Cryopreserved amniotic membrane a treatment option for mechanical dry eye

Characterized by loose and redundant conjunctival folds, conjunctivochalase (CCH)also known as mechanical dry eye (MDE), is a chronic condition that usually affects both eyes and is a common cause of eye irritation and discomfort.1.2

CHC is associated with various ocular and non-ocular conditions, but it is often overlooked and underdiagnosed in clinical practice because the condition may be asymptomatic. CHC is thought to have a multifactorial etiology that is usually associated with age and local trauma, such as eye rubbing. Severe HCC can cause blurred vision, mucous discharge, and subconjunctival hemorrhage.1.2

In patients with CCH/MDE, cryopreserved amniotic membrane (CAM) is a promising therapy to accelerate recovery of ocular surface health and corneal nerve regeneration. CAM helps improve a number of issues, such as pain, corneal staining, general signs and symptoms of dry eye (eg, discomfort, visual disturbances), corneal nerve density, and corneal sensitivity.3 CAM is a biological dressing designed to treat corneal injuries by creating an environment conducive to regenerative healing.4

Amniograft is the only eye transplant graft offering CryoTek CAM tissue to help accelerate postoperative recovery, prevent disease recurrence and optimize long-term patient outcomes. Amniograft’s cryopreservation method maintains all the biological components of the tissue, such as heavy chain hyaluronic acid (HCHA) and pentraxin 3 (PTX3), which help to rapidly restore the healing capabilities of the ocular surface.4

There are some interesting current approaches to diagnosis and management, including the role of CAM.

Overview of Mechanical Dry Eye Disease

EDM is age-related and usually presents in patients over 60 years of age. The etiology of MDE is not fully understood, but is thought to be multifactorial, including local trauma, UV radiation, and increased conjunctival matrix metalloproteinases. Delayed tear clearance can contribute to the buildup of degrading enzymes in tears. This results in redundant and loose folds of the abnormal conjunctiva that prevent normal blinking and the spread of the tear film. Other risk factors include female gender, decreased eye sensitivity, and dermatochalasis.1.2

Presentation of the patient, diagnosis and treatment

Patients with MDE experience excessive tearing, redness, irritation, and eye pain. The pain tends to be sudden, sharp, intermittent, and made worse by looking down. Blinking will not relieve this. Unfortunately, many symptoms parallel or are similar to dry eye. However, these patients may not experience relief from dry eye treatments such as artificial tears. Redundant conjunctiva folds at the nasal level can disrupt tear flow by blocking the lower nasal point and causing epiphora.

Diagnosis is based on clinical findings and patient history, and the extent and location of redundant conjunctiva is noted. Fluorescein or Rose Bengal staining of the cornea tends to be negative. However, there may be discrete punctate or linear staining on the mucosal surface of the lid margin adjacent to the redundant conjunctiva.

No immediate intervention is required for asymptomatic patients. Patients with eye irritation, pain, or subconjunctival hemorrhage may be given tear substitutes, lubricants, and corticosteroid or antihistamine drops. I will also start eyelid hygiene and omega-3s to improve their tear film composition. If they have significant improvement and are satisfied with their comfort level, I will have them continue treatment. However, if they still experience a lot of inflammation, burning and stinging, I may add a mild topical steroid. Cyclosporine (Restasis) ophthalmic emulsion 0.05% or lifitegrast (Xiidra) ophthalmic solution 5% may also be added to help increase tear production.5,6 If these measures fail, surgical intervention becomes necessary. I recommend my patients consider a quick outpatient procedure known as reservoir restoration using AmnioGraft for long term relief.

Tank Rebuild Procedure

The primary goal of the procedure is to restore the normal anatomy of the lower cul-de-sac, restoring a deep, well-defined lower cul-de-sac, which serves as a tear reservoir. Abnormal tenon and conjunctiva and prolapsed orbital fat are removed. Then I glue the CAM over the sclera and into the inferior fornix, providing a base for conjunctival re-epithelialization. Biological growth factors active in CAM prevent inflammation, conjunctival scarring, muscle restriction and orbital fat prolapse. With normalization of the tear reservoir, routine therapy works better and discomfort disappears.

