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Amniotic Membrane Inlay and Overlay Grafting for Corneal Epithelial Defects and Stromal Ulcers
Erik Letko, MD;
Stephen U. Stechschulte, MD;
Kenneth R. Kenyon, MD;
Nadia Sadeq, MD;
Tatiana R. Romero, MD;
C. Michael Samson, MD;
Quan D. Nguyen, MD;
Stephanie L. Harper, MD;
Jonathan D. Primack, MD;
Dimitri T. Azar, MD;
Martin Gruterich, MD;
Claes H. Dohlman, MD;
Stefanos Baltatzis, MD;
C. Stephen Foster, MD
Arch Ophthalmol. 2001;119:659-663.
ABSTRACT
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Objectives To determine the effect of amniotic membrane transplantation (AMT) on
persistent corneal epithelial defects (PEDs) and to compare the efficacy between
inlay and overlay techniques.
Methods Thirty patients (30 eyes) underwent AMT for PED. The use of AMT was
restricted to patients in whom all previous measures, including bandage contact
lens and tarsorrhaphy, had failed. The amniotic membrane was placed on the
surface of the cornea in overlay (group A) or inlay (group B) fashion.
Results The PED healed after the first AMT in 21 eyes (70%) within an average
of 25.5 days after surgery and recurred in 6 eyes (29%). Among the 22 eyes
treated with an overlay AMT (group A), the PED healed after the first AMT
in 14 eyes (64%) within an average of 24.5 days and recurred in 4 eyes (29%).
Among the 8 eyes treated with an inlay AMT (group B), the PED healed within
an average of 27.4 days after AMT, which did not statistically significantly
differ from group A (P = .72). The PED healed after
the first AMT in 7 eyes (88%) and recurred in 2 (29%) of 7 eyes.
Conclusions The AMT can be helpful in the treatment of PED in which all other conventional
management has failed. However, the success rate in our study was not as high
as that previously reported, and our results showed a high incidence of recurrences
of epithelial defects. We did not find any difference between overlay and
inlay techniques in terms of healing time and recurrence rate.
INTRODUCTION
PERSISTENT CORNEAL epithelial defects (PEDs) induced by primary ocular
surface disorders, such as chemical injury, neurotrophic keratitis, and keratoconjunctivitis
sicca, or associated with systemic diseases, such as ocular cicatricial pemphigoid,
Stevens-Johnson syndrome, or toxic epidermal necrolysis, are extremely difficult
to treat. Such disorders cause prolonged inflammation of the ocular surface,
damaging corneal stem cells and epithelial basement membrane (BM)1 and resulting in corneal scarring,2
neovascularization,3 and decreased vision.
In addition, matrix metalloproteinases produced by keratocytes,4
epithelial cells, and neutrophils5 can cause
progressive stromal ulceration with risk of corneal perforation.
Previous studies have shown that the epithelial BM facilitates migration
of epithelial cells,6 reinforces adhesion of
basal epithelial cells,7-8 promotes
epithelial differentiation,9-12
and militates against epithelial apoptosis.13-14
Even when an extensive PED develops, in the presence of an intact BM, the
corneal surface can be replaced by conjunctivally derived epithelium that
can acquire a corneal-type phenotype, ie, express 55-kd keratin.15
Human placental amnion is composed of a single epithelial cell layer,
a BM, and an avascular stroma.16 Both collagens
IV and VII, components of corneal epithelial BM, are present in the BM of
amniotic membrane.17 In addition, collagens
I through III and V are also present in human placental amnion.18
Amniotic epithelium produces basic fibroblast growth factor, hepatocyte growth
factor, and transforming growth factor  .19
Amnion prevents inflammatory cell infiltration20
and reduces apoptosis in keratocytes after transplantation onto the corneal
surface.21 It is noteworthy that matrix metalloproteinases
have also been identified in human amniotic membrane.22
Davis23 first reported on the use of
amniotic membrane for skin transplantation in 1910. Since then, living rather
than preserved amniotic membrane has been used for various purposes,24 and in 1940, De Roth25
first reported its use in the eye, using fresh amnion for the reconstruction
of conjunctival defects. In the early 1990s, Batlle and Perdomo26
reintroduced the use of amniotic membrane transplantation (AMT) for ocular
disorders in North America. Kim and Tseng27
then showed in 1995 that preserved amniotic membrane facilitated corneal surface
reconstruction in rabbits after epithelial removal and limbal lamellar keratectomy.
