Current concepts and techniques in pterygium treatment

A Phase IIa Multicenter, Randomized, Vehicle-Controlled, Dose Escalating Study to Evaluate the Safety, Efficacy, and Pharmacokinetics of CBT-001 Ophthalmic Solution in Patients With Primary or Recurrent Pterygium

Purpose

To evaluate the safety and efficacy of CBT-001, a multitarget tyrosine kinase inhibitor eyedrop, for pterygia.

Design

Phase II clinical trial. Stage 1 was a single center, open-labeled, vehicle-controlled study. Stage 2 was a multicenter, randomized, double-masked, vehicle-controlled trial.

Participants

Patients with primary or recurrent pterygia.

Main Outcome Measures

The primary efficacy end point was lesion vascularity based on masked grading of photographs by an independent reading center. Other end points included dimensions of pterygia and safety.

Methods

In stage 1, 24 eyes of 24 patients received 1 drop of CBT-001 in a dose escalation fashion (0.02%, 0.05%, and 0.2%) to determine the maximally tolerated dose based on adverse events (AEs) and blood drug levels. In stage 2, subjects were randomly assigned to receive the maximally tolerated dose of CBT-001 or vehicle dosed 3 times a day for 4 weeks with a 20-week follow-up.

Results

In stage 1, the plasma maximum concentration values for all doses of CBT-001 were at or below the limit of detection (0.01 ng/ml). The most commonly reported AEs were mild foreign body sensation and irritation. CBT-001 0.2% was evaluated in stage 2. Baseline demographic characteristics were similar between patients receiving CBT-001 (n = 25) and vehicle (n = 23). After 4 weeks of dosing, the mean change from baseline in pterygium vascularity scores was -0.8 ± 0.7 (mean ± standard deviation) in subjects receiving CBT-001 0.2% and 0.0 ± 0.5 in subjects receiving vehicle (P < 0.001; 95% confidence interval: -1.12, -0.40). Pterygium vascularity scores remained significantly decreased, after the 4-week dosing period, at weeks 8 and 16, but not at week 24. The mean changes from baseline in the length of the pterygia were also significantly lower in subjects receiving CBT-001 compared with vehicle at weeks 2, 4, and 8 (P ≤ 0.014). The most commonly reported AEs were ocular, mild in severity, resolved after therapy, and did not result in discontinuation.

Conclusions

CBT-001 0.2% decreased pterygia vascularity and lesion length after 4 weeks of dosing with a prolonged effect after dosing. The drug was well tolerated with minimal detected systemic drug levels.

Financial Disclosures

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Modified sutureless and glue-free method versus conventional sutures for conjunctival autograft fixation in primary pterygium surgery: a systematic review and meta-analysis

BACKGROUND

Pterygium is a common ocular surface disorder that requires surgical intervention for treatment. Conjunctival autografts are preferred over simple excision due to lower recurrence rates. This systematic review and meta-analysis compared the modified sutureless glue-free (MSGF) method with conventional sutures (CS) for conjunctival autograft fixation in primary pterygium surgery.

METHODS

A comprehensive search was conducted in MEDLINE, Embase, CENTRAL, Google Scholar and ClinicalTrials.gov for randomised controlled trials (RCTs) comparing MSGF and CS conjunctival autografts. Outcome measures included operation time, recurrence and postoperative complications. Standardised mean difference (SMD) and risk ratio (RR) were used for continuous and dichotomous outcomes, respectively.

RESULTS

11 RCTs involving 833 participants were included. The analysis revealed that MSGF had a significantly shorter operation time compared with CS (SMD -3.704, 95% CI -5.122 to -2.287, p<0.001). CS was associated with a higher risk of foreign body sensation (RR 0.22, 95% CI 0.06 to 0.74, p=0.01). MSGF was associated with a higher risk of graft dehiscence (RR 9.01, 95% CI 2.74 to 29.68, p=0.000) and graft retraction (RR 2.37, 95% CI 1.17 to 4.77, p=0.02). No significant differences were found in recurrence, graft haemorrhage, granuloma, Dellen and conjunctival oedema.

CONCLUSION

Using the MSGF technique in conjunctival autograft fixation for pterygium surgery reduces operation time by relying solely on the patient's blood for fixation. However, it increases the risk of graft dehiscence and retraction. However, CS is linked to a higher likelihood of experiencing foreign body sensations. Understanding the learning curve and surgeon familiarity with novel techniques is crucial for optimising patient care and surgical outcomes, while individualised decision-making is necessary considering the advantages and disadvantages of each approach. Further research is warranted to minimise complications and optimise surgical outcomes.

High-throughput screening of transient receptor potential (TRP) channels in pterygium

PURPOSE

Pterygium is a hyaline degenerative disease of the conjunctiva characterized by the progression of fibrovascular connective tissue from the bulbar conjunctiva to the cornea. The mechanism of pterygium formation is still not fully understood. Transient receptor potential (TRP) channels are a group of ion channels with distinct characteristics. Recent indications suggest TRP channels may play a significant regulatory role in pterygium development, but previous studies have mainly focused on in silico analysis. Accordingly, in the present study, we aimed to decipher the expression signatures and role of TRP channels in pterygium development.

METHODS

The study encompassed a cohort of 45 patients matched for age and gender distribution, comprising 30 individuals with primary pterygium (PP) and 15 individuals with recurrent pterygium (RP). The control group consisted of unaffected conjunctival tissue obtained from the same set of patients. High-throughput screening of differentially expressed TRP channels in pterygium tissues was achieved with the help of Fluidigm 96.96 Dynamic Array Expression Chip and reactions were held in BioMark™ HD System Real-Time PCR platform.

RESULTS

Statistically significant increases were found in the expression of 21 genes, mainly TRPA1 (p = 0.021), TRPC2 (p = 0.001), and TRPM8 (p = 0.003), in patients with PP, and in TRPC5 (p = 0.05), TRPM2 (p = 0.029), TRPM4 (p = 0.03), TRPM6 (p = 0.045), TRPM8 (p = 0.038), TRPV1 (p = 0.01) and TRPV4 (p = 0.025) genes in RP tissues.

