Intraoperative mitomycin in primary pterygium excision. A prospective, randomized trial

Evaluation of pterygium severity with en face anterior segment optical coherence tomography and correlations with in vivo confocal microscopy

PURPOSE

To describe en face anterior segment optical coherence tomography (EF-OCT) characteristics of pterygia and their correlation with in vivo confocal microscopy (IVCM).

PATIENTS AND METHODS

In this observational case series, we prospectively included 21 eyes of 17 subjects with pterygium. All subjects underwent detailed ophthalmic examination, anterior segment photography, an ocular surface disease index (OSDI) questionnaire, IVCM, and EF-OCT. Eyes were divided into two groups according to pterygium severity (Modified Pterygium Classification System) and OSDI score. EF-OCT images for both groups were analyzed for surface area of Fuchs Patches (FP). The IVCM activity score was based on the number of inflammatory cells, blood vessels, activated keratocytes and the appearance of the cornea/pterygium at the head of the pterygium. The correlations between EF-OCT and IVCM images were then analyzed and compared in both groups.

RESULTS

EF-OCT permits clear visualization and evaluation of FPs and the border between the pterygium and the adjacent cornea. The severe pterygium group was characterized by irregular borders and larger FPs (0.13±0.06 mm² versus 0.06±0.02 mm² respectively) (P=0.003). The mean IVCM activity score was 2.36±0.81 in the severe pterygium group and 1.2±0.42 in the mild pterygium group (P=0.0013). There was a positive correlation between FP surface area and IVCM activity score. A larger FP surface area was associated with a higher activity score on IVCM.

CONCLUSION

EF-OCT allows good evaluation of pterygium extension, borders and FP surface area. EF-OCT analysis of pterygium could represent a simple, non-invasive and reproducible method to evaluate pterygium severity and activity.

Effect of Vitamin D3 on Regulating Human Tenon's Fibroblasts Activity

Purpose

To study the in vitro effect of vitamin D3 on the healing response of human Tenon's fibroblasts (HTF) and its possible role in preventing excessive postoperative subconjunctival fibrosis.

Methods

Effect of vitamin D3 on cytotoxicity and cell survival of primary cultured HTF was measured by lactate dehydrogenase and PrestoBlue assays, respectively. Proliferation and migration of vitamin D3-treated HTF (D3-HTF) was determined by CyQUANT proliferation and scratch assay, respectively. The mRNA expression profiles of control-HTF and D3-HTF from six subjects (three with glaucoma and long-term use of topical medications, three with primary pterygium) were assessed by RNA sequencing analyses to identify potential biomarkers for the inhibitory effect on HTF by vitamin D3. Validation of these biomarkers and their potential pathways were performed by quantitative real-time polymerase chain reaction (qRT-PCR) detection.

Results

Pure monolayers of HTF from controls (retinal detachment or squint surgeries), pterygium, and glaucoma subjects were successfully prepared and passaged. Proliferation and migration of pterygium and glaucoma HTF were inhibited by vitamin D3 in a dose-dependent manner, and without cytotoxicity or decrease in cellular viability with concentrations up to 10 µM. The qRT-PCR results were consistent with the transcriptome analyses, vitamin D3 appears to enhance CYP24A1, SHE, KRT16 but suppresses CILP expression in HTF.

Conclusions

Vitamin D3 can inhibit the in vitro activity of HTF without compromising cellular survivability at concentration up to 10 µM. This has potential clinical application for improving the outcome of pterygium and filtering surgeries.

Translational Relevance

Vitamin D3 can suppress the in vitro proliferation, migration, and transdifferentiation of human Tenon's fibroblasts, without the cytotoxicity of mitomycin-C, the current standard antifibrotic agent in clinical use.

Pterygium: an update on pathophysiology, clinical features, and management

Pterygium is a relatively common ocular surface disease. The clinical aspects and the treatment options have been studied since many years ago, but many uncertainties still exist. The core pathologic pathway and the role of heredity in the development of pterygium are still attractive fields for the researchers. The role of pterygium in corneal irregularities, in addition to the refractive properties of pterygium removal, has been increasingly recognized through numerous studies. The association between pterygium and ocular surface neoplasia is challenging the traditional beliefs regarding the safe profile of the disease. The need for a comprehensive clinical classification system has encouraged homogenization of trials and prediction of the recurrence rate of the pterygium following surgical removal. Evolving surgical methods have been associated with some complications, whose diagnosis and management are necessary for ophthalmic surgeons. According to the review, the main risk factor of pterygium progression remains to be the ultraviolet exposure. A major part of the clinical evaluation should consist of differentiating between typical and atypical pterygia, where the latter may be associated with the risk of ocular surface neoplasia. The effect of pterygium on astigmatism and the aberrations of the cornea may evoke the need for an early removal with a purpose of reducing secondary refractive error. Among the surgical methods, conjunctival or conjunctival-limbal autografting seems to be the first choice for ophthalmic surgeons because the recurrence rate following the procedure has been reported to be lower, compared with other procedures. The use of adjuvant options is supported in the literature, where intraoperative and postoperative mitomycin C has been the adjuvant treatment of choice. The efficacy and safety of anti–vascular endothelial growth factor agents and cyclosporine have been postulated; however, their exact role in the treatment of the pterygium requires further studies.

Pterygium excision with modified bare sclera technique combined with mitomycin C

PURPOSE

Numerous surgical methods, with varying rates of recurrence, have been applied for the treatment of pterygium. Adjuvant mitomycin C (MMC) application has shown promising results in the prevention of recurrence. Here we propose and describe modified bare sclera technique combined with the intraoperative application of MMC for pterygium excision.

