Comparison of Pterygium Recurrence Rates After Limbal Conjunctival Autograft Transplantation and Other Techniques: Meta-analysis

The Safety of Office-Based Pterygium Surgery

PURPOSE

Hospital and ambulatory eye surgical procedures continue to transition to the office setting. Pterygium surgery is the most commonly performed ocular surface surgical procedure in the world. No studies to date have evaluated its safety in the office-based surgical setting. Our study evaluates the safety, complication rate, cost-savings, and cosmetic satisfaction of office-based pterygiectomy.

DESIGN

Retrospective case series.

METHODS

A retrospective review was performed. Procedures were performed in an office-based suite with a Zeiss surgical microscope by two board-certified ophthalmologists under topical anesthesia and oral sedation. Over a 3 year period (2013-2016), 1071 office-based pterygiectomies were performed. Follow-up was performed via in-person office visits. Data collected included: date of service; location of pterygium (nasal, temporal, or both); primary or recurrent; use of mitomycin C, fibrin glue, and amniotic membrane; preoperative and postoperative refraction; intraocular pressure (IOP); endothelial cell density (ECD); patient-reported pain (as measured by an eleven-point visual analog scale, 0-10); cosmetic satisfaction; intraoperative surgical time; speculum width; incidence of ptosis (defined as a decrease in MRD1 by 2 mm) postoperatively at 12 weeks and 1 year and postoperative complications. Postoperative measures were checked at 1 day, 2 weeks, 1 month, 2 months, 3 months, 6 months, and 1 year. The average operational and procedural costs were compared between in-office and comparable surgical centers and academic hospital cases in our area.

RESULTS

A total of 1015 pterygia from 992 eyes were examined postoperatively. One case of central retinal artery occlusion due to peribulbar anesthetic injection with epinephrine at postoperative week 2 was noted, leading to the removal of epinephrine from the anesthetic regimen. At the 1-year follow-up, 393 pterygium cases in 343 eyes were assessed. One-year complication rates included overall recurrence (N = 8/393; 2.04%), dellen (N = 12/393; 3.05%), and granuloma (N = 15/393; 3.82%), ptosis 2.6% (N = 9/343). There were no cases of infection. Patient-reported pain scores remained less than 1.0 peri‑ and postoperatively, and cosmetic satisfaction was greater than 88% at 1 year. The average cost of office-based pterygium surgery was $1795 ($1700-$1890, depending on supplies used). In comparison, the costs at local surgical centers and hospitals were $3812.50 ($2625-$5000) and $5562 ($5095-$6029), respectively.

CONCLUSION

Office-based pterygiectomy is safe, cost-effective, and offers low recurrence rates and high patient satisfaction.

Facilitated Tenon-Free Conjunctival Autograft Preparation and Limited Tenon Removal Technique in Pterygium Surgery

BACKGROUND

The main complication of primary pterygium surgery is the recurrence of the pterygium. In the present study, we aimed to compare a classical technique and facilitated tenon-free conjunctival autograft preparation and a limited tenon removal technique in pterygium surgery in terms of recurrence rate, complications, and operation duration.

MATERIAL AND METHODS

This is a retrospective, comparative, observational study. Group 1 comprised 120 eyes of 115 patients who underwent pterygium excision with a new facilitated tenon-free conjunctival-limbal autograft preparation and limited tenon removal technique between May 2017 and October 2019. Group 2 comprised 117 eyes of 113 patients who underwent pterygium excision with a conventional conjunctival-limbal autograft technique between January 2016 and May 2017.

RESULTS

The mean follow-up time after surgery was 18.2 ± 5.8 months in group 1 and 19.1 ± 6.3 months in group 2 (p = 0.25). The mean operation duration was 5.54 ± 1.22 (4 - 7) minutes in group 1 and 8.23 ± 1.26 (8 - 10) minutes in group 2 (p = 0.02). Flap edema was present in 33 eyes (28.2%) in group 2 and in 11 eyes (9.16%) in group 1. Flap edema was significantly higher in group 2 (p < 0.001). At the end of the 1-year follow-up of the patients, we observed recurrence in only one (0.83%) eye in group 1 and 14 (11.96%) eyes in group 2. The recurrence rate of group 1 was significantly less than that of group 2 (p < 0.001).

CONCLUSIONS

The simplified technique of tenon-free conjunctival autograft preparation and limited tenon removal yielded better clinical outcomes without serious complications. Additionally, this technique shortened the surgical time and reduced surgeon-dependent factors.

The effect of different pterygium surgery techniques on the ocular surface parameters in different durations: a systematic review and meta-analysis

PURPOSE

To evaluate the effects of different pterygium surgery techniques on ocular surface (OS) in different follow-up periods.

METHODS

PubMed, Cochrane Library, Web of Science, China National Knowledge Infrastructure, Wan Fang, and China Biology Medicine disc were searched for studies reporting pre- and post-operative OS parameters in pterygium.

RESULTS

A total of 33 articles were finally included. Three OS parameters showed relatively consistent changing trends after surgery including ocular surface disease index (OSDI), tear film break-up time (BUT), and score of corneal fluorescein staining (SCFS). They worsened significantly at 1w post-operation and then gradually improved: OSDI and BUT showed obvious improvement in 1 m post-operation (SMD =  - 0.58, 95%CI = [- 1.04, - 0.13]; SMD = 0.42, 95%CI = [0.06, 0.78]); SCFS was restored to preoperative levels in 3 m after surgery (SMD =  - 0.54, 95%CI = [- 1.16, 0.07]). Another parameter, Schirmer test without anesthesia (SIT), presented transient increase at 1w post-operation (SMD = 0.87, 95%CI = [0.27, 1.47]) and presented a relatively stable improvement after 1 m post-operation (SMD = 0.52, 95%CI = [0.16, 0.89]). All parameters in amniotic membrane graft (AMT) showed better improvement in early stage and they showed non-inferior improvements in the long term compared with conjunctival autograft (CAG). Limbal-conjunctival autograft (LCAG) made excellent improvement to OS in the long term while pterygium excision (PE) showed the worst OS. The type of pterygium (primary and secondary), diabetes mellitus (DM) status, and fixation method had certain effects on the results.

CONCLUSIONS

OS of pterygium is deteriorated at 1w post-operation then gradually improved to preoperative levels after 1 m post-operation. Among various surgery techniques, LCAG had the best improvement to OS which especially displayed in the long-term outcomes.

Low Rate of Postoperative Pterygium Recurrence in Patients under Treatment with Low-Dose Oral Doxycycline for Chronic Blepharitis: A First Report

PURPOSE

Low doses of systemic doxycycline (LD-SD) inhibit angiogenesis and the expression of matrix metalloproteases, which are determinants of pterygium progression. This study aimed to compare the recurrence rate and visual outcome of pterygium excision in patients undergoing chronic treatment with LD-SD for chronic refractory blepharitis and LD-SD-naive patients.