CONCLUSION

Collectively, TRP channel proteins appear to play pivotal roles in both the development and progression of pterygium, making them promising candidates for future therapeutic interventions in patients afflicted by this condition.

Topical cyclosporine A and interferon alpha-2b as adjuvants to surgery to decrease pterygium recurrence

BACKGROUND

Pterygium is very common in India and is usually removed by limbal conjunctival autograft transplantation (LCAT), which, despite being the first-line therapy, is still associated with recurrences of up to 18%.

OBJECTIVES

To compare the safety and efficacy of topical cyclosporine A (CsA) and interferon (IFN) alpha-2b in the prevention of postoperative recurrence of pterygium.

METHODS

A total of 40 patients with primary pterygium were randomized into two equal groups, Group C and Group I. Both the groups underwent LCAT, with Group C kept on topical cyclosporine 0.05% (CsA) 4 times daily and Group I on topical IFN alpha 2b 0.2 million IU 4 times daily postoperatively for 3 months. Pre- and posttreatment best-corrected visual acuity (BCVA), recurrence, and complications were assessed at day 1, week 1, 1 month, and 3 months.

RESULTS

The mean preoperative BCVA of 0.51 ± 0.18 and 0.51 ± 0.23 improved to 0.13 ± 0.13 and 0.13 ± 0.13 in Group C and Group I, respectively, after 3 months of treatment (P < 0.0001). Recurrence was seen in 2 cases in Group C and in 1 case in Group I at 3 months. No significant complications occurred in either of the groups.

CONCLUSION

Topical CsA and IFN Alpha-2b are newer efficacious adjuvants with LCAT for prevention of postoperative pterygium recurrence.

Pharmacological treatment strategies of pterygium: Drugs, biologics, and novel natural products

Pterygium is a fibrovascular tissue growth invading the cornea. Adjunctive treatment post-surgery includes conventional immunosuppressants as well as antiviral drugs. The use of large- and small-molecule antivascular endothelial growth factor (VEGF) agents remains an integral part of pterygium treatment as well as other neovascular conditions of the eye. Naturally occurring polyphenolic compounds have favorable characteristics for treating neovascular and inflammatory eye conditions, including good efficacy, stability, cost-effectiveness, and the versatility of their chemical synthesis. In this review, we discuss pharmacological treatments of pterygium. Natural products, such curcumin, ellagic acid, and chalcones, are reviewed, with emphasis on their potential as future pterygium treatments.

Ocular surface squamous neoplasia in a patient following oral steroids for contralateral necrotising scleritis

A male patient in his 70s presented with left eye necrotising scleritis. His ocular history was significant for pterygium excision with mitomycin C 3 months prior in the affected eye, open-angle glaucoma, nuclear sclerosis cataract and previous sixth cranial nerve palsy. Scleral culture was negative and blood work was positive for rheumatoid factor and HLA-B27. The patient was treated for necrotising scleritis with oral doxycycline, vitamin C, ranitidine and prednisone with gradual taper over 45 days. Two months after initiating treatment, his necrotising scleritis achieved complete resolution; however, a new-onset ocular surface squamous neoplasia (OSSN) was identified at the temporal limbus of the contralateral eye. He was treated with topical interferon alpha-2b 1 million IU qid and achieved complete resolution after 4 months. The case highlights both the acute precipitation of OSSN following oral steroids and a sight-threatening complication following pterygium excision.

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.

Bindehautdegenerationen und -neoplasien

Erhabenheiten der Bindehaut entstehen durch Gewebevermehrung, die entweder degenerativ oder neoplastisch, aber auch entzündlich sein können. In diesem Artikel werden degenerative (Pterygium und Pinguecula) sowie benigne und maligne neoplastische Bindehautveränderungen (epitheliale, melanozytäre und vaskuläre Tumoren, Choristome sowie Metastasen) bezüglich der Pathogenese, Symptome, Diagnostik und aktuellem Stand der Behandlung dargestellt.

[Conjunctival Degeneration and Neoplasia]

Conjunctival tumors result from gain of tissue, which can be either degenerative or neoplastic, but also inflammatory. In this article, degenerative (pterygium and pinguecula) as well as benign and malignant neoplastic conjunctival changes (epithelial, melanocytic and vascular tumors, choristomas as well as metastases) are discussed with regard to pathogenesis, symptoms, diagnostics and current status of treatment.

Application of platelet-rich fibrin grafts following pterygium excision

PURPOSE

To compare the efficacy, safety and recurrence rate of platelet-rich fibrin (PRF) grafts and limbal conjunctival autografts (LCAs) following pterygium excision.

METHODS

A total of 108 patients (108 eyes) with primary pterygium were included in this study and were divided into group A (56 eyes) and group B (52 eyes). Patients in group A underwent excision of the pterygium followed by LCA while patients in group B underwent PRF grafts following pterygium excision. The PRF was produced using the patient's own whole-blood sample by centrifugation and extrusion. The surgery time, intraoperative complications, postoperative complications, recurrence rate, intraocular pressure (IOP) and follow-up period were recorded and evaluated between the two groups.

RESULTS

The mean surgery time was significantly shorter in group B (25.0 ± 4.2 min) than in group A (36.5 ± 6.3 min) (P < .001). Recurrence was observed in two cases (3.6%) in group A while no recurrence was observed in group B. No graft loss was observed in either group. No other intra/postoperative complications such as a tear in the graft, injury to the medial rectus muscle, excessive bleeding, scleral necrosis, graft oedema, graft necrosis, pannus formation or symblepharon appeared in either group.

CONCLUSIONS

This study presented with a promising outcome of PRF graft applications in primary pterygium surgery. The use of PRF following pterygium excision is a simple, easily applicable, and comfortable method for both patients and surgeons, with less time consumption, recurrence rate and complications, which could be widely used in pterygium management.