The Challenges of EDM Treatment

The main challenge in treating EDM is that patients generally do not see surgery as a solution. Most patients think drops are the solution, so I don’t usually suggest surgery right away either. I let them know that we will try some simple approaches first and then we can reconsider whether the tank restoration procedure is necessary or not.

Another challenge is to help the patient understand the multidimensional and multifactorial basis of their symptoms. Patient education and counseling is important so that they see EDM as a chronic problem that cannot be solved by a simple procedure or a few weeks of treatment. In addition, these patients often have other concomitant forms of ocular surface disease (OSD).

Both EDM and OSD can have a significant impact on patients’ quality of life. We use our eyes all the time, so having chronic symptoms such as foreign body sensations is distracting and disruptive for patients. But when patients see improvement, especially after the reservoir restoration procedure, they are motivated to maintain their results. They often become more engaged in their therapy.

Arla Genstler, MD

Such. : 785/273-8080

Genstler is an ophthalmologist practicing in Topeka, Kansas, specializing in cataract and refractive surgery. She is the founder of the Genstler Eye Center.

Benefits of CAM Therapy

CAM preserves the biological properties of the amniotic membrane and umbilical cord tissue, which have been shown to play a major role in controlling inflammation and preventing scarring. Biologics contained in CAM, such as Pentraxin 3 (PTX3) and heavy chain hyaluronic acid (HC-HA), have anti-inflammatory and anti-scarring properties, which are maintained when cryopreserved. Other amniotic membrane preparations lack these clinical properties because the dehydration involved in these preparations significantly alters the structural and biological integrity of the tissue.3.7

The CAM is also much easier to use than other amniotic membranes. It is more robust and works wonderfully, especially in conjunctival reservoir restorative procedures. CAM has multiple applications, and in my experience its usefulness is validated when a patient requests the same treatment on their other eye.

Patient advice

In order to counsel patients about EDM and their treatment, slit lamp photographs are useful teaching tools that allow patients to visualize the tissue folds hanging over the lower eyelid. A picture is worth a thousand words and helps a lot in explaining the reasons for surgery.

Ophthalmologists are great at treating OSD, but many don’t understand the mechanics and common prevalence of EDM. Greater awareness of this condition is needed, and people need to know that there is specific treatment for it, unlike other forms of dry eye. Reservoir restoration can restore normal conjunctival anatomy and function in patients with MDE. All the drops in the world won’t do that.


  1. Larrazabal LI, Weissbart SB, Ibarra Lozano AF, Bunya VY, Nallasamy N. Conjunctivochalasis. American Academy of Ophthalmology. Updated April 11, 2022. Accessed July 18, 2022.
  2. Yvon C, Patel BC, Malhotra R. Conjunctivochalasis. National Library of Medicine. Updated March 12, 2022. Accessed July 18, 2022.
  3. John T, Tighe S, Sheha H, Hamrah P, et al. Corneal nerve regeneration after cryopreserved self-maintained amniotic membrane in dry eye disease. J Ophthalmol. 2017;2017:6404918.
  4. Data on file. Bio-Tissue, Inc., Miami, FL.
  5. Schultz C. Safety and efficacy of cyclosporine in the treatment of chronic dry eye disease. Ophthalmol Eye Dis. 2014;6:37-42.
  6. Hovanesian JA, Nichols KK, Jackson M, et al. Real-world experience with lifitegrast ophthalmic solution (Xiidra®) in the United States and Canada: a retrospective study of patient characteristics, treatment regimens, and clinical efficacy in 600 dry eye patients. Clin Ophthalmol. 2021;15:1041-1054.

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