METHODS

A retrospective analysis of patients that underwent surgical excision and conjunctival graft apposition was conducted. Patients were divided in a TETRA group (under LD-SD treatment at the moment of surgery) and a control group. The main outcome was the rate of recurrence at 1 year postoperatively. Secondary outcomes were the comparisons of surface regularity, visual quality, and dry-eye symptoms at 6-week, 6-month, and 1-year follow-up in the two groups.

RESULTS

The TETRA group showed a significantly lower rate of 1-year recurrence both in primary (p = 0.034) and recurrent (p < 0.001) pterygia. The best corrected visual acuity (BCVA), astigmatic error, corneal total root mean square (RMS), and ocular surface disease index (OSDI) significantly reduced during the follow-up in both groups. The surface asymmetry index and high-order aberrations (HOAs) significantly reduced only in the TETRA group. The final BCVA was significantly higher, while the OSDI score and total RMS and HOAs were significantly lower in the TETRA group compared to the control.

CONCLUSIONS

Patients under treatment with LD-SD showed a lower rate of recurrence at 1-year follow-up compared to controls. These patients also experienced higher BCVA and surface regularity and less dry-eye symptoms.

Modified Limbal-Conjunctival Autograft Surgical Technique: Long-Term Results of Recurrence and Complications

PURPOSE

The aim of this study was to report the recurrence and complication rates of a modified limbal-conjunctival autograft surgical technique for pterygium excision.

METHODS

This was a retrospective, single-surgeon, single-operating environment, consecutive case series of 176 eyes in 163 patients with a biopsy-proven diagnosis of pterygium. All patients underwent excision using a 23-gauge needle to "behead" the pterygium head, followed by a limbal-conjunctival autograft including ∼50% of the palisades of Vogt. Outcomes measured included recurrence, defined as any conjunctival fibrovascular growth, and complication rates. Correlations between preoperative patient characteristics, pterygium morphology, and intraoperative factors (width of corneal extension, conjunctival defect, and graft) with postoperative recurrence were examined using logistic regression models.

RESULTS

The median age was 59.5 years and 122 eyes (69.3%) had primary pterygium (type I: 17%, II: 37.5%, and III: 45.5%). Kaplan-Meier analysis demonstrated the median pterygium-free follow-up period to be 723 days (range 46-7230 days). Recurrence was observed in 3 eyes of 2 patients (1.7%). No postoperative graft-related complications were observed. Postoperative symptomatology was transient. Age demonstrated a negative correlation with recurrence (odds ratio 0.888, 95% CI, 0.789-0.998, P = 0.046). However, no other correlations with preoperative or intraoperative factors, including whether pterygium was primary or recurrent, were identified (all P > 0.05).

CONCLUSIONS

This modified limbal-conjunctival autograft technique represents an effective alternative that offers a very low recurrence rate and avoids extensive dissection or antimetabolites, with minimal complications and transient postoperative symptomatology, over a long-term follow-up period. This technique is relatively simple and successful for both primary and recurrent pterygia. Future comparative studies with other surgical techniques may determine which are superior.

TFOS Lifestyle Report: Impact of environmental conditions on the ocular surface

Environmental risk factors that have an impact on the ocular surface were reviewed and associations with age and sex, race/ethnicity, geographical area, seasonality, prevalence and possible interactions between risk factors are reviewed. Environmental factors can be (a) climate-related: temperature, humidity, wind speed, altitude, dew point, ultraviolet light, and allergen or (b) outdoor and indoor pollution: gases, particulate matter, and other sources of airborne pollutants. Temperature affects ocular surface homeostasis directly and indirectly, precipitating ocular surface diseases and/or symptoms, including trachoma. Humidity is negatively associated with dry eye disease. There is little data on wind speed and dewpoint. High altitude and ultraviolet light exposure are associated with pterygium, ocular surface degenerations and neoplastic disease. Pollution is associated with dry eye disease and conjunctivitis. Primary Sjögren syndrome is associated with exposure to chemical solvents. Living within a potential zone of active volcanic eruption is associated with eye irritation. Indoor pollution, "sick" building or house can also be associated with eye irritation. Most ocular surface conditions are multifactorial, and several environmental factors may contribute to specific diseases. A systematic review was conducted to answer the following research question: "What are the associations between outdoor environment pollution and signs or symptoms of dry eye disease in humans?" Dry eye disease is associated with air pollution (from NO2) and soil pollution (from chromium), but not from air pollution from CO or PM10. Future research should adequately account for confounders, follow up over time, and report results separately for ocular surface findings, including signs and symptoms.

Efficacy and safety of anti-vascular endothelial growth factor agents in the treatment of primary pterygium

Purpose

To further evaluate the efficacy and safety of anti-vascular endothelial growth factor (VEGF) agents in management of primary pterygium.

Methods

Randomized controlled trials (RCTs) in databases of PubMed, Web of Science, Embase, and the Cochrane Central Register of Controlled Trials were searched from inception to September 2022. Recurrences and complications were evaluated as the pooled risk ratio (RR) and 95% confidence interval (CI) using random-effects model.

Results

In total of 1,096 eyes in 19 RCTs were included. Anti-VEGF agents statistically decreased recurrence rate of pterygium following surgery (RR 0.47, 95% CI 0.31-0.74, P < 0.001). Subgroup analysis showed that anti-VEGF as an adjunct to bare sclera (RR 0.34, 95% CI 0.13-0.90, P = 0.03) and conjunctival autograft (RR 0.50, 95% CI 0.26-0.96, P = 0.04) statistically reduced recurrence rate, while the effect was not favorable for conjunctivo-limbo autograft (RR 0.99, 95% CI 0.36-2.68, P = 0.98). Anti-VEGF agents statistically decreased recurrence in White patients (RR 0.48, 95% CI 0.28-0.83, P = 0.008), while didn't in Yellow patients (RR 0.43, 95% CI 0.12-1.47, P = 0.18). Both topical (RR 0.19, 95% CI 0.08-0.45, P < 0.001) and subconjunctival anti-VEGF agents (RR 0.64, 95% CI 0.45-0.91, P = 0.01) had a positive influence on recurrence. There was no statistically significant difference in complications between the groups (RR 0.80, 95% CI 0.52-1.22, P = 0.29).

Conclusions

As adjuvant treatment, anti-VEGF agents statistically reduced the recurrence following pterygium surgery, especially among White patients. Anti-VEGF agents were well tolerated without increased complications.

Conjunctival and Limbal Conjunctival Autograft vs. Amniotic Membrane Graft in Primary Pterygium Surgery: A 30-Year Comprehensive Review

INTRODUCTION

The purpose of this study is to compare the "real-life" effectiveness of amniotic membrane graft (AMG) and conjunctival (CAT) or limbal conjunctival (LCA) autograft in the management of primary pterygium.

METHODS

Human-based studies on primary pterygium surgery that were published between 1993 and 2022 with at least 3 months of follow-up were identified, and only those that were retrospective were included. The global recurrence rate of pterygium was assessed for each surgical technique separately. Specific recurrence rates taking into consideration the fixation technique (glue versus sutures) were also measured.