RhoA/ROCK Signaling Regulates TGF-β1-Induced Fibrotic Effects in Human Pterygium Fibroblasts through MRTF-A

PURPOSE

The overexpression of transforming growth factor-beta1 (TGF-β1) after surgical excision often leads to excessive fibrosis, indicating the recurrence of pterygium. The aims of the present in vitro study were to investigate the role of RhoA/ROCK signaling in regulating fibrotic effects of primary human pterygium fibroblasts (HPFs), as well as to explore the possible mechanisms of these effects.

METHODS

Pterygium samples were obtained from surgery, and profibrotic activation was induced by TGF-β1. Cell proliferation was detected by CCK-8 assay; cell migration was detected by wound healing assay; quantitative real-time PCR and Western blot were used to detect the effects of TGF-β1 and the role of RhoA/ROCK signaling in the synthesis of alpha-smooth muscle actin (a-SMA), type I and III collagen (COL1 and COL3), and matrix metalloproteinase-9 (MMP9) in HPFs. The changes of signaling pathways were detected by Western blot; and pharmaceutical inhibition of RhoA/ROCK signaling and its downstream MRFT-A/SRF transcription pathway were used to assess their possible mechanism in HPFs fibrosis.

RESULTS

ROCK inhibitor Y-27632 decreased TGF-β1-induced cell proliferation and migration, reduced the TGF-β1-induced expression of profibrotic markers in HPFs, and suppressed TGF-β1-induced nuclear accumulation of Myocardin-related transcription factor A (MRTF-A) as well as accompanied elevation of F/G-actin ratio in HPFs. MRTF-A/Serum response factor (SRF) inhibitor CCG-100602 attenuated the TGF-β1-induced α-SMA expression and reduced myofibroblast activation in HPFs.

CONCLUSIONS

RhoA/ROCK signaling played a pivotal role in TGF-β1-induced fibrosis and myofibroblast activation in HPFs at least in part by inactivating the downstream MRTF-A/SRF transcriptional pathway.

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

Background

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

Methods

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

Results

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

Conclusions

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

[Pterygium: pathogenesis, diagnosis and treatment]

The pterygium is a frequent ultraviolet (UV) light-induced focal fibrovascular proliferation of the conjunctival tissue onto the cornea. Surgical excision should be performed in the case of reduced visual acuity, progressive astigmatism, impending invasion of the optical axis and ocular surface complaints. The main factors in preventing recurrence include optimal surgical treatment by an excision combined with a free conjunctival autograft, consistent postoperative treatment with preservative-free artificial tears and topical steroids as well as long-term UV protection.

Efficacy of second donor conjunctival graft from the same site for pterygium - A retrospective analysis

Purpose

To know the efficacy of the second donor conjunctival graft from the same site as that of the previous donor area in pterygium treatment.

Methods

Case record of patients were retrospectively analysed and those patients who had undergone pterygium excision previously, either for nasal or temporal pterygium excision and came with complaints of pterygium growth in opposite side of the bulbar conjunctiva in the same eye were included in the study. The patients with double head pterygium previously treated only over one side were also included. Total of 23 such patients were included in the study. The patients were followed up on post-operative day 1, 2 weeks, 6 weeks, 6 months and 1 year. The outcome measures like recurrence, graft edema, graft retraction, graft loss and other complications were noted in each follow up.

Results

Among the 23 patients included in the study 9 were male and 14 were female patients with a mean age of 44±7.2 years (range 24-57 years). On an average follow up period of 15±8.5 months, only 1 patient among 23 patients had recurrence (4.43%). Other complications noted were graft retraction in 4 eyes (17.4%), sub conjunctival hemorrhage in 8 eyes (34.8%) and graft edema in 11 eyes (47.8%). Only one patient presented with granuloma (4.34%).

Conclusion

The second conjunctival graft from the same site is safe and effective with encouraging results in indicated cases.

Evaluation of Conjunctival Autografting Augmented with Mitomycin C Application versus Ologen Implantation in the Surgical Treatment of Recurrent Pterygium

Objectives

To evaluate the safety and efficacy of augmenting conjunctival autografting with intraoperative mitomycin C (MMC) application versus Ologen implantation in the management of recurrent pterygium.

Materials and Methods

This prospective randomised study included 63 eyes of 63 patients, with recurrent nasal pterygium, who presented to the outpatient clinic of Menoufia University Hospital in Shebin El Kom and Manshiet Soltan from January 2016 to December 2019. Patients were randomly enrolled into two groups. Group A included 32 eyes of 32 patients who underwent conjunctival autografting augmented with the topical application of MMC (0.2 mg/mL), and group B included 31 eyes of 31 patients who underwent conjunctival autografting augmented with Ologen implantation. All the patients underwent follow-up examinations for a period of 24 months. During each visit, a complete ophthalmic examination was performed. Pterygium regrowth of 1 mm or more, over the cornea, was considered a recurrence.

Results

In the MMC group, no recurrence was reported during the 24-month follow-up period. In the Ologen implantation group, recurrence was reported in 2 (8%) eyes. The time interval from surgery to recurrence was 5 months in one case and 8 months in the other. No other serious postoperative complications were reported, and there was no statistically significant difference between the groups in this regard.

Conclusion

Ologen implantation with conjunctival autografting shows promising results in the surgical management of recurrent pterygium with mild non-vision-threatening postoperative complications comparable to that of MMC application with conjunctival autografting. Registration number: ClinicalTrials.govNCT04419038.

Sutureless versus suture technique for conjunctivolimbal autografting in primary pterygium excision: A prospective study

PURPOSE:

Conjunctivolimbal autograft is proposed to be the best treatment for pterygium and autograft can be fixed either with sutures or without. This study was undertaken to assess and compare the efficacy of sutureless versus suture techniques for conjunctivolimbal autografting in primary pterygium.

METHODS:

A prospective observational study was conducted in the department of ophthalmology in a tertiary care center from March 2018 to September 2019. Twenty consecutive patients in the age group of 20 to 70 years with primary pterygium were included. Ten patients underwent suture technique for autograft placement, whereas ten patients underwent sutureless technique. Comparison of both the groups was done in terms of duration of surgery and postoperative symptoms. Data were entered into Microsoft Excel software and analyzed using SPSS software.

