Download Role of Conjunctival Inflammation in Surgical Outcome After

CLINICAL SCIENCE
Role of Conjunctival Inflammation in Surgical Outcome
After Amniotic Membrane Transplantation With or
Without Fibrin Glue for Pterygium
Ahmad Kheirkhah, MD, Victoria Casas, MD, Hosam Sheha, MD, Vadrevu K. Raju, MD, FRCS,
and Scheffer C. G. Tseng, MD, PhD
Purpose: To determine the clinical significance of postoperative
Key Words: amniotic membrane, conjunctival inflammation, fibrin
glue, mitomycin C, pterygium, suture
conjunctival inflammation noted at the third or fourth week after
intraoperative application of mitomycin C and amniotic membrane
transplantation for pterygium.
(Cornea 2008;27:56–63)
Methods: This retrospective study included 27 eyes of 23 patients
with primary (n = 12) or recurrent (n = 15) pterygia. All cases were
operated by extensive removal of subconjunctival fibrovascular tissue
and intraoperative application of 0.04% mitomycin C in the fornix,
followed by amniotic membrane transplantation by using either fibrin
glue (14 eyes) or sutures (13 eyes). Main outcome measures included
development of conjunctival inflammation, pyogenic granuloma, and
pterygium recurrence after surgery.
Results: For a follow-up of 29.6 6 17.2 months (range, 6–56
months), 16 (59.3%) eyes without postoperative conjunctival inflammation resulted in favorable outcomes. Conjunctival inflammation
around the surgical site was noted in the remaining 11 (40.7%)
eyes and was significantly more common in eyes with sutures
than those with fibrin glue (61.5% vs. 21.4%, respectively; P = 0.05).
Among those with this inflammation, 7 eyes receiving subconjunctival injection of triamcinolone resulted in complete resolution
and a good aesthetic outcome. Four eyes without this injection
gradually developed conjunctival (n = 1) or corneal (n = 1) recurrence
and/or pyogenic granuloma (n = 3).
Conclusions: Host conjunctival inflammation is still common after
intraoperative application of mitomycin C and amniotic membrane
transplantation, especially when sutures are used in pterygium
surgery. If left untreated, persistent inflammation may lead to a poor
surgical outcome.
Received for publication April 25, 2007; revision received July 20, 2007;
accepted August 15, 2007.
From the Ocular Surface Center, Miami, FL.
Supported by an unrestricted grant from Ocular Surface Research and
Education Foundation, Miami, FL. A.K. is a recipient of Joseph Swiger
and Eye Foundation of America Fellowship from Ocular Surface Research
and Education Foundation, Miami, FL.
Dr. Tseng and his family are .5% shareholders of TissueTech, which owns
US patents 6152142 and 6326019 on the method of preparation and
clinical uses of human amniotic membrane distributed by Bio-Tissue. All
other authors state that they have no proprietary interest in the products
named in this article.
Reprints: Scheffer C.G. Tseng, Ocular Surface Center, 7000 SW 97 Avenue,
Suite 213, Miami, FL 33173 (e-mail: [email protected]).
Copyright Ó 2007 by Lippincott Williams & Wilkins
56
P
terygium is characterized by the encroachment of a fleshy
fibrovascular tissue from the bulbar conjunctiva onto the
cornea. The old belief of regarding pterygium as a chronic
degenerative disease with elastotic degeneration caused by
ultraviolet irradiation1 has been challenged by several findings.
Histopathologically, pterygium also exhibits epithelial hyperplasia and exuberant fibrovascular tissue in the stroma,2–4 in
which contractile myofibroblasts are prevalent.5 Importantly,
the extent of fibrovascular tissue in the stroma is a reliable
morphologic index for predicting the tendency of pterygium
recurrence after primary excision.6 Furthermore, intraoperative application of mitomycin C (MMC), an antimetabolite
that inhibits cellular proliferation, has been used as an adjunct
during pterygium excision.7–9 Collectively, these findings
indicate that pterygium is actually a proliferative disease.