RESULTS

35 real-life retrospective subgroups comprising a total of 3747 eyes were included in the final review. The mean global recurrence rates for CAT, LCA and AMG were 7.61%, 5.50% and 9.0%, respectively. Recurrences were less common for patients who received fibrin glue (5.92%, 2.56% and 3.60%) than for those who received sutures (8.99%, 6.03% and 23.0%) for the three groups, respectively. Surgical techniques combining CAT or LCA with AMG yielded an even lower global recurrence rate (1.83%).

CONCLUSION

AMG seems like a reasonable option that could be considered in primary pterygium surgery, especially when glued to the underlying sclera. Combining AMG with other treatment modalities such as CAT or LCA seems to offer an interesting alternative in terms of recurrence.

ZD6474 Attenuates Fibrosis and Inhibits Neovascularization in Human Pterygium by Suppressing AKT-mTOR Signaling Pathway

Purpose: To investigate the antifibrotic effect of ZD6474 in human pterygium fibroblasts (HPFs) and angiogenesis in human umbilical vein endothelial cells (HUVECs) compared with mitomycin C (MMC). Methods: Pterygium and tenon fibroblasts were isolated from patients undergoing surgery to culture HPFs and human tenon fibroblasts (HTFs). The effects of ZD6474 on HPF, HTF, and HUVEC proliferation and migration were detected using CCK8 and wound-healing assays, respectively. Fibrosis and epithelial-mesenchymal transformation (EMT) were evaluated by western blotting [transforming growth factor beta (TGF-β)1/2 and snail] and immunofluorescence (vimentin and α-smooth muscle actin). The antiangiogenic effect of ZD6474 on HUVECs was assessed using a tube formation assay. To determine the potential mechanism, the expression of phosphorylated AKT (p-AKT) and phosphorylated mTOR (p-mTOR) was evaluated by treatment with ZD6474 via western blotting. Results: ZD6474 robustly inhibited the proliferation and migration of HPFs rather than HTFs compared with those in the MMC group (**P < 0.01). In HPFs, fibrosis and EMT (vimentin, TGF-β1/2, and snail) were significantly reversed by ZD6474. MMC (>50 μg/mL) significantly reduced HTF viability, whereas ZD6474 (<5 μM/mL) did not decrease HTF viability. HUVEC proliferation and migration were clearly decreased, and tube formation was notably interrupted by ZD6474. Activation of p-AKT and p-mTOR was inhibited by ZD6474 treatment of HPFs and HUVECs. Conclusion: ZD6474 is more effective than MMC in reducing fibrosis and EMT in HPFs. In addition, ZD6474 was less toxic to HTFs. ZD6474 also exhibited antiangiogenic effects in HUVECs. This study may aid in the development of novel agents to prevent pterygium recurrence after pterygium excision.

Therapeutic effects of auricular point acupressure on the recovery of patients after pterygium surgery: A pilot study

BACKGROUND

and purpose: Postoperative pain in the pterygium of the eye seriously affects patient recovery. This study was conducted to assess the efficacy of auricular point acupressure treatment on post-operative recovery in patients after pterygium surgery.

MATERIALS AND METHODS

This was a pilot, randomized controlled study. A total of 60 patients (60 eyes) were randomly assigned to two groups. After pterygium surgery, the auricular group was treated using ear acupressure (acupressure points with Cowherb seeds) and the control group was treated using sham auricular therapy (acupressure points without Cowherb seeds). Both groups were treated for one week. Outcome measures included pain score, corneal epithelial score, best-corrected visual acuity, and recurrence rate.

RESULTS

Fifty-three patients completed the study. The mean pain scores and corneal epithelial scores were significantly reduced over time in the auricular group compared with those in the control group (p < 0.05). The time-group interaction for both pain scores and corneal epithelial scores was significant between the two groups (p < 0.05). Simple main effect analysis showed the mean pain scores in the auricular group were significantly lower at each time point (the first 2-h, the first day, the third day and the first week, p < 0.05) than the control group. Mean corneal epithelial scores of the auricular group were significantly lower on the first day and third day respectively than the control group (p < 0.05). There was no significant difference in the best-corrected visual acuity or recurrence rate between the two groups (p > 0.05).

CONCLUSION

Auricular point acupressure accelerates corneal epithelium reconstruction and suppresses postoperative pain, making it an ideal adjunct treatment for postoperative pterygium recovery.

CLINICAL TRIAL REGISTRATION NUMBER

ChiCTR2000032490 on http://www.chictr.org.cn/.

[Lamellar keratoplasty in the management of recurrent pterygium]

As it is known, the main problem of surgical treatment of pterygium is associated with high risk of recurrence. Quite a number of surgical techniques now exist, all aimed at pterygium removal and only differing in the method of conjunctival closure following the excision. Due to relatively low recurrence rates, conjunctival or conjunctival-limbal autografts are currently the 'gold standard' of pterygium surgery. The frequency of recurrence is also insignificant in peripheral anterior lamellar keratoplasty, which is rarely performed due to its complexity and the need for donor cornea. However, it is considered to be the method of choice in cases of repeated recurrence as well as in patients with high pterygium activity. This article describes a clinical case of a massive recurrent pterygium (grade IV, activity level 3). The patient has had three previous surgeries (including conjunctival autotransplantation) that yielded no success. By performing large-diameter peripheral anterior lamellar keratoplasty in combination with adjuvant therapy (intraoperative mitomycin C and subconjunctival postoperative aflibercept injections), structural integrity of the cornea was finally restored without further recurrences and visual acuity was increased.

Recurrence Rate and Clinical Outcome of Amniotic Membrane Transplantation Combined with Mitomycin C in Pterygium Surgery: Two-Year Follow-Up

Objective:

To evaluate the recurrence rate and outcome of pterygium surgery with amniotic membrane transplantation (AMT) and intraoperative mitomycin C (MMC).

Methods:

This prospective clinical study included patients with pterygium who were candidates for pterygium excision. After the surgical excision, intraoperative local MMC were applied in the standard protocol followed by AMT. The outcome measures were recurrence and the size change of lesion. Kaplan-Meier estimation and regression analyses were performed.

Findings:

Fifty five eyes of 55 consecutive patients including 30 male (54.5%) and 25 female (45.5%) with mean age of 47.12 ± 15.95 years were operated. The mean follow-up period was 15.21 ± 2.67 months. The overall recurrence rate was 34.5% (19/55 cases). The estimated recurrence time for larger size of pterygium before surgery was short and marginally significant (17.14 ± 0.58 month in size of ≤3.0 mm versus. 18.56 ± 0.60 month in size of <3 mm; P= 0.06). A statistically significant association was found in reduced model among the size change of the pterygium and standardized coefficient was −0.012 (P = 0.044) and −0.743 (P < 0.001) for age and size of lesion before surgery, respectively.

Conclusion:

Our findings suggest that increasing age and pterygial tissue are the risk factors for recurrence and pterygium has a substantial recurrence rate even after AMT combined with MMC.