STUDY DESIGN

Retrospective study.

METHODS

Primary pterygium patients who underwent pterygium excision via the bare sclera combined with 0.04% MMC technique from January 2014 to December 2016 were reviewed. In all patients, the subconjunctival pterygium strand was exposed and then sufficiently excised in combination with the safe use of MMC; i.e., the prevention of MMC dilution and diffusion to surrounding tissue. Surgical complications, recurrence rates, and recurrence onset were recorded.

RESULTS

This study involved 32 primary pterygium eyes (grade T1 = 22 eyes; 68.7%). The mean postoperative follow-up period was 26.4 ± 14.5 months (range: 12-60 months). MMC was applied for 1-3 min. The mean complete epithelialization was 12.6 ± 7.6 days and no surgical complications were observed. In 1 patient with double-head primary pterygium, recurrence occurred at 15-months postoperative.

CONCLUSIONS

The modified bare sclera technique combined with MMC application was found to be safe, effective, and presents good cosmetic appearance for the treatment of primary pterygium when safety points are strictly applied.

Targeted delivery of mitomycin C-loaded and LDL-conjugated mesoporous silica nanoparticles for inhibiting the proliferation of pterygium subconjunctival fibroblasts

Pterygium is a degenerative disease that characterized by excessive fibrovascular proliferation. To reduce the recurrence rate, surgery is the main strategy, in combination with adjacent procedures or adjunctive therapy. One of the most common adjunctive agents, mitomycin C (MMC), is known as an alkylating agent that inhibits fibroblast proliferation but is limitedly applied in pterygium due to various complications. A previous study demonstrated that activated pterygium subconjunctival fibroblasts overexpressed low-density lipoprotein (LDL) receptors. In this study, we designed and synthesized MMC-loaded mesoporous silica nanoparticles conjugated with LDL (MMC@MSNs-LDL) to deliver MMC into activated pterygium fibroblasts in a targeted manner. The MMC loading efficiency was approximately 6%. The cell viability test (CCK-8 assay) revealed no cytotoxicity for the empty carrier MSNs at a concentration of ≤1 mg/ml after administration for 48 h in subconjunctival fibroblasts. Primary pterygium and normal human subconjunctival fibroblasts with or without stimulation by vascular endothelial growth factor (VEGF) were treated as follows: 1) 10 μg/ml MMC@MSNs-LDL for 24 h (MMC concentration: 0.6 μg/ml); 2) 0.2 mg/ml MMC for 5 min then cultured for 24 h after MMC removal; and 3) normal culture without any drug treatment. At 24 h, the anti-proliferative effect of MMC@MSNs-LDL in activated pterygium fibroblasts was similar to that of MMC (cell viability: 46.2 ± 5.5% vs 40.5 ± 1.1%, respectively, P = 0.349). Furthermore, the cytotoxicity of MMC@MSNs-LDL to normal fibroblasts with or without VEGF stimulation was significantly lower than that of traditional MMC (cell viability: 75.6 ± 4.4% vs 36.0 ± 1.5%, respectively, P < 0.001; 84.7 ± 5.5% vs 35.7 ± 1.3%, P < 0.001). The binding of fluorescently labeled MMC@MSNs-LDL in fibroblasts was assessed using confocal fluorescence microscopy. The uptake of targeted nanoparticles in fibroblasts was time dependent and saturated at 6 h. VEGF-activated pterygium fibroblasts showed more uptake of MMC@MSNs-LDL than normal fibroblasts with or without VEGF activation (both P < 0.001). Our data strongly suggest that MMC@MSNs-LDL had an effective antiproliferative role in activated pterygium fibroblasts, with reduced toxicity to normal fibroblasts compared to traditional application of MMC. LDL-mediated drug delivery might have great potential in the management of pterygium recurrence.

How to minimize pterygium recurrence rates: clinical perspectives

The main treatment for pterygium is surgical removal. However, pterygium surgery is concerned with high rates of postoperative recurrence. Predicting factors of recurrence are not fully understood, yet, but they probably depend on a multitude of patient-related, clinical, and/or surgical factors. Several adjuvant treatments have been proposed to reduce postoperative pterygium recurrence, including different antimetabolites, antiangiogenetic factors, and radiation therapy. The purpose of this review is to collect the current evidence regarding application and limits of different therapeutic approaches for preventing postoperative recurrence of pterygium, giving insights and perspectives for better management of this disease. In the light of the current evidence, pterygium surgery cannot disregard wound coverage with conjunctival autografting or rotational flap combined with adjuvant treatments. The rotational flap technique is associated with shorter surgical time rates and prevents graft displacement and necrosis, given its vascular pedicle. Amniotic membrane may still be reserved in case of great conjunctival defects or insufficient conjunctiva. Repeated subconjunctival antivascular endothelial growth factor injections can be considered as an effective and safe adjuvant treatment. Moreover, management of postoperative pain is crucial. Innovative treatment strategies will probably target different molecular pathways, considering recent findings regarding pterygium pathogenesis, to improve better understanding and develop universally shared guidelines. Great importance shall be dedicated to the identification of novel molecular biomarkers and favoring factors of recurrence, in order to achieve a customized surgical treatment for each patient and obtain maximal reduction of postoperative recurrence.

[Pterygium surgery by conjunctiva autograft with autologous blood fixation]

INTRODUCTION

Pterygium surgery is marked by the possibility of recurrences; one of the techniques which results in the least recurrences is conjunctival autograft. Fixation of the conjunctiva had traditionally been accomplished with sutures. In recent years, conjunctival grafting has also been performed with fibrin glue. Even more recently, with a view towards improving the quality of postoperative results, some surgeons recommend the use of autologous blood. This study aims to evaluate the stability of this latest method of graft fixation, while assessing its postoperative results.