Laboratory data further showed that ocular surface
inflammation may play a pathogenic role in the development
of this fibrovascular tissue and hence the progression and
recurrence of pterygium. Proinflammatory cytokines such as
interleukin-1b and tumor necrosis factor-a can stimulate
proliferation of cultured Tenon capsule fibroblasts10 and cause
overexpression of matrix-degrading enzymes such as collagenase and stromelysin in cultured pterygium body fibroblasts.11 Furthermore, several potent fibrogenic and angiogenic
growth factors have been found in pterygium tissues.12,13
These findings also suggest that control of ocular surface
inflammation after pterygium surgery is important in halting
pterygium recurrence. In fact, intraoperative and postoperative
injections of long-acting steroids11,14 and postoperative
injections of 5-fluorouracil (5-FU)14,15 have been advocated
to prevent pterygium recurrence. There is little clinical
information to corroborate with these laboratory findings in
suggesting the potential pathogenic role of ocular surface
inflammation in the outcome of pterygium surgery. Specifically, contributing factors and the clinical significance of
ocular surface inflammation after pterygium surgery remain
largely unknown.
To avoid suture-related complications, mostly inflammatory in origin such as granuloma, abscesses, and giant
Cornea Volume 27, Number 1, January 2008
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Cornea Volume 27, Number 1, January 2008
papillary conjunctivitis, others have recently used fibrin glue to
facilitate conjunctival autograft in pterygium surgery.16–19
Other reported advantages of using fibrin glue include the
ease of use, shorter operating times, and less postoperative
discomfort.16–19 Pyogenic granuloma, an inflammatory lesion,
has been reported after pterygium excision.20–24 However, it
remains unclear whether the incidence and pattern of ocular
surface inflammation or formation of pyogenic granuloma
after pterygium surgery actually differ between fibrin glue and
sutures.
To address these unknown questions, we retrospectively
reviewed our consecutive cases after removal of primary and
recurrent pterygia by using amniotic membrane transplantation (AMT) and intraoperative application of MMC and
summarized herein our analyses.
MATERIALS AND METHODS
Patients
This study was approved by the institutional review
board of Baptist Hospital of Miami/South Miami Hospital
(Miami, FL) to retrospectively review the medical records of
23 patients (27 eyes) with primary or recurrent pterygium who
were seen at the Ocular Surface Center (Miami, FL) and
consecutively operated on with bare sclera excision followed
by intraoperative application of MMC and AMT. The first
13 consecutive eyes, operated on from 2002 to 2004, received
sutures to attach the amniotic membrane, whereas the next
consecutive 14 eyes, operated on from 2005 to 2006, received
fibrin glue.
Before surgery, possible advantages and disadvantages
of the treatment were fully explained to the patients, and their
written informed consents were obtained. Clinical data
concerning patient demography; preoperative examination
including pterygium morphology graded into T1, T2, and T3
as previously described6; surgical procedure; postoperative
follow-up; and the final outcome and complications were
retrieved from patients’ charts. At the Ocular Surface Center,
all surgical procedures have routinely been recorded as digital
video, from which the surgical time was calculated. In
addition, all patients had documented photographs at each
preoperative and postoperative visit; these photographs were
evaluated by a masked reader (V.C.). All subjects were
followed up for a minimum of 6 months.
Surgical Technique
All surgical procedures were performed by the same
surgeon (S.C.G.T.) to ensure consistency in the extent of tissue
removal. Topical anesthesia with 2% lidocaine gel (AstraZeneca, Wilmington, DE) was used for primary cases, and
general anesthesia was used for recurrent cases. Several drops
of nonpreserved epinephrine 1/1000 (Hospira, Lakes Forest,
IL) were instilled to the ocular surface to achieve vasoconstriction for hemostasis. The pterygium area was exposed by
7-0 Vicryl traction sutures placed with episcleral bites at 2–3 mm
from the superior and inferior limbus. The pterygium head was
undermined and removed from the corneal surface by blunt
Inflammation After AMT for Pterygium
dissection, and the pterygium body was excised before the
semilunar fold. An extensive removal of the subconjunctival
fibrovascular tissue was performed to include 3–4 mm beyond
and around the pterygium body in primary cases and more
extensive removal in recurrent cases. In recurrent cases, the
conjunctival tissue was recessed and not resected. The corneal
defect area was polished of any residual tissue with a 64
Beaver blade and/or a dental bur. Sponges soaked in 0.04%
MMC were applied into the fornix, where the subconjunctival
fibrovascular tissue was removed, and care was taken to avoid
contact with the bare sclera. After an incubation time of 1–
5 minutes according to the pterygium morphology grade, with
a longer duration for T3 but a shorter one for T1, copious
irrigation with balanced saline solution was used.