RESULTS:

In the first group, the mean duration of surgery was 48 min and it was 38 min in the second group. The difference was statistically significant (P = 0.000). Postoperatively, foreign-body sensation was present in nine patients in the first group, whereas it was absent among the patients in the second group. The difference was statistically significant (P = 0.000). Four patients in the first group and two patients in the second group had postoperative hyperemia and only one patient in the first group had conjunctival chemosis. A graft-related complication was present in one patient in the second group.

CONCLUSION:

Sutureless technique is a better technique as compared to conventional suture technique.

Postoperative treatment compliance rate and complications with two different protocols after pterygium excision and conjunctival autografting

AIM

To evaluate compliance rate to pterygium postoperative treatment with two different protocols.

METHODS

Review of clinical data of patients submitted to pterygium excision and conjunctival autografting in a single centre (and a single surgeon) in Barcelona between March 2014 and December 2017. Initial postoperative protocol (protocol 1) consisted of 4 months of topical steroids in a tapering fashion. Protocol 2 consisted of topical steroids tapered over 5 weeks. Compliance rate, complications and clinical outcomes were evaluated, and statistical comparisons were made.

RESULTS

120 surgeries were performed in 99 patients. Protocol 1 was applied in 63 cases and the next 57 followed protocol 2. Compliance with protocol 1 (57.6%) was lower than with protocol 2 (84.9%) (p = 0.002). Intraoperative complications (graft tear, corneal thinning, corneal perforation and bleeding) were found in 10 cases of protocol 1 and three cases of protocol 2, p = 0.08. Postoperative complications (graft dislocation, graft haematoma, ocular hypertension and recurrence) were found in 31 cases of protocol 1 (46.2%) and eight cases of protocol 2 (14%), p = 0.001. Six weeks after surgery, ocular hypertension was detected in eight cases corresponding to protocol 1 (13.6%) and two cases of protocol 2 (3.8%), p = 0.099. Recurrence rate during first year was higher in protocol 1 (26.3%) compared to protocol 2 (7.6%), p = 0.011. No cases of visual acuity worsening or infection were registered.

CONCLUSION

Protocol 2 has shown to have higher compliance rate than protocol 1 and less postoperative complications, proving to be a safe and effective postoperative treatment after pterygium surgery.

Femtosecond Laser-assisted Preparation of Conjunctival Autograft for Pterygium Surgery

Femtosecond laser-assisted conjunctival autografts (CAG) preparation was recently proposed. This study reports the outcomes of the first clinical trial on the use of laser to prepare CAG in pterygium surgery, and to compare the outcomes with those of manual technique. Forty eyes undergoing primary pterygium excision with laser-assisted CAG transplantation were prospectively included (L group). Two historical matched cohorts whose CAGs were prepared manually were compared (n = 78 eyes by the same experienced surgeon, M group; n = 78 eyes by trainees; TM group). We found the laser-created CAGs had only 11 μm deviation from the targeted thickness. The best-corrected visual acuity improved, and the astigmatism significantly decreased after surgery, with comparable efficacy across 3 groups. The 1-year recurrence rate was 2.5%, 3.8% and 7.7% in the L, M and TM groups, respectively (P = 0.12). There was no significant difference between the L and M groups in the complication rate (5.0% and 1.3%, respectively), surgical time (19.4 ± 5.1 and 19.1 ± 6.2 minutes, respectively), and postoperative discomfort scores (0.1 ± 0.3 and 0.2 ± 0.3, respectively), but these outcomes were significantly less favorable in the TM group. The results of this first comparative clinical trial suggest that femtosecond laser-assisted CAG preparation can be considered as an alternative technique for CAGs preparation.

Modified Sutureless and Glue-Free Method Versus Conventional Sutures for Conjunctival Autograft Fixation in Primary Pterygium Surgery: A Randomized Controlled Trial

PURPOSE

To compare the advantages and disadvantages of a modified sutureless and glue-free method with those of conventional sutures for conjunctival autograft fixation in pterygium surgery.

METHODS

A prospective randomized controlled study was performed on 73 eyes with primary nasal pterygium. After pterygium excision, the bare sclera was covered with a limbal conjunctival autograft, which was fixed using a modified sutureless and glue-free method in group 1 (39 eyes) and sutures in group 2 (34 eyes). The main outcome measures were operative time, autograft stability, postoperative discomfort, autograft thickness, pterygium recurrence, and complications.

RESULTS

The mean operative time was significantly shorter in group 1 (11.9 ± 1.3 minutes) than in group 2 (24.3 ± 6.1 minutes, P < 0.0001). On day 2 postsurgery, the average conjunctival autograft thickness was significantly higher in group 1 (861 ± 340 μm) than in group 2 (577 ± 287 μm, P = 0.034). Subsequently, conjunctival autograft thickness gradually decreased, with no significant difference between groups after 1 week. There were no significant differences in postoperative discomfort between groups, except for a greater foreign body sensation on day 2 and an itching sensation in 1 week in group 2 compared with group 1. Autograft side displacement occurred in 4 patients (10.3%) in group 1; 2 of these 4 developed a granuloma. There was 1 recurrence (2.9%) in group 2.

CONCLUSIONS

The modified sutureless and glue-free limbal conjunctival autograft fixation method might be effective and efficient for primary pterygium surgery, with potentially decreased recurrence and postoperative discomfort.

Slipped Medial Rectus Muscle With Stretched Scar After Pterygium Surgery

The authors report a rare case of slipped medial rectus muscle with stretched scar in the left eye of a 45-year-old woman following pterygium surgery. There was total limitation of adduction in her left eye with complaints of diplopia in all gazes with maximum separation of images in dextroversion on diplopia charting. Hess charting showed underaction of the medial rectus muscle of the left eye and overaction of the lateral rectus muscle of the right eye. Based on the history and findings, a diagnosis of medial rectus muscle disinsertion of the left eye during pterygium surgery was made. Medial rectus muscle exploration was done and the slipped medial rectus muscle was found attached to its original insertion site via pseudotendon/stretched scar. The capsule was dissected, the scar tissue was excised, and the slipped medial rectus muscle was identified, hooked, and secured with sutures. The muscle was reattached with advancement. Postoperatively, the patient was orthotropic and there was no diplopia. Accidental medial rectus muscle disinsertion during pterygium surgery is a rare but serious complication. Proper care should be taken intraoperatively during pterygium surgery to avoid this complication. However, meticulous surgical exploration and reattachment of the muscle yields satisfactory results. [J Pediatr Ophthalmol Strabismus. 2019;56:e34-e37.].