METHODOLOGY

After diagnosis of pterygium, the patients underwent pterygium surgery with a conjunctival graft fixated with autologous blood. They were then monitored for one year, at 24h postoperatively, then seven days, 15 days, one month 3months, and every 3months thereafter.

RESULTS

In totl, 84.21 % of the patients demonstrated stable postoperative fixation; 5.26 % of patients experienced significant displacement of the graft. After one year of follow-up, 15.79 % of patients experienced recurrent pterygium. Recurrences were more frequent in younger patients and in patients with previous recurrence.

CONCLUSION

Pterygium surgery by conjunctival graft fixated with autologous blood is a safe surgery, with results similar to other pterygium surgery techniques with conjunctival autograft. However, this technique has the advantage less irritation, no risk of transmitting infection and lower cost.

Limbal Conjunctival Mini-Autografting for Preventing Recurrence after Pterygium Surgery

PURPOSE

The aim of the present study was to evaluate limbal conjunctival mini-autografting procedure based on recurrence rates following pterygium surgery.

METHODS

A total of 63 eyes (53 patients) with pterygium, of which 60 were primary and 3 were recurrent, underwent surgery for the removal of pterygia with limbal conjunctival mini-autograft. After the pterygium excision, the limbal portion of the graft was oriented and sutured to the limbus at the recipient bed with the epithelial surface upside. Recurrence was defined as fibrovascular tissue of more than 1 mm over the cornea in the area of previous pterygium excision. The mean follow-up period was 12.5 months (ranging between 6 and 29 months).

RESULTS

The time required for the surgery was approximately 30 minutes (range 20-40 minutes). Recurrence of pterygium was observed in 6 of 63 eyes (9.52%). No eyes with recurrent pterygium developed recurrence postoperatively. There were no severe complications during the operative and postoperative period. Most patients had temporary graft edema, lasting a few days after the operation, and they experienced and complained of foreign body sensations and epiphora.

CONCLUSIONS

Limbal conjunctival mini-autografting appears to be an effective procedure for pterygium surgery resulting in a low recurrence rate.

Sutureless, Glue-less Conjunctival Autograft versus Conjunctival Autograft with Sutures for Primary, Advanced Pterygia: An Interventional Pilot study

INTRODUCTION

Conjunctival Autograft (CAG) in pterygium surgery can be attached by sutures or fibrin glue or autologous in situ blood coagulum. Recurrence rate and other parameters related to pterygium surgery between CAG with sutures and autologous in situ blood coagulum have not been compared uniformly in advanced pterygia alone.

AIM

To compare and evaluate the outcome of sutureless, glue-less CAG with autologous in situ blood coagulum versus CAG with sutures for primary, advanced pterygium.

MATERIALS AND METHODS

Thirty eyes of 30 patients with primary, nasal, advanced, Grade 3 pterygia (as per Tan et al's., classification) were randomized into Group 1 (n=15) (sutureless, glue-less CAG with autologous in situ blood coagulum) and Group 2 (n=15) (conjunctival autograft with 8-0 vicryl sutures) as a pilot study. The outcome parameters evaluated were graft stability and symptoms of pain, foreign body sensation and watering at day 1, day 7, day 14, one month, three months and six months and recurrence at six months.

RESULTS

The mean age in the study was 44.77±13.74 years. Overall, Group 1 had better scores in symptom parameters than Group 2 (p<0.05). Graft stability was better in Group 2 (p<0.05). In Group 1, 3 (20%) patients had one side displacement and 3 (20%) patients had full displacement of graft. At six months, 4 (26.6%) patients in Group 1 had recurrence whereas in Group 2, 5 patients (33.3%) had recurrence (p=0.446).

CONCLUSION

In primary, advanced pterygia, sutureless, glue-less pterygium surgery with autologous in situ blood coagulum was better in symptom scores but graft stability was better in the suture group. Sutureless, glue-less pterygium surgery with autologous in situ blood coagulum was unpredictable in graft stability. There was no statistically significant difference in the recurrence rate between the two groups.

A randomized controlled prospective study to assess the role of subconjunctival bevacizumab in primary pterygium surgery in Indian patients

BACKGROUND

Pterygium is an ocular surface disorder with prevalence rates ranges from 0.3% to 29% in different parts of the world. Vascular endothelial growth factor (VEGF) has been detected in increased amounts in pterygium epithelium, compared with normal conjunctiva. Bevacizumab is a recombinant, humanized anti-VEGF antibody suggested as a possible adjunctive therapy for pterygium excision that appears to have a role in prevention of recurrence. We conducted this study to evaluate the role of subconjunctival bevacizumab in primary pterygium surgery in Indian patients.

METHODS

In this randomized prospective clinical study, the patients were randomized into two groups of 30 patients each. Study group received 1.25 mg/0.05 ml subconjunctival bevacizumab 1 week before pterygium surgery with conjunctival autograft. Control group received 1.25 mg (0.05 ml) subconjunctival normal saline 1 week prior to pterygium surgery with conjunctival autograft. Patients were followed up at day 1, day 7, 1 month and 3 months. The main outcome measures were morphology of pterygium after injection, intra-operative ease, recurrence of pterygia, and any complications.

