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Editors Selection IGR 11-2

Surgery: Amniotic membrane and buttonholes

Comment by Keith Barton on:

19549 Amniotic membrane transplantation for intraoperative conjunctival repair during trabeculectomy with mitomycin C, Li G; Oʼhearn T; Yiu S et al., Journal of Glaucoma, 2007; 16: 521-526

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Li et al. (1127) have reported three cases (four eyes) in which they found amniotic membrane transplantation (AMT) to be useful in closing conjunctival buttonholes discovered at the end of surgery after trabeculectomy with Mitomycin C performed via a limbus-based conjunctival flap. In contrast with previous reports, that used single layer AMT as a replacement for conjunctival defects after glaucoma filtration surgery, the authors placed the AMT over existing conjunctiva and, in one eye, used tissue glue, rather than sutures, to secure the graft. In our previous experience, undersewing the edges of AMT below surrounding conjunctiva was found to be important to promote epithelial migration over the AMT from surrounding conjunctiva. This was especially true when there was a bleb underneath.^1-4

The authors make the valid point that with small buttonholes and a wide surrounding area of tissue apposition between AMT and conjunctiva, AMT placed on top may be more than adequate to repair the buttonhole. The reported technique is potentially useful. Two foreseeable barriers to its wider use would be the requirement that AMT be routinely available in the operating department, and that patients at risk of buttonholes be accurately identified and consented for AMT before surgery, otherwise its use would not be possible.

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