Resolution of Corneal Dellen After an Uneventful Pterygium Surgery with Punctal Cautery

Corneal dellen are a rare and serious complication after primary pterygium surgery with conjunctival limbal autograft (CLAG) with fibrin glue without antimetabolites. Dellen are caused by interruptions of the tear film and local dehydration of the cornea. If untreated, they may lead to corneal perforation. We describe the case of a patient who developed corneal dellen 15 days after uneventful pterygium excision with CLAG with fibrin glue without the use of antimetabolites. There was no satisfactory response to lubricants and patching, and the patient had no associated systemic risk factors. As the thinning increased, cyanoacrylate glue with bandage contact lens was applied, but the dellen reappeared seven days after glue removal. Dellen finally resolved with thermal punctal cautery applied to both puncta. Dellen most commonly respond to artificial tears, antibiotic ointment, and patch application. However, in refractory cases, punctal cauterization can be considered as a good option to increase tear pooling in the area of dellen, thereby promoting healing.

Reliability of the Evidence Addressing Treatment of Corneal Diseases: A Summary of Systematic Reviews

Importance

Patient care should be informed by clinical practice guidelines, which in turn should be informed by evidence from reliable systematic reviews. The American Academy of Ophthalmology is updating its Preferred Practice Patterns (PPPs) for the management of the following 6 corneal diseases: bacterial keratitis, blepharitis, conjunctivitis, corneal ectasia, corneal edema and opacification, and dry eye syndrome.

Objective

To summarize the reliability of the existing systematic reviews addressing interventions for corneal diseases.

Data Source

The Cochrane Eyes and Vision US Satellite database.

Study Selection

In this study of published systematic reviews from 1997 to 2017 (median, 2014), the Cochrane Eyes and Vision US Satellite database was searched for systematic reviews evaluating interventions for the management of any corneal disease, combining eyes and vision keywords and controlled vocabulary terms with a validated search filter.

Data Extraction and Synthesis

The study classified systematic reviews as reliable when each of the following 5 criteria were met: the systematic review specified eligibility criteria for inclusion of studies, conducted a comprehensive literature search for studies, assessed risk of bias of the individual included studies, used appropriate methods for quantitative syntheses (meta-analysis) (only assessed if meta-analysis was performed), and had conclusions that were supported by the results of the systematic review. They were classified as unreliable if at least 1 criterion was not met.

Main Outcomes and Measures

The proportion of systematic reviews that were reliable and the reasons for unreliability.

Results

This study identified 98 systematic reviews that addressed interventions for 15 corneal diseases. Thirty-three of 98 systematic reviews (34%) were classified as unreliable. The most frequent reasons for unreliability were that the systematic review did not conduct a comprehensive literature search for studies (22 of 33 [67%]), did not assess risk of bias of the individual included studies (13 of 33 [39%]), and did not use appropriate methods for quantitative syntheses (meta-analysis) (12 of 17 systematic reviews that conducted a quantitative synthesis [71%]). Sixty-five of 98 systematic reviews (66%) were classified as reliable. Forty-two of the 65 reliable systematic reviews (65%) addressed corneal diseases relevant to the 2018 American Academy of Ophthalmology PPPs; 33 of these 42 systematic reviews (79%) are cited in the 2018 PPPs.

Conclusions and Relevance

One in 3 systematic reviews addressing interventions for corneal diseases are unreliable and thus were not used to inform PPP recommendations. Careful adherence by systematic reviewers and journal editors to well-established best practices regarding systematic review conduct and reporting might help make future systematic reviews in eyes and vision more reliable.

Pterygium: new insights

Pterygia are common conjunctival degenerations with well-documented risk factors but an unclear pathogenesis. Better understanding of the pathogenesis of pterygium could lead to improved surgical outcomes and decreased postoperative recurrence. Currently, pterygium excision with conjunctival autograft remains the preferred surgical technique to decrease pterygium recurrence. Many adjuvant therapies have been used in pterygium surgery to varying degrees of success. Topical cyclosporine, an immunosuppressive medication, in conjunction with conjunctival autograft was found to be most successful in decreasing pterygium recurrence according to a recent meta-analysis. Other adjuvant therapies such as mitomycin-C (MMC), 5-fluorouracil (5-FU), and beta-irradiation have also been used, though usage of these may cause multiple adverse effects. Recent research indicates that interactions between mouse double minute 2 (MDM2) and p53 could play a role in the occurrence of pterygium. Nutlin, an MDM2 antagonist, was found to have significantly less toxicity in conjunctival cells when compared with MMC on laboratory analysis of pterygium samples.

Cellular Proliferation and Migration of Human Pterygium Cells: Mitomycin Versus Small-Molecule Inhibitors

PURPOSE

Nutlin is a drug that has been reported to activate p53 in various cell lines. We aim to study the effects of Nutlin in pterygium and compare the effects of Nutlin and mitomycin C (MMC) in pterygium cell lines.

METHODS

Pterygium samples (n = 3) were collected during surgical excision. Normal conjunctival tissues (n = 3) were collected from another quadrant of the same eye. Cell lines were established, and cells from passages 2 to 5 were used. Pterygium and conjunctival cells were treated with different doses of Nutlin and MMC. Cell proliferation and cell migration were measured.

RESULTS

Cell proliferation was reduced by 39-fold after treatment with 50 μM Nutlin. Cell migration was inhibited with increasing dosages of Nutlin (95% and 28% after treating with 2 and 50 μM Nutlin, respectively). Compared with MMC, Nutlin induced more pterygium cell death and less conjunctival cell death at low doses. At 50% lethal dose for pterygium cells, 95% of conjunctival cells survived after Nutlin treatment, whereas only 63% of conjunctival cells survived after MMC treatment. p21 expression was not detectable in MMC-treated pterygium cells but was detectable after Nutlin treatment.

CONCLUSIONS

In our study, MMC induced cell death in pterygium and conjunctival cell lines, whereas Nutlin had a targeted impact on pterygium cells. Our results implied that MMC inhibited both pterygium cell proliferation and migration through an apoptosis-independent pathway.

Optimal size of pterygium excision for limbal conjunctival autograft using fibrin glue in primary pterygia

BACKGROUND

In our study we describe a method that optimizes size of excision and autografting for primary pterygia along with the use of intraoperative MMC and fibrin glue. Our objective is to propose a simple, optimizedpterygium surgical technique with excellent aesthetic outcomes and low rates of recurrence and otheradverse events.

METHODS

Retrospective chart review of 78 consecutive patients with stage III primary pterygia who underwent an optimal excision technique by three experienced surgeons. The technique consisted of removal of the pterygium head, excision of the pterygium body and Tenon's layer limited in proportion to the length of the head, application of intraoperative mitomycin C to the defect, harvest of superior bulbar limbal conjunctival graft, adherence of graft with fibrin glue. Outcomes included operative time, follow up period, pterygium recurrence, occurrences of incorrectly sized grafts, and other complications.

RESULTS

All patients were followed up for more than a year. Of the 78 patients, there were 2 cases of pterygium recurrence (2.6%). There was one case of wound dehiscence secondary to small-sized donor conjunctivaand one case of over-sized donor conjunctiva, neither of which required surgical correction. There were no toxic complications associated with the use of mitomycin C.