RESULTS

After giving bevacizumab, there was statistically significant improvement in grade, color intensity, size of pterygium, and symptoms of patients. Intra-operatively, less bleeding was observed by the surgeon. No statistically significant difference regarding reduction in astigmatism, improvement of visual acuity, and complications were observed in two groups. Recurrence was noted in five patients (8.33%) in total study population at the end of 3 months. It was present in two patients (6.67%) in Group A and three patients (10%) in Group B.

CONCLUSION

Single preoperative administration of subconjunctival injection bevacizumab given 1 week before the pterygium excision with conjunctival autograft decreases the vascularity of newly formed blood vessels, hence may decrease recurrence rate though not in our study.

Bare sclera resection followed by mitomycin C and/or autograft limbus conjunctiva in the surgery for pterygium: a Meta-analysis

AIM

To evaluate the recurrence and complications after bare sclera resection (BSR) combined with mitomycin C (MMC) treatment and/or autograft limbus conjunctiva (ALC) in the surgery for pterygium.

METHODS

Meta-analysis was used to evaluate the differences in patient outcomes between BSR of pterygium with or without MMC and/or ALC. All included studies were randomized trials of patients with pterygium who received BSR followed by MMC and/or ALC in the surgery. The recurrence of pterygium and other complications resulting from different treatments were extracted for analysis.

RESULTS

Thirteen studies met the inclusion criteria. The recurrence of pterygium with intraoperative (IO) MMC was higher than that with ALC (OR=2.38, 95% confidence interval 1.45-3.91, I (2)=29%). Postoperative MMC resulted in an incidence of recurrence similar to that of ALC (OR=0.66, 95% confidence interval 0.30-1.42, I (2)=0%), and IO MMC treatment in combination with ALC produced similar patient outcomes to ALC alone (OR=0.41, 95% confidence interval 0.16-1.01, I (2)=16%). Other complications such as punctate epitheliopathy, scleral thinning and ischemia, irritation and persistent epithelium defect, were more common in patients in the MMC group as compared to those treated with ALC.

CONCLUSION

The recurrence of pterygium with BSR followed by ALC is lower than that of BSR followed by MMC, and the incidence of other complications is lower. While ALC is a more effective strategy for treating pterygium, the quality of the ALC transplant should be considered when the patient has a history of glaucoma.

Repeated bevacizumab injections versus mitomycin C in rotational conjunctival flap for prevention of pterygium recurrence

Aims:

To evaluate the efficacy of repeated bevacizumab injection in rotational conjunctival flap surgery versus rotational conjunctival flap with adjunctive mitomycin C (MMC) or rotational conjunctival flap alone.

Materials and Methods:

Ninety eyes of 90 patients who underwent primary pterygium surgery with rotational flap were evaluated. Patients were randomly assigned to undergo conjunctival rotational flap alone (Group A) or conjunctival rotational flap with either 0.02% MMC application (Group B) or adjunctive subconjunctival 2.5 mg/0.1 ml bevacizumab injection (Group C). Each group consisted of 30 eyes. Recurrence rates at 9 months were evaluated.

Results:

There were no statistically significant differences in mean size of the pterygium across the limbus in terms of length (P > 0.5). The recurrence rates at 9 months were 26.6% (n = 8) in Group A, 13.3% (n = 4) in Group B, and 10% (n = 3) in Group C. The recurrence rates in Group B and C were significantly lower than in Group A (P =0.1806). The recurrence rates were similar in Group B and C (P > 0.05).

Conclusions:

Subconjunctival bevacizumab injection may decrease the recurrence rate of primary pterygium surgery with rotational conjunctival flap. Further studies with a larger population and longer follow-up period are needed to supplement this study.

Mitomycin C-associated scleral stromalysis after pterygium surgery

PURPOSE

To describe complications after use of mitomycin C (MMC) as a surgical adjuvant in pterygium surgery.

METHODS

This is a retrospective chart review of patients presenting to a tertiary referral center over a 7-year period with a diagnosis of scleral stromalysis after previous pterygium removal.

RESULTS

Sixteen eyes of 15 patients were identified with scleral stromalysis after pterygium surgery with the use of adjuvant MMC. Three eyes were excluded because of insufficient chart information or previous beta-irradiation treatment. Twelve of 13 eyes underwent surgical treatment for primary pterygium, and 1 eye was treated for recurrent pterygium. Time from initial pterygium surgery to presentation ranged from 1 month to 10 years. Dosage and routes of MMC administration included 0.02% intraoperative application to either the bare sclera or Tenon capsule with a range of 30 seconds to 3 minutes or topical administration 4 times daily for 2 weeks. In some cases, the dose and route of MMC administration were unknown. Four of 13 patients (31%) required a scleral patch graft with 1 patient (8%) requiring multiple patch grafts.

CONCLUSIONS

Use of MMC in various forms and concentrations can cause devastating complications including scleral stromalysis. Scleral stromalysis may present anywhere from months to years after application. We suggest that MMC should be used with extreme caution when used as a surgical adjuvant for pterygium surgery. Patients must be urged to continue long-term follow-up after MMC use because of the potential for future anterior segment complications.

Twelve-Year Outcomes of Pterygium Excision with Conjunctival Autograft versus Intraoperative Mitomycin C in Double-Head Pterygium Surgery

Purpose. The study aims to compare the long-term outcome of conjunctival autograft (CAU) and mitomycin C (MMC) in double-head pterygium surgery. Methods. This is a follow-up study of a comparative interventional trial. Thirty-nine eyes of the 36 patients with double-head pterygium excision in the original study 12 years ago were recruited for clinical assessment. Seven out of the 36 patients were lost. In the original study, each eye with double-head pterygium was randomized to have pterygium excision with CAU on one "head" (temporal or nasal) and MMC on the other "head." All patients were invited for clinical assessment for conjunctival bed status and the presence of pterygium recurrence in the current study. Results. There was no significant difference between the size, morphology, and type of pterygium among the two treatment groups. The recurrence rate of CAU group and MMC group 12 years after excision was 6.3% and 28.1%, respectively (P = 0.020). Among eyes without recurrence, the conjunctival bed was graded higher in the MMC group than the CAU group (P = 0.024). Conclusion. The use of conjunctival autograft has a significantly lower long-term recurrence rate than mitomycin C in double-head pterygium surgery.