Amniotic membrane transplantation has recently been used for ocular surface
reconstruction in patients after chemical burn,28
in patients with advanced ocular cicatricial pemphigoid and Stevens-Johnson
syndrome,29 and for pterygium excision,30 conjunctival surface reconstruction,12
sterile corneal ulceration,31 and symptomatic
bullous keratopathy.32
The purpose of this study was to determine the effect of human amniotic
membrane grafts on PEDs of the cornea with or without stromal ulcers and to
compare the efficacy between inlay and overlay techniques.
PATIENTS AND METHODS
Thirty patients (30 eyes) who underwent AMT for PED with or without
stromal ulceration between 1997 and 1999 were studied (Table 1). The duration of corneal epithelial defects varied from
1 to 6 weeks. We used a progressively staged approach in the management of
PED. Thus, all patients were initially treated with removal of toxic topical
antibiotics, lubrication, punctum occlusion if appropriate, and then with
a bandage contact lens. If these techniques were unsuccessful, tarsorrhaphy
was performed. Amniotic membrane transplantation was reserved for patients
in whom all other measures were unsuccessful. In patients who refused to have
tarsorrhaphy, mostly for cosmetic reasons, AMT was performed after treatment
with bandage contact lenses failed.
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Table 1. Data on the 2 Patient Groups*
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Human amniotic membrane grafts were prepared and preserved as previously
described.31 An informed consent was obtained
from each patient before the surgery. After peribulbar or topical anesthesia,
the base of the epithelial defect or stromal ulcer was debrided with a microsponge,
and the poorly adherent epithelium surrounding the defect or ulcer was removed.
The amniotic membrane was placed on the surface of the cornea in overlay (group
A) or inlay (group B) fashion (Figure 1).
After each AMT, a bandage contact lens was applied and 0.35% ciprofloxacin
hydrochloride eyedrops 4 times a day and 1% rimexolone eyedrops 4 times a
day were administered in the postoperative period. The amniotic membrane dissolved
under the bandage contact lens during a period of 4 weeks after surgery. The
bandage contact lens was removed when the epithelial defect had healed.
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Amniotic membrane grafting, inlay (A) and overlay (B) techniques.
Note that the running suture in the overlay technique is optional, at the
surgeon's discretion.
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GROUP A: OVERLAY AMT
Patients with large epithelial defects with or without stromal ulcer
with clinically deficient limbal stem cell function were treated with overlay
AMT. Overlay grafts approximately 12 to 14 mm in diameter covered the entire
corneal, limbal, and perilimbal surfaces. The overlay AMT was placed with
the epithelial BM side up and secured by interrupted 10-0 polyglactin sutures
to the surrounding conjunctiva. In some cases, a running 10-0 polyglactin
suture was placed in the midperipheral cornea.
GROUP B: INLAY AMT
Patients with localized PED (<20% of corneal surface) with or without
stromal ulceration received inlay AMT. Inlay grafts were cut to fit the size
of the epithelial defect or stromal ulceration as described by Lee and Tseng.31 These grafts were placed with the epithelial BM side
up and secured to the edge of the defect by interrupted 10-0 polyglactin sutures.
After each AMT, a bandage contact lens was applied and 0.35% ciprofloxacin
hydrochloride eyedrops 4 times a day and 1% rimexolone eyedrops 4 times a
day were administered in the postoperative period. The amniotic membrane dissolved
under the bandage contact lens during a period of 4 weeks after surgery. The
bandage contact lens was removed when the epithelial defect had healed.
RESULTS
OVERALL OUTCOMES
The overall results for all 30 cases are summarized in Table 2. The mean age of patients was 55.3 years (range, 9-78 years).
The male-female ratio was 2:1. The mean follow-up time after AMT was 8.2 months
(range, 1-32 months). The mean visual acuity before and after the surgery
was 0.04 (range, 0.01-0.13) and 0.05 (range, 0.01-0.20), respectively (P = .45). The PEDs healed within an average of 25.5 days
(range, 5-68 days) after surgery. The epithelial defect healed after the first
AMT in 21 eyes (70%). In 9 eyes (30%), the defect persisted after the first
AMT. The epithelial defect recurred after the first AMT in 6 (29%) of 21 eyes.
