle dehydrated tissue, the ary and has made it possible of the clinical situations in which surgery patients, such as this Cryopreserved amniotic ocular surface to a normal it is a disease of the conjunctiva 4. using multiple-layer cryopre- biologic ocular transplantation for amniotic membrane therapy a biologic corneal bandage has 55-year-old female (see Figure membrane tissue provides that only affects the tear meniscus served amniotic membrane to graft can be precisely placed and to be used in-offi ce for many been very helpful for us and our 3a), to have superfi cial punctate anterior segment surgeons with homeostatic stage so that tissue and can be managed in the same replace the Tenon’s and con- tucked where it is needed during applications. In our practice, patients, as illustrated by the keratitis and the dry eye that a welcome additional resource way as aqueous tear defi ciency. junctiva to help prevent recur- surgery. It also, of course, elimi- cryopreserved amniotic tissue is following three cases. accompanies it preoperatively. for managing the ocular sur- healing can ensue...” The truth is, CCh is a Tenon’s rence and expedite recovery. nates the need for an autograft.

2 Review of Ophthalmology | March 2015 3 Review of Ophthalmology | March 2015 4 Review of Ophthalmology | March 2015

0315_Biotissue_final.indd 2 2/20/15 3:12 PM Sponsored by

The key steps in sutureless The demodex patient discussed reservoir restoration are: “...chronic lid margin disease here used the towelettes as directed From Dry Eye to • inject 2% lidocaine infi ltrated for six weeks after his initial ad- with epinephrine (for hemostasis and infl ammation lead to vanced treatment, which signifi cantly and to separate tissue planes) reduced his eyelid infl ammation, • resect redundant conjunctiva ocular surface infl ammation.” ocular surface infl ammation and red- • remove unhealthy Tenon’s cap- ness and discomfort (see Figure 6). Lid Margin Diseases: sule from scleral bed In addition to demodex, Cliradex® • cauterize any prolapsed fat cedure. They are among the most complaint was bilateral ocular irrita- is also indicated for managing symp- so it shrinks back behind the satisfi ed patients in my practice. tion, and he had been experiencing toms associated with meibomian fornix and the edge of remain- They come in miserable from their redness and recurrent chalazia gland dysfunction, rosacea blepha- Promoting Quality Healing Through ing Tenon’s symptoms, desperate for a solution, for approximately a year (see ritis, dry eye, chalazia and other • with a small amount of fi brin and leave thrilled with the results of Figure 4). He had been diagnosed lid margin diseases, making it a Evidence-Based Therapies glue, secure a small piece of this procedure, which takes 10 to with chronic blepharoconjunctivitis, very useful addition to the treatment AmnioGraft® biologic ocular 12 minutes on average to perform. but his condition had limited re- options I can offer my lid margin/ transplantation graft to cover the sponse to hot compresses, lid scrubs, ocular surface disease patients. inferior rectus muscle insertion topical antibiotics/steroids, lubricants 1. Tan EK, Cooke M, Mandrycky C, et al. Structural (to replace Tenon’s in that area DEALING WITH LID and oral doxycycline. and biological comparison of cryopreserved and discomfort/irritation, as well as ® uring a recent industry meeting, four corneal specialists came and to prevent restriction and MARGIN AND OCULAR Examining this type of patient, Figure 6. Reduced infl ammation and redness following treatment for demodex with Cliradex and fresh amniotic membrane tissues. J Biomaterials and vision-threatening complications Cliradex® Complete. Tissue Engineering 2014;4:379-388. together to discuss how innovative corneal wound-healing and potential diplopia) SURFACE DISEASE ISSUES with chronic symptoms and no 2. Cooke M, Tan EK, Mandrycky C, He H, et al. such as scarring and haze. Thus, • using minimal glue, secure a Preeya K. Gupta, MD relief from the usual therapies, it’s Comparison of cryopreserved amniotic mem- hygiene solutions have changed the way they approach a wide effective control of infl ammation is ® brane and umbilical cord tissue