Analysis of recurrence patterns following pterygium surgery with conjunctival autografts

The aim of this article is to evaluate and classify pathogenetic origins based on morphologic reproliferative patterns in patients who underwent pterygium excision with a conjunctival autograft. In this retrospective, observational case series, a total of 116 eyes of 116 patients with pterygium who underwent pterygium excision with a conjunctival autograft between February 2009 and May 2011 were reviewed. Using consecutively recorded photographs, we evaluated preoperative morphologic severity, postoperative complications, recurrences, and growth patterns. The regrowth of fibrovascular tissue was observed in 14 of our study cases (12.1%). Of these, 5 cases (4.3%) showed clinically significant recurrences. We observed 3 different morphologic patterns of recurrence: regrowth over the epithelial defect; transformation of the conjunctival graft into the pterygial tissue; and regrowth from unexcised pterygial tissue. Each recurrence pattern showed characteristic fibrovascular growth, the origin of this regrowth, and grade of severity. In 25 cases (21.6%), postoperative complications were observed. Of the analyzed variables, age <40 years (P = 0.019; odds ratio [OR], 5.82; 95% confidence interval [CI], 1.34-25.28) and the presence of postoperative complications (P = 0.008; OR, 6.32; 95% CI, 1.62-24.58) were statistically significant in multivariate analyses using logistic regression. The use of conjunctival autografts for pterygium surgery is effective, but recurrences are observed in some cases exhibiting unique pathogenic patterns according to their origin. A complete understanding of the pathogenesis of these lesions based on their morphologic regrowth pattern will help to prevent recurrences in patients who undergo pterygium surgery.

Comparison of Two Techniques for the Treatment of Recurrent Pterygium: Amniotic Membrane vs Conjunctival Autograft Combined with Mitomycin C

PURPOSE

To compare the results of amniotic membrane transplantation (AMT) combined with mitomycin C (MMC) to the results of free conjunctival autograft (CA) combined with MMC for the treatment of patients with recurrent pterygium.

METHODS

In this prospective study, 60 eyes of 55 patients with recurrent pterygium were included and randomly assigned into group I (n = 30) who underwent AMT combined with MMC (AMT-MMC) and group II (n = 30) who underwent CA combined with MMC (CA-MMC). During a mean follow-up of 27.2 ± 20.8 months, recurrence of pterygium, change in uncorrected visual acuity and complications (including pain, corneal, conjunctival or scleral changes) were analyzed and were compared between groups.

RESULTS

Five eyes of 5 patients were lost to follow-up and were removed from analysis. The mean age (p = 0.274), the mean follow-up (p = 0.063), the number of prior pterygium excision surgeries (p = 0.641) and the mean preoperative visual acuity (p = 0.959) were similar in both groups. Recurrence was seen in 2 eyes (8%) in AMT-MMC group and 4 patients (13.3%) in CA-MMC group (p = 0.531). Postoperative visual acuity (p = 0.237), change in visual acuity (p = 0.525), severe pain (p = 0.531) and epithelial defect lasting more than 5 days (p = 0.510) were similar in both groups.

CONCLUSIONS

Amniotic membrane combined with MMC has similar recurrence rate to CA combined with MMC, in patients with recurrent pterygium. Similar outcomes and complication rates make AMT-MMC a promising method for the treatment of recurrent pterygium cases.

Conjunctival autograft in primary and recurrent pterygium: a study

AIM

Investigate the efficiency of limbal conjunctival autograft in primary and recurrent pterygium. (2) To report the incidence of recurrence after primary and recurrent pterygium surgery using limbal conjunctival autograft.

MATERIAL AND METHODS

It is a prospective study conducted at Department of Ophthalmology, Basaveshwar Teaching and General Hospital, Gulbarga Karnataka, India for a period of 1 year (2007 to 2008) 100 patients were operated of which 6 were recurrent pterygium and the remaining were fleshy pterygium. All patients were in age group 20 to 60 and above.

RESULTS

In this study 7% cases were in age group 20 to 30 years, 22% 31 to 40 years, 30% 41 to 50 years, 24% 51 to 60 years and 17% 60 and above. (2) Depending on occupation high incidence is seen in outdoor patients i.e., 80%, indoor 20%. (3) Depending on location, 50% nasal, 30% temporal, bilateral 20%. (4) Laterality - Right eye 52%, left eye 38%, bilateral 10%. (5) Recurrence - More common in younger patients < 40 age 6 patients developed recurrence.

CONCLUSION

Autogenous conjunctival grafting is a safe, uncomplicated, quick procedure and does not involve loss of tissue and prevents recurrence of pterygium. It also reduces the risk of granuloma formation, scleral thinning and necrosis.

Cosmetic regional conjunctivectomy with postoperative mitomycin C application with or without bevacizumab injection

PURPOSE

To evaluate the complications of cosmetic wide conjunctivectomy and postoperative topical mitomycin C application with or without bevacizumab injection.

DESIGN

Cross-sectional cohort study.

