Download EL-MINIA MED. BULL. VOL. 22, NO. 2, JUNE, 2011 Mehany LIMBAL

EL-MINIA MED. BULL. VOL. 22, NO. 2, JUNE, 2011
Mehany
LIMBAL CONJUNCTIVAL AUTOGRAFT VERSUS INTRA-OPERATIVE
MITOMYCIN-C ALONE OR COMBINED WITH labmil CONJUNCTIVAL
AUTOGRAFT IN PRIMARY PTERYGIUM SURGERY.
By
Shaaban A Mehany,
Department of Ophthalmology, El-Minia Faculty of medicine
ABSTRACT:
Purpose: The mainstay for treatment of pterygium is surgical excision with or
without a graft. The most common problem with this intervention is recurrence. Our
aim was to evaluate the recurrence rate of pterygium using three different techniques
after its excision.
Design: Prospective randomized interventional study.
Setting: Department of ophthalmology, Al-Minya University Faculty of medicine,
Egypt.
Materials and methods: A prospective interventional study was conducted in ninety
thgie eyes of 98 patients with an age range from 31 to 68 years (mean 43.58 ± 9.29
years) were included. Males were predominated (n = 70) in the study. Patients
undergoing pterygium excision were divided into three groups. In group 1 limbal
conjunctival autograft (LCAG) transplantation was performed in 34 patients. In group
2 Mitomycin-C (MMC), 0.02% (0.2 mg/ml) was applied intra-operativly for three
minutes to 32 patients. In group 3 MMC, 0.02% (0.2 mg/ml) was applied intraoperativly for one minute combined with limbal conjunctival autograft to 32 patients.
All patients were followed up for 24 months. Any recurrence of pterygium or
complications were recorded during this period .
Results: Ninety eight eyes of 98 patients with an age range of 31 to 68 years were
included. Most of the patients 69 out of 98 (70.4%) had a grade II pterygium.
Recurrence of pterygium was found in 3 eyes out of 34 (8.82%) in group 1, in 5 eyes
out of 32 (15.62%) in group 2, and in 3 eyes out of 32 (9.37%) in group 3. Delayed
corneo-scleral wound epithelial healing occurred in 4 eyes (12.5%) in group 2 and in
2 eyes (6.25%) in group 3. Scleral thining found in 3 eyes (9.37%) and mild scleral
necrosis occurred in 2 eyes (6.25%) in group 2. No serious complications were
demonstrated in any of the study groups.
Conclusion: Limbal conjunctival autologous graft is a safe and effective adjuncts
method for the treatment of primary pterygium on long term follow-up with a minimal
recurrence rate as compared with MMC application with or without limbal
conjunctival autologous graft.
KEY WORDS:
Autologous limbal conjunctival graft
Pterygium recurrence
Mitomycin C
being UV type B radiation.1-,2 Recent
studies have suggested that p53 genes,
human
papillomavirus,
localized
limbal stem cell deficiency and uncontrolled cell proliferation may be
associated with the development of
INTRODUCTION:
A pterygium is a fibrovascular,
wing-shaped encroachment of conjunctiva onto the cornea. Many factors are
associated with the development of
pterygium; the most common cause
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pterygium.3-6 The currently accepted
pathogenesis is the Ultraviolet lightinduced damage to the limbal stem cell
which leads to the subsequent
conjunctivalisation of the cornea.7 The
main histopathologic changes in
primary pterygium is elastotic degeneration of the conjunctival collagen.8
Mehany
DNA, cellular RNA, and protein.15
Studies have reported encouraging
results of decreasing pterygium
recurrence rate and fewer side effects
using
low
dose
intraoperative
application of MMC.16-18 Also, studies
reported the use of conjunctival autograft combined with MMC with fewer
recurrence rate ranging from 2% to
9%.19-21
Indications for surgery include
visual impairment, cosmetic disfigurement, ocular motility restriction,
recurrent inflammation, interference
with contact lens wear and, rarely,
changes suggestive of neoplasia. In
spite of great advances in the field of
ophthalmic surgery, pterygium is still a
challenge to the ophthalmic surgeon.
The success rate of pterygium surgery
is marred by its high rate of recurrence.
Meticulous surgical intervention is
often combined with adjunctive
measures to prevent recurrence.
Adjunctive
measures
include
postoperative beta-irradiation, thiotepa
drops, preoperative, intraoperative and
postoperative mitomycin- C, various
techniques of conjunctival grafting and
amniotic membrane transplantation.9-11
Although the pterygium has been
incised, removed, split, excised, transplanted, coagulated and irradiated,
postoperative recurrence is a universal
problem and there is no single
operation which permanently resolves
it.12 The reported success rates of these
techniques vary widely, from 5% for
pterygium excision with conjunctival
autografting to 89% for simple
excision.13
In our study we report our
technique and results of pterygium
excision with limbal conjunctival
autograft and compare it with other
techniques of pterygium excision
including adjunctive use of MMC
alone or combined with limbal conjunctival autograft in the management of
primary pterygium.