The average time to recurrence of the defect was 5.2 weeks (range, 2-9 weeks).
Thus, the PED did not heal or recurred after the first AMT in 15 (50%) of
30 eyes.
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Table 2. Results in Groups A and B and the 2 Groups Combined*
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During follow-up, AMT was repeated in 5 patients, and in 1 case the
recurrence was successfully treated with a bandage contact lens. The first
AMT was accompanied by additional surgical procedures in 18 eyes. These included
tarsorrhaphy (16 eyes), superficial keratectomy (2 eyes), and lamellar keratoplasty
(1 eye). Among the 16 patients in whom AMT was performed along with tarsorrhaphy,
12 defects (75%) healed; of these, 4 (33%) recurred after the first AMT. Interestingly,
we observed similar results in patients who were treated with AMT alone. In
9 (64%) of 14 patients the defect healed, and in 2 (22%) of the 9 it recurred.
GROUP A
Among the 22 eyes treated with an overlay AMT, the mean age of patients
was 53.1 years (range, 27-75 years). The male-female ratio was 7:4. The mean
follow-up time was 6.8 months (range, 1-22 months) after AMT. The mean visual
acuity before and after the surgery was 0.05 (range, 0.01-0.33) and 0.06 (range,
0.01-0.33), respectively (P = .54). The corneal epithelial
defect healed within an average of 24.5 days (range, 5-68 days) after surgery.
The epithelial defect healed after the first AMT in 14 eyes (64%). The epithelial
defect recurred after the first AMT in 4 (29%) of 14 eyes. The average time
to the recurrence of the defect was 4.5 weeks (range, 2-9 weeks). The PED
did not heal or recurred after the first AMT in 4 patients (45%).
GROUP B
Among the 8 eyes treated with an inlay AMT, the mean age of patients
was 61.1 years (range, 9-78 years). The male-female ratio was 3:1. The mean
follow-up time was 12.2 months (range, 2-32 months) after AMT. The mean visual
acuity before and after the surgery was 0.02 (range, 0.01-0.05) and 0.03 (range,
0.01-0.1), respectively (P = .35). The corneal epithelial
defect healed within an average of 27.4 days (range, 7-41 days) after AMT,
which did not statistically significantly differ from group A (P = .72). The epithelial defect healed after the first AMT in 7 eyes
(88%). The epithelial defect persisted after the first AMT in 1 eye (12%).
The epithelial defect recurred after the first AMT in 2 (29%) of 7 eyes. The
PED did not heal or recurred after the first AMT in 3 (38%) of 8 eyes. There
was not a statistically significant difference (P
= .53) in the average time to the recurrence of epithelial defect between
group B (6.5 weeks) and group A.
COMMENT
The epithelial defects healed after the first AMT in 70% (21/30) of
all eyes in our study. By comparison, Lee and Tseng31
reported an initial success rate of 90% (10/11). In addition, we found a higher
recurrence rate (29%) after the first AMT than that previously reported.31 Given the intrinsic diversity among PED cases, it
might be hypothesized that differences in surgical techniques and/or causes
of the epithelial defects might explain these outcome differences. Lee and
Tseng31 did not observe any recurrence of epithelial
defect when the amniotic membrane graft was placed into the stromal ulcer
and secured by interrupted sutures to the edge of the defect. The corneal
epithelium grew over the amniotic membrane graft. We used an identical technique
in group B, yet the incidence of recurrences was 29%. Again, the difference
in cause of the epithelial defects and extent of damage to the ocular surface
might explain this higher rate of recurrences. Interestingly, our results
show that there was no difference in recurrence rate between overlay and inlay
techniques, although there was a slight difference in success rate after the
first AMT when the inlay technique was used. In addition to using amnion in
the inlay fashion, we used the amniotic membrane graft to cover the entire
corneal surface and perilimbal conjunctiva in some cases, similar to a bandage
contact lens. This technique has been used successfully by others in the treatment
of patients with symptomatic bullous keratopathy,32
limbal stem cell deficiency of various causes,33
and stromal defects after photorefractive keratectomy.20
Among our patients, autoimmune diseases affecting the ocular surface
were involved in the pathogenesis of epithelial defects and stromal ulcers
in 3 of 6 patients with recurrence of epithelial defect. One patient had ocular
cicatricial pemphigoid, 1 had toxic epidermal necrolysis, and the other had
Sjögren syndrome. Tsubota et al29 treated
a group of patients with ocular cicatricial pemphigoid or Stevens-Johnson
syndrome with AMT and limbal stem cell transplantation. They demonstrated
that the entire ocular surface with or without PED in this group of patients
can be restored by AMT along with limbal allograft and tarsorrhaphy, followed
by systemic immunosuppression and topical administration of artificial tears
derived from autologous serum. The authors reported a stable ocular surface
during the follow-up in 9 of 11 patients. However, final visual acuity remained
less than 0.1 in all but 3 patients.