CONCLUSION

Correlating the excision of the pterygium body and underlying Tenon's layer to the length of the pterygium head, along with the use intraoperative mitomycin C, limbal conjunctival autografting, and fibrin adhesionresulted in excellent outcomes with a low rate of recurrence for primary pterygia.

Comparison of conjunctival autograft and conjunctival transposition flap techniques in primary pterygium surgery

PURPOSE

To investigate and compare the efficacy of conjunctival autograft and conjunctival transpositional flap for the treatment of primary pterygium surgery.

DESIGN

Retrospective, interventional case series analysis.

MATERIALS AND METHODS

Medical records of 48 patients who underwent pterygium surgery by conjunctival autograft or conjunctival transpositional graft for primary pterygium surgery were reviewed. The conjunctival defects after pterygium excision were repaired in 21 eyes with conjunctival autograft and in 27 eyes with conjunctival transpositional flaps. All operations were performed under subconjunctival anesthesia using 8.0 vicryl sutures. Two groups were compared in terms of pterygium size, surgery time, complications and pterygium recurrence.

RESULTS

Mean pterygium size was 2.8 mm in conjunctival transpositional flap group, and 3.4 mm in conjunctival autograft group (p < 0.01). Mean surgery time in conjunctival transpositional flap and conjunctival autograft groups was 15.9 and 21.7 min, respectively. The haematoma formation under the graft was observed postoperatively in one eye of conjunctival autograft group. The only one case of recurrence was observed in both conjunctival autograft and conjunctival transpositional flap groups (3.7% and 4.7%, respectively). Mean follow up time was 11.78 months in conjunctival transpositional flap group and 14.95 months in conjunctival autografting group (p < 0.01).

CONCLUSION

Both conjunctival transpositional flap and conjunctival autograft techniques have same results in terms of pterygium recurrence and surgery complications in the treatment of primary pterygium. Surgery time in conjunctival transpositional flap technique is significantly shorter. Conjunctival transpositional flap technique may be a good alternative method for primary pterygıum surgery.

Evaluation of Topical Lignocaine Jelly 2% for Recurrent Pterygium Surgery with Glue-free Autologous Conjunctival Graft

AIM

This study aims to evaluate the efficacy of lignocaine 2% jelly as a topical anesthesia in recurrent pterygium surgery with glue-free conjunctival limbal autograft.

MATERIALS AND METHODS

A prospective, nonrandomized, observational study, comprising of 51 patients (51 eyes) having recurrent pterygium, was conducted at a tertiary eye care center in central India. Pterygium excision with glue-free autologous conjunctival grafting was done under 2% lignocaine jelly. The visual analog scale was utilized to record the intra- and post-operative pain score. Patient comfort, intraoperative painful sensations perceived by the patient, supplemental anesthesia, complications, and surgeon discomfort were noted. Anesthetist also noted vital parameters and any intravenous drugs required.

RESULTS

No difference in intra- and post-operative pain score (P = 0.24) was observed in the patients. Zero score, i.e. no pain was noticed in 30 patients (58.8%) patients. The average surgical time was 29.20 min (+1.11). The average surgeon discomfort score was 0.18 + 0.51. Inadvertent eye movement was seen in 3 patients (5.9%). Lid squeeze was noted in 45 patients (88.2%) during placement of lid speculum. Forty-eight patients (94.1%) gave preference to the topical anesthesia of 2% lignocaine jelly compared to the previous mode of anesthesia.

CONCLUSION

Pterygium surgery with glue-free autogenous conjunctival grafting can be performed successfully by preoperative local application of 2% lignocaine jelly. The ease of application, lack of toxicity and sufficient effect to complete the surgery make it an efficient alternative to injectable anesthetics.

Low recurrence rate of anchored conjunctival rotation flap technique in pterygium surgery

Background

To report the recurrence rate for an anchored conjunctival rotation flap technique in primary pterygium surgery.

Methods

Primary pterygium surgeries performed using anchored conjunctival rotation flap techniques (110 eyes in 110 patients) with a minimum follow-up of 12 months were reviewed. In this technique, a conjunctival flap is rotated to cover the bare sclera and suture-fixated with either 8–0 polyglactin (41 eyes) or 10–0 nylon (69 eyes). The recurrence rate was determined, and the two suture materials utilized were compared.

Results

The recurrence rate was 2.71% (3 cases in 110 eyes) when an anchored conjunctival rotation flap technique was used and patients were monitored for 26.40 ± 17.09 months. Interestingly, the recurrences were only observed in polyglactin-sutured eyes. No recurrence was detected in nylon-sutured eyes. No other complications were observed in either group.

Conclusions

The anchored conjunctival rotation flap technique for pterygium surgery has a relatively low recurrence rate. Nylon suture-fixation of the flap was found to be superior to polyglactin suture-fixation in preventing recurrence.

Electronic supplementary material

The online version of this article (10.1186/s12886-017-0587-z) contains supplementary material, which is available to authorized users.

Comparison of 4 Techniques for Limbal-Conjunctival Autograft Fixation in Primary Pterygium Surgery

Purpose

To compare 4 limbal-conjunctival autograft fixation techniques—conventional suture, commercial fibrin glue, autologous fibrin glue, and cautery—in primary nasal pterygium surgery.

Methods

This is a retrospective and descriptive study. The postoperative patient discomfort, graft edema, ocular inflammation, and other complications of 4 limbal-conjunctival autograft fixation techniques in primary nasal pterygium surgery were evaluated.

Results

Postoperative patient discomfort was significantly lower with the sutureless techniques (p<0.001), with fixation with cautery having the lowest rate of discomfort. Graft edema and ocular inflammation during the early postoperative period were significantly higher when fibrin glue techniques were used (p<0.001). The recurrence rate did not show a statistically significant difference (p = 0.682) among the 4 groups.

Conclusion

In primary nasal pterygium surgery, limbal-conjunctival autograft fixation using cautery is the technique with the lowest postoperative discomfort rate and without a statistically significant increase in recurrence rate when compared to conventional suture and fibrin glue techniques.

Effects of Mitomycin C in Early Conjunctival Inflammation after Pterygium Surgery

PURPOSE

The purpose of this study was to compare inflammatory events and graft characteristics 1 month and 6 months after conjunctival limbal autograft (CLAU) with and without intraoperative mitomycin C (MMC).

METHODS

This study included 69 eyes of 69 patient's eyes with pterygium. Clinical data concerning patient demography, preoperative examination including pterygium morphology, recurrence clinical assessment, and complications after CLAU with (MMC+) and without (MMC-) intraoperative MMC were all registered at 1 month and 6 months after surgery.