Cryopreserved amniotic membrane, obtained from BioTissue (Miami, FL), was peeled off the nitrocellulose filter
paper and laid down on the sclera with the stromal surface
facing down. In 14 eyes, fibrin glue (Tisseel; Baxter, Irvine,
CA) was used to secure the amniotic membrane to the sclera
without the use of the provided dual injector. To do so, half
of the membrane was folded over onto the other half to expose
the stromal surface (Fig. 1A). The fibrinogen solution was
first applied to the scleral surface (Fig. 1B) while the thrombin
solution was applied to the stromal surface of amniotic
membrane that had been exposed through folding (Fig. 1C).
The membrane was flipped back on the sclera, and a muscle
hook was used to spread the fibrin glue under the amniotic
membrane (Fig. 1D). The above steps were repeated for
the other half of the membrane. The excessive membrane
and fibrin gel were trimmed to flush with the conjunctival
edge. In 13 eyes, sutures were used to attach the amniotic
membrane. Interrupted 10-0 nylon sutures were placed at the
perilimbal bulbar conjunctiva, and 8-0 Vicryl sutures with
solid episcleral bites were used at the fornix border, all parallel
(not perpendicular) to the incision line. For 6 eyes with
recurrent pterygium (5 in the suture group and 1 in the fibrin
glue group), a small conjunctival autograft was used in
addition to and over the amniotic membrane. At the end of
operation, 8–12 mg of triamcinolone acetonide (Bristol-Myers
Squibb Company, Princeton, NJ) was injected subconjunctivally in 3 depots in 11 (40.7%) eyes, adjacent to the incision
site where the host conjunctiva appeared to be inflamed.
Postoperatively, all patients received 1% prednisolone
acetate eye drops (Allergan, Irvine, CA) every 2 waking hours
for 4–6 weeks and a topical antibiotic for 3–4 weeks. They
were examined postoperatively at 1 day, 1 week, 3–4 weeks,
and thereafter according to the clinical conditions. Sutures
were removed 3–4 weeks after surgery. The presence of
conjunctival inflammation was assessed at 3–4 weeks postoperatively and graded as 0 (none), I (mild), II (moderate), and
III (severe), as shown in Figure 2. Some eyes with this
inflammation received subconjunctival injection of 4–8 mg of
triamcinolone acetonide according to the surgeon’s discretion.
The grading for inflammation was evaluated before any
interventions such as suture removal or steroid injection. For
postoperative recurrence of pterygium, a grading system was
used on a scale of 1–4 as previously described.25 The operated
site was rated as grade 1 if it was normal, as grade 2 if there
were fine episcleral vessels but without fibrous tissue, as grade
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57
Kheirkhah et al
Cornea Volume 27, Number 1, January 2008
FIGURE 1. Surgical steps for AMT
with fibrin glue for pterygium. Cryopreserved amniotic membrane was
initially laid on the sclera with the
stromal surface facing down. Then,
half of the membrane was folded
over onto the other half to expose
the stromal surface (A). The fibrinogen solution was first applied onto
the scleral surface (B) while the
thrombin solution was applied onto
the stromal surface of the amniotic
membrane that had been exposed
through folding (C). The membrane
was flipped back on the sclera, and
a muscle hook was used to spread
the fibrin glue under the amniotic
membrane (D). The above steps
were repeated for the other half of
the membrane.
3 if fibrovascular tissues reached the limbus, and as grade 4 if
fibrovascular tissues invaded the cornea.
Statistical Analysis
Statistical analysis was performed with SPSS 15 (SPSS,
Chicago, IL). For comparison of conjunctival inflammation,
pyogenic granuloma, and pterygium recurrence between
different subgroups, the Fisher exact test was used. An
independent-sample t test was used for comparing the numerical variables between different subgroups including those
with sutures or fibrin glue. Multiple logistic regression was
used to determine whether the following factors were
FIGURE 2. Grading of postoperative
host conjunctival inflammation. According to the degree of blood vessel
injection, inflammation was graded
as grade 0 (no inflammation, A),
grade I (mild, B), grade II (moderate,
C), and grade III (severe, D).
58
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Cornea Volume 27, Number 1, January 2008
Inflammation After AMT for Pterygium
associated with the presence of postoperative conjunctival
inflammation: age, type of pterygium (primary vs. recurrent),
presence of floppy eyelids, duration of intraoperative MMC
application, using sutures versus fibrin glue for AMT, and
intraoperative injection of triamcinolone acetonide. P # 0.05
was considered statistically significant.
