Amniotic membrane transplantation after extensive removal of primary and recurrent pterygia

Collagen-Based Artificial Cornea for Lamellar Keratoplasty: An Early Case Report

PURPOSE

The aim of this study was to evaluate Viscoll collagen membrane (VCM) for lamellar keratoplasty.

METHODS

A 54-year-old man with grade 4 recurrent pterygium underwent lamellar keratoplasty using VCM as the graft material. Standard keratoplasty postoperative treatments, including topical antibiotic-corticosteroid and artificial tears, were administered.

RESULTS

Complete graft epithelialization was achieved after 4 days of the surgery. Follow-up at 9 months showed no pterygium recurrence as well as good integration of the VCM graft into the surrounding tissues with preserved transparency.

CONCLUSIONS

This case demonstrated that VCM possesses great potential as an alternative to the human donor cornea for lamellar keratoplasty; however, the application of VCM for lamellar keratoplasty still needs additional evaluation.

Comparative Evaluation of Surgical Techniques for Pterygium Management: An In Vitro Study

Background

Pterygium is a common ocular surface disorder characterized by the growth of fibrovascular tissue onto the cornea, leading to discomfort and visual impairment. Various surgical techniques, including conjunctival autografting, amniotic membrane transplantation, and bare sclera excision, are employed in the management of pterygium.

Materials and Methods

Cultured human conjunctival epithelial cells were subjected to simulated pterygium conditions, mimicking the fibrovascular proliferation observed in vivo. Subsequently, different surgical techniques, including conjunctival autografting, amniotic membrane transplantation, and bare sclera excision, were simulated in vitro. Cell viability, proliferation, migration, and inflammatory cytokine expression were assessed using various assays, including MTT assay, scratch assay, and enzyme-linked immunosorbent assay (ELISA). Untreated cells served as controls for comparison.

Results

Conjunctival autografting demonstrated superior outcomes in terms of cell viability and proliferation compared to amniotic membrane transplantation and bare sclera excision. Autografted cells exhibited a significantly higher percentage of viable cells and enhanced proliferative capacity compared to cells subjected to other surgical techniques (P < 0.05). Additionally, conjunctival autografting promoted faster cell migration into the defect area, resulting in more rapid wound closure compared to other techniques. Furthermore, reduced expression of inflammatory cytokines, such as interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α), was observed in cells treated with conjunctival autografts compared to other groups.

Conclusion

In vitro findings suggest that conjunctival autografting may offer superior outcomes in the management of pterygium compared to amniotic membrane transplantation and bare sclera excision.

Study of biomarkers p53, Ki-67, Bcl-2, and VEGF in pterygium

PURPOSE

To study the biomarkers present in primary pterygium samples of patients of Indian ethnicity and compare it with the samples obtained from the unaffected conjunctiva of the same eye.

METHODS

A prospective case-control study of 17 eyes in patients above 10 years of age with primary pterygium who underwent pterygium excision using limbal conjunctival autograft technique. The pterygium samples (cases) and conjunctival samples (controls) were sent for immunohistochemical (IHC) staining for the following biomarkers: p53, Bcl-2, Ki-67, and vascular endothelial growth factor (VEGF).

RESULT

The immunohistochemistry of the samples and the controls revealed p53 positivity in 47.05% of pterygium samples and 29.4% of controls ( P < 0.587). Nine cases each in pterygium and control samples were positive for Ki-67 expression. Differences in the staining pattern between the two groups were not statistically significant ( P < 1.000). Bcl-2 positivity was seen in 10 pterygium samples (58.8%) and 12 controls (70.5%), with no statistical difference between the two groups ( P < 0.455). VEGF expression was seen in both epithelial and endothelial cells of the samples and controls, with no statistical difference between the two groups, with P = 1.000 for the epithelial staining and P = 0.637 for endothelial staining.

CONCLUSION

The expression of biomarkers was comparable in both groups. We conclude that pterygium, against common belief, might not be a localized disease process but a global ocular phenomenon where the apparently healthy tissue also has some ongoing disease process at a molecular level.

Snatching: A modified cosmetic technique in pterygium surgery without using scalpel

AIM

To evaluate the cosmetic surgical outcomes of primary corneal pterygia excision using the avulsion (snatching) technique.

METHODS

A prospective, interventional study included twenty-five eyes of 25 patients with primary pterygium underwent excision were followed up for at least 6 months. In all patients, snatching (modified avulsion) technique was utilised to avulse the pterygium head off the corneal surface and remove any residual fibres by Colibri without need for keratectomy with a scalpel.

RESULTS

The study involved 25 eyes of 25 patients with an average age of 42.5±56.5 years. The mean follow-up was 6 months. One-week post-op, 8 patients (32%) reported they can tell which is the operated eye but looked untouched while 17 (68%) patients reported that the operated eye looked red but is accepted. Twenty patients (80%) reported some discomfort while the remaining 5 patients (20%) reported no discomfort. Cornea examination showed a clear cornea in 18 eyes (72%), 6 eyes (24%) had mild keratitis, and 1 eye (4%) had clouding at the surgical site. Over an average of six months post-op follow-up period, all the patients (100%) reported they cannot tell which eye had the surgery and none (0%) of them reported discomfort. Examination of the cornea was clear in 24 (96%) eyes, but 1 (4%) eye had mild keratitis.

CONCLUSION

Snatching (modified avulsion) technique was found to be effective, safe, and presents decent aesthetic appearance for the management of primary corneal pterygia when safety points are firmly followed.

Surgical Time and Postoperative Symptoms Study in Pterygium Excision and Amniotic Membrane Graft Using Celularity Triple Layer Dehydrated Amniotic Membrane

Purpose

To evaluate a novel sutureless glueless technique using a triple-layer dehydrated amniotic membrane (TLDAM) for pterygia excisions in surgical time, postoperative pain, epiphora, irritation, and FBS.

