Measures for preventing recurrence after pterygium surgery

Pterygium surgery by double-sliding flaps procedure: Comparison between primary and recurrent pterygia

Purpose

This study aimed to evaluate the surgical outcomes of pterygial excision for primary and recurrent pterygia by a single method of pterygia excision combined with two conjunctival flaps.

Methods

This retrospective study divided 193 cases of pterygium into the primary (140 cases) and recurrent (53 cases) pterygium groups. Following double-sliding conjunctival transposition flap operation and surgical excision of the pterygium, the success and recurrence rates of pterygial surgery were assessed based on visual acuity and corneal and total astigmatism during follow-up at least 6 months.

Results

Both primary and recurrent pterygium groups showed significant improvements in visual acuity and astigmatism (corneal and total) between before and after this procedure. Total astigmatism and success rate of primary pterygium were significantly better than those for recurrent pterygium. Two cases (1.4%) of primary pterygium and four cases (7.5%) of recurrent pterygium developed recurrence, corresponding to a rate of 3.1% (6/193 cases). The success rates significantly make a difference between primary and recurrent groups but did not differ significantly between the first recurrent and over twice recurrent pterygium. However, visual acuity, cornea, and total astigmatism improved significantly after surgery in first recurrent group but not in over twice recurrent group.

Conclusion

The double-sliding conjunctival flaps surgery appeared to be a useful method, with a better success rate and lower pterygial recurrence in pterygium surgery. Especially, when pterygium is larger or recurrent type, this technique can be easily covered the bare sclera, as compared to any transposition conjunctival flap operation.

The Efficiency of Limbal Conjunctival Autografting in Pterygium Surgery

PURPOSE

To investigate the efficiency of limbal conjunctival autografting technique in pterygium surgery.

METHODS

Eighty-four eyes of 68 patients with pterygium were treated by simple excision technique and 29 eyes of 24 patients with pterygium were treated by limbal conjunctival autografting technique. The definition of recurrence was fibrovascular tissue over the limbus onto the cornea in the area of previous pterygium excision.

RESULTS

The ages of the patients were between 25 and 88. The follow-up periods ranged from 6 to 25 months. The patients treated by simple excision technique were followed up for 6 to 25 (average 15+/-6) months and the patients treated by limbal conjunctival auto-grafting technique were followed up for 7 to 24 (average 17+/-5) months. The recurrence rates were 27% (23 eyes) and 7% (2 eyes), respectively. There was a statistically significant difference in the recurrence rate between the patients who underwent simple excision and those who underwent limbal conjunctival autografting (p=0.016).

CONCLUSIONS

Limbal conjunctival autografting is an effective surgical technique for the treatment of pterygium. It has a low recurrence rate when compared with the simple excision technique.

Minimally Invasive Pterygium Surgery: A New Approach for Prevention of Recurrence

Purpose

To introduce a novel approach for pterygium excision, to report recurrence rates, and to compare with conjunctival autografting. DESIGN. A comparative, prospective clinical case series design was used.

Methods

The study population consisted of 155 patients with unilateral primary or recurrent pterygia. All patients underwent pterygium excision, either by conventional conjunctival autografting (Group A) or by the minimally invasive pterygium excision (MIPE) technique (Group B). The new technique involves making a limbal incision of the conjunctiva through the body of pterygium, removing the head of the pterygium by blunt dissection, keeping the adjacent Tenon capsule intact, and performing a small conjunctival autograft to cover the epithelial defect. The recurrence rate of each technique was compared statistically.

Results

There were 84 patients in Group A and 71 patients in Group B. The recurrence rates were 18% at 1 year after surgery in the conjunctival autografting technique and 4.2% in the MIPE technique. The MIPE technique had significantly lower recurrence rates compared with conjunctival autografting technique (p<0.0001).

Conclusions

The MIPE technique had lower recurrence rate and fewer postoperative complications than the conjunctival autografting technique. Preserving the Tenon capsule and minimizing conjunctival excision in pterygium surgery does not appear to increase the recurrence rate in the 1-year period. However, the effectiveness of this technique in preventing recurrences needs to be proven with more than 1-year results, which we plan to report in the future.

