Amniotic membrane transplantation (AMT)- the purpose of AMT is to rapidly restore the

conjunctival surface and to reduce limbal and stromal inflammation. The benefits are thought to be
two fold: physical and biological. Physically, AMT has been shown to improve patient comfort by
reduction of eyelid friction. Numerous studies have found a reduction in pain following AMT for
moderate to severe burns.[27][28] Through its physical actions, AMT may also
prevent symblepharon formation. Amniotic membrane is also felt to have biologic effects.[29] It
expresses TGFB1 and epidermal growth factor, which have roles in wound healing.[30][31] It has also
been found to have anti-inflammatory properties.[32][33][34] Taken together, these biological effects may
dampen inflammation, promote epithelial growth, prevent scarring and prevent neovascularization.
New delivery devices like ProKera® (Bio-Tissue, Miami, Florida), which consists of a piece
of cryopreserved amniotic membrane clipped into a dual ring system, like a symblepharon ring,
allows rapid and sutureless placement of amniotic membrane.[35] A recent Cochrane review found
only one randomized controlled trial of amniotic membrane for treatment of chemical ocular burn in
the first seven days following injury.[1] Patients with moderate burns were found to have a significantly
better visual acuity following AMT compared to medical therapy alone.[36] However, this was an
unmasked trial and there were uneven baseline characteristics of the control and treatment
eyes.[1] While case series and reviews show great promise of AMT in the treatment of chemical
burns, conclusive evidence is still lacking.
Limbal stem cell transplant- Much of the damage following chemical injuries results from limbal
ischemia and the subsequent loss of stem cells capable of repopulating the corneal
epithelium. Limbal stem cell transplants have been employed to replace this critical group of cells.
Limbal stem cells are located at the base of the limbal epithelium and are responsible for
repopulation of cells in the corneal epithelium and inhibition of conjunctival growth over the
cornea.[37] Limbal autografts can be used from the healthy contralateral eye if only one eye is injured
in a chemical burn.[38] When both eyes are injured, transplants have been attempted from living
related donors. In a recent study from China, a portion of the limbus of HLA matched living related
donors (allograft) was transplanted following chemical injury. Patients experienced a reduction in
vascularity, improved corneal opacity and corneal epithelialization without the need for systemic
immunosuppression.[37] Another option is to use cadaveric donors. This requires systemic
immunosuppression.[39] When possible, limbal stem cell transplantation should be delayed until
ocular surface inflammation has quieted.[40][41]
Cultivated oral mucosal epithelial transplantation (COMET)- can also be used to promote re-
epithelialization and reduce inflammation in corneal burns. The cells are harvested from the patient’s
own buccal mucosa so that systemic immunosuppression is not necessary.[42][43]
Boston Keratoprosthesis- Severe chemical injury leads to chronic inflammation and scarring,
making visual recovery challenging. In cases with severe inflammation, limbal stem cell transplants
and corneal transplants do not survive. In these most difficult cases, the Boston
Keratoprosthesis can be used. Because it is independent of stem cell function, it does not require
systemic immunosuppression.[44]