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.

Ologen Implantation versus Conjunctival Autograft Transplantation for Treatment of Pterygium

Purpose

To evaluate the effectiveness and safety of Ologen implantation versus conjunctival autograft transplantation for primary pterygium.

Methods

A retrospective case-series analysis. Thirty-one eyes of 29 patients were included in the Ologen group and 42 eyes of 35 patients in the autograft group. The patients were followed up for 1 year and evaluated for slit-lamp biomicroscopy, intraocular pressure, and adverse events. Recurrence rate, complications, and final appearance of the cases were evaluated prospectively.

Result

At 1 year after operation, 2 eyes recurred (6.5%) in the Ologen group and 4 eyes recurred (9.52%) in the autograft group. There was no statistically significant difference between both groups (P=0.157, χ² = 3.781). There was no occurrence of serious complications. Two eyes among the 31 eyes of the Ologen group were conjunctivitis; the incidence of complications was 6.45% (2 eyes). There was conjunctivitis in 3 eyes of the autograft group, 1 eye complicated with symblepharon, and 1 eye with conjunctival granuloma; the incidence of complications was 11.90% (5 eyes), and there was no statistically significant difference between both groups (P=0.094). The conjuntiva was less vascular and inflamed at 1 month postoperatively in the Ologen group than in the autograft group.

Conclusions

Ologen transplantation was technically easier, provided short operative time compared with conjunctival autograft transplantation, and preserved healthy conjunctiva with less complication and less recurrence; it may be a new, safe, and effective alternative for improving the short-term success rate of primary surgery.

Application of autologous serum eye drops after pterygium surgery: a prospective study

PURPOSE

The study aims to determine the effect of 50% autologous serum drops (ASD) on corneal healing and patient comfort following pterygium surgery.

METHODS

Fifty eyes of 50 patients who underwent pterygium excision combined with autologous conjunctival graft were included in this prospective randomized study: in 25 eyes, 50% ASD. In the remaining 25 eyes, conventional artificial tears (CAT) were applied postoperatively until corneal epithelium had completely epithelialized. Corneal epithelium healing speed, visual analog scale (VAS) for postoperative pain assessment, conjunctival inflammation, and recurrences were evaluated. Patients were followed up for 6 months.

RESULTS

Mean corneal epithelium closure time was 3.16 ± 0.37 days (range 3 and 4 days) in ASD group and 4.96 ± 0.84 days in CAT group (range 4 and 6 days), and the difference was statistically significant (p < 0.001). VAS scores were significantly lower in ASD group than CAT group in the first 5 days after surgery. In 9 of 50 eyes, moderate conjunctival inflammation continued 1 month: 4 (16%) in ASD group and 5 (20%) in CAT group (p = 0.713). In total, pterygium recurrence was seen in 5 (10%) eyes: 2 eyes (8%) in ASD group and 3 eyes (12%) in CAT group (p = 0.637).

CONCLUSION

ASD accelerated corneal epithelial healing following pterygium surgery. ASD group had lesser pain that was seem to be related with accelerated corneal epithelial healing.

Comparison of hyperdry amniotic membrane transplantation and conjunctival autografting for primary pterygium

Background

The purpose of this study was to evaluate the safety and effectiveness of the hyperdry amniotic membrane transplantation compared with conjunctival autografting for the treatment of primary pterygium.

Methods

One hundred and forty-one eyes from 130 patients with primary pterygium were treated with excision followed by hyperdry amniotic membrane or conjunctival autografting after random selection. Seventy-nine eyes from 71 patients received hyperdry amniotic membrane transplantation (HD-AM group), and 62 eyes from 59 patients received conjunctival autografting (CG group). Patients were followed up at one week and one, three, six, and 12 months post-surgery. Recurrence rate, postoperative complications, and final follow-up patient visits were prospectively evaluated.

Results

The mean follow-up duration was 12.56 ± 4.35 months in the HD-AM group and 12.85 ± 3.90 months in the CG group. Recurrences were detected in four eyes (5.06%) in the HD-AM group and 13 eyes (20.97%) in the CG group. A statistically significant difference in frequency of recurrence between the two groups (P = 0.003) was observed. The cumulative non-recurrence rates at six and 12 months in all patients stratified by age and sex were not significantly different (P = 0.642 and P = 0.451, respectively, by log-rank test). Graft retraction and necrosis were not detected in the two groups during the follow-up period.

Conclusion

Hyperdry amniotic membrane transplantation was effective in preventing pterygium recurrence when compared with conjunctival autografting and can be considered a preferable and safe grafting procedure for primary pterygium.

Trial registration

Current Controlled Trials ISRCTN16900270, Retrospectively registered (Date of registration: 3 May 2018).

Clinical outcome of combined conjunctival autograft transplantation and amniotic membrane transplantation in pterygium surgery

AIM

To compare long-term outcome of primary and recurrent pterygium surgery with three different techniques: combined conjunctival autograft and overlay amniotic membrane transplantation (CAT with AMT), conjunctival autograft transplantation (CAT) alone and amniotic membrane transplantation (AMT) alone.

METHODS

In this retrospective study, 142 eyes of 142 pterygium patients (104 primary, 38 recurrent) who underwent CAT (group A), AMT (group B) or CAT with AMT (group C) respectively following surgical excision were reviewed and compared based on the recurrences and post-operative complications.

