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The Use of Autologous Serum in the Treatment of Ocular Surface Disease
 

Most of us whose feet are firmly planted in the trenches see a tremendous number of dry eye patients. Fortunately, most respond to first and second line therapies. Occasionally though the severe dry eye patient graces my chair, albeit not as frequently as was the case at the co-management center. Still, we are all familiar with these patients. You've tried every treatment at your disposal, often several times, in an attempt to provide your patient some relief. Yet none is coming. Thoughts of your patient stick with you long after you've left the office. You're trying to help, and the patient is hanging in there with you, but their frustration — and yours — is growing. Nothing seems to be working. So you rack your brain: What else can I do? What haven't I tried? For many of my worst cases, the answer is autologous serum.

The use of autologous serum (AS) for treating ocular surface disorders dates back to at least the 1970s when AS was used via a mobile ocular perfusion pump to treat ocular alkali burns.1 Subsequently, a 1984 report in the journal Arthritis and Rheumatism2 first discussed the use of AS as a tear substitute. The use of AS for the treatment of ocular surface disorders did not gain widespread support until the late 1990s.3 Since then, many indications for its use have been described. The most common uses include the treatment of dry eyes4 but AS has also been suggested to be effective in the treatment of neurotrophic keratopathy,5 recurrent corneal erosion6 and superior limbic keratoconjunctivitis.7

AS for Dry Eye
One of the major indications for the use of AS is dry eyes. The most frequent therapy utilized to treat ocular surface disorders is artificial tears. However, none of the commercially available artificial tear preparations include essential tear components such as growth factors, vitamins, and immunoglobulins.8 The use of AS arose out of the need to find tear substitutes that, in addition to lubricating the ocular surface, were able to provide other components of tears that are reduced in ocular surface disease.9 Human serum contains substances such as epidermal growth factor, vitamin A, fibronectin and cytokines normally found in tears. These factors are important for maintaining a healthy corneal and conjunctival epithelium.10

Drawbacks of Serum Eye Drops Treatment
Since AS preparation is a body fluid, it is able to transmit infections.11 It was found that 3.3 % of all patients who donated blood for autologous serum production in Germany showed previously unknown viral infections with hepatitis B or C virus.12 Transmission of HIV by a single serum droplet into one eye has been reported in at least one case.13 Therefore, confirmation of the absence of HIV virus and hepatitis B and C infections in the subject must be conducted. Another drawback of AS treatment lies in the frequent blood extractions from the patient requiring prolonged treatment. Patients who need to use AS eye drops for an extended period of time will need to provide blood samples at least every three months.3 AS contains no preservatives, which avoids the risk of preservative toxicity, however there is a potential risk of inducing infections because of microbial contamination of the dropper bottle.4

AS eye drop therapy can be expensive. The daily cost of serum eye drops is approximately equivalent to one bottle of preserved artificial tears.11 Patients generally have to pay out-of-pocket for the AS eye drops because the majority of insurance carriers do not cover this treatment.

Conclusion
The use of AS requires proper preparation of the serum formulation with adequate informed consent and education of the patient. Before application, the patient must be informed in writing about the planned therapy, its experimental nature, the risks involved (i.e., bacterial contamination), and alternative methods of treatment. All aspects considered, AS eye drops are beneficial in many refractory OSD patients. It is a valuable option in those patients who have exhausted other treatment options.

REFERENCES
1. Ralph RA, Doane MG, Dohlman CH. Clinical experience with a mobile ocular perfusion pump. Arch Ophthalmol 1975; 93 (10): 1039-1043.
2. Fox RI, Chan R, Michelson JB, et al. Beneficial effects of artificial tears made with autologous serum in patients with keratoconjunctivitis sicca. Arthritis Rheum 1984; 27 (4): 459-461.
3. Jeng BH. Use of autologous serum in the treatment of ocular surface disorders. Arch Ophthalmol 2011; 129 (12): 1610-1612.
4. Lee GA, Chen SX. Autologous serum in the management of recalcitrant dry eye syndrome. Clin Experiment Ophthalmol 2008; 36 (2): 119-122.
5. Matsuoto Y, Dogru M, Goto E, et al. Autologous serum application in the treatment of neurotrophic keratopathy. Ophthalmology 2004; 111 (6): 1115-1120.
6. delCastillo JMB, de las Casa JMM, Sardina RC, et al. Treatment of recurrent corneal erosions using autologous serum. Cornea 2007; 21 (8): 781-783.
7. Goto E, Shimmura S, Shimazaki J, et al. Treatment of superior limbic keratoconjunctivitis by application of autologous serum. Cornea 2001; 20 (8): 807-810.
8. Quinto GG, Campos M, Behrens A. Autologous serum for ocular surface diseases. Arq Bras Oftalmol 2008; 71 (6 Suppl): 47-54.
9. Lopez-Garcia JS, Garcia-Lozano I, Rivas L, et al. Use of autologous serum in ophthalmic practice. Arch Soc Esp Oftalmol 2007; 82 (1): 9-20.
10. Koffler BH. Autologous serum therapy of the ocular surface with novel delivery by platelet concentrate gel. Ocul Surf 2006; 4(4): 188-195.
11. Geerling G, Maclennan S, Hartwig D. Autologous serum eye drops for ocular surface disorders. Br J Ophthalmol 2004 (88): 1467-1474.
12. Weisbach V, DietrichT, Kruse FE, et al. HIV and hepatitis B/C infections in patients donating blood for use as autologous serum eye drops. Br J Ophthalmol 2007; 91 (12): 1724-1725.
13. Eberle J, Habermann J, Gurtler IG. HIV-1 infection transmitted by serum droplets into the eye: a case report. AIDS 2000; 14: 206-207.






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