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Whitcup SM, Sall KN, Hovanesian JA, Goldberg DF, Lee OL, Yang R, Ni J. 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. OPHTHALMOLOGY SCIENCE 2024; 4:100502. [PMID: 38883924 PMCID: PMC11179250 DOI: 10.1016/j.xops.2024.100502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 02/26/2024] [Accepted: 02/26/2024] [Indexed: 06/18/2024]
Abstract
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.
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Affiliation(s)
- Scott M Whitcup
- Department of Ophthalmology, UCLA Stein Eye Institute, Los Angeles, California
| | | | | | | | - Olivia L Lee
- Department of Ophthalmology, UCI Gavin Herbert Eye Institute, Irvine, California
| | - Rong Yang
- Cloudbreak Pharma, Irvine, California
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Arun K, Grillon F, Georgoudis P. Primary Pterygium Excision Surgery: Analysis of Risk Factors and Clinical Outcomes. Cureus 2024; 16:e62440. [PMID: 38882219 PMCID: PMC11179689 DOI: 10.7759/cureus.62440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2024] [Indexed: 06/18/2024] Open
Abstract
Purpose To evaluate clinical outcomes of primary pterygium excision surgery and analyze risk factors for pterygium recurrence. Setting Eye Treatment Centre, Cornea and External Diseases Service, Whipps Cross Hospital, London, United Kingdom. Methods Retrospective case series of eyes undergoing primary pterygium excision between August 2017 and July 2022. Patients who underwent "pterygium excision" documented in the electronic patient record system were identified. Patients with recurrent pterygium and those lost-to-follow-up were excluded. The duration of follow-up, type of surgery performed (primary conjunctival closure, conjunctival autograft, and amniotic membrane transplantation), recurrences with respect to the type of surgery performed, and postoperative complications were collected and analyzed. Results In total, 83 eyes (from 79 patients) were included. The mean age of our patient cohort was 59.3 ± 5.9 years. The most common ethnic distribution was Black Caribbean (15.7%). Conjunctival autograft was performed in 76 eyes (91.6%), primary conjunctival closure was performed in five eyes (6%) and amniotic membrane transplantation was performed in two eyes (2.4%). The recurrence rate with conjunctival autograft was 1.3% with a median time to recurrence of 2.98 months. Recurrence was significantly more common in patients below the age of 40 years (p=0.03). Recurrence was not significantly associated with gender (p=0.23), ethnicity (p=0.17), or grade of surgeon (p=0.38). Conclusion Our findings demonstrate the effectiveness of conjunctival autograft with fibrin glue fixation for the surgical management of primary pterygium. Recurrence was found to be significantly more common in patients under the age of 40 years old. However, recurrence was not associated with ethnicity, gender, or surgeon grade.
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Liu Y, Xu C, Wang S, Chen Y, Lin X, Guo S, Liu Z, Wang Y, Zhang H, Guo Y, Huang C, Wu H, Li Y, Chen Q, Hu J, Luo Z, Liu Z. Accurate detection and grading of pterygium through smartphone by a fusion training model. Br J Ophthalmol 2024; 108:336-342. [PMID: 36858799 PMCID: PMC10894821 DOI: 10.1136/bjo-2022-322552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 01/06/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND/AIMS To improve the accuracy of pterygium screening and detection through smartphones, we established a fusion training model by blending a large number of slit-lamp image data with a small proportion of smartphone data. METHOD Two datasets were used, a slit-lamp image dataset containing 20 987 images and a smartphone-based image dataset containing 1094 images. The RFRC (Faster RCNN based on ResNet101) model for the detection model. The SRU-Net (U-Net based on SE-ResNeXt50) for the segmentation models. The open-cv algorithm measured the width, length and area of pterygium in the cornea. RESULTS The detection model (trained by slit-lamp images) obtained the mean accuracy of 95.24%. The fusion segmentation model (trained by smartphone and slit-lamp images) achieved a microaverage F1 score of 0.8981, sensitivity of 0.8709, specificity of 0.9668 and area under the curve (AUC) of 0.9295. Compared with the same group of patients' smartphone and slit-lamp images, the fusion model performance in smartphone-based images (F1 score of 0.9313, sensitivity of 0.9360, specificity of 0.9613, AUC of 0.9426, accuracy of 92.38%) is close to the model (trained by slit-lamp images) in slit-lamp images (F1 score of 0.9448, sensitivity of 0.9165, specificity of 0.9689, AUC of 0.9569 and accuracy of 94.29%). CONCLUSION Our fusion model method got high pterygium detection and grading accuracy in insufficient smartphone data, and its performance is comparable to experienced ophthalmologists and works well in different smartphone brands.