with dehydrated D second piece of AmnioGraft important to consider the full range to examine the base of the eyelashes fective at low concentrations, which amniotic membrane/chorion tissue. J Wound Care. range of ocular surface and eyelid margin diseases and disorders, an important strategy for promoting (cut larger than the defect) over As knowledge about ocular sur- of potential causes, such as meibo- for cylindrical dandruff (see Figure is important in terms of patient 2014;23(10):465-74, 476. including dry eye, epithelial defects, conjunctivochalasis, blepharitis quality healing and minimizing the 3. Data on fi le, Bio-Tissue. the entire defect (overshoot the face disease has advanced, it mian gland dysfunction associated 5), which is pathognomonic for comfort and tolerability. 4. Carson CF, Hammer A, Riley TV. Melaleuca and demodex. They shared their experiences with Bio-Tissue Inc.’s risk of scar and haze. ® edges when pulling the graft into has become clear that chronic lid with rosacea, chronic conjunctivi- demodex. When this is observed, The kit also includes 24 Cliradex alternifolia (tea tree) oil: a review of antimicrobial ® ® Biologic corneal bandages can and other medicinal properties. Clin Microbiol Rev. PROKERA biologic corneal bandage, AmnioGraft biologic ocular ® place), tucking the edges a mini- margin disease and infl ammation tis, toxicity issues, mucous fi shing a few eyelashes should be plucked lid, lash and facial cleanser tow- 2006;19(1):50-62. transplantation graft and Cliradex lid, lash and facial cleanser. High- promote quality healing because mum of 1 mm under the conjunc- lead to ocular surface infl amma- syndromes, lid apposition problems and closely examined for the pres- elettes for patients to use at home. 5. Gao Y-Y, Di Pascuale MA, Li W, et al. In vitro and they modulate infl ammation (see in vivo killing of ocular Demodex by tea tree oil. Br J lights from their discussion follow. tiva on the sides (as if tucking a tion. Without proper management and, in this particular case, based ence of the demodex mites (see Like the gel, the towelettes are Ophthalmol. 2005;89:1468-1473. Figure 1) and in my experience, they bed sheet under a pillow). of the infl ammation, patients are at on the chronic chalazia, sebaceous Figure 5 inset). The mites, which preservative-free and contain 6. Tighe S, Gao Y-Y, Tseng SCG. Terpinen-4-ol is the have made a big difference—in most active ingredient of tea tree oil to kill Demodex • “squeegee” excess glue (anteri- increased risk for impaired vision, cell carcinoma. It is also important are present on everyone’s skin but 4-Terpineol. My patients fi nd them mites. Trans Vis Sci Tech. 2013;2(7):2. HEALING healing of the ocular surface, more both easy and recalcitrant cases. In ® orly or laterally, never posteriorly) infection and subop- usually do not cause problems, live easy to use, which improves compli- PROKERA®, AmnioGraft® and Cliradex® EPITHELIAL DEFECTS tissue damage, chronic pain and fact, PROKERA products provide and excise excess tissue. timal cataract and in the glands and feed on meibum. ance. The gel contains approximate- are registered trademarks of Bio-Tissue Inc. Eric Donnenfeld, MD ® Most of my patients who have refractive surgical When they become a source of in- ly double the concentration of the CryoTek is a registered trademark of Tissue-Tek. Controlling the Wound Healing Cascade had sutureless reservoir restora- outcomes. fl ammation, they require treatment. towelettes and therefore serves as a Restasis® is a registered trademark of To obtain and sustain the best ® tion with an AmnioGraft biologic Demodex blepha- In this case, we treated the loading dose when applied in-offi ce. Allergan Inc. possible outcomes for patients, Injury to Host Tissue ocular transplantation graft begin to ritis is a common, but patient in-offi ce with the Cliradex® cornea specialists strive to achieve feel relief within 24 hours of the pro- frequently overlooked Complete Advanced Lid Hygiene quality healing of the ocular sur- cause of lid margin Kit, which includes a gel solution Eric Donnenfeld, MD, Neel R. Desai, MD, face. What is quality healing of the Normal Wound Healing +Cryopreserved Amniotic Membrane