MATERIALS AND METHODS:
Ninty eight eyes of 98 patients
complaining of primary pterygium
with eye redness, tearing, rapid growth
with cosmetic concerns, encroachment
of the pupillary area threatening the
visual axis or blurred vision from
induced astigmatism were enrolled in
this prospective interventional study.
Recurrent pterygium, pseudopterygium, patients not willing to participate
in the study, all cases not completed
the follow up period for two years,
atrophic pterygium, ocular surface
pathology, infection, previous limbal
surgery or double head pterygium were
excluded. The study was approved by
the local Institutional Research
Committee, conformed in compliance
with the Helsinki Declaration for
research in human and informed
written consent was obtained from all
patients.
Pterygium excision with a
limbal conjunctival autologous graft
has gained worldwide acceptance as
the most favorable technique because it
has proven to be both safe and
effective in reducing pterygium
recurrence.14 Mitomycin C (MMC) is
an antibiotic-antineoplastic agent that
selectively inhibits the synthesis of
All of cases the pterygium was
located nasally, with patient age range
from 31 to 68 years (mean 43.58 ±
9.29 years). Males were predominated
(n = 70) and 28 were females in the
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study. In sixty five eyes, pterygium
was present in right eye and 33 in left
eye. All of the eyes underwent detailed
ophthalmological examination including visual acuity assessed by Snellen
Vision Box, refraction, slit lamb
biomicroscopy with the slit beam
focused on the nasal limbus, the
pterygium was graded depending on
the extent of corneal involvement as
follows. Grade I: head of pterygium
present between the limbus and a
midway point between the limbus and
nasal pupillary margin. Grade II: head
of pterygium present between the
midway point and nasal papillary
margin) Grade III: crossing nasal
pupillary margin and threatening the
visual axis, The cases with grade II as
in (Figures 1-a, 2-a and 3-a) and grade
III as in (Fig. 4-a) were posted for
pterygium surgery, measurement of
intraocular
pressure,
extraocular
muscle movements, anterior segment
camera photographs were taken for
documentation of pterygium grade as
well as morphologic appearance and
dilated fundoscopy were done. All data
collected on a predesigned pro forma
sheet.
Mehany
traction suture (6-0 Vicryl on a
spatulated needle) is placed near to the
limbus at the “12 and 6- O’clock” for
all of patients groups. Hand held
cautery is used to outline the edge of
the pterygium to be excised. Local
anesthesia is used to balloon the
pterygium separating it from the sclera.
Excision consisted of detachment of
the pterygium head using crescent
knife and the corneal epithelium was
scraped off 2 mm ahead of the head of
the pterygium, then dissection of the
body from the overlying conjunctiva in
a smooth clear plane as possible using
blunt and sharp dissection, the process
was completed towards the upper
fornix, caruncle and lower fornix in the
shape of a triangle with its apex at the
limbus avoiding any conjunctival
buttonholing. Then the subconjuctival
ptergium tissue, the thickened part of
conjunctiva (cicatrix) and adjacent
Tenon´s capsule were excised leaving
bare sclera. Any residual fibrous tissue
on the cornea was removed by sharp
dissection with a No.15 Bard-Parker
blade.
In group 2, after pterygium
excision a 2 × 4 mm sponge (Fig. 3-b)
was soaked in a solution of MMC
0.02% until its maximal absorbance
capacity. The sponge was placed over
the scleral bed and the conjunctiva was
pulled over the sponge with non
toothed forceps and the sponge was
held for three minutes, the sponge was
removed and the ocular tissue
thoroughly washed with 50 ml normal
saline. Then the conjunctiva was
secured to the sclera with interrupted
10/0 nylon sutures. Sutures were
removed 2 weeks after surgery.
Surgical technique
The patients were randomly
classified for tiett groups: group 1 to
receive limbal conjunctival autograft,
34 eyes, in group 2 (MMC), 0.02%
(0.2 mg/ml) was applied intraoperativly for three minutes to 32 eyes
and in group 3 MMC, 0.02% (0.2
mg/ml) was applied intra-operativly
for one minute combined with limbal
conjunctival autograft to 32 eyes. The
goals of pterygium surgery are to
remove the pterygium, restore the
conjunctival anatomy, leave the cornea
as smooth and clear as possible, and
prevent recurrence. Simple pterygium
excision was
performed
under
peribulbar anesthesia (Xylocaine 2%).
After an eyelid speculum is inserted, a
For harvesting the limbal
conjunctival autograft in patients of
group 1 and 3 measurement of the size
of bare scleral area was done by using
Castroviejo calipers in (mm²). Then the
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globe is rotated upward with the limbal
traction suture. The inferior temporal
quadrant of bulbar conjunctiva was
injected by 1 cc of (Xylocaine 2%)
local anesthesia to facilitate separation
of the conjunctiva from Tenon´s
capsule then, marker was used to mark
four corners of the limbal conjunctival
graft to be created 2 mm larger in
width and length than the recipient bed
as shown in (Fig. 2-b). A small
opening was created and careful blunt
dissection with Wescott scissors was
performed until the entire graft
undermined and free from Tenon´s
reaching to the limbus to include
limbal stem cells that act as a barrier to
the conjunctival cells migrating onto
the corneal surface as shown in (Fig. 1b). Then the edges of the graft were cut
by Vannas scissors. Non toothed
forceps is used to gently slide the graft
to the recipient bed with the epithelial
side up and keeping the limbal edge
towards the limbus as shown in (Fig.
