Treatment of Primary Pterygium

Characteristics and recurrence of pterygium in Saudi Arabia: a single center study with a long follow-up

Background

This study described the clinical features of patients with pterygium and analyzed the recurrence rate of conjunctival autografting alone, conjunctival autografting combined with intraoperative mitomycin C, and amniotic membrane grafting.

Methods

A retrospective cohort study of primary pterygium was conducted between January 2017 and February 2020. Factors associated with pterygium severity and recurrence were analyzed by univariate analysis and logistic regression models.

Results

The study included 292 patients with an average age of 53.3 ± 14.1 years, while the number of operated cases was 94. Pterygia involving the cornea were observed in 55 % of the cases. The overall rate of recurrence for the three procedures was 17 %. The average time of recurrence was 14.2 ± 11.9 months, with 37 % of the recurrences occurring after the first year. The only factor associated with a significant risk of recurrence was dry eye disease in both univariate (p = 0.021) and multivariate analysis (p = 0.026). The recurrence rates following conjunctival autografting with and without mitomycin C were 15.6 and 15.8 %, respectively. The recurrence rate following the amniotic membrane graft was  twofold (OR= 2.02)  (27 %) that following the conjunctival autograft (15.8 %).

Conclusions

The only factor associated with the recurrence of pterygium was dry eye disease. More than one-third of recurrences developed after the first year, which stresses the importance of a long follow-up. The recurrence rate in our study following conjunctival graft was slightly higher compared to the literature mainly due to differences in study areas, populations, and follow-up periods.

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.

Conjunctival autograft for pterygium

BACKGROUND

A pterygium is a fleshy, wing-shaped growth from the conjunctiva, crossing over the limbus onto the cornea. Prevalence ranges widely around the world. Evidence suggests that ultraviolet light is a major contributor in the formation of pterygia. Pterygia impair vision, limit eye movements, and can cause eye irritation, foreign body sensation, and dryness. In some susceptible patients, the pterygium can grow over the entire corneal surface, blocking the visual axis.Surgery is the only effective treatment for pterygium, though recurrences are common. With simple excision techniques (that is, excising the pterygium and leaving bare sclera), the risk of recurrence has been reported to be upwards of 80%. Pterygium excision combined with a tissue graft has a lower risk of recurrence. In conjunctival autograft surgery, conjunctival tissue from another part of the person's eye along with limbal tissue is resected in one piece and used to cover the area from which the pterygium was excised. Another type of tissue graft surgery for pterygium is amniotic membrane graft, whereby a piece of donor amniotic membrane is fixed to the remaining limbus and bare sclera area after the pterygium has been excised.

OBJECTIVES

The objective of this review was to assess the safety and effectiveness of conjunctival autograft (with or without adjunctive therapy) compared with amniotic membrane graft (with or without adjunctive therapy) for pterygium. We also planned to determine whether use of MMC yielded better surgical results and to assess the direct and indirect comparative costs of these procedures.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (Issue 10, 2015), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to November 2015), EMBASE (January 1980 to November 2015), PubMed (1948 to November 2015), Latin American and Caribbean Health Sciences Literature Database (LILACS) (1982 to November 2015), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com) (last searched 21 November 2014), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic search for trials. We last searched the electronic databases on 23 November 2015.

SELECTION CRITERIA

We included in this review randomized controlled trials that had compared conjunctival autograft surgery (with or without adjunctive therapy) with amniotic membrane graft surgery (with or without adjunctive therapy) in people with primary or recurrent pterygium.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search results and assessed full-text reports from among the potentially eligible trials. Two review authors independently extracted data from the included trials and assessed the trial characteristics and risk of bias. The primary outcome was the risk of recurrence of pterygium at 3 months and 6 months after surgery. We combined results from individual studies in meta-analyses using random-effects models. Risk of recurrence of pterygium was reported using risk ratios to compare conjunctival autograft with amniotic membrane transplant.