RESULTS
There were 27 eyes of 23 patients (11 men and 12
women) with a mean age of 53.7 6 16.2 years (range, 29–80
years). Twelve (44.4%) eyes had primary pterygium, and
15 (55.6%) eyes had recurrent pterygium. The number of
previous pterygium surgeries in the recurrent group was 1
(8 eyes), 2 (4 eyes), 3 (2 eyes), and 8 (1 eye) times. Among
cases with recurrent pterygium, motility restriction with
symblepharon was noted in 5 eyes, motility restriction without
symblepharon in 1 eye, and symblepharon without motility
restriction in 2 eyes. There was no statistically significant
difference between the suture group and fibrin glue group
regarding the age, type or morphology of pterygium, or
intraoperative use of MMC or triamcinolone (Table 1).
However, the follow-up period was significantly longer in
the suture group than in the fibrin glue group because the
former was performed earlier than the latter (Table 1).
There was no intraoperative complication in any eyes.
Sutures and fibrin glue were used to secure the amniotic
TABLE 1. Clinical Findings of Patients With Pterygium and
Their Postoperative Complications After Intraoperative
Application of MMC and Amniotic Membrane
Transplantation With Either Fibrin Glue or Suture
Variable
Fibrin Glue
Suture
P
No. eyes
Age (y)
Type of pterygium
Primary
Recurrent
Pterygium morphology
T1
T2
T3
Intraoperative MMC (min)
Intraoperative triamcinolone
Postoperative complications
Conjunctival inflammation
Grade 0
Grade I
Grade II
Grade III
Postoperative triamcinolone*
Pyogenic granuloma
Pterygium recurrence
Follow-up (mo)
14
58 6 17.3
13
50.7 6 14.7
0.27
7
7
5
8
3
4
7
3.4 6 1.3
7
2
5
6
3.9 6 1.4
4
11
1
0
2
2/3
2
0
14.7 6 5.9
5
3
3
2
5/8
3
2†
45.6 6 8.3
0.34
0.27
0.05
0.72
0.65
0.26
,0.0001
*Denominator is the number of eyes with conjunctival inflammation.
†One eye with grade 3 outcome (conjunctival recurrence) and 1 eye with grade 4
outcome (corneal recurrence).
membrane to the underlying sclera in 5 and 7 primary pterygia
and in 8 and 7 recurrent pterygia, respectively. The mean
surgical time was significantly shorter in eyes with fibrin glue
than in eyes with sutures (46.4 6 13.6 vs. 77 6 27.4 minutes,
respectively; P = 0.003). Conjunctival epithelial defect over
the amniotic membrane healed within 2, 4, and 8 weeks in 5, 5,
and 3 eyes with sutures, respectively, and in 4, 8, and 2 eyes
with fibrin glue, respectively. There was no statistically
significant difference between eyes with fibrin glue or sutures
in healing of the epithelial defect within the above time frames
(P = 0.27, P = 0.39, and P = 0.40, respectively). No
complication such as graft edema or subgraft hematoma was
noted postoperatively.
The visit at 3–4 weeks after surgery showed that the
amniotic membrane–covered area was not inflamed in all these
eyes; the surrounding conjunctiva was also not inflamed in
16 eyes (59.3%). However, conjunctival inflammation judged
by hyperemia of blood vessels was evident in the remaining 11
(40.7%) eyes and tended to occur around the surgical site and
the caruncle in 8 eyes, only the surrounding host conjunctiva
in 2 eyes, and only the caruncle in 1 eye. The intensity of such
inflammation was greater at the border and gradually faded
away from the membrane-covered area. Severity of the
inflammation was graded as grade I (mild) in 4 eyes, grade
II (moderate) in 3 eyes, and grade III (severe) in 4 eyes (Fig. 2;
Table 1). The incidence of such conjunctival inflammation was
significantly higher in eyes with sutures than in those with
fibrin glue [8/13 (61.5%) vs. 3/14 (21.4%), respectively, P =
0.05]. Regression analysis revealed that only the use of sutures
was significantly associated with postoperative conjunctival
inflammation (P = 0.05), whereas other factors such as age,
type of pterygium (primary vs. recurrent), presence of floppy
eyelids, duration of intraoperative MMC application, and
intraoperative injection of triamcinolone acetonide were not.