2-c) .
Mehany
covered by pulling the forniceal
conjunctiva forward. At the conclusion
of the procedure, in all of the three
techniques subconjunctival injection of
corticosteroid and antibiotic was done.
Then the eye was patched firmly after
the application of antibiotic eye
ointment.
Postoperatively analgesia was
prescribed two times daily. Predforte
eye drops (Allergan) four times daily,
tobradex ointment (Alcon) three times
daily were used for 1 week then
gradual tapering for 3 weeks and
liberal use of topical lubricating eye
drops four times daily for 4 weeks.
Patients instructed to avoid rubbing
their eyes, dust, heat, direct sun
exposure and advised wearing sun
glasses to reduce UVB exposure. The
patients were also advised to report
immediately if any discomfort other
than that described during counseling
occurred. All patients were followed
up after 1 day, weekly for one month
then for 3,6, 9, 12, 18 and 24 months.
The main postoperative outcomes
measure the recurrence rate which was
defined as fibrovascular proliferation
invading the clear cornea more than
1.5 mm at the site of previously
excised pterygium, graft dehiscence,
graft retraction. The secondary
outcomes measure, the complications
including, persistent epithelial defect,
dellen, inclusion cyst, pyogenic granuloma, conjunctival edema, corneoscleral necrosis, infective scleritis,
keratitis and endophthalmitis. All data
collected were entered into Statistical
Package for Social Sciences version 16
and analyzed.
In group 1, the graft was
smoothened out on its bed taking care
to avoid any folding of the edges or
including Tenon´s capsule. The graft
sutured in position by (10/0 nylon) first
the two limbal corners keeping the
limbal edge of the graft on gentle
stretch then the posterior corners of the
graft was sutured to bulbar conjunctiva
and additional sutures were placed to
close the wound edges as shown in
(Fig. 1-c) .
In group 3, application of a
sponge soaked in MMC 0.02% for one
minute then washing by the same way
like group 2 was done. Securing the
limbal conjunctival autograft in place
in the same manner like group 1 as
shown in (Fig. 4-b and c). Then, in all
of groups the limbal traction suture
was removed and the donor area was
STATESTICAL ANALYSIS:
Data are expressed as mean ±
SD. Statistical analysis was performed
using one-way ANOVA. The P-values
less than 0.05 were considered to be
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EL-MINIA MED. BULL. VOL. 22, NO. 2, JUNE, 2011
statistically significant (using SPSS 16
for Windows).
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occupation, the presenting comp-laint,
and the duration of the disease. Preoperative visual acuity frequency
percentage was 30 patients (30.6%)
had presenting visual acuity of 6/6 on
their affected eyes, 46 patients (46.9
%) had visual acuity of 6/9 to 6/12, and
22 patients (22.5%) had visual acuity
of 6/18 or below. Post-operative visual
acuity improved to be 6/6 in 42
patients (42.86 %) on their affected
eyes, 50 patients (51.02 %) had visual
acuity of 6/9 to 6/12, and only 6
patients (6.12 %) had visual acuity of
6/18 or below. Also, there is
statistically significant difference
between all of the three groups in preoperative and postoperative visual
acuity (P ˂ 0.05).
RESULTS:
Table (1) demonstrate the
patients demographic data. Ninety
eight eyes of 98 patients were
evaluated. Patients were classified into
three groups, in group 1 (LCAG)
transplantation was performed in 34
patients, in group 2 MMC, 0.02% (0.2
mg/ml) was applied intra-operatively
for three minutes to 32 patients, and in
group 3 MMC, 0.02% (0.2 mg/ml) was
applied intra-operatively for one
minute combined with (LCAG) to 32
patients. All patients were followed up
for 24 months. Patients age ranged
from 31 to 68 years with a mean age of
43.58±9.29.
Male
gender
was
predominated in the study 70 out of 98
(71, 42%). Sixty five (66.32%) of
patients were right eyes and 33
(33.68%) were left eyes. Sixty nine
(70.4%) of patients had grade II and 29
(29.6%) had grade III pterygium. No
significant difference was demonstrated between all of the three groups
regarding range of age of patients, sex,
laterality, and grade of pterygium.
(Table 3) demonstrate postoperative main and secondary outcomes. Only three patients (8.82%) in
group 1 had a recurrence of pterygium,
one after two months, and the other
two after four months post-operatively.
Five patients (15.62 %) in group 2 had
a recurrence of pterygium, two after
three months, and the other three after
six months post-operatively. Three
patients (9.37%) in group 3 had a
recurrence of pterygium, one after four
months, and the other two after six
months post-operatively. Delayed
corneoscleral wound epithelial healing
for 3 weeks occurred in 4 patients
(12.5 %) in group 2 as shown in (Fig.