disease. It can exac- and an applicator brush that is is founding partner of specializes in cornea, cataract ocular surface? It’s the reproduction erbate pre-existing used to loosen debris at the eyelash Ophthalmic Consultants and refractive surgery and of quality cells on the ocular sur- Immune Response Regenerative Wound Healing conditions such as dry base and lid margin so it can be of Long Island and clinical is the medical director of the face, or the regeneration of healthy eye and pterygium, cleaned away. The lashes and lid professor of Ophthalmology International Sight Restoration tissue, rather than the need for Sustained Inflammation Selective Immune Respons and it has been impli- margin should be “combed” and at New York University. Eye Bank. repair with granulation tissue to re- cated as a contributor cleaned for no more than one to Brandon D. Ayres, MD, Preeya K. Gupta, MD, store normal tissue function. Visual Uncontrolled Angiogenesis Suppressed Inflammation to rosacea. It can also two minutes. The gel is all natural acuity, quality of life, comfort and is part of the Cornea Service is a corneal specialist at Duke make patients quite and preservative-free. It contains cosmetic appearance all depend Fibrotic Tissue Formation at Wills Eye Institute, where he Eye Center in North Carolina. Inhibited Angiogenesis uncomfortable, as it 4-Terpineol, the component of on quality healing; needless to say, serves as an assistant surgeon. Her clinical interests include did for a 49-year-old antimicrobial and anti-infl ammatory it is quite important. Disorganized Scar Tissue Remodeled Host Tissue He is also an instructor at corneal transplantation as well as patient who recently tea tree oil4,5 that has been shown Infl ammation is the fi rst step in Jefferson Medical College, cataract and refractive surgery. Figure 1:PROKERA® biologic corneal bandages, AmnioGraft® biologic ocular transplantation graft and Amnio- presented in my Figure 5. Cylindrical dandruff at the eyelash bases is a strong indica- to be the most effective component wound healing, but uncontrolled ® Figure 4. Chronically red eye prior to diagnosis Thomas Jefferson University. Guard biologic glaucoma shunt tube graft are the only amniotic membrane tissue products cleared by the FDA of demodex blepharitis. tion that demodex mites are the cause of lid margin and ocular surface 6 practice. His chief infl ammation. Inset: Demodex mites found on a patient’s eyelashes. for killing demodex mites. It is ef- infl ammation can cause delayed for reducing infl ammation and promoting regenerative healing of the ocular surface. SM-135, Rev 1

5 Review of Ophthalmology | March 2015 6 Review of Ophthalmology | March 2015 1 Review of Ophthalmology | March 2015

0315_Biotissue_final.indd 1 2/20/15 3:12 PM Sponsored by

The key steps in sutureless The demodex patient discussed reservoir restoration are: “...chronic lid margin disease here used the towelettes as directed From Dry Eye to • inject 2% lidocaine infi ltrated for six weeks after his initial ad- with epinephrine (for hemostasis and infl ammation lead to vanced treatment, which signifi cantly and to separate tissue planes) reduced his eyelid infl ammation, • resect redundant conjunctiva ocular surface infl ammation.” ocular surface infl ammation and red- • remove unhealthy Tenon’s cap- ness and discomfort (see Figure 6). Lid Margin Diseases: sule from scleral bed In addition to demodex, Cliradex® • cauterize any prolapsed fat cedure. They are among the most complaint was bilateral ocular irrita- is also indicated for managing symp- so it shrinks back behind the satisfi ed patients in my practice. tion, and he had been experiencing toms associated with meibomian fornix and the edge of remain- They come in miserable from their redness and recurrent chalazia gland dysfunction, rosacea blepha- Promoting Quality Healing Through ing Tenon’s symptoms, desperate for a solution, for approximately a year (see ritis, dry eye, chalazia and other • with a small amount of fi brin and leave thrilled with the results of Figure 4). He had been diagnosed lid margin diseases, making it a Evidence-Based Therapies glue, secure a small piece of this procedure, which takes 10 to with