[Long-term results of autologous conjunctiva-limbus transplantation in pterygium]

[Visual self-assessment with the ACTO test during follow-up of AMD patients after intravitreal injections]

INTRODUCTION

Monthly controls are necessary after injections of vascular endothelial growth factor (VEGF) to enable timely recognition of a renewed decrease in vision. However, these monthly control intervals are not realistic for many older patients with age-related macular degeneration (AMD), and outpatient clinics often reach their logistical limits because of inadequate funding for the additional medical work. Against this background, we conceived the ACTO self-test as a novel screening method for patients to discover unnoticed visual changes outside the routinely scheduled ophthalmic examination.

MATERIAL AND METHODS

The paper version of the ACTO self-test consists of a reading chart gradated in decimal steps as well as six questions regarding the quality of the Amsler grid. The patient uses a self-screening test to examine each eye separately and then transfers the results to a table. Along with the self-examination, the Action Eyesight Service Center is available to the patient by phone to motivate the patient and schedule a new appointment if improved test results occur. If decreased values or suspected decreased visual function occur, these are verified immediately by the referring physician.

RESULTS

There is a good correlation between the steps of the ACTO self-test and standard visual acuity at 4 m (r(2)=0.9). Altogether, 1,444 patients were followed by phone and 745 participated in repeated regular audits, for a total of 3,003 phone contacts. The treating physician was informed about decreased visual acuity or increased Amsler distortion in the ACTO test in 137 cases, and immediate verification was done. We had 699 dropouts; the reasons were decreased visual acuity below the limits of the ACTO test in 39%, additional monthly examinations by the local ophthalmologist in 29%, and a desire for no more telephone follow-up (despite initial written consent) in 32%. Decreased vision when reading or an increased score on the Amsler test within the ACTO screening test was observed in 18% of AMD patients during the maintenance phase.

CONCLUSION

Monthly screening by the ACTO screening test in combination with phone audits offers a new way to test visual acuity, with the Amsler score helping to detect changes in visual function. For patients with visual changes, confirmation by the ophthalmic physician can be achieved in time. Self-assessment cannot replace qualified ophthalmologic examination, but monthly self-controls enhance safety, reduce the number of physician contacts, and improve the detection of visual changes, with the option of immediate ophthalmic retreatment.

Conjunctivolimbal autograft using a fibrin adhesive in pterygium surgery

Purpose

To evaluate the efficacy and safety of fibrin bioadhesive in conjunctivolimbal autograft surgery for primary pterygium.

Methods

Thirty-six eyes in 34 patients were reviewed with nasal primary pterygium who were treated with pterygium excision with superior conjunctivolimbal transplantation with fibrin bioadhesive. Surgical durations were recorded and the patients were followed up on the first day after surgery and then at 1, 2, 4, 8 and 12 weeks postoperatively. The graft-recipient site attachments were examined and subjective symptoms of patients were recorded at every follow-up examinations.

Results

The mean patient age was 57.9±10.1 (ranging from 33 to 83) years. The mean follow-up period was 22.05±5.78 weeks. The mean surgery time was 18.04±5.65 minutes. The subjective symptoms (pain, foreign body sensation, tearing and discomfort) disappeared in 23 of 36 eyes (64%) in one week after surgery, and all discomforts subsided within two weeks after surgery in all patients. The conjunctivolimbal autograft was correctly positioned and fixed in 34 of 36 eyes (94.4%) throughout the follow-up period. Graft dehiscence was seen in two eyes (5.6%), one eye was treated with remedial sutures, and the other eye showed a spontaneous healing without remedial sutures. Transient graft edema occurred in four eyes (11.2%) but subsided spontaneously within a month. There were no cases of pterygium regrowth or complications due to the fibrin bioadhesive.

Conclusions

The use of fibrin bioadhesive in conjunctivolimbal autograft surgery in primary pterygium simplifies surgical techniques, shorten surgical duration, and produce less postoperative subjective symptoms. Therefore, the fibrin bioadhesive is a safe and effective tool to attach conjunctivolimbal autograft in primary pterygium surgery.