3-c) and for 2 weeks in 2 patients (6.25
%) in group 3. Mild scleral necrosis
occurred in 2 patients (6.25 %) after 2
weeks pot-operatively, as well as
scleral thinning in 3 patients (9.37%)
in group 2 and managed by using a
pressure patch and topical corticosteroids. Four patients (11.76%) in
group 1 had early graft retraction, one
in the third and the other three in the
seventh post operative day also, 2
patients (6.25%) in group 3 had early
graft retraction occurred within the
Table (2) demonstrate patients
occupation, in which 38 (38.8 %) of all
patients were outdoor activity employee, 30 (30.6%) farmers and agricultural workers, 19 (19.4%) working in
mason and concrete, and 11 (11.2%)
were indoor activity employee. The
presenting complaint of the patients
varied largely as follows: dry eyes 70
(71.4%), cosmetic 11 (11.2%), foreign
body sensation 9 (9.2 %), and blurring
of vision 8 (8.2%). The duration since
the development of pterygium varied
from < 2 years in 48 (49 %), 2 – 5
years in 38 (38.8 %) to more than 5
years in 12 (12.2%) of all patients.
There is no statistically significant
difference between all of the three
groups regarding the nature of
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EL-MINIA MED. BULL. VOL. 22, NO. 2, JUNE, 2011
first post-operative week. All of them
resolved by conservative management
and eye patch. Conjunctival edema
occurred in 5 patients (14.7%) in group
1, one patient (3.13%) in group 2, and
in 2 patients (6.25%) in group 3, all of
them resolved gradually in the first
post-operative week. One patient
(2.94%) in group 1, 2 patients (6.25%)
in group 2, and 2 patients (6.25%) in
group 3 had sutural granuloma present
within the first two weeks of
postoperative period they improved
with suture removal and topical corticosteroid treatment. Faint corneal
nebula occurred in 3 patients (8.82%)
in group1, 2 patients (6.25%) in group
2, and 2 patients (6.25%) in group 3.
Dellen occurred in one patient (2.94%)
in group 1. Conjunctival cyst occurred
Mehany
in one patient (2.94%) in group 1 and
one patient (3.13%) in group 3. Mild
graft necrosis observed in one patient
(3.13%) in group 3 and resolved by
topical steroids and pressure patch.
Although there were slight
difference in postoperative outcomes
of the three groups, there were no
statistically significant difference
except for scleral necrosis & conjunctival edema in which there is significant difference (P ˂ 0.05) and highly
significant difference for scleral
thinning in which (P ˂ 0.01). No
anesthetic complications, symblepharon or major complications like
globe perforation, excessive bleeding,
medial rectus injury were noticed in all
of patient groups.
Table (1): Clinical Data
Items
* Range of age
in years
Mean, SD
* Sex:
N of eyes & %
 Males
 Females
Total
N= (98
eyes)
Group 1
Group 2
Group 3
Significance
N= (34 eyes)
N= (32 eyes) N= (32 eyes)
GACL
MMC (0.02 %) MMC (0.02%)
+ LCAG
31– 68
31– 66
35 – 67
33 – 68
NS
43.58±(9.29) 43.12 ± (8.45) 44.87± (9.25) 44.15 ± (7.59)
NS
70 (71.42%) 24 (71.59 %)
28 (28.58 %) 10(29.41 %)
23(71.88%)
9 (28.12 %)
*Laterality:
N of eyes & %
65 (66.32 %) 25(73.53 %)
18 (56.25 %)
 Right
33 (33.68 %) 9 (26.47%)
14 (43.75 %)
Left
*Grade of pterygium
69 (70.40 %) 24 (70.59 %) 24 (75 %)
 Grade I
29
(29.60 %) 10 (29.41 %) 8 (25 %)
 Grade II
NS= Not significant (P > 0.05) ), * = significant (P < 0.05),
and ** = highly significant (P < 0.01)
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23 (71.88 %)
9 (28.12 %)
NS
NS
22 (68.75 %)
10 (31.25 %)
NS
NS
21 (65.62 %)
11 (34.38 %)
NS
NS
EL-MINIA MED. BULL. VOL. 22, NO. 2, JUNE, 2011
Mehany
Table (2): Clinical Data Continu.
Items
 Occupation
 Outdoor activity
employee
 In door activity
employee
 Farmer
 Masson & Concrete
 Complain
 Dry eye
 Cosmetic app.