METHODS

Medical records of 1713 consecutive subjects who received cosmetic wide conjunctivectomy plus postoperative topical mitomycin C by a single surgeon at a single center with or without bevacizumab injection from November 2007 to May 2010 were reviewed. A telephone interview was conducted with 557 of the subjects who could be contacted and agreed to participate in the study. Complications, recurrences, and patient satisfaction were the main outcome measures.

RESULTS

A total of 1713 consecutive patients underwent cosmetic wide conjunctivectomy to treat conjunctival hyperemia. Ocular diagnoses in the medical records at the time of surgery included hyperemia (8.8%), pterygium (14.0%), dry eye (3.5%), pinguecula (1.5%), and conjunctival disorder (23.3%). For the remaining 48.9% of subjects, the diagnosis was not mentioned, or the surgical procedure was for cosmetic purposes. Patients were followed for a mean of 10.9 months (range, 0-30.3 months). The overall complication rate was 82.9%, of which 55.6% were considered severe (fibrovascular conjunctival tissue proliferation, 43.8%; scleral thinning, 4.4%; scleral thinning with calcified plaques, 6.2%; intraocular pressure elevation, 13.1%; diplopia, 3.6%; and recurrence of hyperemic conjunctiva, 28.1%).

CONCLUSIONS

Cosmetic wide conjunctivectomy plus postoperative topical mitomycin C with or without bevacizumab injection has a high rate of complications and reoperations.

Ten-year results of a randomized controlled trial comparing 0.02% mitomycin C and limbal conjunctival autograft in pterygium surgery

OBJECTIVE

To compare the long-term outcome of pterygium surgery and the long-term effect on endothelial counts after mitomycin C (MMC) or limbal conjunctival autograft (LCAU) in pterygium surgery.

DESIGN

We performed a 10-year follow-up study of a randomized controlled trial.

PARTICIPANTS

A total of 115 eyes of 114 patients with primary pterygium were treated with intraoperative MMC (n = 63) or LCAU transplants (n = 52). A total of 76 patients completed the current 10-year long-term follow-up (47 in the MMC group, 29 in the LCAU group).

METHODS

This is a follow-up study of a randomized controlled trial of a cohort of 114 patients in 2 groups that was performed at the Prince of Wales Hospital 10 years ago: group 1, intraoperative 0.02% MMC for 5 minutes; group 2, LCAU. Consecutive patients enrolled in the original study (recruitment began in February 2001) were invited back for a detailed clinical examination to document the long-term outcome of both surgical groups.

MAIN OUTCOME MEASURES

The main outcome measures included the recurrence rate, residual conjunctival bed status, complications, and corneal endothelial cell density (ECD) differences.

RESULTS

A total of 115 eyes of 114 patients were enrolled and randomized in our previous study. For the current study, 76 of the 114 patients (47 in the MMC group, 29 in the LCAU group) were contacted, whereas 18 patients were lost to follow-up and 20 patients had died. The mean follow-up period was 138 ± 2 months in the MMC group and 137 ± 2 months in the LCAU group. Twelve of 47 patients (25.5%) in the original MMC group and 2 of 29 patients (6.9%) in the LCAU group had recurrent pterygium (P = 0.021). The mean ECD was 2,39 2 ± 342 cells/mm(2) in the MMC group and 2,390 ± 388 cells/mm(2) in the LCAU group (P = 0.978). There was no significant difference in the ECD between the operated eyes and the fellow eyes in both groups (P = 0.926 MMC, P = 0.468 LCAU). No other significant ocular complications were observed in either group at the 10-year postoperative follow-up.

CONCLUSIONS

Limbal conjunctival autograft was more effective than intraoperative MMC in minimizing pterygium recurrence at the 10-year follow-up. Treatment with intraoperative MMC was not associated with long-term corneal endothelial cell loss.

Efficacy of preoperative injection versus intraoperative application of mitomycin in recurrent pterygium surgery

Purpose:

To determine the efficacy of preoperative subconjunctival injection of mitomycin C a day before surgery in the management of recurrent pterygium.

Materials and Methods:

Randomized comparative case series. Fifty eyes with recurrent pterygium were randomly divided into two groups; the mitomycin injection group (25 eyes) and the mitomycin application group (25 eyes). The mitomycin injection group underwent preoperative subconjunctival injection of mitomycin C in low dose (0.1 ml of 0.15 mg/ml) a day before bare sclera pterygium excision surgery. The mitomycin application group underwent bare sclera pterygium excision with topical application of mitomycin C (same concentration).

Results:

At one year of follow-up, 24 of 25 eyes (96%) in the mitomycin injection group and 23 of 25 (92%) eyes in the mitomycin application group were free of recurrence. The difference was statistically insignificant. As regards postoperative complications, delayed epithelization (more than two weeks) occurred in two eyes (8%) in the mitomycin injection group and in one eye (4%) in the mitomycin application group. Scleral thinning was reported in one eye (4%) in the mitomycin application group which resolved within three weeks after surgery, no other serious postoperative complications were reported.

Conclusion:

Preoperative subconjunctival injection of mitomycin C in low dose (0.1 ml of 0.15 mg/ml) a day before pterygium surgery is a simple and effective modality for management of recurrent pterygium. It has the advantage of low recurrence and complications’ rate.

Intraoperative mitomycin C versus autologous conjunctival autograft in surgery of primary pterygium with four-year follow-up

PURPOSE

To compare the 4-year outcome of primary pterygium excision using intraoperative mitomycin C (MMC) with suturing a free conjunctival autograft (CA).