The growth of new epithelium, particularly in patients with multiple
causative factors involved in the pathogenesis of epithelial or stromal defects,
may be altered by the absence of direct contact with BM. Tseng et al33 recently showed that AMT alone is superior to AMT
with limbal allotransplantation in patients with partial limbal stem cell
deficiency, whereas limbal allotransplantation with AMT is needed for patients
with total limbal stem cell deficiency.
Active conjunctival inflammation can complicate the postoperative period
after ocular surface reconstruction,34 with
resultant failure of the ocular surface. Keratoprosthesis may then be the
procedure of last resort in such cases.35
Shimazaki et al19 claimed that the epithelium
of the amniotic membrane may survive up to 70 days after cryopreservation.
Their study showed that living epithelium of amnion produces basic fibroblast
growth factor, hepatocyte growth factor, and transforming growth factor .19 Whether cryopreserved transplanted amniotic membrane
confers such benefit is uncertain. Because the epithelium of amnion expresses
neither HLA class I nor II antigens,36-38
the use of systemic immunosuppressive therapy in AMT is not required.
Amniotic membrane transplantation can improve visual acuity by both
corneal surface restoration and improvement of corneal transparency.31 In our study, the average visual acuity improved
after AMT, but the difference between the preoperative and final visual acuities
was not statistically significant (P = .45). A statistically
significant difference between visual acuity before AMT and final visual acuity
was not observed in either group A (P = .54) or group
B (P = .35). These results suggest that the effect
of AMT on vision rehabilitation is very limited and is unrelated to the technique
used.
In summary, our study confirms the results of previous reports that
AMT can be helpful in the treatment of epithelial defects and stromal ulcers
in which all other conventional management has failed. However, the success
rate in our study was not as high as that previously reported, and our results
showed a high incidence of recurrences of epithelial defects.
We therefore believe that AMT for PED, with or without stromal ulceration,
should not be used as first- or even second-line therapy. The use of AMT for
PED should be reserved for cases in which removal of medications toxic to
the epithelium, aggressive lubrication and ocular surface protection (eg,
bandage contact lens and tarsorrhaphy), and control of inflammation have failed
to promote closure of the defect. We did not find any difference between overlay
and inlay techniques in terms of healing time, recurrence rate, and effect
on vision rehabilitation. Further studies are required to confirm our results,
to compare AMT with other strategies in treatment of PEDs and stromal ulcers,
to compare the results after different techniques of transplantation, and
to estimate the outcomes in various groups of patients.
AUTHOR INFORMATION
Accepted for publication December 15, 2000.
Corresponding author and reprints: C. Stephen Foster, MD, Immunology
Service, Massachusetts Eye and Ear Infirmary, 243 Charles St, Boston, MA 02114
(e-mail: fosters{at}uveitis.org).
From the Immunology and Uveitis Service (Drs Letko, Romero, Samson,
Nguyen, Harper, and Foster) and Cornea Service (Drs Stechschulte, Primack,
Azar, and Dohlman), Massachusetts Eye and Ear Infirmary, Harvard Medical School,
Boston; Cornea Consultants, Boston (Drs Stechschulte and Kenyon); Ludwigs
Maximilian Universitat Augenklinik, München, Germany (Drs Kenyon and
Gruterich); Al-Bahar Ophthalmology Center, IBN Sina Hospital, Safat, Kuwait
(Dr Sadeq); and General Hospital of Athens, University Eye Clinic, Athens
Medical School, Athens, Greece (Dr Baltatzis).