Methods

Twenty eyes with pterygia underwent excision with mitomycin C. The conjunctival defect was closed with TLDAM placed on the dried scleral bed with the edges of the amniotic membrane tucked under the edges of the conjunctival defect. Surgical times were measured from injection of lidocaine to final placement of bandage contact lens. After a bandage contact lens was placed, the eye was patched until POD1. Patients graded self-administered questionnaires to rate pain, FBS, irritation, and epiphora on a scale of 1-5 (1-none; 5-severe) at POD1 and POW1.

Results

Surgical times ranged from 6:55 to 12:00, with mean of 8:29. Compared with a previous study of sutureless glueless methodology, the difference in mean surgical time was 11.9 (p < 0.0001). Mean questionnaire scores were as follows: POD1 pain 1.8, FBS 2.3, irritation 1.0, and epiphora 2.6; POW1 pain 1.5, FBS 1.6, irritation 1.6, and epiphora 1.6. Compared to previous studies, this technique showed significantly improved pain at POD1 (p=0.0086, p<0.0001, p<0.0001, p<0.0001) and POW1 (p=0.0002, p=0.0016, p<0.0001). Significant improvement in irritation and FBS was noted at POD1 and POW1. See Table 1 for full analysis.

Conclusion

The sutureless glueless technique using TLDAM is a safe and effective technique compared to current standard methods. There appears to be a significant benefit regarding surgical time and postoperative pain, irritation, epiphora, and FBS compared to previous studies.

Cryopreserved Amniotic Membrane Using the TissueTuck Technique: A Sutureless Approach for Pterygium Surgery

PURPOSE

The purpose of this study was to evaluate the clinical outcomes of the TissueTuck technique in the management of pterygium.

METHODS

This was a single-center, retrospective review of patients with primary or recurrent pterygium that underwent surgical excision followed by application of cryopreserved amniotic membrane (AM) using the TissueTuck technique. All patients underwent surgery between January 2012 and May 2019. Patient profile, surgical time, complications, and rates of pterygium recurrence were analyzed.

RESULTS

A total of 582 eyes of 453 patients (328 female patients; 65.1 ± 13.9 years) were included for analysis and initially presented with primary (92%) pterygium. The average duration of pterygium excision surgery was 14.7 ± 5.2 minutes (median: 14, range: 4-39 minutes) with mitomycin C administration in 257 (45%) eyes. At the last follow-up of 30.2 ± 22.2 months (median: 24.5, range: 3-94 months), BCVA significantly improved from logMAR 0.23 at baseline to logMAR 0.19 ( P < 0.0001). Recurrence rate was 2.3% but only 0.7% (2/274) in those cases with primary, single-headed pterygium without mitomycin C treatment. Other postoperative complications in that cohort included granuloma (7.9%), scarring (3.8%), and diplopia in extreme lateral gaze (2.5%). The AM remained secured to the ocular surface throughout the postoperative period.

CONCLUSIONS

The TissueTuck surgical technique with cryopreserved AM can be performed in minimal time and result in a low recurrence and complication rate after pterygium surgery.

Biological properties and surgical applications of the human amniotic membrane

The amniotic membrane (AM) is the inner part of the placenta. It has been used therapeutically for the last century. The biological proprieties of AM include immunomodulatory, anti-scarring, anti-microbial, pro or anti-angiogenic (surface dependent), and tissue growth promotion. Because of these, AM is a functional tissue for the treatment of different pathologies. The AM is today part of the treatment for various conditions such as wounds, ulcers, burns, adhesions, and skin injury, among others, with surgical resolution. This review focuses on the current surgical areas, including gynecology, plastic surgery, gastrointestinal, traumatology, neurosurgery, and ophthalmology, among others, that use AM as a therapeutic option to increase the success rate of surgical procedures. Currently there are articles describing the mechanisms of action of AM, some therapeutic implications and the use in surgeries of specific surgical areas, this prevents knowing the therapeutic response of AM when used in surgeries of different organs or tissues. Therefore, we described the use of AM in various surgical specialties along with the mechanisms of action, helping to improve the understanding of the therapeutic targets and achieving an adequate perspective of the surgical utility of AM with a particular emphasis on regenerative medicine.

Sandwich (Amnion/Conjunctival-Limbal Autograft/Amnion) Transplantation for Recurrent Pterygium with Restrictive Strabismus

(1) Background: This study aimed to evaluate the clinical outcome of Sandwich (Amnion/Conjunctival-Limbal Autograft/Amnion) transplantation for recurrent pterygium with restrictive strabismus. (2) Methods: This retrospective study included 11 eyes in 11 patients diagnosed with recurrent pterygium with restrictive strabismus who received sandwich transplantation. The outcomes were measured by pterygium recurrence, best-corrected visual acuity, esotropia (prism diopters), and treatment complications. (3) Results: Eleven patients (six males, five females) had a mean age of 60.5 (range 36-80) years. The previously received pterygium excision surgery number was 1.8 ± 1.02 (range 1-4). The mean follow-up period was 19.9 ± 8.41 (range 12-36) months. All patients had a restriction of abduction in the previously operated eye, causing esotropia in the primary position. Pre-operative esotropia was 17.2 (range 10-30) prims diopter (PD). Five eyes (45.5%) had symblepharon before surgery. All patients were orthotropic until the last follow-up. Symblepharon was released in all eyes. Free ocular motility was present in all eyes. No donor site scar formation, scleral melt, or corneal ulcer was noted. (4) Conclusions: Sandwich transplantation for recurrent pterygium with restrictive strabismus is safe and effective.