METHODS

A total of 115 eyes with nasal primary pterygium of 115 patients were included in the study. After randomization into two groups, the eyes were operated on by a single surgeon (GK). After excision of the pterygium, 56 eyes received 0.04% MMC intraoperatively on the bare sclera for 3 min and 59 eyes received a free CA sutured using 7-0 Vicryl. Postoperative follow-up was 4 years. Main outcome measures were recurrences, re-operations, surgery time, complications, visual acuity and astigmatism. Statistical evaluation was performed with the chi-squared test.

RESULTS

The recurrence rate was 38% in the MMC group and 15% in the CA group (p < 0.05). The re-operation rate of the recurrences was 53% in the MMC group and 29% in the CA group. Average surgery time was 13 minutes (range: 6-22 min) in the MMC group and 26 min (range: 18-32 min) in the CA group (p < 0.01). There was no significant change in best-corrected visual acuity and astigmatism. One major complication occurred in each group. The most frequently observed complication was delayed epithelial healing (40%) and mild scleral thinning (20%) in the MMC group and suture-related inflammation in the CA group (10%).

CONCLUSION

Pterygium surgery including free autologous conjunctival grafting is associated with fewer recurrences, re-operations and complications than using the bare sclera technique together with single-dose intraoperative MMC.

A retrospective comparison of surgical removal and subsequent CO2 laser ablation versus topical administration of mitomycin C as therapy for equine corneolimbal squamous cell carcinoma

OBJECTIVE

  To compare the complications and nonrecurrence rate following topical mitomycin C (MMC) therapy vs. CO(2) laser ablation for treating equine corneolimbal squamous cell carcinoma (SCC).

STUDY DESIGN

  Retrospective study.

SAMPLE POPULATION

  Twenty-five horses with corneolimbal SCC.

PROCEDURES

  Medical records of horses undergoing surgical tumor resection followed by either topical MMC therapy (0.04%) or CO(2) laser ablation between the years of 2004 and 2010 were reviewed. Recurrence and complications were compared between groups and within MMC subgroups defined by the time at which treatment was initiated relative to surgery.

RESULTS

  Therapy with topical MMC resulted in a nonrecurrence rate comparable to that achieved with CO(2) laser ablation (82.4% vs. 85.7%, respectively). Initiation of MMC following epithelialization of the surgical site a mean of 15 days postoperatively did not result in increased recurrence rates relative to treatment in the immediate postoperative period. Vision- or globe-threatening complications tended to occur with greater frequency in horses receiving topical MMC in the immediate postoperative period (5 of 6 major complications) relative to following epithelialization of the surgical site (1 of 6 major complications).

CONCLUSIONS

  Horses receiving adjunctive topical MMC therapy were no more likely to experience tumor recurrence than were horses undergoing CO(2) laser ablation in the horses in this study. Initiation of two to three rounds of MMC following epithelialization of the surgical site results in fewer major complications and achieves comparable disease resolution relative to treatment in the immediate postoperative period.

Randomized trial of pterygium surgery with mitomycin C application using conjunctival autograft versus conjunctival-limbal autograft

PURPOSE

To compare the outcomes of free conjunctival autograft (CAU) versus conjunctival-limbal autograft (CLAU) in the prevention of recurrence after pterygium surgery with adjunctive mitomycin C application in patients with primary or recurrent pterygia.

DESIGN

Prospective, randomized study.

PARTICIPANTS AND CONTROLS

Eighty-seven eyes of 86 patients with primary or recurrent nasal pterygia were included.

METHODS

All eyes underwent pterygium excision followed by removal of subconjunctival fibrovascular tissue and application of 0.02% mitomycin C for 3 minutes. The eyes then were assigned randomly to receive either CAU (44 eyes) or CLAU (43 eyes).

MAIN OUTCOME MEASURES

Rate of conjunctival or corneal recurrence of pterygium after surgery.

RESULTS

A follow-up of at least 12 months (mean, 14 ± 2.2 months) was achieved in 78 eyes of 78 patients, including 39 eyes in the CAU group (31 primary and 8 recurrent pterygia) and 39 eyes in the CLAU group (33 primary and 6 recurrent pterygia). After surgery, no eye in the CLAU group developed pterygium recurrence; however, recurrence was seen in 2 eyes (5.1%) in the CAU group, including 1 of 31 patients (3.2%) with primary pterygia and 1 of 8 patients (12.5%) with recurrent pterygia. There was no statistically significant difference in recurrence rates between the 2 groups or in the primary and recurrent subgroups. In the CLAU group, a localized pannus formation at the donor site of the limbal graft was noted in 5 eyes (12.8%), with the appearance of pseudopterygium in 1 eye.

CONCLUSIONS

There was no significant difference in recurrence rates of pterygium after surgery with mitomycin C application between the CAU and CLAU groups, more remarkably in primary cases. Limbal damage was seen in some eyes with CLAU.

Preoperative subpterygial mitomycin C injection versus limbal conjunctival autograft transplantation for prevention of pterygium recurrence

PURPOSE

To evaluate postoperative outcome and recurrence rate after primary pterygium excision using preoperative Mitomycin C (MMC) injection versus limbal conjunctival autograft transplantation (LCAT).

METHODS

Ninety-one eyes with primary pterygium were divided into 2 groups. Group A eyes (included 48 eyes) were operated upon with pterygium excision 1 month after subpterygial injection of MMC 0.015%. Group B eyes (included 43 eyes) were operated upon with pterygium excision followed by LCAT technique. Pterygium regrowth over the cornea for 1 mm or more was considered as a recurrence.

RESULTS

The follow-up period was 24 months. In group A, reported recurrence was found in 2 (4.2%) eyes with a complication rate of 16.80%. While in group B, recurrence was reported in 4 (9.3%) eyes with a complication rate of 11.63%. No serious postoperative complications were reported. There was no statistically significant difference between the 2 groups regarding the recurrence rate as well as the complication rate.