chronic blepharoconjunctivitis, very useful addition to the treatment AmnioGraft® biologic ocular 12 minutes on average to perform. but his condition had limited re- options I can offer my lid margin/ transplantation graft to cover the sponse to hot compresses, lid scrubs, ocular surface disease patients. inferior rectus muscle insertion topical antibiotics/steroids, lubricants 1. Tan EK, Cooke M, Mandrycky C, et al. Structural (to replace Tenon’s in that area DEALING WITH LID and oral doxycycline. and biological comparison of cryopreserved and discomfort/irritation, as well as ® uring a recent industry meeting, four corneal specialists came and to prevent restriction and MARGIN AND OCULAR Examining this type of patient, Figure 6. Reduced infl ammation and redness following treatment for demodex with Cliradex and fresh amniotic membrane tissues. J Biomaterials and vision-threatening complications Cliradex® Complete. Tissue Engineering 2014;4:379-388. together to discuss how innovative corneal wound-healing and potential diplopia) SURFACE DISEASE ISSUES with chronic symptoms and no 2. Cooke M, Tan EK, Mandrycky C, He H, et al. such as scarring and haze. Thus, • using minimal glue, secure a Preeya K. Gupta, MD relief from the usual therapies, it’s Comparison of cryopreserved amniotic mem- hygiene solutions have changed the way they approach a wide effective control of infl ammation is ® brane and umbilical cord tissue with dehydrated D second piece of AmnioGraft important to consider the full range to examine the base of the eyelashes fective at low concentrations, which amniotic membrane/chorion tissue. J Wound Care. range of ocular surface and eyelid margin diseases and disorders, an important strategy for promoting (cut larger than the defect) over As knowledge about ocular sur- of potential causes, such as meibo- for cylindrical dandruff (see Figure is important in terms of patient 2014;23(10):465-74, 476. including dry eye, epithelial defects, conjunctivochalasis, blepharitis quality healing and minimizing the 3. Data on fi le, Bio-Tissue. the entire defect (overshoot the face disease has advanced, it mian gland dysfunction associated 5), which is pathognomonic for comfort and tolerability. 4. Carson CF, Hammer A, Riley TV. Melaleuca and demodex. They shared their experiences with Bio-Tissue Inc.’s risk of scar and haze. ® edges when pulling the graft into has become clear that chronic lid with rosacea, chronic conjunctivi- demodex. When this is observed, The kit also includes 24 Cliradex alternifolia (tea tree) oil: a review of antimicrobial ® ® Biologic corneal bandages can and other medicinal properties. Clin Microbiol Rev. PROKERA biologic corneal bandage, AmnioGraft biologic ocular ® place), tucking the edges a mini- margin disease and infl ammation tis, toxicity issues, mucous fi shing a few eyelashes should be plucked lid, lash and facial cleanser tow- 2006;19(1):50-62. transplantation graft and Cliradex lid, lash and facial cleanser. High- promote quality healing because mum of 1 mm under the conjunc- lead to ocular surface infl amma- syndromes, lid apposition problems and closely examined for the pres- elettes for patients to use at home. 5. Gao Y-Y, Di Pascuale MA, Li W, et al. In vitro and they modulate infl ammation (see in vivo killing of ocular Demodex by tea tree oil. Br J lights from their discussion follow. tiva on the sides (as if tucking a tion. Without proper management and, in this particular case, based ence of the demodex mites (see Like the gel, the towelettes are Ophthalmol. 2005;89:1468-1473. Figure 1) and in my experience, they bed sheet under a pillow). of the infl ammation, patients are at on the chronic chalazia, sebaceous Figure 5 inset). The mites, which preservative-free and contain 6. Tighe S, Gao Y-Y, Tseng SCG. Terpinen-4-ol is the have made a big difference—in most active ingredient of tea tree oil to kill Demodex • “squeegee” excess glue (anteri- increased risk for impaired vision, cell carcinoma. It is also important are present on everyone’s skin but 4-Terpineol. My patients fi nd them mites. Trans Vis Sci Tech. 2013;2(7):2. HEALING healing of the ocular surface, more both easy and recalcitrant cases. In ® orly or