5-Fluorouracil in primary, impending recurrent and recurrent pterygium: Systematic review of the efficacy and safety of a surgical adjuvant and intralesional antimetabolite

Pterygium is an ultraviolet-related disease characterized by an aberrant, wing-shaped and active wound-healing process. There is nothing quite as disheartening for the surgeon or patient as the recurrence of pterygium, and various adjuvants have been studied to ameliorate this. This systematic review provides a comprehensive summary of the efficacy and safety of 5-Fluorouracil (5-FU) as an antimetabolite agent for pterygium management. An appraisal of electronic searches of six databases identified 34 clinical studies reporting recurrence outcomes of 5-FU use in primary, impending recurrent and recurrent pterygia. In vitro and in vivo studies of 5-FU showed dose- and duration-dependent cytostatic and cytotoxic effects in human cells. 5-FU is relatively inexpensive, available, and easy to administer, making it attractive for resource-limited scenarios. However, the published evidence demonstrates a recurrence rate of 11.4-60% with the bare scleral technique, 3.5-35.8% with conjunctival rotational flaps, 3.7-9.6% with conjunctival autografts for intraoperative topical 5-FU, and 14-35.8% for preoperative and intraoperative injections. This suboptimal efficacy brings the role of 5-FU as an adjuvant for pterygium surgery into question and the authors do not recommend its use. In contrast, postoperative intralesional injections of 5-FU to arrest progression in impending recurrent pterygium and true recurrent pterygia were more promising, with success rates of 87.2-100% and 75-100%, respectively. Furthermore, 5-FU as a treatment modality, without surgery, effectively arrested progression in 81.3-96% of primary and recurrent pterygia. Other treatments such as topical and intralesional corticosteroids, cyclosporine and anti-VEGF agents are discussed. Complications of 5-FU increase with higher doses and range from transient and reversible to severe and sight-threatening. For pterygium, 5-FU has a predilection for causing scleral thinning, corneal toxicity, and graft-related complications. Additional study with extended follow-up is needed to elucidate the optimal dose, frequency, duration, and long-term safety of 5-FU injections. If 5-FU is used in the management of pterygium, it should be with caution, in selected patients and with vigilant long-term monitoring.

Autologous simple conjunctival epithelial transplantation for primary pterygium

PURPOSE

To evaluate the feasibility of a new method of conjunctival transplantation to achieve recovery of the normal conjunctival epithelium over the bare sclera after pterygium excision and prevent its recurrence.

METHODS

After excision of the primary pterygium, we performed simple conjunctival epithelial transplantation (SCET) in which we glued an amniotic membrane patch pre-loaded with tiny autologous conjunctival tissue fragments over the scleral defect. Slit-lamp evaluation was performed at 2 and 7-10 days, and then at 1, 3, 6, and 12 months after surgery, together with confocal microscopy at 3, 6, and 12 months.

RESULTS

Surgical excision and SCET for nasal primary pterygium were performed in 6 eyes (6 patients). No graft detachment occurred. An inflammatory granuloma was excised without sequelae in one patient 2 months after surgery. No signs of recurrence or sight-threatening complications were recorded at 12 months, and in vivo confocal microscopy showed progressive expansion of the conjunctival cell population and formation of a clear corneal-conjunctival transition.

CONCLUSIONS

SCET takes advantage of the ability of the amniotic membrane and conjunctival cells to renew. Outcomes after SCET are comparable to conventional conjunctival flap surgery and can be achieved in less surgical time and with less donor tissue to be removed.

Membrane of Plasma Rich in Growth Factors in Primary Pterygium Surgery Compared to Amniotic Membrane Transplantation and Conjunctival Autograft

This prospective and comparative study aimed to compare the use of a conjunctival autograft (CAG), plasma rich in growth factors fibrin membrane (mPRGF) or amniotic membrane transplantation (AMT) in primary pterygium surgery. Patients were assigned for surgery with CAG (group A), mPRGF (group B), or AMT (group C). Pterygium recurrence, Best Corrected Visual Acuity (BCVA), graft size (measured with anterior segment optical coherence tomography (AS-OCT)), and ocular surface symptoms (visual analogue scale (VAS) and ocular surface disease index (OSDI)) were evaluated. Thirteen eyes in group A, 26 in group B, and 10 in group C were evaluated. No changes in BCVA (p > 0.05) were found. Recurrence cases for groups A, B, and C were none, two, and two, respectively, and three cases of pyogenic granulomas in group A. The horizontal/vertical graft size was lower in group B vs group A (p < 0.05) from months 1 to 12. The improvement in VAS frequency for groups A, B, and C was: 35.5%, 86.2%, and 39.1%, respectively. The OSDI scale reduction for groups A, B, and C was: 12.7%, 39.0%, and 84.1%. The use of the three surgical techniques as a graft for primary pterygium surgery was safe and effective, showing similar results. The mPRGF graft represents an autologous novel approach for pterygium surgery.

Impact of fibrin glue versus suture closure on double-headed pterygia in Asian eyes - a 7-year study in a tertiary institution

BACKGROUND

To compare the recurrence rate and outcomes of double-headed pterygia using fibrin glue versus suture closure of conjunctival autograft.

METHODS

All patients with double-headed pterygia who underwent pterygia excision with conjunctival autograft from January 2012 to January 2019 in the National University Hospital of Singapore were included. Patients were divided into 2 groups depending on whether fibrin glue or sutures were used to secure the conjunctival autograft in place. All patients had a minimum of 6 months follow-up.

RESULTS

A total (26 patients) of 22 eyes had fibrin glue, while eight eyes underwent suture closure of their conjunctival autograft. Fibrin glue group had 4.5% recurrence rate, while suture group had 37.5% recurrence rate (p = .021). There is statistically significant improvement for overall visual acuity (p = .009) and cylinder (p = .002). There is also statistically significant improvement for visual acuity in the glue group (p = .026), but not in the suture group. Fibrin glue group had a shorter operation duration time compared to suture group (p < .001).There were no cases of graft dislocation, contraction or limbal stem cell deficiency.

CONCLUSIONS

Low recurrence rates and good postoperative visual outcomes can be achieved with the split conjunctival autograft technique. Our study suggests that fibrin glue has an additional benefit over the use of sutures in the management of these complex cases.

