Multilayer Amniotic Membrane Transplantation: An Effective Globe-Preserving Approach In Perforated Corneal Disease

Severe corneal ulcers refractory to medical treatment or complicated by perforation represent an ophthalmological emergency threatening both anatomical integrity and visual function of the eye. Prompt management is essential to prevent severe complications. Owing to its anti-inflammatory and pro-healing properties, the amniotic membrane represents an effective therapeutic option, particularly when used as a multilayer graft for deep stromal defects.The aim of this study was to describe our sutured multilayer amniotic membrane transplantation technique and to evaluate its outcomes in a series of ten cases of perforated corneal ulcers and abscesses.

This prospective study included ten patients managed at the Ophthalmology Department of Hassan II University Hospital in Fez. All patients underwent multilayer amniotic membrane transplantation. The amniotic membrane used was a cryopreserved lyophilized graft measuring 2 × 3 cm.

The surgical technique consisted of dividing the amniotic membrane into four to five fragments. Each layer was secured using two cardinal sutures with 10-0 monofilament. With each additional layer, sutures were anchored to the previously fixed layers to enhance graft stability. Postoperative follow-up included spectral-domain optical coherence tomography (SD-OCT) performed in all patients at day 1, day 7, day 15, month 1, and month 3.

Ten patients were included, comprising six men and four women.The mean age was 53.3 years . Etiologies included two exposure ulcers, four immune-mediated ulcers, three refractory infected ulcers, and one perforated corneal abscess, predominantly located in the central or paracentral cornea The mean perforation size was 3.2 mm. Mean preoperative stromal thickness was 200 µm, ranging from complete stromal loss to 320 µm. Favorable anatomical outcomes were achieved in nine patients, with complete perforation closure and ulcer healing. The mean epithelial healing time was 13 days (range: 8–18 days). Mean amniotic membrane resorption time was 8 days (range: 5–13 days). Functionally, a mean visual improvement of 3.5 lines was observed.

Amniotic membrane transplantation represents an effective therapeutic alternative for small- to medium-sized corneal perforations. The five-layer technique (four inlay layers and one overlay) offers several advantages, including progressive stromal filling and improved mechanical resistance with enhanced sealing achieved through fixation to previously sutured layers. The use of two cardinal sutures per layer provides adequate stabilization while minimizing tissue trauma. Compared with emergency penetrating keratoplasty, this approach represents a conservative strategy particularly suitable in active infectious or inflammatory settings.