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Affiliation(s)
- Yuwen Liu
- Eye Institute, Xiamen University, Xiamen, Fujian, China
- Xiamen University National Institute for Data Science in Health and Medicine, Xiamen, Fujian, China
| | - Changsheng Xu
- Eye Institute, Xiamen University, Xiamen, Fujian, China
- Institute of Artificial Intelligence, Xiamen University, Xiamen, Fujian, China
| | - Shaopan Wang
- Eye Institute, Xiamen University, Xiamen, Fujian, China
- Institute of Artificial Intelligence, Xiamen University, Xiamen, Fujian, China
| | - Yuguang Chen
- Eye Institute, Xiamen University, Xiamen, Fujian, China
- Institute of Artificial Intelligence, Xiamen University, Xiamen, Fujian, China
| | - Xiang Lin
- Eye Institute, Xiamen University, Xiamen, Fujian, China
- Department of Ophthalmology, Xiang'an Hospital of Xiamen University, Xiamen, China
| | - Shujia Guo
- Eye Institute, Xiamen University, Xiamen, Fujian, China
| | - Zhaolin Liu
- Eye Institute, Xiamen University, Xiamen, Fujian, China
- Department of Ophthalmology, The First Affiliated Hospital of University of South China, Hengyang, Hunan, China
| | - Yuqian Wang
- Eye Institute, Xiamen University, Xiamen, Fujian, China
| | - Houjian Zhang
- Eye Institute, Xiamen University, Xiamen, Fujian, China
| | - Yuli Guo
- Eye Institute, Xiamen University, Xiamen, Fujian, China
| | - Caihong Huang
- Eye Institute, Xiamen University, Xiamen, Fujian, China
| | - Huping Wu
- Eye Institute, Affiliated Xiamen Eye Center of Xiamen University, Xiamen, Fujian, China
| | - Ying Li
- Department of Ophthalmology, Xi'an People's Hospital, Xi'an, Shaanxi, China
| | - Qian Chen
- Eye Institute, Xiamen University, Xiamen, Fujian, China
| | - Jiaoyue Hu
- Eye Institute, Xiamen University, Xiamen, Fujian, China
- Eye Institute, Affiliated Xiamen Eye Center of Xiamen University, Xiamen, Fujian, China
| | - Zhiming Luo
- Department of Artificial Intelligence, Xiamen University, Xiamen, Fujian, China
| | - Zuguo Liu
- Eye Institute, Xiamen University, Xiamen, Fujian, China
- Eye Institute, Affiliated Xiamen Eye Center of Xiamen University, Xiamen, Fujian, China
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Xu W, Li X. The effect of pterygium on front and back corneal astigmatism and aberrations in natural-light and low-light conditions. BMC Ophthalmol 2024; 24:7. [PMID: 38178053 PMCID: PMC10768295 DOI: 10.1186/s12886-023-03270-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 12/18/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND To investigate the effect of different sizes of pterygium on the front and back corneal topography, refractive changes and aberrations in natural-light and low-light conditions. METHODS Sixty subjects with unilateral primary nasal pterygium were enrolled in this study. All the patients' uncorrected, best spectacle-corrected visual acuity, corneal topographic aberration data in 3 mm and 7 mm areas were collected. The pterygium size was evaluated by the slit-lamp photography and Sirius Scheimpflug Analyzer. RESULTS The front topographic astigmatism values, corneal total aberrations, and higher-order aberrations in 3 mm and 7 mm areas were higher in the pterygium group than those in the control group. The pterygium horizontal length and thickness were moderately to strongly correlated with astigmatism and RMS of aberrations, while pterygium vertical length showed no or just mild correlation with the corneal astigmatism and aberrations. Compared to the readings in 3 mm area, the front and back corneal astigmatism and aberrations were larger in 7 mm area. CONCLUSIONS Pterygium led to visual impairment by inducing astigmatism and aberrations. In low-light condition, the visual function worsened due to increased corneal astigmatism values and aberrations.
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Affiliation(s)
- Weiwei Xu
- Shanghai Aier Eye Hospital, NO. 83 Wuzhong Road, Xuhui District, Shanghai, 200031, China
- Shanghai Aier Eye Institute, PR, NO. 83 Wuzhong Road, Xuhui District, Shanghai, 200031, China
| | - Xia Li
- Shanghai Aier Eye Hospital, NO. 83 Wuzhong Road, Xuhui District, Shanghai, 200031, China.