Progress in the use of plasma rich in growth factors in ophthalmology: from ocular surface to ocular fundus

Introduction: The use of blood derivatives and especially Plasma rich in growth factors (PRGF), for regenerative purposes has been a common trend along the last decades in the field of oral surgery, dermatology, orthopedics, and more recently in ophthalmology.Areas covered: PRGF is a type of platelet-rich plasma that is being explored for the treatment of ocular injuries. The present review article highlights 50 ophthalmology-related publications about the application of PRGF in the treatment of acute and chronic pathologies in ophthalmology as well as most relevant challenges and future prospects.Expert opinion: PRGF technology provides a wide range of formulations that can be used therapeutically in many different acute and chronic ocular pathologies. In addition to eye drops enriched with autologous growth factors, PRGF enables the preparation of both immunologically safe and fibrin-based formulations. Recent advances in the field have promoted PRGF storage for 12 months under freezing conditions, its daily use for 7 days at room temperature and the freeze-dried formulation. The thermally treated immunosafe formulation has shown promising clinical results for the treatment of several diseases such as Sjögren syndrome, graft versus host disease or cicatrizing conjunctivitis. In addition, several fibrin formulations have been preclinically evaluated and clinically incorporated as an adjuvant to ocular surface or glaucoma surgeries, dermal fat graft procedures, limbal stem cell expansion and retinal surgeries. The present review explores the latest scientific and clinical data, current challenges, and main prospects of this technology for the treatment of several ocular injuries.

Comparison of horizontal versus vertical split conjunctival autograft in the management of double head pterygium: A retrospective analysis

Purpose

To compare horizontal and vertical split conjunctival autograft technique in the management of double head pterygium.

Methods

Retrospective analysis of 96 and 99 eyes with double head pterygia that underwent horizontal (Group 1) and vertical (Group 2) split conjunctival autografting, respectively. Comparison of recurrence rates and other complications was done.

Results

Recurrence was seen in 5.2% and 4% of the eyes in Groups 1 and 2, respectively (P > 0.05). Other complications like subconjunctival hemorrhage, graft edema, graft retraction, granuloma, and graft loss were also comparable among the two groups.

Conclusion

Both the techniques provide good results with comparable efficacy in terms of rates of recurrence and complication profiles.

Update on the application of amniotic membrane in immune-related ocular surface diseases

Immune-related ocular surface diseases, a group of diseases in which immune dysregulation damages the ocular surface, can induce uncontrolled inflammation and persistent epithelial defect, thus leading to the most severe forms of acute keratoconjunctivitis, dry eye disease, epithelial keratitis, stromal ulceration, and corneal perforation. As these diseases are often refractory to treatments, they have a threatening impact on the vision and life quality of patients. This review summarizes the current literature regarding the clinical application of sutured and self-retained cryopreserved amniotic membrane (AM) in treating Stevens-Johnson syndrome/toxic epidermal necrolysis, ocular graft-versus-host disease, Sjögren's syndrome, Mooren's ulcer, and peripheral ulcerative keratitis. Current evidence supports the safety and effectiveness of AM, especially self-retained cryopreserved AM, in decreasing ocular surface inflammation, promoting corneal epithelial and stromal healing, improving visual acuity, and preventing sight-threatening complications. Future studies are still required to validate the above findings and explore the varied application methods of AM to improve the clinical efficacy in maintaining ocular surface health.

Role of Surgeon Experience in Pterygium Surgical Outcomes: A Comparative Study Between Ophthalmology Resident and Consultant

Purpose

Although surgical technique and patient variables are responsible for the recurrence of pterygium, the surgeon's experience has been sparsely studied. This retrospective study was designed to compare the surgical time, complications, and rates of recurrence after primary pterygium excision between consultant ophthalmologists and trainee residents.

Material and methods

In this retrospective study, we collected the data of 176 primary pterygium eyes, who were operated on with excision and sutureless/glueless conjunctival autograft either by the consultant (group A) or by the trainee (group B). The demographic profile, surgical time, complications, and recurrences between both groups were analyzed.

Results

Both the groups were comparable with regards to age, gender, religion, side of the eye, size of the pterygium, and duration of follow-up. The mean operative time was longer in group B (26.5+/-3.8 minutes) than group A (14.2+/-1.6 minutes). Though a relatively higher percentage of complications was observed in group B (12% vs. 9%), the difference was statistically not significant (Mann-Whitney U test, p-value 0.271). There was no statically significant difference in recurrence rate (6.8% vs 9.4%) between the groups.

Conclusion

With regards to the role of surgeon experience in primary pterygium excision using the sutureless and glueless conjunctival autografting technique, the residents did not have any statistically significant differences in their postoperative complications and recurrence rates. However, the surgical time was significantly higher in the resident group owing to the learning curve.

Comparison of inferior conjunctival autografting and conjunctival tissue grafting from pterygium itself in the cases of filtering blebs and glaucoma suspects-A retrospective analysis

PURPOSE

This study aims at comparing the effectiveness of inferior conjunctival autografting (CAG) and conjunctival tissue grafting from pterygium itself (CTG) in the cases of filtering blebs/glaucoma suspects.

METHODS

One hundered and five eyes of 97 patients who underwent pterygium excision with conjunctival autografting (CAG) in the period from 2010 to 2016 were included. Fifty one eyes had filtering blebs and 54 were glaucoma suspects. Fifty two eyes of 49 patients (Group 1) had undergone pterygium excision with inferior conjunctival autograft (CAG) and 53 eyes of 48 patients (Group 2) had undergone pterygium excision with conjunctival tissue graft (CTG) from the pterygium itself. The minimum follow up period was 6 months.

RESULTS

Both groups had 2 eyes with recurrence, which was not statistically significant. Among other complications, graft retraction was seen with a higher incidence in Group 2, which was statistically significant.

CONCLUSION

In situations where sparing of the superior conjunctiva is mandatory, both the techniques of inferior conjunctival autografting and conjunctival tissue graft from the pterygium itself are excellent alternate options with comparable outcomes and no additional risk of significant complications.

Cosmetic Pterygium Surgery: Techniques and Long-Term Outcomes

Background

To demonstrate the long-term results of enhanced cosmetic pterygium surgery with extensive Tenonectomy, adjunctive fibrin-glued amniotic membrane transplantation (AMT), and mitomycin C (MMC).

