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We would like to thank Dr Panda for the comments on our paper. We agree that amniotic membrane grafts yield excellent results in various ocular surface defects, without donor site morbidity.
We also agree that frozen section control of excised tissue might prevent incomplete removal of a malignant conjunctival melanoma. Although we were able to totally excise this tumour in our four reported cases, we wil...
We also agree that frozen section control of excised tissue might prevent incomplete removal of a malignant conjunctival melanoma. Although we were able to totally excise this tumour in our four reported cases, we will surely consider this option in relevant cases.
A point of criticism regards the use of a corneo-scleral graft to reconstruct a partial-thickness corneo-limbal defect in two of our cases, since the lack of transparency of such a graft might interfere with the detection of any deep melanoma recurrence. We agree that this might be possible - especially in the scleral part - but we believe that primary reconstruction is easier and leads to better functional results than corneo-scleral grafting at a later stage, when fibrosis and scarring may hamper surgery. In the event that the histopathologist indicates that there was incomplete excision of tumour, we prefer to remove the graft to facilitate further excision. We are looking forward to reports from other surgeons in these regards.
WA van den Bosch
We read with interest the article titled "Amniotic membrane transplantation in the management of conjunctival malignant melanoma and primary acquired melanosis with atypia" by Paridaens D et al and compliment the authors for bringing the important upcoming issue of Amniotic membrane transplantation (AMT) to the limelight.
The authors described the favourable outcome of AMT for the reconstruction of su...
The authors described the favourable outcome of AMT for the reconstruction of surface defects resulting from surgical excision of conjunctival malignant melanoma and primary acquired melanosis (PAM) with atypia. They have further commented on its role in repairing larger defects involving the fornix or palpebral conjunctiva still needs to be established. As per our experience goes we feel the procedure should be followed after any type of ocular surface reconstruction as a primary procedure. Besides the advantages put forward by the authors that it helps in post operative monitoring of tumour recurrence and cosmesis, it provides the additional encouraging factor that unlike other grafting procedures, it does not hamper the recipient tissue integrity for which it can be repeated several times. Moreover, even if there is formation of some degree of symblepharon in due course of time the same can be tackled by local excision and repeat AMT without hampering the integrity of recipient's vital ocular tissues.
While we entirely agree with the technique the authors described, our only concern is about the frozen section. It is always better to perform the frozen section in suspected tumour as its exact malignant nature could not be predicted clinically. It is more so for the extensive tumour in guiding the surgeon for precise excision.
The second point, which bothers us about the corneo-scleral graft. No doubt, the corneo scleral grafting is desirable following the side partial thickness excision of cornea and sclera[3,4]. However, while the procedure is quite safe and effective for inflammatory and degenerative lesions, its use may raise questions in neoplastic lesions. Though very barely evident, the fear of masking the recurrent lesion in surgeon's mind always persists. Therefore, in an era of AMT, we do not advocate the corneo scleral grafting for neoplastic lesions for primary procedure. However, either tectonic sclero corneal graft or limbal cell transplantation can be performed at a later date depending on the situation/status of the recipient's eye.
Once again we congratulate the authors for bringing this valuable technique to the attention of ophthalmic surgeons.
(1) Paridaens D, Beekhuis H, Vanden Bosch W, Remeyer L, Melles G. Amniotic membrane transplantation in the management of conjunctival malignant melanoma and primary acquired melanosis with atypia. Br Jour Ophthalmol 2001; 85:658-61.
(2) Panda A, Sharma N. Frozen section guided excision and LK. Ophthalmic Surg. News International 1996;7:42.
(3) Panda A, Sharma N, Sen S, Ghose S, Tityal JS, Das GK. Lamello lamellar sclerokeratoplasty in squamous cell carcinoma of conjunctiva and cornea. Year Book. Proceedings A.I.O.S. 1996, pp278-9.
(4) Panda A, Sharma N, Sen S. Frozen section guided excision and lamellar sclerokeratoplasty for squamous cell carcinoma of conjunctiva and cornea. Advance cornea 1997, Plenium press, Boston pp 373-79.