Amniotic membrane, scleral lenses, glues & flaps
Amniotic membrane transplantation (AMT)
AMT has transformed the prognosis of ulcers. Rich in growth factors and protease inhibitors, it provides a non-denatured matrix that favors epithelialization and limits neutrophil infiltration. Modalities: "overlay" (placed as a patch, sutured or glued, resorbable) or "inlay" (sutured/glued into the base of the ulcer, in one or several layers; filling). Self-retained devices (cryopreserved amniotic membrane ring, ProKera® type) and dehydrated membranes now allow placement without an operating room.
Scleral lenses (including PROSE-type devices) create a permanent fluid reservoir over the cornea, at once a mechanical protector and a trophic "bath." They are a major option for refractory persistent epithelial defects and neurotrophic keratitis, often avoiding recourse to more invasive procedures.
Tissue adhesives and conjunctival flap
Cyanoacrylate glue is used urgently for impending or established perforations < 1 mm; fibrin glue serves to fix grafts. The conjunctival flap (Gundersen flap) retains its place in chronic, painless, non-visual ulcers.
Tarsorrhaphy and botulinum toxin
Tarsorrhaphy (temporary by suture/glue, or permanent) and botulinum toxin injection into the levator (induced protective ptosis) help "get through a difficult phase" in cases of malocclusion, exposure or lagophthalmos.
Tectonic grafting, corneal neurotization & limbal cell therapies
"Patch" corneal graft
A lamellar or penetrating graft for tectonic purposes ("patch") is performed for a descemetocele or a large-diameter perforation. A modified deep anterior lamellar keratoplasty (DALK) may be proposed in certain descemetoceles [6].
Corneal neurotization aims to re-innervate the cornea in severe neurotrophic keratitis by bringing in healthy sensory axons (contralateral supra-/infratrochlear nerve, great auricular or sural nerve as an interposition graft), by direct approach or nerve graft, now often via a minimally invasive/endoscopic route. Published series show recovery of sensation and improved trophicity, restoring a setting compatible with later visual rehabilitation [12].
Cell therapies for limbal deficiency
When ulceration occurs within a limbal stem cell deficiency, surface reconstruction relies on limbal grafting (autologous kerato-limbal or allogeneic), on cultivated limbal epithelial transplantation (CLET) — an autologous therapy of which obtained a European MA (Holoclar®, 2015) for limbal deficiency after burns — and on SLET (Simple Limbal Epithelial Transplantation), a simplified single-stage technique, sparing of donor tissue and of growing use [14].