RESULTS

The number of recurrence post-surgery were 17 (9 from primary, 8 from recurrent; the same description below), 18 (10, 8) and 2 (1, 1) in groups A, B, and C respectively; dry eyes were 22 (16, 6), 27 (18, 9) and 7 (3, 4); conjunctival inflammations were 30 (17, 13), 27 (16, 11) and 11 (6, 5). Patients in group C (either primary or recurrent or both) mainly showed significantly better results than those in group A or B (P<0.05) regarding above-mentioned clinical effects.

CONCLUSION

Combined CAT and overly AMT have significantly lower rates of recurrence and postoperative complications for primary and recurrent pterygium surgery than CAT or AMT alone.

Risk factors for pterygium recurrence after limbal-conjunctival autografting: a retrospective, single-centre investigation

PURPOSE

To determine the risk factors related to recurrence of pterygium after pterygium excision with limbal-conjunctival autograft.

STUDY DESIGN

Retrospective, observational case series.

METHODS

The current study included 310 patients who underwent surgical removal of pterygium using limbal-conjunctival autografting. All surgery was performed by the same surgeon at a single Hospital from 2006 to 2011. Preoperative and postoperative patient data were collected. The patients were summoned to follow-up examinations. Procedures with at least 12 months of follow-up were included in the final analysis. Potential risk factors for pterygium recurrence were determined by Cox proportional-hazard linear analysis and recurrence-free survival time was evaluated using Kaplan-Meier method.

RESULTS

The overall recurrence rate was 5.2% during an average follow-up time of 20.1±8.6 months (range, 12-37 months). According to Kaplan-Meier evaluation, the estimated time to recurrence was 34.2 ± 0.5 months (95% confidence interval 33.3-35.0 months) for the whole population. Multivariate analysis showed that age < 45 years old (RR = 3.582, 95% CI 1.984-13.044, P = 0.047), recurrent type of pterygia (RR = 4.856, 95% CI 1.794-13.142, P = 0.002), and vertical size of pterygium > 6.7 mm (RR = 2.529, 95% CI 1.053-6.075, P = 0.038) were significantly associated with increased risk of recurrence.

CONCLUSION

Our findings suggest that young age, recurrent type of pterygia, and larger pterygial tissue are risk factors for pterygium recurrence after surgical excision. Hence, early excision of pterygium is recommended to decrease the recurrence rate.

Evaluation of Topical Lignocaine Jelly 2% for Recurrent Pterygium Surgery with Glue-free Autologous Conjunctival Graft

AIM

This study aims to evaluate the efficacy of lignocaine 2% jelly as a topical anesthesia in recurrent pterygium surgery with glue-free conjunctival limbal autograft.

MATERIALS AND METHODS

A prospective, nonrandomized, observational study, comprising of 51 patients (51 eyes) having recurrent pterygium, was conducted at a tertiary eye care center in central India. Pterygium excision with glue-free autologous conjunctival grafting was done under 2% lignocaine jelly. The visual analog scale was utilized to record the intra- and post-operative pain score. Patient comfort, intraoperative painful sensations perceived by the patient, supplemental anesthesia, complications, and surgeon discomfort were noted. Anesthetist also noted vital parameters and any intravenous drugs required.

RESULTS

No difference in intra- and post-operative pain score (P = 0.24) was observed in the patients. Zero score, i.e. no pain was noticed in 30 patients (58.8%) patients. The average surgical time was 29.20 min (+1.11). The average surgeon discomfort score was 0.18 + 0.51. Inadvertent eye movement was seen in 3 patients (5.9%). Lid squeeze was noted in 45 patients (88.2%) during placement of lid speculum. Forty-eight patients (94.1%) gave preference to the topical anesthesia of 2% lignocaine jelly compared to the previous mode of anesthesia.

CONCLUSION

Pterygium surgery with glue-free autogenous conjunctival grafting can be performed successfully by preoperative local application of 2% lignocaine jelly. The ease of application, lack of toxicity and sufficient effect to complete the surgery make it an efficient alternative to injectable anesthetics.

Releasable Single Suture for Primary Pterygium Excision With a Conjunctival Autograft

PURPOSE

To evaluate the efficacy of a releasable single suture for pterygium excision with a conjunctival autograft (CAG).

METHODS

Retrospective case series at a tertiary eye care center in central India was conducted. Medical records of 150 patients, who underwent primary pterygium excision with a CAG secured by a single releasable 10-0 nylon suture in the last year were reviewed. The surgical duration was noted. The suture was released on the first postoperative day under topical anesthesia. Patients were followed up until 1 year. At each visit, factors studied were patient comfort [pain grading on a visual analog scale], graft apposition, complications, and recurrence.

RESULTS

Mean age of patients was 39 ± 11 years. Most patients in our study were female (58.7%). Sixty percent of pterygia were of Tan grade 2. The mean duration of surgery was 4.8 ± 1.3 minutes. The maximum size of the CAG was 6 mm (3-6 mm). The graft retraction rate was 5.3% (1 mm retraction in the CAG more than 5.5 mm) with no event of graft loss. Four percent of patients had grade 1 recurrence.

CONCLUSIONS

Releasable single suture may offer a good and simple alternative, which uses the gold standard technique of the CAG with exclusion of suture-related complications.

Sutureless, Glue-less Conjunctival Autograft versus Conjunctival Autograft with Sutures for Primary, Advanced Pterygia: An Interventional Pilot study

INTRODUCTION

Conjunctival Autograft (CAG) in pterygium surgery can be attached by sutures or fibrin glue or autologous in situ blood coagulum. Recurrence rate and other parameters related to pterygium surgery between CAG with sutures and autologous in situ blood coagulum have not been compared uniformly in advanced pterygia alone.

AIM

To compare and evaluate the outcome of sutureless, glue-less CAG with autologous in situ blood coagulum versus CAG with sutures for primary, advanced pterygium.

MATERIALS AND METHODS

Thirty eyes of 30 patients with primary, nasal, advanced, Grade 3 pterygia (as per Tan et al's., classification) were randomized into Group 1 (n=15) (sutureless, glue-less CAG with autologous in situ blood coagulum) and Group 2 (n=15) (conjunctival autograft with 8-0 vicryl sutures) as a pilot study. The outcome parameters evaluated were graft stability and symptoms of pain, foreign body sensation and watering at day 1, day 7, day 14, one month, three months and six months and recurrence at six months.