 FB sensation
 Blurring of vision
 noiiaauD of
pterygium
 < 2 years
 2- 5 year
 > 5 years
 V/A before
surgery
 6/6
 6/9-6/12
 6/18-6/24
 6/60
 V/A after surgery
 6/6
 6/9-6/12
 6/18-6/24
 6/60
Total
Group 1
Group 2
N=(98 eyes) N= (34 eyes) N= (32eyes)
GACL
MMC(0.02%)
Group 3
Significance
N=(32eyes)
MMC(0.02%)
+ LCAG
38 (38.8 %)
11 (11.2 %)
30 (30.6 %)
19 (19.4 %)
14 (41.2 %)
3 (8.8 %)
10 (29.4 %)
7 (20.6 %)
12 (37.5 %)
5 (15.6 %)
11 (34.4 %)
4 (12.5 %)
12 (37.5 %)
3 (9.4 %)
9 (28.1 %)
8 (25 %)
NS
NS
NS
NS
70 (71.4 %)
11 (11.2 %)
9 (9.2 %)
8 (8.2%)
22 (64.7 %)
4 (11.8 %)
5 (14.7)
3 (8.8 %)
25 (78 %)
3 (9.4 %)
2 (6.3%)
2 (6.3%)
23 (71.8 %)
4 (12.5 %)
2 (6.3 %)
3 (9.4 %)
NS
NS
NS
NS
48 (49 %)
38 (38.8 %)
12 (12.2 %)
17 (50 %)
14 (41.2 %)
3 (8.8%(
15 (46.9 %)
13 (40.6 %)
4 (12.5 %)
16 (50 %)
11 (34.4 %)
5 (15.6 %)
NS
NS
NS
30 (30.6 %)
46 (46.9 %)
18 (18.4 %)
4 (4.1 %)
12 (35.3 %)
18 (52.9 %)
2 (5.9 %)
2 (5.9 %)
8 (25 %)
16 (50 %)
7 (21.9 %)
1 (3.1 %)
10 (31.3 %)
12 (37.5 %)
9 (28.1 %)
1 (3.1 %)
NS
*
*
NS
42 (42.86 %)
50 (51.02 %)
6 (6.12 %)
0 (0 %)
14 (41.2 %)
20 (58.8 %)
0 (0 %)
0 (0 %)
13 (40.6 %)
16 (50 %)
3 (9.4 %)
0 (0 %)
15 (46.9 %)
14 (43.7 %)
3 (9.4%)
0 (0 %)
NS
*
*
NS
NS= Not significant (P > 0.05), and * = significant (P < 0.05)
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Table (3): Showing postoperative main and secondary outcomes.
Items
Recurrence rate
Group 1
Group 2
Group 3
N= (34 eyes) N= (32 eyes)
N= (32 eyes)
LCAG
MMC (0.02%) MMC (0.02 %)+ LCAG
3 (8.82 %)
5 (15.62 %)
3 (9.37 %) NS
Delayed Corneo-scleral
wound epithelial healing
Scleral necrosis
0 (0 %)
4 (12.5 %)
2 (6.25 %) NS
0 (0 %)
2 (6.25 %)
0 (0 %) *
Scleral thinning
0 (0 %)
3 (9.37 %)
0 (0 %) **
Graft dehiscence
0 (0 %)
0 (0 %)
0 (0 %) NS
0(0 %)
2 (6.25 %) NS
Conjunctival edema
4 (11.76
%)
5 (14.7 %)
1 (3.13%)
2 (6.25 %) *
Conjunctival granuloma
1 (2.94 %)
2 (6.25 %)
2 (6.25 %) NS
Corneal scar (faint nebula)
3 (8.82 %)
2 (6.25 %)
2 (6.25 %) NS
Dellen
Conjunctival cyst
1 (2.94 %)
1 (2.94 %)
0 (0 %)
0 (0 %)
0 (0 %) NS
1 (3.13 %) NS
Graft necrosis
0 (0 %)
0 (0 %)
1 (3.13 %) NS
Symblepharon
0 (0 %)
0 (0 %)
0 (0 %) NS
Early graft retraction
NS= Not significant (P > 0.05), * = significant (P < 0.05),
and ** = highly significant (P <0.01)
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Fig. (1- a) A case of preoperative grade II left
nasal pterygium from
group 1.
Fig. (1-b) Same case, intraoperative harvesting the
LCAG from the inferior
temporal quadrant after
pterygium excision.
Fig. (1- c) Same case, postoperative after suturing
LCAG to the remaining
conjunctiva.
Fig. (2- a) A case of preoperative grade II left
nasal pterygium from
group 1.
Fig. (2-b) The same case,
intra-operative site marking
for harvesting the LCAG
from the inferior temporal
quadrant after pterygium
excision.
Fig. (2-c) The same case,
intra-operative placing the
harvested LCAG before
suturing at the site of excised
pterygium.
Fig. (3-a) A case of preoperative grade II right
nasal pterygium from
group 2.
Fig.(3-b) The same case,
showing intra-operative
application of MMC soaked
sponge after pterygium
excision .
Fig. (3-c )The same case, 18
days postoperatively after
suture removal showing
delayed corneo-scleral wound
epithelial healing.
Fig. (4- a) A case of preoperative grade III left
nasal pterygium from
group 3.
Fig. (4- b) The same case
showing start suturing the
LCAG after ptergyium
excision and application of
sub- conjunctival MMC.
Fig. (4- c) The same case
showing continue suturing
the LCAG.