- Shanghai Aier Eye Institute, PR, NO. 83 Wuzhong Road, Xuhui District, Shanghai, 200031, China.
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Cypel MC, Berezovsky A, Fernandes AG, Watanabe SS, Kimie Higashi Mitsuhiro MR, Ferraz NN, Sacai PY, Furtado JM, Morales PH, Muñoz S, Cohen JM, Belfort R, Salomão SR. Regional Disparities in Prevalence and Causes of Visual Impairment and Blindness, Cataract Surgical Coverage and Ocular Findings in Adults 50 Years and Older in Brazil: A Comparative Analysis between Two Population-Based Cross-Sectional Surveys Performed Within a 10-Year Interval. Semin Ophthalmol 2023; 38:656-664. [PMID: 37154578 DOI: 10.1080/08820538.2023.2209164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 02/09/2023] [Accepted: 02/17/2023] [Indexed: 05/10/2023]
Abstract
PURPOSE To investigate disparities in the prevalence and causes of visual impairment and blindness, cataract surgical coverage, and ocular findings in older adults from two Brazilian geo-socio-demographic areas, São Paulo and Parintins cities. METHODS Data from two population-based studies including participants 50 years and older from the cities of São Paulo (São Paulo Eye Study - SPES, 2004) and Parintins (Brazilian Amazon Region Eye Survey - BARES, 2014) were aggregated. RESULTS A total of 5318 participants (3677 from SPES;1641 from BARES) were included. The prevalence of severe visual impairment (SVI) and blindness were, respectively, 0.74% (0.46-1.02) and 0.77% (0.48-1.05) in SPES and 1.72% (1.09-2.35) and 3.44% (2.55-4.33) in BARES. SVI and blindness were associated with BARES study [OR = 2.27 (1.30-3.95); p = .004 - SVI] [OR:4.07 (2.51-6.60); p < .001- blindness]; and older age [OR = 10.93 (4.20-28.45); p < .001 - SPES; OR = 17.96 (8.75-36.83); p < .001 - BARES] while higher education level was a protective factor [OR = 0.21 (0.05-0.95) - SPES; p = .042; OR = 0.21 (0.05-0.91); p = .037 - BARES]. Cataract was the main cause of bilateral severe visual impairment (25.93% in SPES and 64.29% in BARES) and bilateral blindness (21.43% in SPES and 35.71% in BARES). Cataract surgical coverage was significantly lower in BARES (36.32%) compared to SPES (57.75%). CONCLUSION The prevalence of SVI and blindness was three times higher in older adults from the Brazilian Amazon compared to those living in São Paulo city, despite a 10-year interval between the two studies. These disparities should be mitigated by initiatives to promote access to eye care services targeting underprivileged and remote Brazilian areas.
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Affiliation(s)
- Marcela Colussi Cypel
- Núcleo de Epidemiologia Ocular, Departamento de Oftalmologia e Ciências Visuais, Escola Paulista de Medicina, Universidade Federal de São Paulo - UNIFESP, São Paulo, Brazil
| | - Adriana Berezovsky
- Núcleo de Epidemiologia Ocular, Departamento de Oftalmologia e Ciências Visuais, Escola Paulista de Medicina, Universidade Federal de São Paulo - UNIFESP, São Paulo, Brazil
| | - Arthur Gustavo Fernandes
- Núcleo de Epidemiologia Ocular, Departamento de Oftalmologia e Ciências Visuais, Escola Paulista de Medicina, Universidade Federal de São Paulo - UNIFESP, São Paulo, Brazil
| | - Sung Song Watanabe
- Núcleo de Epidemiologia Ocular, Departamento de Oftalmologia e Ciências Visuais, Escola Paulista de Medicina, Universidade Federal de São Paulo - UNIFESP, São Paulo, Brazil
| | - Marcia Regina Kimie Higashi Mitsuhiro
- Núcleo de Epidemiologia Ocular, Departamento de Oftalmologia e Ciências Visuais, Escola Paulista de Medicina, Universidade Federal de São Paulo - UNIFESP, São Paulo, Brazil
| | - Nivea Nunes Ferraz
- Núcleo de Epidemiologia Ocular, Departamento de Oftalmologia e Ciências Visuais, Escola Paulista de Medicina, Universidade Federal de São Paulo - UNIFESP, São Paulo, Brazil
| | - Paula Yuri Sacai