Effect of transverse conjunctival advancement flap surgery for primary pterygium

OBJECTIVE

To introduce a new surgical technique, transverse conjunctival advancement flap, and to evaluate the efficacy and safety of the technique in primary pterygium surgery.

DESIGN

Retrospective, noncomparative, interventional case-series analysis.

PARTICIPANTS

Sixty-three eyes of 63 patients.

METHODS

The patients with primary pterygium were treated with transverse conjunctival advancement flap technique. After excision of the pterygium head and the perilimbal part of the pterygium body (within 2 mm from the limbus), the bare sclera was covered with the transverse conjunctival advancement flap using the conjunctiva of the remaining posterior part of the pterygium body. The patients were followed up for more than 6 months.

RESULTS

The mean age of patients was 64.9 ± 8.7 years (range 43-85 years), and the mean follow-up period was 9.8 ± 3.9 months (range 6-18 months). In all cases, surgery did not exceed 20 minutes. During the follow-up period, recurrence of the pterygium occurred in 1 (1.5%) of the 63 cases, with recurrence only in the conjunctiva. There was no occurrence of serious complications.

CONCLUSIONS

The transverse conjunctival advancement flap technique may be considered a safe and effective method, with a low rate of pterygium recurrence, after primary pterygium excision.

Pterygium surgery using the principle of contact inhibition: results of 13 years' experience

Purpose

To report a technique to prevent pterygium recurrence using the principle of contact inhibition.

Methods

Two hundred and fifteen patients (232 eyes; average age, 64.1 years) with primary pterygia who underwent pterygium surgery at the Hara Eye Hospital between 1999 and 2012. We retrospectively evaluated the patients who underwent the following procedure to prevent pterygium recurrence. The surface conjunctiva on the pterygium body was not removed. After removing the pterygium body, by placing a narrow pedicle autoconjunctival flap along the corneal limbus and tying it tightly to the front area of the residual conjunctiva, there is no room for the active residual tissue to proliferate, thus preventing a recurrence by contact inhibition. The key factor is conjunctival suturing, which establishes face-to-face contact of both areas of cut conjunctival tissue. Mitomycin C is applied locally for 3 min intraoperatively and 5 days postoperatively. The main outcome measure was the prevention of pterygium recurrence using this technique.

Results

By the end of the average follow-up of 5 years 4 months, three eyes (1.3%) had a recurrence. Among the 232 eyes, 23 eyes had large pterygia extending to the pupillary area. Using the surgical technique, there were no recurrences. No specific characteristic of the recurrence was found in association with the eye, sex, and preoperative grade.

Conclusions

This surgery has three relevant features: (1) reconfirmation of the effect of contact inhibition, (2) the anatomic structure of the conjunctival sac scarcely changes postoperatively, because the surface conjunctiva of the pterygium body is not removed, and (3) a low recurrence rate.

Electronic supplementary material

The online version of this article (doi:10.1007/s00417-016-3558-9) contains supplementary material, which is available to authorized users.

Conjunctival mini-flap operation for restrictive strabismus after periocular surgery

PURPOSE

To investigate the effect of conjunctival mini-flap operation to treat restrictive strabismus in patients with diplopia caused by conjunctival adhesion and hyperplasia after periocular surgery.

DESIGN

Case series study.

METHODS

Eleven patients with diplopia and restrictive strabismus attributable to conjunctival dysplasia after periocular surgery underwent a conjunctival mini-flap surgery without a muscle operation and were followed-up at 1, 3, and 6 months after surgery. The Hess screen test, binocular single vision field with Goldmann perimetry, and extraocular muscle movement were analyzed pre- and post-operatively. Patient satisfaction with the cosmetic results of conjunctival mini-flap operation was also investigated.

RESULTS

The mean preoperative alignment deviation in primary position was 10.4 ± 5.6 prism diopters (PD). Diplopia in the primary position was resolved in 95% of the patients. The mean postoperative deviation was 1.36 ± 2.34 PD at the primary position. No significant complications or recurrences were noted after mean 9.5 ± 4.2 months follow-up.

CONCLUSION

Conjunctival mini-flap operation is an effective and safe surgical technique for treating patients with diplopia and restrictive strabismus following periocular surgery.