CONCLUSION

Both techniques used in the current study proved to be effective in reducing the recurrence rate after excision of primary nasal pterygium with minimal postoperative complications. Preoperative MMC injection was technically easier, with shorter operative and preservation of healthy conjunctiva. However, LCAT is a one-stage procedure and independent from adjunctive pharmacological or radiation therapies with their hazards.

Comparison of limbal-conjunctival autograft and intraoperative 0.02% mitomycin-C for treatment of primary pterygium

PURPOSE

To compare the outcomes of use of intraoperative 0.02% mitomycin-C (MMC) and limbal-conjunctival autograft (LCAG) for treatment of primary pterygia.

MATERIAL AND METHOD

One hundred and twelve eyes of eighty patients with primary pterygia were randomly treated either by intraoperative 0.02% MMC for 5 min or LCAG. Recurrence (defined as fibrovascular tissue invading the cornea >1.5 mm) and complications were evaluated.

RESULTS

Fifty-two eyes were included in the MMC group and sixty in the LCAG group. Recurrence occurred in three eyes (5.76%) in the MMC group and in two eyes (3.33%) in the LCAG group. This difference between recurrence in the two groups was not statistically significant (P > 0.05). Incidence of complications such as conjunctival cysts, symblephara, conjunctival hyperemia, and subconjunctival hemorrhage was similar in both groups (P > 0.05) whereas corneal epithelial defects (CED), irritation, lacrimation, and photophobia were more common in the MMC group (P < 0.05).

CONCLUSION

Simple excision then intraoperative use of 0.02% (MMC) for 5 min or LCAG are similarly successful in the treatment of primary pterygia. Some complications, for example irritation, lacrimation, photophobia, and CED are more common when simple excision is followed by MMC.

Current concepts and techniques in pterygium treatment

PURPOSE OF REVIEW

Pterygium is a common ocular disorder in many parts of the world. At present, there is a wide variety of surgical methods but very few clinical guidelines on the optimal treatment of primary or recurrent pterygium. The purpose of this review is to summarize the more recent and relevant studies on pterygium treatment.

RECENT FINDINGS

The primary aim is to excise the pterygium and prevent its recurrence. 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 consensus regarding the ideal treatment for the disease. Comparability between studies is also hampered by the various definitions of pterygium recurrence.

SUMMARY

This article reviews the current concepts and techniques used for the treatment of pterygium. Conjunctival autografting and mitomycin C application are the most commonly used methods for preventing recurrences. The use of mitomycin C and beta-irradiation should be used judiciously because of the potential long-term risk of sight-threatening complications. Additional clinical trials should be performed to evaluate the relative efficacies and long-term safety of the various treatment modalities.

Uses and complications of mitomycin C in ophthalmology

Mitomycin C is a chemotherapeutic agent that acts by inhibiting DNA synthesis. Its use and application in ophthalmology has been increasing in recent years because of its modulatory effects on wound healing. Current applications include pterygium surgery, glaucoma surgery, corneal refractive surgery, cicatricial eye disease, conjunctival neoplasia and allergic eye disease. Although it has been used successfully in these conditions, it has also been associated with significant complications. This article reviews the current trends and uses of mitomycin C in the eye and its reported complications.

Novel clinical application of sterilized, freeze-dried amniotic membrane to treat patients with pterygium

PURPOSE

To evaluate the use of sterilized, freeze-dried amniotic membrane (FD-AM) transplantation for pterygium surgery.

METHODS

This study involved a prospective, non-comparative, interventional case series. Thirteen eyes of 13 patients with primary (eight eyes) or recurrent (five eyes) pterygium were studied. After excision of the pterygium fibrous tissues and application of intraoperative use of mitomycin-C, sterilized FD-AM was sutured over the bare scleral defect. The integrity of the FD-AM graft, epithelialization over the FD-AM, pterygium recurrence and postoperative complications were evaluated.

RESULTS

Postoperatively, the FD-AM was well retained in all patients, and complete epithelialization over the transplanted membrane was achieved within 1-2 weeks. All patients demonstrated early resolution of ocular inflammation and there was no recurrence of pterygium in any of the treated patients during the mean follow-up of 13.9 +/- 6.0 months. No ocular complications were noted following transplantation.

CONCLUSION

Sterilized FD-AM showed excellent biocompatibility on the human ocular surface. This novel and promising biomaterial may be a useful alternative to conjunctival grafting in the treatment of pterygium.

Mitomycin: clinical applications in ophthalmic practice

Mitomycin (mitomycin C; MMC) is an antibiotic isolated from Streptomyces caespitosus. The drug is a bioreductive alkylating agent that undergoes metabolic reductive activation, and has various oxygen tension-dependent cytotoxic effects on cells, including the cross-linking of DNA. It is widely used systemically for the treatment of malignancies, and has gained popularity as topical adjunctive therapy in ocular and adnexal surgery over the past 2 decades. In ophthalmic medicine, it is principally used to inhibit the wound healing response and reduce scarring of surgically fashioned ostia. Hence, it has been used as adjunctive therapy in various ocular surgeries, such as glaucoma filtering surgeries, dacryocystorhinostomy, corneal refractive surgery and surgeries for ocular cicatrisation. In addition, it has been used as an adjunct in the surgical management of pterygia, ocular surface squamous neoplasia, primary acquired melanosis with atypia and conjunctival melanoma. In many of these surgeries and ophthalmic pathologies, MMC showed a significant beneficial effect.