REFERENCES
| |
1. Tsai RJF, Tseng SCG. Effect of stromal inflammation on the outcome of limbal transplantation
for corneal surface reconstruction. Cornea. 1995;14:439-449.
ISI
| PUBMED
2. Foster CS, Zelt RP, Mai-Phan T, Kenyon KR. Immunosuppression and selective inflammatory cell depletion. Arch Ophthalmol. 1982;100:1820-1824.
ABSTRACT
3. Thoft RA, Friend J, Murphy HS, et al. Ocular surface epithelium and corneal vascularization in rabbits, I. Invest Ophthalmol Vis Sci. 1979;18:85-92.
FREE FULL TEXT
4. Brown SI, Hook CW. Isolation of stromal collagenase in corneal inflammation. Am J Ophthalmol. 1971;72:1139-1142.
ISI
| PUBMED
5. Kenyon KR, Berman M, Rose J, Gage J. Prevention of stromal ulceration in the alkali-burned rabbit cornea
by glued-on contact lens. Invest Ophthalmol Vis Sci. 1979;18:570-587.
FREE FULL TEXT
6. Terranova VP, Lyall RM. Chemotaxis of human gingival epithelial cells to laminin: a mechanism
for epithelial cell apical migration. J Periodontol. 1986;57:311-317.
ISI
| PUBMED
7. Khodadoust AA, Silverstein AM, Kenyon KR, Dowling JE. Adhesion of regenerating corneal epithelium. Am J Ophthalmol. 1968;65:339-348.
ISI
| PUBMED
8. Sonnenberg A, Calafat J, Janssen H, et al. Integrin  6/4 complex is located in hemidesmosomes, suggesting
a major role in epidermal cell–basement membrane adhesion. J Cell Biol. 1991;113:907-917.
FREE FULL TEXT
9. Barcellos-Hoff MH, Aggeler J, Ram TG, Bissell MJ. Functional differentiation and alveolar morphogenesis of primary mammary
cultures on reconstituted basement membrane. Development. 1989;105:223-235.
ABSTRACT
10. Guo M, Grinnel F. Basement membrane and human epidermal differentiation in vitro. J Invest Dermatol. 1989;93:372-378.
FULL TEXT
|
ISI
| PUBMED
11. Streuli CH, Bailey N, Bissell MJ. Control of mammary epithelial differentiation. J Cell Biol. 1991;115:1383-1395.
FREE FULL TEXT
12. Tseng SCG, Prabhasawat P, Lee SH. Amniotic membrane transplantation for conjunctival surface reconstruction. Am J Ophthalmol. 1997;124:765-774.
ISI
| PUBMED
13. Boudreau N, Sympson CJ, Werb Z, Bissell MJ. Suppression of ICE and apoptosis in mammary epithelial cells by extracellular
matrix. Science. 1995;267:891-893.
FREE FULL TEXT
14. Boudreau N, Werb Z, Bissell MJ. Suppression of apoptosis by basement membrane requires three-dimensional
tissue organization and withdrawal from the cell cycle. Proc Natl Acad Sci U S A. 1996;93:3509-3513.
FREE FULL TEXT
15. Kurpakus MA, Stock El, Jones JCR. The role of the basement membrane in differential expression of keratin
proteins in epithelial cells. Dev Biol. 1992;150:243-255.
FULL TEXT
|
ISI
| PUBMED
16. van Herendael BJ, Oberti C, Brosens I. Microanatomy of the human amniotic membranes. Am J Obstet Gynecol. 1978;131:872-880.
ISI
| PUBMED
17. Fukuda K, Chikama T, Nakamura M, Nishida T. Differential distribution of subchains of the basement membrane components
type IV collagen and laminin among the amniotic membrane, cornea, and conjunctiva. Cornea. 1999;18:73-79.
FULL TEXT
|
ISI
| PUBMED
18. Polzin WJ, Lockrow EG, Morishige WK. A pilot study identifying type V collagenolytic activity in human amniotic
fluid. Am J Perinatol. 1997;14:103-106.
ISI
| PUBMED
19. Shimazaki J, Shinozaki N, Tsubota K. Transplantation of amniotic membrane and limbal autograft for patients
with recurrent pterygium associated with symblepharon. Br J Ophthalmol. 1998;82:235-240.