The use of mitomycin C with autologous limbal-conjunctival autograft transplantation for management of recurrent pterygium

PURPOSE

The purpose of this study is to evaluate and compare recurrence rates upon using mitomycin C (MMC) with limbal-conjunctival autograft for treating recurrent pterygia.

METHODOLOGY

An interventional, prospective, comparative clinical study was performed in 30 eyes (26 patients) with recurrent pterygia, allocated into two groups: Group A (19 eyes) operated by pterygium excision and limbal-conjunctival autograft transplantation (L-CAT) without MMC and Group B (20 eyes) operated with injection of 0.1 mL of MMC 0.15 mg/mL 1 month before L-CAT surgery. Exclusion criteria included patients with symblepharon, cicatricial conjunctival diseases, limbal stem cell deficiency, and other intraocular diseases.

RESULTS

A total of four cases of recurrences for Group A (P = 0.012) and one case of recurrence for Group B (P < 0.001) were recorded.

CONCLUSIONS

Preoperative injection of MMC in low dose and concentration improves the results of L-CAT in recurrent pterygium.

Photorefractive keratectomy with mitomycin C versus LASIK in custom surgeries for myopia: a bilateral prospective randomized clinical trial

PURPOSE

To compare photorefractive keratectomy (PRK) with prophylactic use of mitomycin C (MMC) and LASIK in custom surgeries for myopic astigmatism.

METHODS

Eighty-eight eyes of 44 patients with a minimum estimated ablation depth of 50 microm were randomized to receive PRK with MMC 0.002% for 1 minute in one eye and LASIK in the fellow eye. Uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), cycloplegic refraction, slit-lamp microscopy, contrast sensitivity, specular microscopy, aberrometry, and a subjective questionnaire were evaluated. Forty-two patients completed 6-month follow-up.

RESULTS

Mean spherical equivalent refraction error before surgery and mean ablation depth were -3.99+/-1.20 diopters (D) and 73.09+/-14.55 microm in LASIK eyes, and -3.85+/-1.12 D and 70.7+/-14.07 microm in PRK with MMC eyes, respectively. Uncorrected visual acuity was significantly better in PRK with MMC eyes 3 months (P=.04) and 6 months (P=.01) after surgery. Best spectacle-corrected visual acuity and spherical equivalent refraction did not differ significantly in the groups during follow-up (P>.05). Significant haze was not observed in any PRK with MMC eye. Mean higher order aberration was lower in PRK with MMC eyes postoperatively compared with LASIK eyes (P=.01). Better contrast sensitivity was observed in PRK with MMC eyes than LASIK eyes (P<.05). The endothelial cell count did not differ significantly between groups (P=.65). In terms of visual satisfaction, PRK with MMC eyes were better rated.

CONCLUSIONS

Photorefractive keratectomy with MMC appears to be more effective than LASIK in custom surgery for moderate myopia. During 6-month follow-up, no toxic effects of MMC were evident. Long-term follow-up is necessary to attest its safety.

Narrow-strip conjunctival autograft for treatment of pterygium

PURPOSE

To determine the efficacy of narrow-strip conjunctival autograft surgery in the treatment of pterygium.

DESIGN

Retrospective noncomparative interventional case series.

PARTICIPANTS

Twenty-one consecutive interventions between 1994 and 2005 in 20 eyes of 18 patients for primary (n = 17 cases) or recurrent (n = 4 cases) pterygia.

INTERVENTION

Surgical excision of the pterygium and conjunctival transplantation with a narrow-strip technique. In all cases, a 2-mm-wide autograft was secured adjacent and posterior to the limbus, leaving a 2- to 3-mm zone of bare sclera between the graft and the anterior margin of the conjunctival wound. All conjunctival margins were secured by suture to bare sclera.

MAIN OUTCOME MEASURE

Recurrence of pterygium at 12 months.

RESULTS

Mean follow-up after surgery was 41 months (median, 42; range, 4-132). At 1 year and all time points thereafter, 18 of 19 (94.7%) cases were free of recurrence. One patient was lost to follow-up at 4 months, and another died after 9 months of follow-up. The lone recurrence occurred inferiorly in an eye that had undergone an adjacent narrow-strip conjunctival transplantation 6 months previously for a recurrent temporal pterygium. The same patient remains recurrence-free 67 months after inferior pterygium excision and a second narrow-strip autograft surgery.