MAIN RESULTS

We identified 20 studies that had analyzed a total of 1947 eyes of 1866 participants (individual studies ranged from 8 to 346 participants who were randomized). The studies were conducted in eight different countries: one in Brazil, three in China, three in Cuba, one in Egypt, two in Iran, two in Thailand, seven in Turkey, and one in Venezuela. Overall risk of bias was unclear, as many studies did not provide information on randomization methods or masking to prevent performance and detection bias.The risk ratio for recurrence of pterygium using conjunctival autograft versus amniotic membrane transplant was 0.87 (95% confidence interval (CI) 0.43 to 1.77) and 0.53 (95% CI 0.33 to 0.85) at 3 months and 6 months, respectively. These estimates include participants with primary and recurrent pterygia. We performed a subgroup analysis to compare participants with primary pterygia with participants with recurrent pterygia. For participants with primary pterygia, the risk ratio was 0.92 (95% CI 0.37 to 2.30) and 0.58 (95% CI 0.27 to 1.27) at 3 months and 6 months, respectively. We were only able to estimate the recurrence of pterygia at 6 months for participants with recurrent pterygia, and the risk ratio comparing conjunctival autograft with amniotic membrane transplant was 0.45 (95% CI 0.21 to 0.99). One included study was a doctoral thesis and did not use allocation concealment. When this study was excluded in a sensitivity analysis, the risk ratio for pterygium recurrence at 6 months' follow-up was 0.43 (95% CI 0.30 to 0.62) for participants with primary and recurrent pterygium. One of the secondary outcomes, the proportion of participants with clinical improvement, was analyzed in only one study. This study reported clinical outcome as the risk of non-recurrence, which was seen in 93.8% of participants in the conjunctival limbal autograft group and 93.3% in the amniotic membrane transplant group at 3 months after surgery.We did not analyze data on the need for repeat surgery, vision-related quality of life, and direct and indirect costs of surgery due to an insufficient number of studies reporting these outcomes.Thirteen studies reported adverse events associated with conjunctival autograft surgery and amniotic membrane transplant surgery. Adverse events that occurred in more than one study were granuloma and pyogenic granuloma and increased intraocular pressure. None of the included studies reported that participants had developed induced astigmatism.

AUTHORS' CONCLUSIONS

In association with pterygium excision, conjunctival autograft is associated with a lower risk of recurrence at six months' after surgery than amniotic membrane transplant. Participants with recurrent pterygia in particular have a lower risk of recurrence when they receive conjunctival autograft surgery compared with amniotic membrane transplant. There are few studies comparing the two techniques with respect to visual acuity outcomes, and we identified no studies that reported on vision-related quality of life or direct or indirect costs. Comparison of these two procedures in such outcome measures bears further investigation. There were an insufficient number of studies that used adjunctive mitomycin C to estimate the effects on pterygium recurrence following conjunctival autograft or amniotic membrane transplant.

Comparison of conjunctival graft thickness after primary and recurrent pterygium surgery: anterior segment optical coherence tomography study

OBJECTIVE

The objective of the following study is to compare the conjunctival graft thickness measured with anterior segment optical coherence tomography (OCT) after primary and recurrent pterygium excision.

DESIGN

Prospective, interventional and comparative study.

PARTICIPANTS

A total of 20 eyes of 20 patients with primary pterygium (primary group) and 20 eyes of 20 patients with recurrent pterygium (recurrent group) were enrolled.

MATERIALS AND METHODS

All patients underwent pterygium excision with conjunctival autograft transplantation. Conjunctival graft thickness was measured at 1 week, 1 month and 3 months after surgery using the Visante-OCT (Carl-Zeiss Meditec, Dublin, CA, USA). Main outcome measure was the mean conjunctival thickness determined as the mean of three measurements at 1, 2 and 3 mm posterior to the scleral spur.

RESULTS

There were no statistically significant differences in age, sex, or laterality between the groups. Mean thickness of the graft in primary and recurrent groups, respectively, was 430 ± 127 μm and 461 ± 178 μm at 1 week after surgery (P = 0.587), 114 ± 19 μm and 162 ± 48 μm at 1 month after surgery (P = 0.001) and 109 ± 15 μm and 107 ± 18 μm at 3 months after surgery (P = 0.726).

CONCLUSION

The findings revealed that conjunctival thickness after primary or recurrent pterygium excision was greatest at 1 week after surgery and continued to decrease for up to 3 months. Mean graft thickness differed significantly between the two groups only at 1 month after surgery.

