Effects of intraoperative steroid injection on the outcome of pterygium surgery

Subconjunctival dexamethasone-assisted conjunctival autograft harvesting versus normal saline during pterygium surgery - A randomized clinical trial

PURPOSE

To evaluate the effect of subconjunctival dexamethasone compared to normal saline on conjunctival autograft harvesting in patients undergoing pterygium surgery.

METHODS

Fifty-two eyes of 52 patients who underwent pterygium excision combined with autologous conjunctival graft (CAG) using releasable suture were included in this prospective interventional study. The patients were randomized into two groups of 26 patients each. Group A consisted of patients in whom CAG was harvested using subconjunctival 0.5 ml of 0.4% dexamethasone sodium phosphate and in group B patients, normal saline was used. The patients were assessed for postoperative pain, foreign body sensation, and watering as the subjective signs of inflammation and conjunctival inflammation and lid edema as the objective signs of inflammation at 12 and 24 h postsurgery.

RESULTS

The mean age of group A and B patients was 47.69 + 13.09 and 46.00 + 10.76 years, respectively. The male:female ratio was 1.6:1 in group A and 1.1:1 in group B. The mean surgical time in group A was 243.96 ± 52.13 s and in group B was 258.08 ± 43.99 s. Postoperative pain, foreign body sensation, and watering were significantly lower in group A patients than in group B patients at both 12 and 24 h postoperatively (group A: 4.65 ± 1.33, 4.88 ± 1.73, and 3.85 ± 1.43, respectively, at 12 h; 1.89 ± 1.03, 1.69 ± 1.09, and 1.69 ± 0.97, respectively, at 24 h and group B: 6.42 ± 0.95, 6.65 ± 0.98, and 6.27 ± 1.40, respectively, at 12 h; 3.27 ± 1.43, 3.12 ± 1.25, 2.58 ± 1.14, respectively, at 24 h) ( P < 0.001). Conjunctival inflammation was significantly lower in group A at 12 h ( P < 0.05) and 24 h ( P < 0.05) after surgery compared to group B. Lid edema failed to show any significant ( P = 0.17) difference with respect to severity in both the groups at 12 and 24 h ( P = 0.699).

CONCLUSION

Subconjunctival dexamethasone decreased patient discomfort following pterygium surgery. The dexamethasone group had reduced conjunctival inflammatory signs without any notable complications.

Evaluating the Efficacy and Safety of Different Pterygium Surgeries: A Review of the Literature

The search for the "gold standard" in the surgical treatment of pterygium has been ongoing for over two decades. Despite the development of various surgical techniques, recurrence rates range from 6.7% to 88% depending on the method used. This review discusses the latest and most commonly used methods for the surgical removal of pterygium, primarily focusing on efficacy and safety. Moreover, this review includes articles that either evaluated or compared surgical methods and clinical trials for primary and recurrent pterygium. Limited data are available on combined methods as well as on the efficacy of adjuvant treatment. The use of adjuvant intraoperative mitomycin C (MMC) and conjunctival autografting (CAU) are the two most highly recommended options, as they have the lowest rates of postoperative recurrence.

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.

Comparison between the triamcinolone and bevacizumab subconjunctivals and changes in Interleukin-1 mRNA expression in pterygium

Objectives

Pterygium is a fibrovascular external ocular mass that grows from the conjunctiva into the cornea. The effect of subconjunctival injection of triamcinolone and bevacizumab has been inadequately investigated worldwide. This study aims to analyse the expression of IL-1 after the injection of triamcinolone and bevacizumab subconjunctiva.

Methods

All patients are randomized into three groups: the triamcinolone, bevacizumab group, and placebo groups, with 5 patients in each in group. All subjects are injected subconjunctivally one week before surgery, and then surgery is performed with the autograft technique. The main outcome measures include changes in the IL-1 mRNA expression between the triamcinolone, bevacizumab, and placebo groups.

Results

All samples are completed after one month of follow-up. The changes in blood levels of mRNA IL-1 expression are as follows: 4.81 ± 0.52 in the bevacizumab group, 3.40 ± 2.63 in the triamcinolone group, and 1.08 ± 1.48 in the placebo group (p = 0.04). In the comparison between groups, there is a significant effect between the bevacizumab and placebo groups, 3.73 ± 1.12 (p = 0.00), with no significant effect in the triamcinolone group, 1.40 ± 1.12 (p = 0.06).

Conclusion

The subconjunctival injection of bevacizumab and triamcinolone before surgery is effective in suppressing inflammation in pterygium.

Bromfenac Inhibits TGF-β1-Induced Fibrotic Effects in Human Pterygium and Conjunctival Fibroblasts

Purpose

Nonsteroidal anti-inflammatory drugs (NSAIDs) have shown antifibrotic effects on several diseases. The aims of the present in vitro study were to investigate the antifibrotic effects of bromfenac (a kind of NSAID) on primary human pterygium fibroblasts (HPFs) and primary human conjunctival fibroblasts (HConFs), as well as to explore the possible mechanisms of these effects.

Methods

The cells used in this study were primary HPFs and HConFs, and profibrotic activation was induced by transforming growth factor-beta1 (TGF-β1). Western blot, quantitative real-time PCR, and immunofluorescence (IF) assays were used to detect the effects of TGF-β1 and bromfenac on the synthesis of fibronectin (FN), type III collagen (COL3), and alpha-smooth muscle actin (α-SMA) in HPFs and HConFs; the changes of signaling pathways were detected by Western blot; cell migration ability was detected by wound healing assay; cell proliferation ability was detected by CCK-8 assay; and pharmaceutical inhibitions of the downstream signaling pathways of TGF-β1 were used to assess their possible associations with the effects of bromfenac.

Results

Bromfenac suppressed the TGF-β1-induced protein expression of FN (0.59 ± 0.07 folds, P = 0.008), COL3 (0.48 ± 0.08 folds, P = 0.001), and α-SMA (0.61 ± 0.03 folds, P = 0.008) in HPFs. Bromfenac also attenuated TGF-β1-induced cell migration (0.30 ± 0.07 folds, P < 0.001), cell proliferation (0.64 ± 0.03 folds, P = 0.002) and the expression levels of p-AKT (0.66 ± 0.08 folds, P = 0.032), p-ERK1/2 (0.69 ± 0.11 folds, P = 0.003), and p-GSK-3β-S9 (0.65 ± 0.10 folds, P = 0.002) in HPFs. PI3K/AKT inhibitor (wortmannin) and MEK/ERK inhibitor (U0126) reduced the TGF-β1-induced synthesis of FN, COL3, and α-SMA in HPFs. All the results were similar in HConFs.

Conclusions

Bromfenac protects against TGF-β1-induced synthesis of FN, α-SMA, and COL3 in HPFs and HConFs at least in part by inactivating the AKT and ERK pathways.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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