Greffe de membrane amniotique avec greffe conjonctivo-limbique dans le traitement des ptérygions récidivants, invasifs ou intéressant l’axe optique

OBJECTIVE

To evaluate amniotic membrane transplantation with limbic-conjunctival autograft during recurrent pterygium surgery in cases with a risk of stromal defect or with optic axis involvement, in order to limit the corneal defect in pterygium and preserve vision with moderate astigmatism.

MATERIALS AND METHODS

Retrospective study of 50 cases. Three clinical aspects were encountered: A, recurrent pterygium after simple surgery (a corrected stromal defect)--six cases; B, primary pterygium at risk of stromal defect - five cases; C, primary pterygium with optic axis involvement--four cases. Each patient underwent ablative surgery followed by ocular surface rebuilding with limbic-conjunctival autograft combined with amniotic membrane graft on the corneal defect. Visual acuity and astigmatism were measured and compared before and after surgery.

RESULTS

The mean follow-up was 13 months. At the end of the follow-up, the recurrence rate was 27% (four cases: two in A, two in B, and none in C). Mean visual acuity was improved from 0.7 to 0.8 postoperatively (p=0.041). Astigmatism changed slightly from 1.47 to 1.98 dioptres (p=0.155).

DISCUSSION

For recurrent pterygium, with stromal defect or optic axis involvement, amniotic membrane transplantation and limbic-conjunctival autograft seems not to influence the recurrence rate. However, by limiting initial keratectomy, this surgical procedure only slightly modifies visual acuity and astigmatism in the cases where the two parameters are slightly affected. Failure can be easily managed with further surgery such as lamellar keratoplasty.

CONCLUSION

Amniotic membrane transplantation and limbic-conjunctival autograft for recurrent pterygium or with optic axis involvement can be useful to integrate in the therapeutic arsenal of pterygium surgery.

Intraoperative mitomycin C in the treatment of pterygium

PURPOSE

To evaluate the effectiveness of intraoperative mitomycin C in preventing the recurrence of primary pterygium.

METHODS

In this prospective, randomized study, 38 eyes of 35 patients with primary pterygium were evaluated. In 19 eyes, the "bare sclera technique" combined with intraoperative application of 0.2 mg/mL (0.02%) mitomycin C for five minutes was performed (mitomycin C treated group). The other 19 eyes--taken as control group--underwent surgical excision alone. Statistics were analyzed using the Mann-Whitney U test and the Fischer's exact test.

RESULTS

Patients were 20-38 years of age. The mean age was 25.29 +/- 5.08 in the mitomycin C treated group and 25.00 +/- 5.19 in the control group. During the mean follow-up of 17.04 months (range, 12-36 months; SD = 5.89), 4 recurrences (21%) were observed in the mitomycin C treated group and 11 (57.8%) in the control group. The difference between the two groups was significant (p = 0.045). No postoperative complication was encountered in both groups except for recurrences.

CONCLUSION

Intraoperative mitomycin C was found to be effective in preventing the recurrence of primary pterygium.

The pathogenesis of pterygia

Pterygium is an active, invasive, inflammatory process, a key feature of which is focal limbal failure. In a two-stage process, "conjunctivalization" of the cornea occurs with tissue characterized by extensive chronic-inflammation, cellular proliferation, connective tissue remodeling, and angiogenesis. An understanding of this process has resulted in efforts aimed at limbal reconstruction, which is considered the gold standard for surgical care. Although good results have been obtained with other treatment methods, a long-term approach to follow-up with at least 5-year survival figures is desirable. Sophisticated analyses of the tear film and surface epithelium in patients with pterygium may help explain symptoms. The efficacy, at least in the short term, of nonsteroidal anti-inflammatory drugs in the treatment of inflamed pterygia has been confirmed. Corneal topographic analysis has shown that surgery reduces induced astigmatism and also causes subtle changes that may explain postsurgical improvements in vision.