RESULTS

Thirty-five eyes were included in MMC+ and 34 in MMC-. Preoperative data were similar in both groups (Student's t test and Fisher's exact test; p > 0.05). Thirty-four (49.6%) eyes in the whole sample showed at least one inflammatory complication at 1 month after surgery. MMC- group showed a significantly higher number of cases with complications (p < 0.001; Chi² test) (MMC+ 28.5%; MMC- 70.5%). No patients presented clinical recurrence at 1 month after surgery. The examination revealed a higher incidence of clinical hyperemia surrounding the surgical site and graft contraction on the host site on the MMC- group, both with statistical signification (p < 0.001; Chi² test). Although the hemorrhages were less frequent in the MMC- group, there were no significant differences between the two groups (p > 0.05; Chi² test). Pyogenic granuloma developed at the surgical site in three eyes (4.37%), two of those granulomas were at the MMC- group (p > 0.05). Tendency for recurrences was significantly different between both groups (p = 0.0001; Fisher's exact test) at the end of 6 months. Thirteen (38%) eyes showed recurrence in MMC- and no cases were displayed in MMC+. Presence of at least 1 inflammatory event was only seen in 16 (23%) cases, all of them in MMC-. Specifically, 15 (44%) eyes showed hyperemia and one (3%) eye presented conjunctival hemorrhages. No new cases of pyogenic granuloma or graft contraction were seen at this time point in both groups. Hyperemia was the only specific event with significant differences between MMC- and MMC+ (p = 0.0001; Fisher's exact test) at 6 months after surgery.

CONCLUSION

The eyes receiving intraoperative MMC after CLAU seem to present less hyperemia and graft contraction after surgery than those that did not receive MMC as an adjuvant factor. Intraoperative MMC could be associated with a lower recurrence rates.

Limbal conjunctival versus amniotic membrane in the intraoperative application of mitomycin C for recurrent pterygium: a randomized controlled trial

PURPOSE

This study compared the outcomes of a limbal conjunctival autograft (LCAG) with those of an amniotic membrane graft (AMG) followed by intraoperative 0.02 % mitomycin C (MMC) to treat recurrent pterygium.

METHODS

In this randomized controlled trial, ninety-six eyes with recurrent pterygium were enrolled and randomly allocated into two groups using a computer-generated random number table. Pterygium removal was followed by intraoperative 0.02 % MMC for 3 min and then either LCAG or AMG transplantation. The major outcomes were recurrence rate, conjunctival inflammation grade, healing time of the corneal epithelial defect, eye-movement amplitude (EMA), uncorrected distance visual acuity (UDVA), and complications.

RESULTS

A follow-up of 12 months was conducted for 93 eyes of 82 patients. Grade D (recurrence) presented in one eye of the LCAG group and five eyes of the AMG group, with no between-group difference (p = 0.196). However, Grades A, B, and C presented in 46, zero and zero eyes of the LCAG group respectively, and in 37, two and two eyes of the AMG group respectively, with the surgical bed generally showing a better appearance in the LCAG group than in the AMG group (p = 0.008). Compared with baseline values, the postoperative EMA improved significantly in both groups (p < 0.001 for the LCAG group; p = 0.001 for the AMG group), as did UDVA (p = 0.005 for the LCAG group; p = 0.012 for the AMG group). No between-group differences were found in terms of the healing time for epithelial defect, conjunctival inflammation grade, or the frequency of complications such as punctate epithelial keratitis, episcleral melting, corneal pannus, and delayed corneal epithelium healing.

CONCLUSIONS

LCAG transplantation with intraoperative 0.02 % MMC is as efficacious in treating recurrent pterygium as AMG transplantation with MMC. The former procedure results in an attractive cosmetic appearance but might result in limbal damage in some eyes. The surgeon's familiarity with these procedures should determine the method of treatment.

Removal of Tenon fortified by conjunctival-limbal autograft in treatment of pterygium

PURPOSE

To describe a simple and effective technique for the prevention of pterygium recurrence.

METHODS

This is a retrospective consecutive single-center case series with recurrence rate as the main outcome measure. Dissection of the conjunctiva, the Tenon's layer, and the sclera was continued up to the insertion of medial rectus. The exposed Tenon's layer was excised for 2 to 3 mm. The entire free edges of the conjunctiva was tacked firmly to the sclera. The conjunctival-limbal graft was sutured firmly to the sclera, recipient limbus, and to the conjunctiva incorporating the reciprocal edges.

RESULTS

We report findings in a total of 36 patients, with 20 (%55.5) males and 16 (%44.4) females. Median age of the patients was 44.5 years (range 16-80). The mean follow-up period was 23.1 ± 6.5 months. The mean size of pterygium in mm length was 3.8 ± 0.7. Recurrence did not occur in any patient. Diplopia was not reported by any patients.

CONCLUSIONS

Conjunctival-limbal autograft combining with selective exicison of Tenon's layer but without damage to any essential tissue such as the semilunar fold or Tenon's capsule pulley is a relatively simple and effective procedure.

Surgical Management of Double-Head Pterygium Using a Modified Split-Conjunctival Autograft Technique

AIM

To describe a modified split-conjuctival autograft technique for double-head pterygium and evaluate the postoperative outcomes.

METHODS

A retrospective analysis of all patients who underwent split-conjunctival autograft surgery for double-head pterygium from November 2012 to March 2014. Conjunctival autograft was split vertically, in order to obtain limbal sides of cojunctival autograft for both sides. No adjunctive agent was used. Records of included patients were reviewed and outcomes and recurrence rates were noted.

RESULTS

Eight cases of double-head pterygia were noted in 158 total cases of pterygia evaluated (5%). The baseline characteristics included 2 female and 6 male with an age between 26 and 71 (average 42.63) years. All eyes had 12-month follow-ups in average (6-21 months). No intraoperative or postoperative complications were noted. No recurrence was observed.

CONCLUSION

A modified, vertical-split conjunctival autograft without any adjunctive agents is a successful and safe technique in management of double-head pterygium.

Safety and efficacy of human amniotic membrane in primary pterygium surgery

Grafts made from human amniotic membrane are used to prevent recurrence of pterygium after excision. The success of the procedure can be affected by the quality of preparation and preservation of the grafts. We prospectively evaluated the safety and efficacy of cryopreserved amniotic membrane prepared at the research tissue bank of the Biotechnology Research Center in Tripoli, Libya, and used as adjunct therapy in primary pterygium excision. Twenty-six patients (15 males and 11 females) aged 21-78 years and indicated for primary pterygium excision were transplanted at the Tripoli Eye Hospital with the amniotic membrane grafts. Sixteen patients (62 %) were available for all three follow-up visits scheduled at 1, 3 and 6 months post-surgery. By the third visit, two patients (12.5 %) developed granuloma and three (18.8 %) had pterygium recurrence. The grafts were used after cryopreservation for ≤180 days or >180 days, but statistical analysis showed that the complications were not associated with the length of storage. Moreover, the high rate of complications in this study was not caused by use of cryopreserved AM. In conclusion, locally produced cryopreserved AM is safe as an adjunct therapy for treatment of primary pterygium excision.

Vascular Regression After Pinguecula Excision and Conjunctival Autograft Using Fibrin Glue

OBJECTIVES

To determine the change in local vascularization after pinguecula excision and conjunctival autograft secured with fibrin glue at 12 months.