FREE FULL TEXT
20. Choi YS, Kim JY, Wee WR, Lee JH. Effect of the application of human amniotic membrane on rabbit corneal
wound healing after excimer laser photorefractive keratectomy. Cornea. 1998;17:389-395.
FULL TEXT
|
ISI
| PUBMED
21. Wang M, Gray T, Prabhasawat P, et al. Corneal haze is reduced by amniotic membrane matrix in excimer laser
photoablation in rabbits [abstract]. Invest Ophthalmol Vis Sci. 1997;38(suppl):405.
22. Athayde N, Edwin SS, Romero R. A role for matrix metalloproteinase-9 in spontaneous rupture of the
fetal membranes. Am J Obstet Gynecol. 1998;179:1248-1253.
FULL TEXT
|
ISI
| PUBMED
23. Davis JW. Skin transplantation with a review of 550 cases at The Johns Hopkins
Hospital. Johns Hopkins Med J. 1910;15:307-396.
24. Trelford JD, Trelford-Sauder M. The amnion in surgery, past and present. Am J Obstet Gynecol. 1979;134:833-845.
ISI
| PUBMED
25. De Roth A. Plastic repair of conjunctival defects with fetal membrane. Arch Ophthalmol. 1940;23:522-525.
FULL TEXT
|
ISI
26. Batlle JF, Perdomo FJ. Placental membranes as a conjunctival substitute [abstract]. Ophthalmology. 1993;100:107. Abstract 9A.
27. Kim JC, Tseng SCG. Transplantation of preserved human amniotic membrane for surface reconstruction
in severely damaged rabbit corneas. Cornea. 1995;14:473-484.
ISI
| PUBMED
28. Shimazaki J, Yang HY, Tsubota K. Amniotic membrane transplantation for ocular surface reconstruction
in patients with chemical and thermal burn. Ophthalmology. 1997;104:2068-2076.
ISI
| PUBMED
29. Tsubota K, Satake Y, Ohyama M, et al. Surgical reconstruction of the ocular surface in advanced ocular cicatricial
pemphigoid and Stevens-Johnson syndrome. Am J Ophthalmol. 1996;122:38-52.
ISI
| PUBMED
30. Prabhasawat P, Barton K, Burkett G, Tseng SCG. Comparison of conjunctival autografts, amniotic membrane grafts, and
primary closure for pterygium excision. Ophthalmology. 1997;104:974-985.
ISI
| PUBMED
31. Lee SH, Tseng SCG. Amniotic membrane transplantation for persistent epithelial defects
with ulceration. Am J Ophthalmol. 1997;123:303-312.
ISI
| PUBMED
32. Pires RT, Tseng SC, Prabhasawat P, et al. Amniotic membrane transplantation for symptomatic bullous keratopathy. Arch Ophthalmol. 1999;117:1291-1297.
FREE FULL TEXT
33. Tseng SCG, Prabhasawat P, Barton K, Gray T, Meller D. Amniotic membrane transplantation with or without limbal allografts
for corneal surface reconstruction in patients with limbal stem cell deficiency. Arch Ophthalmol. 1998;116:431-441.
FREE FULL TEXT
34. Shore JW, Foster CS, Westfall CT, Rubin PAD. Results of buccal mucosa grafting for patients with medically controlled
ocular cicatricial pemphigoid. Ophthalmology. 1992;99:383-395.
ISI
| PUBMED
35. Dohlman CH, Doane MG. Some factors influencing outcome after keratoprosthesis surgery. Cornea. 1994;13:214-218.
ISI
| PUBMED
36. Adinolfi M, Akle CA, McColl I, et al. Expression of HLA antigens, 2-microglobulin and enzymes
by human amniotic membrane. Nature. 1982;295:325-327.
FULL TEXT
| PUBMED
37. Akle CA, Adinolfi M, Welsh KI, Leibowitz S, McColl I. Immunogenicity of human amniotic epithelial cells after transplantation
into volunteers. Lancet. 1981;2:1003-1005.
ISI
| PUBMED
38. Houlihan JM, Biro PA, Harper HM, Jenkinson HJ, Holmes CH. The human amniotic membrane is a site of MHC class 1b expression: evidence
for the expression of HLA-E and HLA-G. J Immunol. 1995;154:5665-5674.
ABSTRACT
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