Correlation of surgical outcome with postoperative
conjunctival inflammation is shown in Figure 3. During the
follow-up of 29.6 6 17.2 months (range, 6–56 months) after
surgery, no recurrence was noted in 16 eyes without
conjunctival inflammation; all showed grade 1 or 2 outcomes
(Figs. 4A–C). On the other hand, 7 of 11 eyes with conjunctival inflammation received subconjunctival injection of
triamcinolone at the time of detection, namely, 3–4 weeks after
surgery. After injection, inflammation resolved in all these 7
eyes without development of recurrence, pyogenic granuloma,
or transient increase of intraocular pressure (Figs. 4D, E).
The remaining 4 eyes with grade I (2 eyes), grade II (1 eye),
and grade III (1 eye) conjunctival inflammation did not receive
subconjunctival steroid injections. The 2 eyes with grade I
inflammation subsequently developed pyogenic granuloma
and 1 of them developed grade 3 outcome with conjunctival
recurrence after 7 months (Figs. 4F–I). The eye with grade II
inflammation developed grade 4 outcome with corneal
recurrence after 4 months; the eye with grade III inflammation
developed pyogenic granuloma (Figs. 5A–C). Therefore,
pyogenic granuloma developed in 3 (75%) of 4 eyes with
untreated postoperative inflammation compared with 2 (8.7%)
of 23 eyes without inflammation or with treated inflammation
(P = 0.01; Figs. 5D–F). In these 5 eyes with pyogenic
granuloma, the lesions were all found around the caruncle
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59
Cornea Volume 27, Number 1, January 2008
Kheirkhah et al
FIGURE 3. Correlation of surgical
outcome with postoperative conjunctival inflammation. Surgery with
intraoperative application of MMC
and AMT was done for 27 eyes with
primary or recurrent pterygia. Examination at 3–4 weeks after surgery
revealed lack of conjunctival inflammation around the surgical site
in 16 eyes and the presence of
such inflammation in other 11 eyes.
During postoperative follow-up, no
recurrence of pterygium but 2 pyogenic granulomas occurred in the 16
eyes without this inflammation. Of
11 eyes with such inflammation, 7
received subconjunctival triamcinolone injection, whereas 4 did not. No
complication was noted in the former eyes, but 2 pterygium recurrences and 3 pyogenic granulomas
developed in the latter eyes.
area, but were not associated with suture location, and
developed 6.6 6 2.2 weeks (range, 3–8 weeks) after surgery.
Incidences of the above complications in eyes with fibrin glue
or sutures are summarized in Table 1.
DISCUSSION
Postoperative conjunctival inflammation, defined by
injection of blood vessels, is common after any ocular surface
surgeries and is usually regarded as a normal wound healing
response. Consequently, its frequency and significance might
have been overlooked in pterygium excision. When judged at
3rd–4th postoperative weeks, a period sufficient to allow
normal inflammatory responses to subside, host conjunctival
inflammation with various intensities was still present in 40%
of eyes in this study despite intraoperative application of MMC
and AMT. At that time, conjunctival inflammation was accentuated at the border and faded from there (Figs. 2 and 4),
a finding noted previously,21,25 whereas the amniotic membrane–covered area was noninflamed. Similar host conjunctival
inflammation has also been described in some eyes receiving
AMT for conjunctivochalasis and fornix reconstruction for
other cicatricial diseases.26–28 It remains unclear whether such
inflammation is contingent on certain diseases or eye conditions. Nevertheless, its incidence might be higher if pterygium
excision is not accompanied by transplantation of amniotic
membrane, which is known to exert anti-inflammatory and
antiangiogenic actions.29 One may also suspect that its incidence is higher without MMC, of which one known pharmacologic action is to reduce vascularity in the treated area. On the
other hand, at postoperative 3–4 weeks, transient conjunctival
hyperemia and chemosis frequently occur in eyes receiving
conjunctival autograft before remitting to a quiet surface.30
60
Bekibele et al31 also noted significant early postoperative inflammation at 2 weeks after pterygium surgery by using 80 silk sutures in 17.1% of 33 cases using conjunctival autograft.
