Surgical Techniques and Adjuvants for the Management of Pterygium

Prospective Study: Utility of Anterior Segment Optical Coherence Tomography to Identify Predictive Factors of Recurrence in Pterygium Surgery

Background/Objectives: The main purpose of this study is to determine, by anterior segment optical coherence tomography (AS-OCT), the anatomical characteristics, both preoperatively and postoperatively, that correlate with a higher rate of pterygium recurrence after surgery with exeresis and conjunctival autograft with biological glue. Methods: A total of 50 eyes which were listed for primary pterygium surgery at an ophthalmology tertiary centre were treated with standard pterygium excision and a conjunctival autograft with tissue glue. Ten variables were measured with AS-OCT (Casia 2; Tomey Corp., Nagoya, Japan) during six control visits with all patients. Finally, statistical analysis was performed using SPSS (SPSS stadistics®, IBM®, version 21.0.0.0) for descriptive variables and R-project (The R foundation©, version 3.0.2) for the rest of the analyses, including a descriptive analysis and an inferential analysis studying prognostic factors of recurrence and their predictive capacity. Results: Among the 50 patients who underwent surgery, recurrence was detected in 8 cases (rate 16%; 95% CI: 5.8-26.2%). Most cases (n = 6) were detected 3 months after surgery. The pattern of recurrences was atrophic in two thirds of the cases; none required reintervention. Preoperative total conjunctival thickness at 3 mm was significantly increased in patients who developed recurrence. One week after surgery, epithelial and stromal thickness at 1 mm and total thickness at 3 mm proved to be useful for predicting recurrence. Both models have significant discriminant capacity. Conclusions: By imaging the graft with AS-OCT preoperatively and 7 days after surgery, the risk of future recurrence can be predicted.

Risk factors for pterygium: Latest research progress on major pathogenesis

A pterygium is a wedge-shaped fibrovascular growth of the conjunctiva membrane that extends onto the cornea, which is the outer layer of the eye. It is also known as surfer's eye. Growth of a pterygium can also occur on the either side of the eye, attaching firmly to the sclera. Pterygia are one of the world's most common ocular diseases. However, the pathogenesis remains unsolved to date. As the pathogenesis of pterygium is closely related to finding the ideal treatment, a clear understanding of the pathogenesis will lead to better treatment and lower the recurrence rate, which is notably high and more difficult to treat than a primary pterygium. Massive studies have recently been conducted to determine the exact causes and mechanism of pterygia. We evaluated the pathogenetic factors ultraviolet radiation, viral infection, tumor suppressor genes p53, growth factors, oxidative stress, apoptosis and neuropeptides in the progression of the disease. The heightened expression of TRPV1 suggests its potential contribution in the occurrence of pterygium, promoting its inflammation and modulating sensory responses in ocular tissues. Subsequently, the developmental mechanism of pterygium, along with its correlation with dry eye disease is proposed to facilitate the identification of pathogenetic factors for pterygia, contributing to the advancement of understanding in this area and may lead to improved surgical outcomes.

Comparing Intracanalicular and Topical Steroid Use in Patients Undergoing Pterygium Surgery

OBJECTIVE

The study received funding from Ocular Therapeutix, Inc., Bedford, MA.We undertook this study to compare the efficacy of intracanalicular dexamethasone 0.4 mg with topical prednisolone acetate (PA) 1% in controlling postoperative pain and inflammation in patients undergoing pterygium surgery.

METHODS

This was an open-label, prospective, interventional, nonrandomized comparative trial. Thirty patients were assigned to one of the following groups: Group A [intracanalicular insert of 0.4 mg dexamethasone placed into upper and lower puncta during the procedure, followed by at postoperative month 1 visit institution of topical PA 1% twice daily × 2 weeks then once daily × 2 weeks] or Group B [nonintervention group with institution on postoperative day 1 topical PA 1% every 2 hours × 2 weeks then four times per day × 2 weeks then twice daily × 2 weeks then once daily × 2 weeks].

RESULTS

Fifteen cases and 15 controls were enrolled. There was no statistical difference in patient-reported pain or satisfaction between the case and control groups at 1 day; 1 week; and 1, 3, and 6 months postoperatively. There was no significant difference in time to an ocular hyperemia score of 0 between the two groups. There was no difference in the rate of corneal reepithelialization and recurrence rate (two controls). Nine eyes had transient ocular hypertension (seven cases and two controls).

CONCLUSION

Intracanalicular dexamethasone 0.4 mg may reduce the medication burden for patients who need prolonged postoperative steroid therapy as is routine in the setting of pterygium surgery. It is a safe and effective alternative to PA 1% drops alone for postoperative control of pain and inflammation in pterygium surgery.

Transparent intrastromal corneal lenticule obtained from SMILE surgery as a free graft for the treatment of primary pterygium: A pilot study

PURPOSE

To report our initial experience in patients with primary pterygium surgery who had a transparent intrastromal corneal lenticule as a free graft obtained during small incision lenticule extraction (SMILE) surgery.

OBSERVATIONS

This study enrolled five eyes of 5 patients with pterygium who were surgically treated with single or double free lenticule that was sutured to the defective area of the nasal corneosclera immediately following pterygium excision. All cases with pterygium were primary, and topical mitomycin C was not used at the time of surgery. The mean age of the patients was 51.0 years and 2 of the 5 eyes belonged to male subjects. The patients were followed up for an average of six months. During the follow-up period, the lenticule grafts demonstrated no sign of rejection and were intact in all cases. All patients recovered well with no complications or recurrences at six months postoperatively.

CONCLUSIONS AND IMPORTANCE

This report suggests that transparent corneal lenticules obtained during SMILE laser surgery may be used as an alternative novel graft source for the surgical treatment of patients with primary pterygium. It appears to be a safe, easy, cost- and time-effective reliable method.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Preoperative Intralesional Bevacizumab Injection in Primary Pterygium in Tunisian Patients: A Randomized Controlled Prospective Study

Purpose

To assess the efficacy and safety of a single preoperative intralesional bevacizumab injection as an adjuvant treatment before primary pterygium surgery.

Methods

We conducted a randomized controlled interventional study from January 2019 to December 2020. The study included a total of 60 patients (60 eyes) with primary pterygium. We defined two groups of 30 patients each. Group A received an intralesional injection of bevacizumab (Avastin), 1 month before surgery (lesion excision and conjunctival autograft). Group B (control) had only the surgical treatment. Patients were followed up 7 days (D7), 1 month (M1), 3 months (M3), and 6 months (M6) postoperatively. Pre-, per-, and postoperatively, photographs of the lesions were taken, as well as a histopathological examination. The main outcome measures were the change in functional discomfort following intralesional bevacizumab injection and pterygium recurrence. Recurrence was defined as fibrovascular tissue growth invading the cornea. Therapeutic success was defined as the absence of pterygium recurrence in M6.

Results

The mean age of the 60 patients was 54.17 ± 10.53. After bevacizumab injection, the preoperative functional discomfort score decreased significantly (P = 0.048). There was a significant improvement in grade and color intensity (P = 0.001). We noted no local nor systemic complications after intralesional injection of bevacizumab. After pterygium excision, the success rate was statistically higher in Group A (P = 0.047). There was no significant difference in either final best-corrected spectral visual acuity or astigmatism between the two groups. We noted a statistically significant association between recurrence and color intensity (P = 0.046), vascular density (P = 0.049), and the degree of elastic tissue degeneration (P = 0.040).

Conclusion

A single preoperative subconjunctival injection of bevacizumab 1 month before surgery decreases the vascularity of newly formed blood vessels and hence may reduce the recurrence rate.