- Núcleo de Epidemiologia Ocular, Departamento de Oftalmologia e Ciências Visuais, Escola Paulista de Medicina, Universidade Federal de São Paulo - UNIFESP, São Paulo, Brazil
| | - João Marcello Furtado
- Núcleo de Epidemiologia Ocular, Departamento de Oftalmologia e Ciências Visuais, Escola Paulista de Medicina, Universidade Federal de São Paulo - UNIFESP, São Paulo, Brazil
- Departamento de Oftalmologia, Otorrinolaringologia, Cirurgia de Cabeça e Pescoço, Faculdade de Medicina de Ribeirão Preto, USP, Ribeirão Preto, Brazil
| | - Paulo Henrique Morales
- Núcleo de Epidemiologia Ocular, Departamento de Oftalmologia e Ciências Visuais, Escola Paulista de Medicina, Universidade Federal de São Paulo - UNIFESP, São Paulo, Brazil
| | - Sergio Muñoz
- Department of Public Health-CIGES, Universidad de La Frontera, Temuco, Chile
| | - Jacob Moysés Cohen
- Divisão de Oftalmologia, Departamento de Cirurgia, Faculdade de Medicina da Universidade Federal do Amazonas (UFAM), Manaus, Brazil
| | - Rubens Belfort
- Núcleo de Epidemiologia Ocular, Departamento de Oftalmologia e Ciências Visuais, Escola Paulista de Medicina, Universidade Federal de São Paulo - UNIFESP, São Paulo, Brazil
- Instituto da Visão, Instituto Paulista de Estudos e Pesquisas em Oftalmologia (IPEPO), São Paulo, Brazil
| | - Solange Rios Salomão
- Núcleo de Epidemiologia Ocular, Departamento de Oftalmologia e Ciências Visuais, Escola Paulista de Medicina, Universidade Federal de São Paulo - UNIFESP, São Paulo, Brazil
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Alves M, Asbell P, Dogru M, Giannaccare G, Grau A, Gregory D, Kim DH, Marini MC, Ngo W, Nowinska A, Saldanha IJ, Villani E, Wakamatsu TH, Yu M, Stapleton F. TFOS Lifestyle Report: Impact of environmental conditions on the ocular surface. Ocul Surf 2023; 29:1-52. [PMID: 37062427 DOI: 10.1016/j.jtos.2023.04.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 04/06/2023] [Indexed: 04/18/2023]
Abstract
Environmental risk factors that have an impact on the ocular surface were reviewed and associations with age and sex, race/ethnicity, geographical area, seasonality, prevalence and possible interactions between risk factors are reviewed. Environmental factors can be (a) climate-related: temperature, humidity, wind speed, altitude, dew point, ultraviolet light, and allergen or (b) outdoor and indoor pollution: gases, particulate matter, and other sources of airborne pollutants. Temperature affects ocular surface homeostasis directly and indirectly, precipitating ocular surface diseases and/or symptoms, including trachoma. Humidity is negatively associated with dry eye disease. There is little data on wind speed and dewpoint. High altitude and ultraviolet light exposure are associated with pterygium, ocular surface degenerations and neoplastic disease. Pollution is associated with dry eye disease and conjunctivitis. Primary Sjögren syndrome is associated with exposure to chemical solvents. Living within a potential zone of active volcanic eruption is associated with eye irritation. Indoor pollution, "sick" building or house can also be associated with eye irritation. Most ocular surface conditions are multifactorial, and several environmental factors may contribute to specific diseases. A systematic review was conducted to answer the following research question: "What are the associations between outdoor environment pollution and signs or symptoms of dry eye disease in humans?" Dry eye disease is associated with air pollution (from NO2) and soil pollution (from chromium), but not from air pollution from CO or PM10. Future research should adequately account for confounders, follow up over time, and report results separately for ocular surface findings, including signs and symptoms.
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Affiliation(s)
- Monica Alves
- Department of Ophthalmology and Otorhinolaryngology, University of Campinas Campinas, Brazil.