RESULTS

The mean age in the study was 44.77±13.74 years. Overall, Group 1 had better scores in symptom parameters than Group 2 (p<0.05). Graft stability was better in Group 2 (p<0.05). In Group 1, 3 (20%) patients had one side displacement and 3 (20%) patients had full displacement of graft. At six months, 4 (26.6%) patients in Group 1 had recurrence whereas in Group 2, 5 patients (33.3%) had recurrence (p=0.446).

CONCLUSION

In primary, advanced pterygia, sutureless, glue-less pterygium surgery with autologous in situ blood coagulum was better in symptom scores but graft stability was better in the suture group. Sutureless, glue-less pterygium surgery with autologous in situ blood coagulum was unpredictable in graft stability. There was no statistically significant difference in the recurrence rate between the two groups.

Inhibitory effects of rosmarinic acid on pterygium epithelial cells through redox imbalance and induction of extrinsic and intrinsic apoptosis

Pterygium is a common tumor-like ocular disease, which may be related to exposure to chronic ultraviolet (UV) radiation. Although the standard treatment for pterygium is surgical intervention, the recurrence rate of pterygium is high when no effective inhibitory drug is used after surgery. Rosmarinic acid (RA) is a polyphenol antioxidant with many biological activities, including anti-UV and anti-tumor properties. This study aimed to examine the inhibitory effects of RA on pterygium epithelial cells (PECs). Methylthiazolyldiphenyl-tetrazolium bromide (MTT) assay was used to examine the cell cytotoxicity of PECs after RA treatment. A fluorescent probe, DCFH-DA (2',7'-dichlorofluorescin diacetate), was stained with PECs to measure intracellular reactive oxygen species (ROS) levels. Antioxidant activity assays were used to measure the levels of superoxide dismutase (SOD) and catalase (CAT) in PECs. Western blot analysis was used to determine the protein expression of nuclear factor E2-related factor 2 (Nrf2), heme oxygenase 1 (HO-1), quinone acceptor oxidoreductase 1 (NQO1), and apoptosis-associated proteins. RA significantly reduced the cell viability of the PECs. Treatment with RA remarkably increased the Nrf2 protein expression levels in the nucleus, HO-1 and NQO1 protein expression levels, and the activities of SOD and CAT. As a result, intracellular ROS levels in PECs were decreased. Additionally, the induction of extrinsic apoptosis on PECs by RA was associated with increasing expressions levels of Fas, Fas-associated protein with death domain (FADD), tumor necrosis factor-alpha (TNF-α), and caspase 8 protein. Moreover, the induction of intrinsic apoptotic cell death in PECs was confirmed through upregulation of cytochrome c, Bax, caspase 9, and caspase 3 and downregulation of Bcl-2 and pro-caspase 3. Our study demonstrated that RA could inhibit the viability of PECs through regulation of extrinsic and intrinsic apoptosis pathways. Therefore, RA may have potential as a therapeutic medication for pterygium.

[Pterygium: etiology, pathogenesis, treatment]

Pterygium is a degenerative condition characterized by fibrovascular outgrowth of conjunctiva over the cornea. Many theories exist that try to explain its pathogenesis. The current belief is that this disease is multifactorial with ultraviolet radiation being the most important trigger. Attention is also paid to such factors as tear film changes, cytokines and growth factors disbalance, immunologic disturbances, genetic mutations, and viral infections. Modern classifications consider the rate of fibrovascular growth, its progressive potential, and histological features. In the beginning pterygium is usually asymptomatic, however, dry eye manifestations may be present, such as burning, itching, and/or tearing. As the lesion grows toward the optical zone, visual acuity gets compromised, and thus, surgical treatment is required. Because of recurrences and repeated surgeries, the growth of the lesion may become more aggressive and cause irregular astigmatism. Comprehensive surgery of pterygium is aimed at not only removing the lesion, but also preventing recurrences. Advisable are modified bare sclera techniques with subsequent transposition of the conjunctival flap, conjunctival autotransplantation, amniotic membrane transplantation, and peripheral lamellar keratoplasty (in cases of significant ingrowth). In some cases, antirecurrent adjuvant therapy may be considered that involves the use of mitomycin C, 5-fluoruracil, and VEGF inhibitors. However, the search for the best treatment for pterygium, i.e. an easy to perform, cosmetically-friendly method associated with minimal risk of recurrences and/or complications, remains an interest of modern ophthalmology.

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.

K-ras oncogene mutation in pterygium

PurposePterygium is claimed to be a benign proliferation triggered by prolonged exposure to ultraviolet radiation. The frequency of K-ras oncogene mutation, which is among the initial mutations in tumorigenesis, is evaluated in this study.Patients and methodsIn this prospective randomized clinical, trial pterygium tissues and normal conjunctiva tissue specimens are obtained from the superotemporal quadrant of patients who underwent primary pterygium excision with autograft transplantation. DNA extraction from tissues was performed using the QIAamp DNA FFPE tissue kit. A PCR reaction was performed to amplify sequences containing codons 12, 13, and 61 of the K-ras gene in DNA. These PCR products then underwent the 'pyrosequencing' procedure for mutations at these codons.ResultsPterygium and normal conjunctival tissue samples of 25 patients (10 females, 15 males) were evaluated in the study. The mean age of the patients was 54.54±13.13 years. Genetic analysis revealed no K-ras mutations in normal conjunctival tissues, whereas pterygium tissues of the same cases demonstrated mutation at codon 12 in one case and mutations at codon 61 in seven cases, which was statistically significant (P<0.05). The point missense mutations at codon 61 were glutamine to arginine (Glu61Arg CAA>CGA) in four cases and glutamine to leucine (Glu61Leu CAA>CTA) in three cases.ConclusionThe significantly higher frequency of codon 61 mutation of the ras oncogene in primary and bilateral pterygium specimens compared with normal conjunctiva supports the tumoral origin of pterygium, and thus set the stage for research into a targeted therapy for pterygium with better outcomes than surgical excision.