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Mehany
As bare sclera excision is associated
with a high recurrence rate, pterygium
excision is often combined with
conjunctival autograft, mitomycin C,
beta-irradiation or other adjunctive
therapies to reduce recurrence rates.
There is currently, however, no conesnsus on the ideal treatment of the
disease (Ang et al., 2007).23
DISCUSSION:
In spite of numerous techniques
and improvements in microsurgery,
recurrence of pterygium is still a major
concern for ophthalmic surgeons.
While the definitive management of a
pterygium is surgical, the ideal adjunctive procedure is still to be determined. A wide range of recurence rates
reported has been attributed to various
study differences including methodology (prospective or retrospective),
patient characteristics (race, age and
gender), nature of pterygium (advanced, inflamed, recurrent, progressive,
and atrophic), geographic area of
domicile, number of patients studied,
definition of recurrence, duration of
follow up, surgical technique and
surgeon’s experience.
Rao et al., (1998)24 highlighted
that the surgical technique could
probably be the single most important
factor influencing recurrence. He
emphasized that the meticulousness
with which the limbal tissue was
included in the conjunctival autograft,
determines the success of the procedure. We also followed the surgical
technique described by him in group1
and 3 by using LCAG which involved
conjunctival limbal stem cells that act
as a barrier to conjunctival cells
migrating onto the corneal surface and
to fight against the pterygium recurence as well as, we chose the inferior
temporal quadrant for harvesting donor
LCAG to reserve the superior
conjunctiva intact for future surgical
procedures if needed.
In a study done by ( Pandey et
al., 1984)22 males were predominant
(males 1051, 75.1%; females, 349;
24.9%). Our study in agreement with
this study and it suggests that males
have more exposure to external
atmosphere than females, indicating
that the environment plays a predominant role in pterygium formation. In
our study, outdoor activity employet
and farmers were mostly involved,
which could be due to increased
exposure to dust and UV rays.
Exposure to dryness, hot weather and
ultraviolet rays causes primary
thickening of a limbal mass, leading to
limbal elevation. This in turn causes
irritation and further elevation which
causes exposure of the cornea due to
improper apposition of the lids. Thus, a
dellen forms and prevents a smooth
tear film from covering the cornea
causing dry eyes and this explains the
predominance of dry eye complaint in
70 patients (71.4%) in our study.
Koch et al., (1992)25 described
that a pterygium also exhibits features
seen in limbal stem cell deficiency
(SCD) states, stromal inflammation
and corneal vascularisation and
conjunctivalization. Thus, the importance of limbal transplantation in
ensuring low recurrence rates has also
been stressed by (Figueiredo et al.,
1997) 26 and (Dushku et al.,1994).7
On the other hand MMC acts as
an alkylating agent and causes
irreversible damage to the DNA of the
cell. In pterygium surgery postoperative use of topical MMC is not
recommended because of possible drug
misuse which cause severe ocular
complications such as scleromalacia,
The primary aim of the surgical
intervention in pterygium is to excise
the pterygium and prevent recurrence.
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EL-MINIA MED. BULL. VOL. 22, NO. 2, JUNE, 2011
corneal perforation, glaucoma, irritis
and punctate keratopathy stressed by
(Hyasaka et al.,1988)27 and (Rubinfeld
et al., 1992).28 Single intra-operative
use of MMC is safer and the
recurrence rate was approximately 6%
with mild post-operative complications
such as superficial punctuate keratopathy and avascularity of the bare
sclera area, the epithelium of the
wound area is usually completed
within 2 weeks (Frucht et al., 1996).17
Mehany
suturing the remaining conjunctiva to
the sclera in group 2.
Delayed corneoscleral wound
epithelial healing in our study was
postulated in 4 patients (12.5%) in
group 2, none in group 1, and 2
patients (6.25%) in group 3 was
comparable to the study of ( Sharma et
al., 2000)31 in which it was (9.52%) for
MMC group. Scleral thinning occurred
in 3 patients (9.37%) in group 2. Mild
scleral necrosis occurred in 2 patients
(6.25%) in group 2 and mild graft
necrosis occurred in one patient
(3.13%) in group 3. We attributed
those complications to be MMCrelated complications, as they higher in
group 2 in which longer intra-operative
MMC application time. Conjuctival
edema occurred in 5 patients (14.7%)
in group1, in one patient (3.13%) in
group 2 and in 2 patients (6.25%) in
group 3, as we used interrupted Nylon
10/0 suture in all of our patient three
groups which allows for any fluid
build up to escape through the
intervening spaces rather than it has
minimal reaction, most of cases
resolved spontaneously with conservative treatment.
In our study we compared the
post-operative main outcome and
secondary outcomes of the three
techniques of LCAG alone in group1,
intra-operative use of MMC, 0.02%
alone for three minutes in group 2, and
combined use of LCAG with intraoperative MMC, 0.02% for one minute
in group 3. The post-operative main
outcomes in the form of recurrence
rate and graft retraction and secondary
outcomes in the form of other related
complications.