laterally, never posteriorly) infection and subop- usually do not cause problems, live easy to use, which improves compli- PROKERA®, AmnioGraft® and Cliradex® EPITHELIAL DEFECTS tissue damage, chronic pain and fact, PROKERA products provide and excise excess tissue. timal cataract and in the glands and feed on meibum. ance. The gel contains approximate- are registered trademarks of Bio-Tissue Inc. Eric Donnenfeld, MD ® Most of my patients who have refractive surgical When they become a source of in- ly double the concentration of the CryoTek is a registered trademark of Tissue-Tek. Controlling the Wound Healing Cascade had sutureless reservoir restora- outcomes. fl ammation, they require treatment. towelettes and therefore serves as a Restasis® is a registered trademark of To obtain and sustain the best ® tion with an AmnioGraft biologic Demodex blepha- In this case, we treated the loading dose when applied in-offi ce. Allergan Inc. possible outcomes for patients, Injury to Host Tissue ocular transplantation graft begin to ritis is a common, but patient in-offi ce with the Cliradex® cornea specialists strive to achieve feel relief within 24 hours of the pro- frequently overlooked Complete Advanced Lid Hygiene quality healing of the ocular sur- cause of lid margin Kit, which includes a gel solution Eric Donnenfeld, MD, Neel R. Desai, MD, face. What is quality healing of the Normal Wound Healing +Cryopreserved Amniotic Membrane disease. It can exac- and an applicator brush that is is founding partner of specializes in cornea, cataract ocular surface? It’s the reproduction erbate pre-existing used to loosen debris at the eyelash Ophthalmic Consultants and refractive surgery and of quality cells on the ocular sur- Immune Response Regenerative Wound Healing conditions such as dry base and lid margin so it can be of Long Island and clinical is the medical director of the face, or the regeneration of healthy eye and pterygium, cleaned away. The lashes and lid professor of Ophthalmology International Sight Restoration tissue, rather than the need for Sustained Inflammation Selective Immune Respons and it has been impli- margin should be “combed” and at New York University. Eye Bank. repair with granulation tissue to re- cated as a contributor cleaned for no more than one to Brandon D. Ayres, MD, Preeya K. Gupta, MD, store normal tissue function. Visual Uncontrolled Angiogenesis Suppressed Inflammation to rosacea. It can also two minutes. The gel is all natural acuity, quality of life, comfort and is part of the Cornea Service is a corneal specialist at Duke make patients quite and preservative-free. It contains cosmetic appearance all depend Fibrotic Tissue Formation at Wills Eye Institute, where he Eye Center in North Carolina. Inhibited Angiogenesis uncomfortable, as it 4-Terpineol, the component of on quality healing; needless to say, serves as an assistant surgeon. Her clinical interests include did for a 49-year-old antimicrobial and anti-infl ammatory it is quite important. Disorganized Scar Tissue Remodeled Host Tissue He is also an instructor at corneal transplantation as well as patient who recently tea tree oil4,5 that has been shown Infl ammation is the fi rst step in Jefferson Medical College, cataract and refractive surgery. Figure 1:PROKERA® biologic corneal bandages, AmnioGraft® biologic ocular transplantation graft and Amnio- presented in my Figure 5. Cylindrical dandruff at the eyelash bases is a strong indica- to be the most effective component wound healing, but uncontrolled ® Figure 4. Chronically red eye prior to diagnosis Thomas Jefferson University. Guard biologic glaucoma shunt tube graft are the only amniotic membrane tissue products cleared by the FDA of demodex blepharitis. tion that demodex mites are the cause of lid margin and ocular surface 6 practice. His chief infl ammation. Inset: Demodex mites found on a patient’s eyelashes. for killing demodex mites. It is ef- infl ammation can cause delayed for reducing infl ammation and promoting regenerative healing of the ocular surface. SM-135, Rev 1

5 Review of Ophthalmology | March 2015 6 Review of Ophthalmology | March 2015 1 Review of Ophthalmology | March 2015

0315_Biotissue_final.indd 1 2/20/15 3:12 PM