Although a multitude of factors might contribute to
postsurgical conjunctival inflammation, our study identified
the use of sutures as the only significant risk factor among
others examined. Incidence of the inflammation was significantly higher in eyes using sutures than in those receiving
fibrin glue (61.5% vs. 21.4%, respectively). Sutures as foreign
bodies elicit inflammation in any eye surgeries. Naturally, they
could aggravate inflammation in eyes with pterygium after
surgery. The use of fibrin glue for conjunctival autograft in
pterygium surgery reveals several advantages including a
shorter operating time, increased postoperative comfort, and
avoiding other suture-related complications such as buttonholes, suture abscesses, tissue necrosis, and giant papillary
conjunctivitis.17–19,32 Our study was the first showing that
conjunctival inflammation was significantly reduced by fibrin
glue in lieu of sutures in pterygium surgery using cryopreserved amniotic membrane. Furthermore, the surgical time
was shortened by fibrin glue, allowing topical anesthesia for at
least primary pterygium.
Clinical significance of prolonged conjunctival inflammation was revealed by correlating it with the postoperative
outcome (Fig. 3). As stated in the introduction, ocular surface
inflammation could play a significant pathogenic role not only
in pathogenesis of primary pterygium but also in progression
of recurrence. A satisfactory aesthetic outcome (grades 1 and
2) was noted in all 16 eyes that did not manifest conjunctival
inflammation at 3–4 postoperative weeks and in 7 eyes whose
inflammation was treated with subconjunctival steroid injections. In contrast, 1 eye with conjunctival recurrence (grade 3)
and 1 eye with corneal recurrence (grade 4) were noted among
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Cornea Volume 27, Number 1, January 2008
Inflammation After AMT for Pterygium
FIGURE 4. Correlation of surgical outcome with control of postoperative conjunctival inflammation: case examples. An eye with
recurrent pterygium with symblepharon and restricted motility after 8 pterygium excisions (A) underwent surgery by using sutures.
Four weeks after surgery (B), there was no sign of host conjunctival inflammation. This eye showed grade 1 outcome with
restoration of full ocular motility at 4 years postoperatively (C). Three weeks after surgery with fibrin glue for a primary pterygium
(D), the amniotic membrane–covered surgical area was not inflamed; however, moderate inflammation (grade II) was noted in the
surrounding host conjunctiva. Subconjunctival injection of triamcinolone resulted in a smooth and quiet ocular surface with grade
1 outcome 4 months after surgery (E). Another eye with primary pterygium (F) underwent surgery by using sutures. Four weeks
after surgery (G), mild inflammation (grade I) was visible only in the caruncle, but triamcinolone was not injected. This inflammation gradually developed into grade 3 conjunctival recurrence, as shown at 3.5 (H) and 7 months (I) after surgery.
4 eyes with untreated postoperative conjunctival inflammation,
with sutures being used in both these eyes. When sutures were
used, Solomon et al21 noted conjunctival inflammation in 17
(31.5%) of 54 eyes within 3 postoperative months after
pterygium excision with AMT but without MMC. Intriguingly, their life table analysis showed delayed recurrences, ie,
after 3 months. Herein, we also noted that grade 3 and grade
4 recurrences occurred at 7 and 4 months after surgery,
respectively (Fig. 4). It is also known that a follow-up period
for as long as 1 year is needed to determine whether corneal
recurrences will develop.35 Collectively, these findings prompted us to speculate that persistent postoperative conjunctival inflammation, if not halted, might lead to conjunctival and
corneal recurrences after pterygium surgery.
The above hypothesis calls for taking preoperative,
intraoperative, and postoperative measures to prevent and/or
treat the conjunctival inflammation to improve the surgical
outcome of pterygium surgery. Postoperatively, it is prudent to
eradicate causes such as dry eye, which may stir up ocular
surface inflammation.33,34 Adjunctive therapies such as intraoperative MMC or 5-FU or postoperative b-irradiation or
5-FU are needed in bare sclera excision of pterygium if a conjunctival autograft is not used. Even if a conjunctival autograft
is performed with sutures, Yaisawang and Piyapattanakorn36
noted a higher recurrence rate in patients who received
inadequate postoperative topical corticosteroids. We previously reported that AMT without such adjunctive therapies
did not achieve the same outcome as conjunctival autograft in
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61
Kheirkhah et al
Cornea Volume 27, Number 1, January 2008
FIGURE 5. Pyogenic granuloma after pterygium surgery. An eye with primary pterygium (A) underwent surgery with AMT by using
sutures. Three weeks postoperatively (B), severe conjunctival inflammation (grade III) was noticed in the host conjunctiva. Without
steroid injection, a pyogenic granuloma was visible in the caruncle 6 weeks after surgery (C). An eye with recurrent pterygium (D)
underwent surgery with AMT by using sutures. Conjunctival inflammation was absent 4 weeks postoperatively (E), but a pyogenic
granuloma was evident at 8 weeks after surgery (F).