The recurrence rate was
postulated in 3 patients (8.82%) in
group 1 in comparable to 5 patients
(15.62%) in group 2 and 3 patients
(9.37%) in group 3. Tan, (1999)29
advocated graft retraction to subconjunctival fibrosis and recommended
meticulous dissection of sub-epithelial
graft tissue. In our study early graft
retraction was reported in 4 patients
(11.76%) in group 1 and in 2 patients
(6.25%) in group 3 and those results
were lower than that reported by
(Foroutan et al., 2011)30 as high as
(20%) in their study because in our
study we stressed on stretching and
tightening of the LCAG in group 1 and
3 to the sclera and optimal apposition
by suturing of the graft edges to the
recipient conjunctiva for faster healing,
formation of anastomotic vessels and
to decrease the rate of graft retraction
and granuloma formation as well as
Pyogenic sutural granuloma
occurred in one patient (2.94%) in
group 1, in 2 patients (6.25%) in group
2 and in 2 patients (6.25%) in group 3
in spite of using 10/0 Nylon which has
minimal reaction and removed after 2
weeks with some discomfort and
foreign body sensation in postoperative period. Cyst formation
occurred in one patient (2.94%) in
group 1 and in one patient (3.13%) in
group 3. Dellen also occurred in one
patient (2.94%) in group 1.
Fernandes et al., (2005)32 has
compared the outcome of various
surgical techniques following primary
and recurrent unilateral pterygium
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EL-MINIA MED. BULL. VOL. 22, NO. 2, JUNE, 2011
excision respectively. Recurrences
were noted in 46 (19.4%) and one
(33.3%) eyes after bare sclera
technique; in five (16.7%) and 0 after
primary closure; in 28 (26.7%) and 0
with Amniotic membrane graft
(AMG); in 42 (12.2%) and five
(31.3%) with conjunctival autologous
graft (CAG) and in nine (17.3%) and
two (40%) with limbal conjunctival
autograft (LCAG). Our results in the
three groups were comparable because
most of surgical techniques, including
the method of tissue dissection was
performed in all patients using the
same principles and by the same
surgeon on the same population under
the same setting for a period of time.
Mehany
the relative efficacy and long-term
safety of the various treatment options
to define a suitable pterygium
management.
REFERENCES:
1- Moran DJ, Hollows FC (1984).
Pterygium and ultraviolet radiation: a
positive correlation. Br J Ophthalmol;
68:343–346.
2- Taylor HR, West S, Munoz B
et al (1992). The long-term effects of
visible light on the eye. Arch
Ophthalmol; 110:99–104.
3- Di Girolamo N, Chui J, Coroneo
MT, Wakefield D (2004). Pathogenesis
of pterygia: role of cytokines, growth
factors, and matrix metalloproteinases.
Prog Retin Eye Res; 23(2):195–228.
4- Gallagher MJ, Giannoudis A,
Herrington CS, Hiscott P (2001).
Human papillomavirus in pterygium.
Br J Ophthalmol; 85:782–784.
5- Reisman D, McFadden JW, Lu
G (2004). Loss of heterozygosity and
p53 expression in pterygium. Cancer
Lett; 206:77–83.
6- Tan DT, Tang WY, Liu YP et al
(2000). Apoptosis and apoptosis
related gene expression in normal
conjunctiva and pterygium. Br J
Ophthalmol; 84:212–216.
7- Dushku N, Reid TW (1994).
Immunohistochemical evidence that
human pterygia originate from an
invasion of vimentin – expressing
altered limbal epithelial basal cells.
Curr Eye Res; 13:473 81.
8Spencer
WH
(1985).
Ophthalmic pathology: An Atlas and
Textbook. 3rd edition. Philadelphia:
WB Saunders Vol I:174-76.
9- Kenyon KR, Wagoner MD,
Hettinger ME (1985). Conjunctival
autograft transplantation for advanced
and recurrent pterygium. Ophthalmology; 92:1461-70.
10- Singh G, Wilson MR, Foster
CS (1990). Long term follow up study
of mitomycin eye drops as adjunctive
Our study results comparable
with other similar study of (Young et
al., 2004)14 in which the recurrence
rate was (15.9%) 10 patients out of 63
for MMC group and (1.9%) one
patient out of 52 for LCAG group.
Also, with (Sharma et al., 2000)31 in
which the recurrence rate was (14.3%)
for MMC group versus (5%) for
conjunctival autograft and with (Wong
and Law, 1999)20 in which the
recurrence rate was (18%) for conjunctival autograft alone and (9%) for
combined MMC with conjunctival
autograft.
CONCLUSION:
Primary pterygium excision
with adjunct use of LCAG (Limbal
conjunctival autograft) transplantation
alone in spite of it is time consuming
and required significant learning curve
it has equal or less post-operative
recurrence rate as compared with
adjunct use of MMC alone or
combined with LCAG with avoidance
of MMC-related complications. LCAG
is the safe and effective method for
treating primary pterygium. However,
additional large randomized clinical
trials need to be performed to evaluate
204
EL-MINIA MED. BULL. VOL. 22, NO. 2, JUNE, 2011
treatment of pterygia and its
comparison with conjunctival autograft
transplantation. Cornea; 9:331-34.