Methods

Retrospective chart review of patients who had pterygium surgery with AMT and MMC between January 2001 to July 2017 and had completed at least 6 months of follow-up. Early and long-term postoperative cosmetic outcomes, recurrence rate, and complications were analyzed. Cosmetic outcomes were evaluated based on patient and surgeon reported outcome measures.

Results

The study was conducted on a total of 603 eyes of 578 patients (316 males, 262 females) with an average age of 52.9 ± 15.1 years. At post-op day 1, patients reported no discomfort and could not tell which eye had surgery based on patient reported subjective grading scales. Over an average follow-up period of 23.1 ± 35 months (range: 6–216 months), there was one pterygium recurrence (0.2%), eighteen granulomas (2.9%), one self-resolving scleral melt (0.2%), one correctable restricted ocular motility (0.2%), one pupil abnormality (0.2%), one dellen (0.2%) and one correctable upper lid abnormality (0.2%). Planned laser vision correction was used for residual corneal scar in eleven eyes (1.8%) as a staged refractive approach.

Conclusion

This study highlights an improved technique of an old concept of pterygium surgery that not only reduces the recurrence but also enhances cosmetic excellence and improves the quality of vision.

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.

A Survey of Surgical Techniques in Pterygium, Thailand 2016

BACKGROUND

Pterygium causes a significant ocular disturbance which usually requires surgical removal; however, recurrence of pterygium after surgery frustrates both patients and surgeons. This survey aimed to determine the current surgical approaches in primary and recurrent pterygium, and the ideal surgical techniques among Thai ophthalmologists.

METHODS

Questionnaires were sent to 1150 ophthalmologists who are members of Royal College of Ophthalmologists of Thailand (RCOPT). A survey was conducted between 21 September and December 21, 2016.

RESULTS

438 of 515 responded questionnaires were valid. The highest number of the respondents applied the bare sclera technique (BST) (37.4%) and conjunctival autograft transplantation (CAGT, 44.9%) in primary pterygium and recurrent pterygium, respectively. The recurrence was the most reported late postoperative complication. An ideal technique for primary pterygium surgery was CAGT (42.4%), whereas amniotic membrane transplant (AMT) with adjuvant therapy (27.4%) was most selected for recurrent pterygium. Around half of the respondents currently applied the ideal techniques in their practice. The inaccessible and unaffordable amniotic membranes or fibrin glues (58%) concerning about complications (26%), inexperience in surgical procedures (25%), large number of patients in the surgery waiting list, prolonged surgical time, and need for conjunctiva preservation in glaucoma patients were reported as the obstacles to the ideal techniques.

CONCLUSIONS

BST and CAGT were the most selected surgical techniques for primary and recurrent pterygium, respectively. Better provision and distribution of amniotic membranes and fibrin glue along with training courses would promote the ideal surgical techniques.

Long-term analysis of an unconventional way of doing double-head pterygium excision

AIM:

The aim of the study is to describe an unconventional technique of vertically split conjunctival autograft (CAG) for primary double-head pterygium and its long-term outcome.

MATERIALS AND METHODS:

This was a retrospective, noncomparative, interventional case series of 95 eyes of 95 patients, who underwent vertical, split CAG surgery without maintaining limbus–limbus orientation for primary double-head pterygium from January 2013 to January 2017. All patients were reviewed for recurrence in their follow-up period.

RESULTS:

The mean follow-up was 14.12 ± 9.42 months. The baseline characteristics included 44 males and 51 females, with a mean age of 56.24 ± 10.03 years. The only significant complication was recurrence rate of 2.10% (2 eyes out of 95). The most common secondary outcome was graft edema (36.84%, 35 eyes out of 95), which resolved without any intervention. The other outcomes such as graft retraction (12.63%), Tenon's granuloma (1.05%), and subconjunctival hemorrhage (34.73%) were also recorded.

CONCLUSION:

Unconventional vertical split CAG without maintaining limbus–limbus orientation has convincing results in treating double-head pterygium with lower recurrence rate.

Outcomes of Vertical Split Conjunctival Autograft Using Fibrin Glue in Treatment of Primary Double-Headed Pterygia

Purpose

To evaluate the efficiency of pterygium excision with the vertical split conjunctival technique using fibrin glue in treatment of primary double-headed pterygia.

Patients and Methods

15 eyes of 15 patients with primary double-headed pterygia that underwent vertical split conjunctival autograft pterygium surgery were retrospectively reviewed. Recurrence was defined as fibrovascular proliferation over the limbus onto the cornea.

Results

The patients' mean age was 36.92 ± 10.8 years. At 12-month follow-up, recurrence was not seen in any cases. Regarding postoperative cosmetic grading, grade 1 (the appearance of the operated site is not different from the normal appearance) was found in 12 eyes (80%) and grade 2 (some fine episcleral vessels in the excised area extending up to but not beyond the limbus and without fibrous tissue) was found in 3 eyes (20%). None of the cases showed conjunctival scarring or fibrosis at the conjunctival donor area. Preoperative Sim K astigmatism at the central 3 mm and BCVA were 3.05 ± 1.5 diopters (D) and 0.64 ± 0.26 logMAR, which improved significantly to 1.15 ± 0.84 D and 0.26 ± 0.18 logMAR at 12-month follow-up postoperatively, respectively.

Conclusion

Vertical split conjunctival autograft using fibrin glue is an effective technique with good cosmetic results and low to no recurrence for primary double-headed pterygia treatment. This trial is registered with NCT03507283.

How to minimize pterygium recurrence rates: clinical perspectives

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

Homologous cryopreserved amniotic membrane in the repair of myelomeningocele: preliminary experience

OBJECTIVE

Surgical management of spinal dysraphism often requires the use of dural substitutes. Amniotic membrane (AM) has drawn the interest of clinicians for its valuable concentration of cytokines and factors capable of promoting wound healing, re-epithelialization, inhibiting fibrosis and regulating angiogenesis. These beneficial qualities could make AM an interesting dural substitute for spina bifida repair. In this study, we describe the use of banked homologous AM as a dural substitute for the repair of spinal dysraphism in newborns. Our purpose is to test the mechanical characteristics, as well as the safety and effectiveness of AM in preventing postoperative complications and re-tethering.