CONCLUSION

Narrow-strip conjunctival autografting appears to be an effective surgical technique in preventing pterygium recurrence. Creating an intervening bare sclera area between the secured conjunctival graft and the anterior margin of the conjunctival wound may be important in preventing recurrence.

A Scleral Soft Contact Lens Designed for the Postoperative Management of Pterygium Surgery

PURPOSE

To introduce a new hydrophilic contact lens design to be used as a corneoscleral bandage for different types of conjunctival surgery and pterygium surgery.

METHODS

The soft lenses are fabricated in large diameters from 17.5 to 19 mm and have custom peripheral curvatures to guarantee a normal tear film circulation to allow for extended wear for 2 or 3 consecutive weeks.

CONCLUSIONS

This novel design facilitates postoperative recovery and reduces the chance of recurrence after pterygium surgery. The authors have been using this type of lens in their clinical practice for more than 4 years.

Safety and Efficacy of the Technique of Complete Tenon’s Membrane Excision and Mitomycin C in Pterygium Surgery

PURPOSE

Despite the established efficacy of mitomycin C (MMC) in preventing recurrence after pterygium surgery, there is no consensus on the optimal operative technique or dose of MMC.

METHODS

The authors retrospectively evaluated 90 single-headed pterygium resections performed with excision of the entire pterygium to the plica and removal of all Tenon's membrane from the scleral bed and rectus muscle. Bare sclera was exposed to 0.4 mg/mL MMC for 5 minutes for primary pterygia and 6 minutes for recurrent pterygia. These procedures were compared to a previous series of 58 procedures using bare sclera technique with MMC, but without extensive Tenon's membrane removal.

RESULTS

Extensive Tenon's membrane removal was associated with significantly fewer recurrences (6.7% vs. 21%; P< or =0.025) and significantly less pyogenic granuloma formation (24.4% vs. 40%; P< or =0.05). In addition, there were no vision-threatening complications, such as scleral melting or persistent corneal epithelial defects, in any of the patients.

CONCLUSIONS

These findings suggest that complete removal of all Tenon's membrane in the affected quadrant combined with topical MMC in the aforementioned dose is a safe method of pterygium excision with a low rate of recurrence and pyogenic granuloma formation.

Transepithelial phototherapeutic keratectomy/photorefractive keratectomy with adjunctive mitomycin-C for complicated LASIK flaps

PURPOSE

To evaluate the efficacy of transepithelial phototherapeutic keratectomy/photorefractive keratectomy (PTK/PRK) with prophylactic mitomycin-C for the treatment of refractive errors and maintenance of corneal clarity following flap complications in laser in situ keratomileusis (LASIK).

SETTING

Outpatient tertiary care center, Chicago, Illinois, USA.

METHODS

Ten eyes of 10 patients with LASIK flap complications had transepithelial PTK/PRK for correction of ametropia. Mitomycin-C 0.02% was applied to the stroma for 2 minutes following laser ablation. Postoperative uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), refractions, and slitlamp examinations were obtained.

RESULTS

Preoperatively, the mean UCVA was 20/400 (range 20/40 to counting fingers), the mean BSCVA was 20/28.5, and the spherical equivalent refractive errors ranged from +4.00 to -10.75 diopters (D). After the procedure, the mean UCVA was 20/28, the mean BSCVA was 20/21, and the spherical equivalent refractive errors ranged from +0.37 to -1.00 D. The mean follow-up ranged from 8 to 28 months. No patient experienced delayed reepithelialization, haze, or other signs of toxicity.

CONCLUSION

Mitomycin-C can be a useful adjunctive therapy for the prevention of haze when applying surface excimer laser therapy to a cornea following LASIK flap complications.

The treatment of pterygium

The treatment of pterygium is still quite controversial, with various treatments being advocated in the scientific literature. Unfortunately, there are very few well-conducted controlled clinical trials of treatments. However, years of anecdotal and noncontrolled studies have confirmed that some methods, such as bare scleral closure, are no longer acceptable in the treatment of pterygium and that other methods are likely to be more useful. In the future it will be important to develop a grading system, and surgeons will need to be conservative in the treatment of pterygium until such time as a single treatment provides a lower recurrence rate and complication rate.