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We read with keen interest the article by Espana et al on the use of amniotic membrane transplantation (AMT) for ocular surface reconstruction after excision of large neoplasia.1 We fully endorse their views that AMT is rapidly evolving as a viable option in the management of a wide spectrum of ocular surface disorders because of a multitude of beneficial properties that it possesses. However, we would like to clarify a few misgivings in some crucial areas of concern.
As the authors have aptly emphasised total eradication of tumour cells from the ocular surface is essential for successful treatment and minimising recurrences. To achieve this objective, in our own clinical experience and in the literature, frozen section controlled excision (FSCE) of the tumour, combined with a double freeze-thaw cycle of cryotherapy is now a recognised, accepted technique in a majority of centres across the world.2–4 It has been reported to achieve very effective tumour control and reduce recurrence rates from as high as 24–50% to a negligible 4.5%.3 It is especially useful in patients with conjunctival malignant melanoma where lack of pigmentation may not always be indicative of a tumour free margin. Although the authors have reported a relatively low recurrence rate of 10% in cases of conjunctival intraepithelial neoplasia (CIN) even without this technique, we strongly feel that FSCE should be routinely used when dealing with such lesions.
Secondly, it is our considered opinion that in case tumour excision is being carried out on the basis of clinical parameters alone, without confirmation with FSCE, a double freeze-thaw cycle of cryotherapy (in contrast to the single freeze thaw cycle used in this study) is advisable.3,4 Moreover, leaving a clinically assessed tumour free margin of 3–4 mm, as described, may not be safe enough and it may be more prudent to leave a healthy margin of at least 5 mm, even at the cost of sacrificing a bit of extra normal tissue, thereby gaining a lower probability of tumour recurrence and patient morbidity in the bargain.
Finally, we would like to say that the results achieved by the authors are commendable by any standards and indicate a really meticulous surgical technique and painstaking follow up.
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