This case was included in a study that adhered to the tenets of the Declaration of Helsinki and was approved by the Ethics Committee of the Faculty of Medicine and Psychology at the Baja California Autonomous University which authorized the use of HAM for the treatment of injuries of the ocular surface. We present a case of a 12-year-old male patient with a tumour in the superotemporal region of the RE, with decreased VA, burning eye, foreign body sensation and photophobia of the affected eye, reporting tumour growth during the last year. Ophthalmological examination of his RE, un-corrected VA and finger count from 1 m distance showed no improvement with pinhole. Visual acuity was 20/20 on the LE (Snellen chart). After the administration of 1% cyclopentolate cycloplegic refraction was performed using a phoropter and retinoscopy. Results were VA + 3.25–3.00 × 175, 20/80 on the RE and VA + 1.75, 20/20 (Snellen chart) on the LE. Palpebral elevation, anterior segment and biocular motility were normal. The bio-microscopic ophthalmological examination confirmed the presence of a tumour mass (15 mm × 12 mm) on the surface of his RE, invading the superior and temporal sector of the eye. The tumour had a lobulated appearance, a shiny vascularized surface covered by conjunctiva, a pearlescent-pink colour, a medium consistency, was renitent and painless. The tumour adhered to deep layers in more than an upper third (Fig. 1A), resulting in asymmetry of the upper eyelid of the RE, which was elevated and had a closed appearance. The function of the upper right eyelid elevator muscle was normal; there were no alterations in the LE.
Isochoric pupils with normal pupillary reflexes were revealed. Wide anterior chamber with normal iris, transparent crystalline, vitreous and homogeneous in eyes, applied retina, normal macula, apparently normal retinal vessels, retinal pigment epithelium (RPE) area of atrophy and upper nasal sector revealing choroidal vessels were evident. No pathological scleral indentation was found. The cycloplegic refraction showed high hypermetropic astigmatism (Fig. 1B). A B-scan ultrasonography revealed a tumour on the eye surface that did not invade the anterior chamber or deep layers of the eyeball. The vitreous and retina showed no damage. A CT scan revealed a recurrent lesion consistent with an epibulbar dermoid cyst without extension to orbit and without orbital rim bone erosion (Fig. 2). It should be noted that the lesion started when the patient was three years old (2006) and was characterized by a tumour mass. No macroscopic characteristics or clinical symptoms of the tumour were provided. An exeresis biopsy was performed to remove the tumour and the histopathological analysis showed the presence of lacrimal acini, adipose tissue and blood cells consistent with a conjunctival dermolipoma. During five years there was no clinical follow-up.
The preparation of the AM was performed using slight modifications of the method described by Kim and Tseng. The human placenta was obtained shortly after elective caesarean delivery in women who were between 18 and 35 years of age. All donors signed an informed consent prior to caesarean delivery. Women had been controlled for at least 6 months, had a healthy foetus without placental pathology and were seronegative for human immunodeficiency virus type 1 and 2, hepatitis B and C, Treponema pallidum, Brucella abortus and Trypanosoma cruzi. Next, in a laminar flow hood, the placenta was cleaned with a sterile phosphate and saline solution containing antibiotic/antimycotic (50 μg/ml of penicillin, 50 μg/ml of streptomycin and μg/ml of amphotericin B) (Sigma-Aldrich Corp, Saint Louis, USA) to remove blood clots. The amnion was separated from the chorion using a blunt dissection and the membrane was cut to 4 × 4 cm. Membrane squares were spread on a nitrocellulose filter paper, placed in a sterile vial containing Dulbecco’s modified Eagle’s medium (Biowest SAS, Nuaillé, France) plus glycerol and human albumin (Sigma-Aldrich Corp, Saint Louis, USA) in a 1:1 ratio at 10% and frozen at − 80 °C. The AM was thawed in a water bath at + 37 °C with saline solution, and samples were taken for microbiological and histological controls [30].