METHODS

The AM patch was carefully detached from the chorion of donors undergoing caesarean section, rinsed in saline solution, and cryopreserved in liquid nitrogen. Five newborns were treated using AM: three affected by open spinal dysraphism and two by spina bifida occulta. The AM patch was used as a dural substitute with two different positions and purposes: the amnion-side down covering the placode to prevent adhesions or placed extradurally facing the dura to avoid scarring and facilitating the sliding of the dural sac itself under the extradural tissue layers.

RESULTS

No adverse events occurred, and the surgical wounds healed without complications. MRI scans taken at 3 and 6 months after surgery showed a satisfying de-tethering of the spinal cord with no obvious evidence of new adherence formation.

CONCLUSIONS

We present a multimodal interposition technique using AM as a reconstructive and anti-adhesive tissue for the treatment of open myelomeningocele (MMC) and lipomeningocele (LMC) treatment. In our experience, AM proved its efficacy in restoring the dural sac integrity without complications. We support the use of AM as a promising dural substitute, speculating on how the use of AM could potentially change reconstructive strategies for spinal dysraphism.

Amniotic Membrane Grafts to Reduce Pterygium Recurrence

PURPOSE

To demonstrate the long-term outcome of pterygium surgery with adjunctive amniotic membrane transplantation (AMT) and intraoperative mitomycin C (MMC) in a large case series.

METHODS

Medical records were retrieved for this noncomparative retrospective study of all patients who had pterygium excision with adjunctive AMT and intraoperative MMC, from October 2010 to June 2016 with at least 6 months of follow-up.

RESULTS

There were a total of 556 eyes of 535 patients (291 males and 244 females) with average age of 51.9 ± 13 years who had pterygium excision (527 primary and 29 recurrent). For an average follow-up period of 17.3 ± 0.8 months (range 6-74 months), corneal recurrence occurred in 20 eyes (3.6%) and conjunctival recurrence in 12 (2.2%) in a total of 32 eyes (5.8%). Eleven eyes (2%) underwent reoperation. Other complications included granuloma (0.5%), diplopia (1.1%), and steroid-induced ocular hypertension (4.3%).

CONCLUSIONS

Adjunctive use of AMT and short exposure of MMC can reduce recurrence after pterygium surgery. The procedure is less tedious and less time consuming, resulting in early recovery while saving the conjunctiva for future surgeries.

A novel case using femtosecond laser-acquired lenticule for recurrent pterygium: case report and literature review

Small incision lenticule extraction (SMILE) is a minimally invasive, safe and flapless femtosecond laser technique used mainly to correct myopia through extraction of a corneal lenticule. Lenticules obtained in this way are transparent and of high quality, and thus, can be used to treat other corneal diseases. A 65-year-old male patient presented with recurrent pterygium complicated by thin cornea. The patient was treated surgically using a SMILE-extracted lenticule to avoid further complications and to maintain eyeball integrity. The lenticule was sutured over the thin section of cornea using 10-0 interrupted nylon sutures and enclosed by a single layer of amniotic membrane. The patient was evaluated using slit-lamp biomicroscopy and anterior-segment optical-coherence tomography. During an 8-month follow-up, the graft remained intact with no sign of rejection and corneal thickness was maintained. Tectonic keratoplasty using a SMILE-extracted lenticule appears to be a safe, cost-effective and reliable method for treating thin cornea due to repeated surgeries for recurrent pterygium. This is the first case of recurrent pterygium complicated by thin cornea managed surgically using a SMILE-extracted lenticule.

Concomitant use of conjunctival tissue graft from the pterygium itself without rotation in pterygium surgery: A full circle in conjunctival autografting

Purpose:

The aim of this study is to describe a modified technique of using conjunctival tissue from the pterygium itself without any rotation of graft for the primary pterygium in eyes with glaucoma filtering bleb, glaucoma suspects, and in primary double-head pterygium using fibrin glue.

Methods:

In this retrospective, noncomparative, interventional case series, 98 eyes of 98 patients with primary pterygium operated between July 2011 to July 2016 were included. They underwent this technique from the pterygium tissue itself. There was no rotation of this graft, and it was adhered to the bare scleral defect with fibrin glue. Histopathological analysis of pterygium tissue was done to look for morphology and thickness of this thin conjunctival tissue obtained from pterygium tissue itself. The primary outcome measure was recurrence rate. Other outcome measures studied was graft retraction and graft edema.

Results:

The mean age was 52 ± 10.04 years. Mean follow-up was 14 ± 8.24 months. The only significant complication was recurrence rate of 4.08% (4 eyes out of 98). The most come secondary outcome was graft edema, 52.04% (51 eyes out of 98) which resolved without any intervention. Other outcome such as graft retraction, 32.65% was also recorded.

Conclusion:

Conjunctival tissue from the pterygium tissue itself without actual rotation appears to be a successful technique with lower recurrence rate for treating primary pterygium in eyes with glaucoma filtering bleb, glaucoma suspects, and in primary double-head pterygium.

Recurrent pterygium treatment using mitomycin C, double amniotic membrane transplantation, and a large conjunctival flap

Purpose

The aim of this study was to evaluate the clinical outcomes of surgery for recurrent pterygia using mitomycin C (MMC), double amniotic membrane transplantation (AMT), and a large conjunctival flap.

Patients and methods

This retrospective case series included 31 eyes in 31 patients with recurrent pterygia. All patients underwent pterygium excision, application of MMC, double AMT, and placement of a large conjunctival flap. Outcome measures were visual acuity, astigmatism, and recurrence. Recurrence was defined as the presence of fibrovascular proliferative tissue crossing the limbus.