11- Sangwan VS, Burman S,
Tejwani S, Mahesh PS, Murthy R
(2007). Amniotic membrane transplantation: A review of current indications
in the management of ophthalmic
disorders. Indian JO phthalmol; 55(4):
251-260.
12- Singh G, Rana RK (1982).
Evaluation of a new polishing technique in surgery of primary pterygium.
Indian J Ophthalmol; 30(4): 281-284.
13- Sebban A, Hirst LW, Kynaston
B, Bain C (1991). Pterygium recurence rate at the Princess Alexandra
Hospital.
14- Young AL, Leung GY, Wong
AK, et al. A randomised trial omparing
0.02% mitomycin C and limbal
conjunctival autograft after excision of
primary pterygium. Br J Ophthalmol
2004; 88:995–997.
15- Goodman LS, Gilman A,
Goodman Gilman A, editors. The
pharmacological basis of therapeutics,
8th ed. Elmsford, New York:
Pergamon Press 1990;1247 1248.
16- Frucht-Pery J, Ilsar M, Hemo I.
Single dosage of mitomycin C for
prevention of recurrent pterygium:
preliminary
report.
Cornea
1994;13:411– 413.
17- Frucht-Pery J, Siganos CS,
Ilsar M. Intraoperative application of
topical mitomycin C for pterygium
surgery. Ophthalmology 1996;103:
674–677.
18- Mastropasqua L, Carpineto P,
Ciancaglini M, Lobefalo L,Gallenga
PE. Effectiveness of intraoperative
mitomycin C in the treatment of
recurrent pterygium. Ophthalmologica
1994; 208:247–249.
19- Mutlu FM, Sobaci G, Tatar T,
Yildirim E. A comparative study of
recurrent pterygium surgery: limbal
conjunctival autograft transplantation
versus mitomycin C with conjunctival
Mehany
flap. Ophthalmology 1999;106:817–
821.
20- Wong VA, Law FC. Use of
mitomycin C with conjunctival autograft in pterygium surgery in AsianCanadians. Ophthalmology 1999;106:
1512–1515.
21- Segev F, Jaeger-Roshu S,
Gefen-Carmi N, Assia EI. Combined
mitomycin C application and free flap
conjunctival autograft in pterygium
surgery. Cornea 2003;22:598 – 603.
22- Pandey DJ, Mishra VK, Singh
YP, Kumar A, Pandey DN (1984).
Quantitative and qualitative estimation
of tear in pterygium. Indian J Ophthalmol; 32(5): 373-77)
23- Ang LPK, Jocelyn LL Chua,
Tan DTH (2007). Current concepts and
techniques in pterygium treatment.
Current Opinion in Ophthalmology;
18:308–313.
24- Rao SK, Lekha T, Mukesh BN,
Sitalakshmi G, Padmanabhan P (1998).
Conjunctival-limbal autografts for
primary and recurrent pterygia:
Technique and results. Indian J
Ophthalmol; 46:(4):203-209.
25- Koch JM, Mellin JB, Wauble
TN (1992). The pterygium –Autologous conjunctiva – limbus transplantation as treatment. Ophthalmology;
89:143-46.
26- Figueiredo RS, Cohen EJ,
Gomes JAP, Rapuano CJ, Laibson PR
(1997). Conjunctival autograft for
pterygium surgery: how well does it
prevent recurrences? Ophthalmic Surg
Lasers; 28:99-104.
27Hayasaka S, Noda S,
Yamamoto Y, Setogawa T. Postoperative instillation of low-dose
mitomycin C in the treatment of
primary pterygium. Am J Ophthalmol
1988;106:715–718.
28- Rubinfeld RS, Pfister RR,
Stein RM, et al. Serious complications
of topical mitomycin C after pterygium
surgery. Ophthalmology 1992;99:
1647–1654.
205
EL-MINIA MED. BULL. VOL. 22, NO. 2, JUNE, 2011
29- Tan D. Conjunctival grafting
for ocular surface disease. Curr Opin
Ophthalmol 1999; 10: 277–281.
30- Foroutan A, Beigzadeh F,
Ghaempanah
MJ,
Eshghi
P,
Amirizadeh N, Sianati H, Foroutan P
(2011). Efficacy of autologous fibrin
glue for primary pterygium surgery
with conjunctival autograft. Iranian
Journal of ophthalmology 23: 39- 47.
Mehany
31- Sharma A, Gupta A, Ram J,
Gupta A. Low-dose intraoperative
mitomycin-C versus conjunctival autograft in primary pterygium surgery:
long-term followup. Ophthalmic Surg
Lasers 2000; 31:301–307.
32- Fernandes M, Sangwan VS,
Bansal AK et al (2005). Outcome of
pterygium surgery: Analysis over 14
years. Eye;19:1182-90.
206