Removal of the tumour was performed under general anaesthesia prior preoperative patient preparation and preoperative tests. Xylocaine with epinephrine was injected for vasoconstriction and dissection of adherent tissues. The excision started at the level of the sclero-corneal limbus using Stevens’ scissors and a scalpel blade # 15 and continued toward the bottom of the superior nasal and the superior temporal socket respecting mainly the superior and lateral rectus eye muscles which were free of tumour. The dissection was carefully performed given the adhesions to Tenon and sclera sectors and lamellar keratoplasty of the cornea was performed up to the superficial stroma. 0.02% MMC was applied with a merocel sponge for 3 min and washed profusely thereafter with 10 cc of physiological solution. The stromal side of the AM implant was placed on the conjunctiva and over the entire cornea and sutured with interrupted 7/0 Vicryl stitches in the denuded area up to near the bottom of the superior socked, covering the cornea completely. Eye drops and antibiotic ointment were applied, the eye was patched and the patient was discharged (Fig. 3). The biopsy was sent for a histopathological study, data were obtained from medical records. The dermoid cyst socket, the initial and final vision, the improvement of the corrected VA in both eyes, the presence or absence of symptoms such as irritation, surgical or postoperative complications and good cosmetic result, defined as the absence of any mass or unsightly scars in the primary position of the lesion by external examination, were evaluated at different periods of time.
The preoperative study results were normal; the ultrasonography showed a clear image with defined edges, amblyopia of the right eye with atrophy of the superior nasal RPE and diagnosis of conjunctival tumour on the right eye. Computed tomography suggested a recurrent lesion consistent with dermoid cyst. The cystic mass located in the nasal and temporal region of the eyeball upper part, with projection to the bottom of the socket and invasion of the cornea, conjunctiva and parotid duct, required the removal of the lesion through an incision along the lower orbital margin and superficial layers of the cornea with the application of 0.02% MMC during 3 min over the sclera with a merocel sponge and profuse washing with physiological solution. Over the follow-up period to evaluate symptoms and possible infections the patient reported moderate pain during the first 24 to 48 h. During the first week the patient’s symptoms were foreign body sensation, mucous secretion, tearing and blepharospasm. During the second week the cornea appeared opaque due to the coating of the HAM and the patient could only see lumps with his RE. Tobramycin/dexamethasone was applied and cleaning solution and lubricant drops were recommended for a period of one month. The correction of the VA was variable, the RE VA without correction was 20/70 at 9 weeks and 20/50–1 at 5 months. His RE VA without correction was 20/100 at 8 months improving with pinhole to 20/80. At 5 months the cornea was completely clear and the incorporation of the implant into the cornea and sclera was very good. No signs of implant rejection were detected and the right upper eyelid showed normal symmetry. Symptoms decreased and there were no postoperative complications. The visual outcome was moderately good; the cosmetic result was very good, as defined by the absence of significant or unsightly scars in the primary site of the lesion during external examination. There were no adhesions or symblepharon. Several tissue fragments in formalin, designated as tumour of the right eye conjunctiva dependent, were sent for histopathological study. The histopathological report described a piece of tissue with irregularly lobed surface, pale pink colour and soft consistency measuring 2.6 × 0.6 × 0.5 cm. A mixed tumour was identified histologically; this lesion was located within the choristomas (benign neoplasm of heterotopic location). This biphasic neoformation showed mesenchymal tissue, which was represented by loose connective tissue with abundant congestive blood vessels with thin walls and few fat cells. Cystic formations coated with keratinized stratified squamous epithelium containing thin slices of keratins. Groups of sebaceous glands immersed in dense bundles of keratin corresponded to the epithelial component (Fig. 4a). When the lesion was analysed on higher magnification it was cytologically identified that the elements that formed it were well differentiated and had no atypia suggestive of malignancy (Fig. 4b). No visible remains or tumour recurrence as well as scarring in the first year of follow-up were present. The revitalization of the area where the AM was implanted and treated with MMC healed during the first month without any postoperative complication. The results of the clinical course were good injury site healing, subconjunctival haemorrhage and conjunctival inflammation only during the first two weeks of the postoperative and complete absence of infection, necrosis, edema, diplopia, recurrence or symblepharon up to 14th months after the postoperative follow-up confirms the patient good clinical outcome. The patient was satisfied with the cosmetic appearance and with the clinical outcome, giving a high satisfaction score (Fig. 5a and b).