Results

The patients' mean age was 68.2 years. The mean follow-up period was 3.6 years. The mean preoperative and postoperative best-corrected visual acuities (logMAR conversion) were 0.23 and 0.13, respectively. There was a significant difference between the mean preoperative (-3.85 D) and postoperative (-2.22 D) astigmatism. The recurrence rate was 3.2% (1/31 cases).

Conclusion

Surgical pterygium excision with application of MMC, double AMT, and placement of a large conjunctival flap was an effective treatment for recurrent pterygia.

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.

Efficacy and Safety of a Large Conjunctival Autograft for Recurrent Pterygium

PURPOSE

To evaluate the efficacy and safety of pterygium excision using a large conjunctival autograft for the treatment of recurrent pterygium.

METHODS

The medical records of 120 patients (126 eyes) with recurrent pterygium were reviewed. For each affected eye, pterygium excision with a large conjunctival autograft was performed. The graft was harvested from the superior bulbar area and measured more than 8 × 10 mm in size. Only patients who completed at least six months of follow-up were included. Postoperative clinical outcomes, recurrence rate, and complications were analyzed. Patients with any evidence of recurrence after surgery received a subconjunctival bevacizumab injection.

RESULTS

The average patient age was 56.5 ± 10.2 years, and 45 out of 120 patients were male. The mean study follow-up period was 17.7 ± 17.6 months. Most patients were satisfied with the cosmetic outcome. Postoperative visual acuity improved from 0.69 to 0.75 (p < 0.05). Postoperative refractive astigmatism and corneal astigmatism decreased by 0.55 and 2.73 diopters, respectively (p < 0.05). The postoperative recurrence rate was 4.0%, and the average recurrence period was 7.4 ± 0.6 weeks. A subconjunctival injection of 5 mg bevacizumab was performed in cases of recurrence; no progression of the pterygium was observed following the injection. Postoperative complications included 2 cases of conjunctival graft edema in 2 eyes, 5 donor site scars in 5 eyes, 13 pyogenic granulomas in 13 eyes, and a conjunctival epithelial inclusion cyst in 7 eyes.

CONCLUSIONS

Pterygium excision with a large conjunctival autograft for the treatment of recurrent pterygium produced an excellent cosmetic outcome, a low recurrence rate, and minimal complications. A subconjunctival bevacizumab injection given in cases of recurrence following surgery might be effective in preventing progression of the pterygium.

Double-head pterygium excision with modified vertically split-conjunctival autograft: Six-year long-term retrospective analysis

Purpose:

The aim of this study is to describe a modified technique of vertically split-conjunctival autograft (CAG) for primary double-head pterygium and evaluate its postoperative outcome.

Methods:

In this retrospective, noncomparative, interventional case series, 87 eyes of 87 patients of double-head pterygium from June 2009 to June 2015 were included. They underwent vertical split CAG. A limbus-limbus orientation was not strictly maintained. Primary outcome measure was recurrence rate. Other outcome measures studied were graft retraction, Tenon's granuloma, dellen, and so on.

Results:

Mean age was 54.54 ± 11.51 years; M:F was 41:46. Mean follow-up was 17.28 ± 10.28 months. The only significant complication was recurrence rate of 3.45% (3 eyes out of 87). Other most common secondary outcome was graft edema, 42.52% (37 eyes out of 87) which resolved without any intervention. Other outcomes such as graft retraction (31.03%), dellen (1.15%), Tenon's granuloma (3.45%), and subconjunctival hemorrhage (36.78%) were recorded.

Conclusion:

Modified vertical split CAG without maintaining limbus-limbus orientation, just large enough to cover the bare scleral defect, appears to be a successful technique with lower recurrence rate in treating double-head pterygium.

Cryopreserved rabbit amniotic membrane alleviated inflammatory response and fibrosis following experimental strabismus surgery in rabbits

We evaluate the ability of cryopreserved rabbit amniotic membrane (AM) transplantation to reduce postoperative inflammation and the extent of fibrosis following experimental strabismus surgery. Ten white rabbits underwent bilateral superior rectus (SR) muscle resection. In the left eye, the resected SR muscle was wrapped with cryopreserved rabbit AM. The right eye underwent SR resection only and served as a control. The eyes were enucleated 4 weeks after strabismus surgery. The degree of postoperative inflammatory infiltration, the extent of fibrosis, and profile of the relative expression of inflammatory mediators in the SR muscle were evaluated and compared between the two groups by histological analysis and real-time polymerase chain reaction (PCR). There were statistically meaningful differences in the degree of postoperative inflammatory infiltration and extent of fibrosis between the eyes treated with cryopreserved rabbit AM after SR resection and those underwent SR resection only. A significant decrease in the expression of inflammatory cytokines [interleukin (IL)-12a, IL-12b, IL-17f, and tumor necrosis factor- alpha (TNF-α)], and a markedly increased expression of anti-inflammatory cytokines (transforming growth factor-beta-1(TGFβ-1) and IL-10) were observed in the eyes treated with cryopreserved rabbit AM. In this study, we demonstrate that cryopreserved rabbit AM is effective in reducing postoperative inflammation and extent of fibrosis in a rabbit model of strabismus surgery. Our results imply that cryopreserved AM allograft has anti-inflammatory and anti-scarring properties that can prevent postoperative adhesions following strabismus surgery.

Comparison of free conjunctival autograft versus amniotic membrane transplantation for pterygium surgery

Purpose

To compare the recurrence rate and surgical outcomes of amniotic membrane transplantation (AMT) and free conjunctival autograft (CAT) for pterygium surgery.

Methods

In this prospective study, 60 patients with primary pterygium were randomly assigned to two groups of CAT or AMT and were compared in terms of recurrence rate, mean healing time of corneal epithelial defects, the mean level of inflammation, and complications.

Results

The mean ± SD age of patients was 48.98 ± 9.8 years (range, 27–71 years). 73.3% were men, and 26.7% were women. The groups did not differ with respect to demographic characteristics (P > 0.05). Patients were followed for an average of 12.6 ± 1.3 months. The recurrence rates were 6.7% and 3.3% in the AMT and CAT groups, respectively (P > 0.05). Comparison of mean inflammation score showed higher inflammation in the AMT group in the first, third, and sixth postoperative month (P < 0.05). Mean healing times of corneal epithelial defects were 2.5 ± 0.572 and 2.67 ± 0.479 days in the CAT and AMT groups, respectively (P = 0.173).