METHODS

Thirty-one eyes of 31 patients which underwent excision and conjunctival autografting with fibrin glue were retrospectively reviewed. Anterior segment photography was obtained before and after the surgery. Cosmetic outcome was evaluated by patient self-grading (five-point scale; excellent (5), good (4), acceptable (3), poor (2), and very poor (1)), and medical evaluation of treatment outcome was based on subjective evaluation of vascularization on anterior segment photography (four-point severity scale; 0 [low] to 3 [high]). Clinical outcome and complications are reported at 12 months.

RESULTS

Overall cosmetic results were excellent or good in 93.5% (29 of 31) (score 4.68±0.60). Anterior segment photography showed that most cases demonstrated complete removal of pinguecula and regression of surrounding vascularization with mean change in score from 2.13±0.34 preoperatively to 0.09±0.30 postoperatively.

CONCLUSIONS

Pinguecula excision and conjunctival autograft using fibrin glue is an effective and safe method to remove pinguecula for cosmetic purposes. The method presented facilitated regression of vascularization.

Evaluation of LATS1 and LATS2 Promoter Methylation with the Risk of Pterygium Formation

Purpose. Pterygium is a serious eye problem in countries with high exposure to UV. However, despite numerous studies, the molecular etiology of pterygium is unclear. Recent studies have indicated that LATS1 and LATS2 genes are involved in DDR signaling pathways against continuous UV exposure. Our aim was to evaluate the LATS1 and LATS2 promoter methylation with the risk of pterygium formation. Methods. We evaluated the promoter methylation status of LATS1 and LATS2 using methylation-specific PCR technique. Also, mRNA expression of LATS1 and LATS2 was assessed in 14 cases of pterygium and 14 normal specimens by real-time PCR. Results. Promoter methylation of LATS1 and LATS2 was detected significantly between pterygium tissues and normal tissues [LATS1; OR = 4.9; 95% CI: 1.54 to 15.48, P = 0.003; LATS2; OR = 7.1; 95% CI: 1.53 to 33.19, P = 0.004]. The gene expression analysis showed a statistically significant difference between pterygium tissues and healthy controls for both LATS1 and LATS2 (P < 0.05). Conclusions. The data of this study is the first report regarding the effect of promoter methylation of the LATS1 and LATS2 in the pterygium. To confirm these data, doing further studies in various genetic populations with large sample sizes using advanced molecular techniques is proposed.

Non-Recurrence Complications of Fibrin Glue Use in Pterygium Surgery: Prevention and Management

Purpose :

To present complications of using fibrin glue in conjunctival-limbal autografting in pterygium surgeries other than recurrences and discuss their prevention and management strategies.

Materials and Methodology:

The charts of all patients who underwent fibrin glue assisted pterygium excision surgery with conjunctival-limbal autograft transplantation from 2010 to 2013 were reviewed. Patients who developed complications except recurrence postoperatively were included in this study.

Results :

Sixteen (17.39%) of the 92 patients were detected with a complication. Graft dehiscence was diagnosed in 7 (7.6%) patients with 5 of them treated conservatively and 2 patients requiring suturing. Five (5.43%) patients were diagnosed with cyst formation between the graft and conjunctiva or in the graft-removal area; these cysts were primarily excised and no additional problems occurred. Corneal dellen developed in 3 (3.26%) patients and 2 of them regressed after cessation of topical steroids and application of lubricant therapy while one was treated with amniotic membrane transplantation. Residual fibrin glue particles had stiffened on the ocular surface, which resulted in intensive pain and irritation in one (1.08%) patient on the same day of the surgery. The patient’s complaints were reduced by removing these particles from the ocular surface under topical anesthesia.

Conclusion :

Complications in fibrin glue assisted pterygium surgery are relatively different from other techniques. To avoid potential complications of fibrin glue in pterygium surgery, peroperatively ophthalmologists should ensure the conjunctival autograft and conjunctiva are properly adhered, fibrin glue remnants are completely removed from the ocular surface, and no Tenon’s capsule remains between the graft and the conjunctiva.

Conjunctival Short-term Evolution after Pterygium Excision

PURPOSE

To analyze conjunctival cytological features 1 month after pterygium excision using limbo-conjunctival autograft (LCA) with and without intraoperative mitomycin C and to assess tissue short-term evolution in both situations.

METHODS

Fifty-nine primary nasal pterygia from 59 patients were excised with LCA. Twenty-nine were treated with intraoperative mitomycin C 0.02% (MMC+) and 30 were treated without it (MMC-). Impression cytology was performed in nasal and temporal conjunctiva before and 1 month after the excision. Goblet cell density (GCD) and nucleus-to-cytoplasm nongoblet epithelial cell ratio were quantified.

RESULTS

Surgical strategy comparisons (intergroup comparisons): All the preoperative data were, in mean, within the reference range, except for a slight goblet cell hyperplasia in the area of the lesion in MMC+ but no significant differences were found between the groups (p = 0.079 for GCD and p = 0.245 for nucleus-to-cytoplasm ratio; analysis of variance). Clinically relevant differences after surgery were only shown in nasal GCD that was significantly lower in MMC+ than in MMC- (p = 0.000; analysis of variance), with the mean value in MMC+ slightly below normal values whereas that in MMC- remained normal. Tissue evolution (intragroup comparisons): No clinically relevant changes were found in MMC-. Data from MMC+ displayed no changes 1 month after surgery, except for nasal GCD that showed a significant reduction (p = 0.000; paired t test). Nevertheless, this GCD decrease was more modest than that previously described using mitomycin C without autograft, because in the present study, nasal GCD was not lower but similar to postoperative temporal data of the same eye (p = 0.164; paired t test).

CONCLUSIONS

Limbo-conjunctival autograft is a good technique for conjunctiva early recovery. When mitomycin C was added, the GCD reduction was lower than described using other surgical techniques. Mitomycin C, in optimal concentration and exposure, associated with LCA could be a good clinical option to minimize pterygium recurrence.

Auto-avulsion and resolution of corneal pterygium

PURPOSE

Corneal pterygium is a frequently encountered ocular condition in clinical practice. The lesion presents as a fibrous, winged-like growth that typically manifests on the nasal aspect of the conjunctiva and cornea. Pterygia can be surgically removed by excision when they cause significant discomfort, visual impairment, or poor cosmesis. However, the recurrence rate after excision remains high without adjunctive therapy. We present an exceedingly rare case of resolution of a pterygium by auto-avulsion followed by subsequent recurrence of the lesion.

CASE REPORT

A 63-year-old Asian man presented to the clinic with pain and foreign body sensation. Anterior segment evaluation revealed a large corneal epithelial defect with an adjacent area of loose conjunctival tissue. Ocular history included a pterygium in the same area of the defect. Subsequent follow-up revealed a regrowth of the pterygium at the exact location.

CONCLUSIONS

Strong tension imposed on the cornea by a pterygium could result in auto-avulsion of the lesion. The resulting corneal defect can then be treated accordingly. Recurrent pterygium is possible without adjunctive therapy, such as those seen with bare sclera excision.