Combined conjunctival autograft and overlay amniotic membrane transplantation; a novel surgical treatment for pterygium

The authors report the long-term results of combined conjunctival autograft and overlay amniotic membrane transplantation (AMT) for treatment of pterygium as a new surgical technique. Nineteen patients including 12 male and 7 female subjects with pterygium (primary, 14 cases; recurrent, 5 cases) underwent combined conjunctival autograft and overlay AMT and were followed from 10 to 26 months. Mean age was 44.21±12.49 (range, 29.0-73.0) years. In one patient with grade T3 primary pterygium, the lesion recurred (5.2%, recurrence rate). No intra-and postoperative complication developed. This procedure seems a safe and effective surgical technique for pterygium treatment. Protection of the ocular surface during the early postoperative period reduces the friction-induced inflammation and might be helpful to prevent the recurrence.

Threshold to predict astigmatism reduction after pterygium excision

PURPOSE

To compare corneal astigmatism after pterygium excision, using limbal-conjunctival autograft (LCA) with and without mitomycin C (MMC) and to establish a threshold for postoperative astigmatism reduction.

METHODS

Sixty-eight eyes with primary pterygium were consecutively sampled and assigned to LCA with MMC (MMC+) or LCA without MMC (MMC-). Corneal lesion length, corneal lesion area, preoperative corneal astigmatism (PRCA), and postoperative corneal astigmatism (POCA) at 1, 3, and 6 months were assessed.

RESULTS

Thirty-six men and 24 women (60 eyes), aged between 24 and 65 years (mean ± SD, 41 ± 8.2 years), completed the study. Thirty-one eyes were included in the MMC+ group and 29 were in the MMC- group. Both groups showed astigmatism reduction (p < 0.05; paired, two-tailed t test) 1 month after the surgery and remained stable. No differences were found between groups in corneal lesion length, corneal lesion area, or astigmatism results at the four time points (p > 0.05, independent t test). Preoperative corneal astigmatism showed a significant correlation with POCA at 6 months (r = 0.529; p < 0.01). According to receiver operating characteristic curve analysis, the better threshold for astigmatism reduction with the surgery was 1.05 diopters of PRCA, with 82.5% sensitivity and 80.5% specificity.

CONCLUSIONS

Both surgical procedures could have similar astigmatism results. Pterygium patients with more than 1.05 diopters of PRCA could reduce it after the surgery. Direct relationship between PRCA and POCA revealed that postoperative astigmatism reduction was partial. Therefore, for minimizing final astigmatism, preoperative values should be slightly above the threshold.

Inferior conjunctival autografting for pterygium surgery: an alternative way of preserving the glaucoma filtration site in far western Nepal

BACKGROUND

The purpose of this study was to evaluate the outcome of pterygium excision with inferior conjunctival autografting for primary pterygium.

METHODS

This was a prospective noncomparative interventional case series study enrolling 50 eyes of 50 patients with primary pterygium between November 1, 2010 and October 30, 2011. All patients underwent the standard surgical technique for pterygium excision with inferior conjunctival autografting. The sampling method was purposive. The study variables were complications of surgery and recurrence rates during a follow-up period of 6 months.

RESULTS

The mean age of the patients was 43 ± 7.97 (range 26-64) years. Grade 1 pterygium comprised 64% while grade 2 pterygium comprised 36% of cases. The mean size of pterygium was 3.2 ± 0.60 mm. Minor complications did occur, but only 4% required resuturing. Recurrence occurred in two eyes (4%) which we detected 3 months after surgery in both cases. We observed conjunctival scarring at the donor site in four eyes (8%); however, there was no symblepharon formation or restriction of upgaze.

CONCLUSION

Inferior conjunctival autografting is an effective technique with a low recurrence rate. This is a useful technique when it is not possible or desirable to use the superior conjunctiva as a donor source. It is an especially good option for preserving the glaucoma filtration site for the future.

Postoperative conjunctival inflammation after pterygium surgery with amniotic membrane transplantation versus conjunctival autograft

PURPOSE

To compare the postoperative conjunctival inflammation around the surgical site after pterygium surgery using either amniotic membrane transplantation (AMT) or free conjunctival autograft.