Conclusions

No significant complication was observed during or after both surgical methods. No statistically significant difference was seen in visual acuity changes and epithelial healing in CAT and AMT groups, but more inflammation and recurrence rate were seen in AMT group.

Double-Headed Pterygia Treated With P.E.R.F.E.C.T for PTERYGIUM

PURPOSE

There are very few studies that describe the technique and results of double-headed pterygium removal and most of these have recurrence rates higher than those described for single pterygium removal. P.E.R.F.E.C.T for PTERYGIUM has a very low recurrence rate, and this study describes the recurrence rate and cosmesis when used on double-headed pterygia.

METHODS

A prospective intervention series was performed on 20 eyes with a follow-up of 1 year or more with examination for recurrence and cosmetic appearance.

RESULTS

There were no recurrences. Cosmetic appearance in 20 eyes was normal or excellent, and the conjunctival donor site was normal in appearance in 19 eyes.

CONCLUSIONS

P.E.R.F.E.C.T for PTERYGIUM provides excellent cosmetic results and no recurrences, and slit-lamp examination of the superior bulbar conjunctiva is normal in most cases after 2 graft retrievals from the same site.

Conjunctival Autograft Versus Amniotic Membrane Transplantation After Double Pterygium Excision: A Randomized Trial

PURPOSE

To compare the outcome of amniotic membrane transplantation (AMT) and conjunctival autograft (CAG) after pterygium excision in patients with nasal and temporal pterygium (double pterygium) in the same eye.

METHODS

Tertiary care medical center. A total of 33 eyes of 33 patients with previously unoperated double pterygium were enrolled in the randomized trial, of which 31 remained in follow-up at 1 year. Eyes with double pterygium were randomized to either nasal AMT and temporal CAG (nasal AMT group) or to temporal AMT and nasal CAG (temporal AMT group). The primary prespecified outcome was pterygium recurrence at the excised site 1 year after pterygium excision.

RESULTS

At 1 year none of the 31 pterygia randomized to CAG showed recurrence in either the nasal or temporal location (0%, 95% confidence interval, 0%-11.2%). In contrast, 8 of 31 pterygia randomized to AMT exhibited recurrence at 1 year (25.8%, 95% confidence interval, 11.9%-44.6%), with 4 temporal recurrences and 4 nasal recurrences. The recurrence rate was significantly higher for AMT than CAG (P = 0.005: primary analysis), but not significantly different between the nasal and temporal sites (P ≥ 0.99).

CONCLUSIONS

The use of CAG in pterygium surgery led to fewer recurrences than AMT, irrespective of the site of replacement.

A New Conjunctival Free Flap Design Technique for Pterygium Surgery: Stamp Technique

PURPOSE

To introduce a new conjunctival free flap design technique for pterygium surgery.

PATIENTS AND METHODS

This study was a retrospective medical chart review of 20 patients (21 eyes) who underwent pterygium excision and conjunctival free flap by one surgeon. The following surgical procedures were used in conjunctival free flap design during pterygium surgery. We used the paper wrapper of 10-0 nylon, which will be used for the conjunctival suture, for making an imprint of the recipient defect. The paper was cut to an ellipsoidal shape of 2 to 3 mm larger than the recipient defect with utility scissors. The margin of the recipient defect was marked using a gentian violet pen. The paper was positioned carefully on the recipient defect and pushed down gently with a cotton tip. After removing the paper, the margin of the conjunctival defect was imprinted on the paper in the shape of a "C," The paper was cut according to the inner line of the "C" marking. The paper was placed on the superior conjunctiva. Conjunctival marking was applied according to the outline of paper with a pen.

RESULTS

The operation duration ranged from 64 min to 132 min (mean 88 min). The conjunctival free flap was identical to the recipient defect. Complications included recurrence (5%), wound dehiscence (19%), and granulation (5%).

CONCLUSIONS

We think that this stamp technique is an efficient method for designing donor conjunctiva that is identical to the defect for free conjunctival transplantation during pterygium surgery.

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.

Amniotic Membrane Transplantation with Narrow-Strip Conjunctival Autograft vs Conjunctival Autograft for Recurrent Pterygia

Purpose

To compare amniotic membrane transplantation (AMT) associated with narrow-strip conjunctival autograft vs conjunctival autograft alone for the treatment of recurrent pterygium.

Methods

In this prospective consecutive interventional study, patients with recurrent pterygium were randomly divided into one of 2 groups; group 1: patients undergoing AMT associated with autologous conjunctival graft; and group 2: patients undergoing conjunctival autograft alone.

Results

Of the 80 operated eyes included in this study, 39 (group 1, mean patient age 52.1 ± 11.7 SD years) underwent AMT associated with narrow-strip conjunctival autograft and 41 (group 2, mean patient age 45.8 ± 12.9 SD years) underwent conjunctival autograft alone. In group 1, 6 eyes (15.4%) had grade 1 pterygium, 19 eyes (48.7%) had grade 2 pterygium, and 14 eyes (35.9%) had grade 3 pterygium. In the second group, 5 eyes (12.2%) had grade 1 pterygium, 18 eyes (43.9%) had grade 2 pterygium, and 14 eyes (35.9%) had grade 3 pterygium. No statistically significant difference was found between the 2 groups (p = 0.752). Of the 39 eyes in group 1, recurrent pterygium was observed in 7 cases (17.9%). However, of the 41 eyes in group 2, recurrent pterygium was observed in only 4 cases (9.75%). No statistically significant difference was found between the 2 groups (p = 0.2684).

Conclusions

The results of this study indicate that conjunctival autograft alone might be a better surgical choice for the treatment of recurrent pterygia than combining it with AMT; however, this second option provides a good surgical alternative in cases where little conjunctival donor tissue is available.

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.