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.

Does topical bevacizumab prevent postoperative recurrence after pterygium surgery with conjunctival autografting?

AIM

To assess the effect of topical bevacizumab use on postoperative pterygium recurrence in eyes who underwent pterygium excision with limbal-conjunctival autograft transplantation (LCAT).

METHODS

Eighty-eight eyes of 88 patients with primary pterygium were included. Pterygia were graded preoperatively from type 1 to type 3 (type 1 atrophic, type 3 inflamed) according to the inflammatory status. The eyes were preoperatively randomized to receive topical steroid and antibiotic treatment (group 1, 46 eyes) and additional topical bevacizumab (5 mg/mL; group 2, 42 eyes) in the postoperative period. All eyes underwent pterygium excision and LCAT. Medications were tapered and discontinued at one month. Postoperative complications and recurrence rates were recorded.

RESULTS

The mean follow-up duration was 29.3±4.2mo (24-52mo) and 28.5±3.4 (24-48mo) in group 1 and 2, respectively (P>0.05). There were no statistically significant differences regarding the age or gender between groups (P>0.05). Also, the difference between groups with respect to pterygium type was not significant. During the follow-up period, recurrence developed in 2 eyes (4.3%) in group 1, whereas in one eye (2.4%) in group 2. No statistically significant difference between groups was found in recurrence rates (P>0.05). No re-operation for recurrence was necessary during the follow-up period in both groups.

CONCLUSION

Topical bevacizumab seems to have no additonal effect on pterygium recurrence after LCAT.

An update on the surgical management of pterygium and the role of loteprednol etabonate ointment

Pterygium, a sun-related eye disease, presents as wing-shaped ocular surface lesions that extend from the bulbar conjunctiva onto the cornea, most commonly on the nasal side. Pterygia show characteristic histological features that suggest that inflammation plays a prominent role in their initial pathogenesis and recurrence. Appropriate surgery is the key to successful treatment of pterygia, but there is also a rationale for the use of anti-inflammatory agents to reduce the rate of recurrence following surgery. Multiple surgical techniques have been developed over the last two millennia, but these initially had little success, due to high rates of recurrence. Current management strategies, associated with lower recurrence rates, include bare sclera excision and various types of grafts using tissue glues. Adjunctive therapies include mitomycin C and 5-fluorouracil, as well as the topical ocular steroid loteprednol etabonate, which has been shown to have a lower risk of elevated intraocular pressure than have the other topical ocular steroids. Here, the surgical management of pterygium is presented from a historical perspective, and current management techniques, including the appropriate use of various adjunctive therapies, are reviewed, along with an illustrative case presentation and a discussion of the conjunctival forceps designed to facilitate surgical management. Despite thousands of years of experience with this condition, there remains a need for a more thorough understanding of pterygium and interventions to reduce both its incidence and postsurgical recurrence. Until that time, the immediate goal is to optimize surgical practices to ensure the best possible outcomes. Loteprednol etabonate, especially the ointment formulation, appears to be a safe and effective component of the perioperative regimen for this complex ocular condition, although confirmatory prospective studies are needed.

Prevalence and risk factors for pterygium in rural older adults in Shandong Province of China: a cross-sectional study

To investigate the prevalence and risk factors for pterygium in rural older adults in Shandong Province, eastern China, a population-based, cross-sectional study was performed from April to July 2008. By means of cluster random sampling methods, a total of 19,583 people aged 50 years or above were randomly selected from four rural counties. Out of 19,583 people, 1,767 residents were excluded mainly because they were migrant workers when this study was performed. Finally, 17,816 (90.98%) people were included as eligible subjects. They received a comprehensive eye examination and a structured questionnaire voluntarily. Patients with pterygium were defined as having pterygium at the time of survey or pterygium surgery had been performed. 1,876 people were diagnosed as pterygium, either unilateral (1,083) or bilateral (793), which is equivalent to a prevalence of 10.53% (95% CI, 10.08–10.98). The multivariate logistic regression analysis showed that pterygium was independently associated with older age, areas, outdoor time, educational level, and use of hat and/or sunglasses. The prevalence of pterygium increased with age and hours spent under sunshine per day. Meanwhile, the higher the educational level and the more use of hat and/or sunglasses, the lower the pterygium prevalence.

A comparison of anchored conjunctival rotation flap and conjunctival autograft techniques in pterygium surgery

PURPOSE

To compare conjunctival autograft and anchored conjunctival rotation flap techniques, in terms of recurrence and complication rates, after performing a primary pterygium surgery.

METHODS

Sixty patients who underwent pterygium surgery, which was performed on 1 eye (M:F = 25:35), either using conjunctival autograft (25 eyes) or anchored conjunctival rotation flap (35 eyes) techniques, were followed up postoperatively for a minimum period of 18 months. The anchored conjunctival rotation flap surgery was conducted by designing a conjunctival flap with a similar shape as that of the autograft, but with the preservation of the inferior limbal anchoring point (1 mm) by the incomplete cutting of the limbal area. After rotation of the flap around the anchoring point, the flap was tightened with sutures to cover the bare scleral area. Early postoperative complications, such as flap or graft edema and granuloma formation, were assessed. The recurrence rate of pterygium was evaluated, and a comparison was made between the 2 surgical techniques.

RESULTS

The recurrence rate was 8.0% in the conjunctival autograft group and 8.6% in the anchored conjunctival rotational flap group (P = 0.659). However, the occurrence of flap or graft edema was lower for anchored conjunctival rotational flap surgery (14.3% vs. 72.0%, P < 0.001). No granuloma formation was observed in either group.

CONCLUSIONS

The anchored conjunctival rotational flap surgery showed similar pterygium recurrence rates and a lower incidence of flap edema, while enabling simple recognition of flap orientation, compared with the conjunctival autograft technique.

Effect of pterygium surgery on tear osmolarity

Purpose. To investigate changes of dry eye test results in patients who underwent pterygium surgery. Methods. Seventy-four patients who underwent primary pterygium surgery were enrolled in this study. At the baseline, 3-, 12-, and 18-month visits, measurements of tear osmolarity, BUT, and Schirmer test were performed. The patients were divided into 2 groups: Group 1, which consisted of patients in whom pterygium did not recur, and Group 2, which consisted of patients in whom pterygium recurred after surgery. Results. The patients in Group 1 had lower tear osmolarity levels after surgery than those at baseline (all P < 0.001). In Group 2 the tear osmolarity levels did not differ from baseline after 18 months (P = 0.057). The prevalence rates of dry eye syndrome (DES) were lower than that at baseline and 18 months after surgery in Group 1 (P = 0.002). In Group 2, the incidence of DES was lower after 3 months than at baseline (P = 0.03) but was similar to the baseline rate after 12 and 18 months (both P > 0.05). Conclusions. Anormal tear film function associated with pterygium. Pterygium excision improved tear osmolarity and tear film function. However, tear osmolarity deteriorated again with the recurrence of pterygium.