primary pterygium.25 We subsequently found that sublesional
injection of triamcinolone resulted in resolution of increased
fibrovascular or inflammatory activity in 12 of 17 eyes that
manifested grade 3 outcome at the postoperative 3 months,
giving rise to the same outcome as conjunctival autograft for
primary pterygium.21 The latter finding was confirmed by
a recent study by Prabhasawat et al,14 who also found that
sublesional injection of 5-FU was equally effective, and both
were significantly more effective than topical steroid alone in
halting progression to grade 4 corneal recurrence. Herein, we
noted that such inflammation was more prevalent in the suture
group and best aborted at an earlier stage, ie, postoperative 3–4
weeks, by subconjunctival injection of triamcinolone before
any fibrovascular tissue ingrows into the amniotic membrane–
covered area. This notion was supported by the finding that
all eyes with such injection resulted in grade 1 or 2 outcomes.
On the other hand, 2 of 4 eyes without injection developed
conjunctival and corneal recurrences. Further study is needed
to elucidate how anti-inflammatory and antifibrotic therapies
may halt pterygium recurrence by aborting host tissue
inflammation.
Pyogenic granuloma is thought to be an inflammatory
conjunctival lesion, but it is neither pyogenic nor granulomatous. It may occur when minor trauma or surgery stimulates
exuberant healing with fibrovascular proliferation, although
the exact underlying triggering factors remain obscured. Pyogenic granuloma has been recognized as a postoperative complication after pterygium surgery, with incidences reaching up
to 40%, 7.9%, and 9.2% when bare sclera excision is
62
accompanied by intraoperative application of MMC, conjunctival autograft, and AMT, respectively.20–22 An earlier study did
not show any correlation between its incidence and wound
closure with sutures or without.37 In our study, conjunctival
pyogenic granuloma, diagnosed solely by clinical observation,
developed in 5 (18.5%) of 27 eyes, seemingly higher than that
in our earlier experiences where AMT was performed without
MMC.21 Importantly, all pyogenic granulomas were located
around the caruncle, developed within 2 months after surgery,
and unlike conjunctival inflammation, occurred equally in both
suture and fibrin glue groups. Although impaired wound
closure, delayed apposition, chronic irritation, and incomplete
removal of the Tenon capsule have been implicated as causes of
this complication,22,38 none were apparent in our series. However, the incidence of pyogenic granuloma was significantly
higher in eyes with untreated host conjunctival inflammation
than in those without inflammation or in eyes whose
inflammation had been treated with injection of triamcinolone.
Further research is necessary to determine the pathogenesis of
this seemingly higher incidence of pyogenic granuloma around
the caruncle and its effect on the long-term outcome.
Previously, we reported that AMT was inferior to
conjunctival autograft with sutures but without intraoperative
MMC for recurrent pterygia,21,25 a finding that was also noted
recently by others.24,39 Nevertheless, in the current study,
a similar satisfactory aesthetic outcome with total restoration
of ocular motility was achieved in 7 eyes with recurrent and
multirecurrent pterygia by AMT with fibrin glue and intraoperative MMC together with early subconjunctival injection
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Cornea Volume 27, Number 1, January 2008
of triamcinolone to control postoperative conjunctival inflammation. Although our data analyses were from serial
digital photographs and digital video recordings of surgical
procedures, one’s enthusiasm is understandably dampened
by several limitations of this study such as a relatively small
sample size and its being retrospective and uncontrolled.
Furthermore, a higher incidence of pterygium recurrence in
the suture group may be attributed to a longer follow-up time.
This concern is negated by the fact that the mean follow-up for
both groups was .12 months, an interval in which most cases
of pterygium recurrences are expected to have developed.35 To
resolve these potential drawbacks, future prospective controlled studies designed to focus on the corneal early control of
host conjunctival inflammation may not only clarify the
pathogenesis of pterygium recurrence but also help formulate
a better strategy for managing other forms of cicatricial
keratoconjunctivitis of the ocular surface.
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