DESIGN

Prospective, randomized, interventional study.

METHODS

Forty-two eyes of 42 patients with primary pterygium underwent surgical excision followed by removal of subconjunctival fibrovascular tissue and intraoperative application of 0.02% mitomycin C. Then, the patients were randomized to receive either AMT (21 eyes) or free conjunctival autograft (21 eyes), with sutures used in both groups. Main outcome measures included presence of host conjunctival inflammation around the surgical site at 1 month after surgery and also recurrence of pterygium.

RESULTS

Twelve-month follow-up was completed in 39 eyes of 39 patients (19 in the AMT group and 20 in the conjunctival autograft group). At 1 month after surgery, different grades of host conjunctival inflammation were present in 16 eyes (84.2%) in the AMT group and in 3 eyes (15%) in the conjunctival autograft group (P = .02). Subconjunctival injection of triamcinolone was performed in eyes with moderate or severe inflammation, which included 12 eyes (63.1%) in the AMT group and 2 eyes (10%) in the conjunctival autograft group (P < .001). Conjunctival recurrence of pterygium was seen in 2 eyes (10.5%) in the AMT group and in 2 eyes (10%) in the conjunctival autograft group (P = .92). After surgery, pyogenic granuloma developed in 3 eyes (15.8%) in the AMT group and in 1 eye (5%) in the conjunctival autograft group (P = .31).

CONCLUSIONS

After pterygium surgery, conjunctival inflammation was significantly more common with AMT than with conjunctival autograft. However, with control of such inflammation and intraoperative application of mitomycin C, similar final outcomes were achieved with both techniques.

Comparison of conjunctival autograft transplantation and amniotic membrane transplantation for pterygium: a meta-analysis

BACKGROUND

Conjunctival autograft transplantation (CAT) and amniotic membrane transplantation (AMT) are two widely used techniques for pterygium treatment. However, previous studies comparing the outcomes of CAT and AMT have generally had small sample sizes and conflicting results. The aim of this report was to evaluate and comment on peer-reviewed literature for evidence of effectiveness and safety of CAT and AMT for management of pterygium.

METHODS

Studies comparing outcomes of CAT and AMT for pterygium treatment were identified by searching PubMed, Embase, Web of Knowledge, and a search of all references in relevant papers. Two reviewers confirmed study eligibility and extracted data independently, and data were pooled using standard meta-analysis techniques.

RESULTS

Five eligible studies reporting outcomes in 538 eyes were included. The pooled hazard ratio (HR) estimate for recurrence of CAT compared to AMT was 0.30 (95% confidence interval (CI) [0.16, 0.59], p < 0.001) and 0.22 (95%CI [0.02, 2.37], p = 0.214), respectively, for primary and recurrent pterygium. For unacceptable appearance, the pooled HR estimate was 0.33 (95% CI [0.16, 0.66], p = 0.002). There were no statistically significant differences in adverse events (odds ratio (OR) = 0.96, 95% CI [0.46, 1.97], p = 0.901).

CONCLUSIONS

Available trials indicate that CAT has lower recurrence risk compared to AMT for primary pterygium treatment, as well as lower risk of unacceptable appearance risk.

Novel sutureless transplantation for primary pterygium associated with cysts

AIM

To evaluate the efficacy and safety of a novel sutureless AMT (amniotic membrane transplantation) or CAT (conjunctivolimbal autograft transplantation) using fibrin glue for reconstructing corneoconjunctival surfaces for primary pterygium associated with cysts.

METHODS

A prospective descriptive study was made of the period 1 January 2006-1 May 2009. Nine patients with primary pterygium associated with cysts underwent pterygium and cyst excision followed by sutureless AMT or CAT using fibrin glue.

RESULTS

During a mean follow-up of 8.00±0.67 months, all eyes maintained a smooth and stable corneal epithelial surface without recurrent erosion or persistent epithelial defect. The limbal donor site showed the presence of mild depressions without the formation of pseudopterygium. All eyes have good tear secretion function, tear film stability and ocular motility.

CONCLUSION

Sutureless transplantation using fibrin glue is safe and effective for restoring a stable corneoconjunctival epithelium in primary pterygium associated with cysts.