Subtenon Injections of Ranibizumab Arrest Growth in Early Recurrent Pterygium

IMPORTANCE

Currently the only treatment for recurrent pterygium is surgery. This is a phase 1 trial investigating ranibizumab as a medical treatment for recurrent pterygium.

OBJECTIVE

To assess the safety and efficacy of subtenon Ranibizimab for recurrent pterygia.

DESIGN

Subjects with recurrent pterygium received subtenon ranibizumab and were followed for 1 year. Safety parameters were measured. Photographs were taken and quantitatively analyzed to measure the short-term (2 months) and long-term (5-26 months) response to treatment.

SETTING

University of New Mexico Eye Clinic.

PARTICIPANTS

Eight subjects with recurrent pterygia.

INTERVENTIONS

Subtenon delivery of 0.5 to 2 mg of ranibizumab, at day 0, month 1, and month 2.

MAIN OUTCOME MEASURES

Safety parameters included visual acuity, intraocular pressure, and assessment of ocular surface. Efficacy was assessed by comparing photographs taken at day 0 with a short-term follow-up photograph taken at month 2 and a long-term follow-up image taken at the final patient visit (range 5-26 months). Quantitative analysis of photographs was performed to measure vascularity in the treated zone.

RESULTS

Four subjects had an arrest of pterygium growth with a visual reduction in vascularity and a quantitative reduction in the area of vascularization (average vascularized area in short-term follow-up images was 51% of the baseline photos at day 0, and in the long-term photos was 36% of day 0). The other four subjects had a less marked reduction in their vascularity in the short-term photos (69% of their baseline photos). This resulted in two subjects withdrawing from the study early. Long-term quantitative analysis for the two remaining "nonresponders," who completed the study, showed an average vascularized area that was 71% of that in their baseline photos. The long-term photos in these subjects did not appear to have a clinically relevant difference from the short-term photos.

CONCLUSIONS

In half of the subjects, subtenon ranibizumab appeared to arrest growth. Although the response is variable, this may warrant the drug's use when attempting to control growth of recurrent pterygia, and may prevent consecutive surgery for some patients.

MicroRNA-215 Regulates Fibroblast Function: Insights from a Human Fibrotic Disease

MicroRNAs are implicated in the regulation of gene expression via various mechanisms in health and disease, including fibrotic processes. Pterygium is an ocular surface condition characterized by abnormal fibroblast proliferation and matrix deposition. We aimed to investigate the role of microRNAs in pterygium and understand the relevant cellular and molecular mechanisms. To achieve this objective, a combination of approaches using surgically excised paired human pterygium and conjunctival tissues as well as cultured primary fibroblast cells from tissue explants were evaluated. Fibroblast dysfunction has been shown to play a central role in pterygium pathology. Here we show that miR-215, among a few others, was down-regulated (2-fold) in pterygium compared to control, and this was consistent in microarray, real-time PCR and fluorescent in-situ hybridization. The effects of increased miR-215 were investigated by adding exogenous miR-215 to fibroblasts, and this showed a decrease in cell proliferation but no significant apoptosis compared to control. Further cell cycle analysis showed that miR-215 depressed progression of cells at G1/S as well as G2/M. A few cell cycle related transcripts were downregulated (2.2-4.5-fold) on addition of miR-215: Mcm3, Dicer1, Cdc25A, Ick, Trip13 and Mcm10. Theoretic binding energies were used to predict miR-215 binding targets and luciferase reporter studies confirmed Mcm10 and Cdc25A as direct targets. In summary, mir-215 could play a role in inhibiting fibroblast proliferation in ocular surface conjunctiva. Dampening of this mir-215 could result in increased fibroblast cell cycling and proliferation, with possibly increased fibroblastic production of matrix, inducing pterygium formation.

Mitomycin C in pterygium treatment

Pterygium is a benign lesion usually growing from the nasal side of the conjunctiva onto the cornea. Most cases of pterygium does not cause problem or requires specific treatment. The exact cause of pterygium is not clear yet, but some factors are pointed as causes, being the most important the long-term ultraviolet ray exposure. Pterygium surgery is usually considered when there are symptoms that do not respond to conservative treatment. Recurrence is the main complication of the surgery, and much has been done to avoid it. Mitomycin C (MMC) has been used as a fibroblast proliferation inhibitor during the surgery to reduce the chance of recurrence of the pterygium. This review describes the use of MMC as an adjunctive, the optimal dosage, the duration of administration of MMC and possible complications, when used during, after and before the surgery. Most studies suggest that increased exposure (dose or duration) of MMC is associated with a lower recurrence, but with higher risks of complications.

Claudin-1 expressions decrease in pterygium with respect to normal conjunctiva

CONTEXT

Pterygium is the fibrovascular growth of the limbal conjunctiva over cornea. This proliferative nature might have a pathogenesis associated with tight junction proteins.

OBJECTIVE

To investigate the tight junction protein claudin-1 expressions in pterygium with respect to normal conjunctiva.

MATERIALS AND METHODS

This retrospective study included 28 patients who underwent pterygium surgery with autograft. Claudin-1 expressions were immunohistochemically evaluated in normal and lesional conjunctiva of the same eye. Immunohistochemical evaluation was done with regard of both the intensity and the extent of staining. The distribution of the immunohistochemical scores in pterygium and normal conjunctiva has been compared with using McNemar test.

RESULTS

The mean age of the patients was 52.2 ± 11.2 years and male/female ratio was 8/20. Among 28 samples of normal conjunctiva 25 (89.2%) demonstrated a strong immunohistochemical expression with claudin-1 whereas this rate was 10.8% for pterygium samples. Statistical analysis revealed a significant decrease in claudin-1 expressions in pterygium with respect to normal conjunctiva (p < 0.001).

DISCUSSION AND CONCLUSIONS

The loss of claudin-1 appears to be involved in the pathogenesis of pterygium and the future studies will elucidate the exact role of tight junction proteins in the invasive and recurrent nature of pterygium.

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

OBJECTIVE

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

DESIGN

Prospective, interventional and comparative study.

PARTICIPANTS

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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