| | - Penny Asbell
- Department of Bioengineering, University of Memphis, Memphis, USA
| | - Murat Dogru
- School of Optometry and Vision Science, UNSW, Sydney, NSW, Australia
| | - Giuseppe Giannaccare
- Department of Ophthalmology, University Magna Graecia of Catanzaro, Cantanzaro, Italy
| | - Arturo Grau
- Department of Ophthalmology, Pontifical Catholic University of Chile, Santiago, Chile
| | - Darren Gregory
- Department of Ophthalmology, University of Colorado School of Medicine, Aurora, USA
| | - Dong Hyun Kim
- Department of Ophthalmology, Korea University College of Medicine, Seoul, South Korea
| | | | - William Ngo
- School of Optometry & Vision Science, University of Waterloo, Waterloo, Canada
| | - Anna Nowinska
- Clinical Department of Ophthalmology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Ian J Saldanha
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Edoardo Villani
- Department of Clinical Sciences and Community Health, University of Milan, Eye Clinic, San Giuseppe Hospital, IRCCS Multimedica, Milan, Italy
| | - Tais Hitomi Wakamatsu
- Department of Ophthalmology and Visual Sciences, Paulista School of Medicine, São Paulo Hospital, Federal University of São Paulo, Brazil
| | - Mitasha Yu
- Sensory Functions, Disability and Rehabilitation Unit, World Health Organization, Geneva, Switzerland
| | - Fiona Stapleton
- School of Optometry and Vision Science, UNSW, Sydney, NSW, Australia
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Gomes JAP, Azar DT, Baudouin C, Bitton E, Chen W, Hafezi F, Hamrah P, Hogg RE, Horwath-Winter J, Kontadakis GA, Mehta JS, Messmer EM, Perez VL, Zadok D, Willcox MDP. TFOS Lifestyle: Impact of elective medications and procedures on the ocular surface. Ocul Surf 2023; 29:331-385. [PMID: 37087043 DOI: 10.1016/j.jtos.2023.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 04/10/2023] [Indexed: 04/24/2023]
Abstract
The word "elective" refers to medications and procedures undertaken by choice or with a lower grade of prioritization. Patients usually use elective medications or undergo elective procedures to treat pathologic conditions or for cosmetic enhancement, impacting their lifestyle positively and, thus, improving their quality of life. However, those interventions can affect the homeostasis of the tear film and ocular surface. Consequently, they generate signs and symptoms that could impair the patient's quality of life. This report describes the impact of elective topical and systemic medications and procedures on the ocular surface and the underlying mechanisms. Moreover, elective procedures performed for ocular diseases, cosmetic enhancement, and non-ophthalmic interventions, such as radiotherapy and bariatric surgery, are discussed. The report also evaluates significant anatomical and biological consequences of non-urgent interventions to the ocular surface, such as neuropathic and neurotrophic keratopathies. Besides that, it provides an overview of the prophylaxis and management of pathological conditions resulting from the studied interventions and suggests areas for future research. The report also contains a systematic review investigating the quality of life among people who have undergone small incision lenticule extraction (SMILE). Overall, SMILE refractive surgery seems to cause more vision disturbances than LASIK in the first month post-surgery, but less dry eye symptoms in long-term follow up.
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Affiliation(s)
- José Alvaro P Gomes
- Dept. of Ophthalmology and Visual Sciences, Federal University of Sao Paulo/Paulista School of Medicine (UNIFESP/EPM), Sao Paulo, SP, Brazil.
| | - Dimitri T Azar
- University of Illinois College of Medicine, Chicago, IL, USA
| | - Christophe Baudouin
- Quinze-Vingts National Eye Hospital & Vision Institute, IHU FOReSIGHT, Paris, France
| | - Etty Bitton
- Ecole d'optométrie, Université de Montréal, Montréal, Canada
| | - Wei Chen
- Eye Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | | | - Pedram Hamrah
- Department of Ophthalmology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Ruth E Hogg
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Belfast, UK
| | | | | | | | | | - Victor L Perez
- Foster Center for Ocular Immunology, Duke University Eye Center, Durham, NC, USA
| | - David Zadok
- Shaare Zedek Medical Center, Affiliated to the Hebrew University, School of Medicine, Jerusalem, Israel
| | - Mark D P Willcox
- School of Optometry and Vision Science, University of New South Wales, Sydney, Australia
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Zhang J, Zhang L, Hu H, Sun L, He W, Zhang Z, Wang J, Nie D, Liu X. The influence of pterygium on corneal densitometry evaluated using the Oculus Pentacam system. Front Med (Lausanne) 2023; 10:1184318. [PMID: 37396900 PMCID: PMC10310544 DOI: 10.3389/fmed.2023.1184318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 05/30/2023] [Indexed: 07/04/2023] Open
Abstract
Purpose To assess the effect of pterygium on corneal densitometry (CD) values. Methods One hundred and nine patients (155 eyes) with primary pterygium were divided into a severe pterygium group (79 eyes) and a mild-to-moderate pterygium group (76 eyes) according to pterygium severity. Among them, 63 patients had monocular pterygium; and 25 patients (38 eyes) underwent pterygium excision combined with conjunctival autograft follow-up. A Pentacam anterior segment analyzer was used to obtain the CD values and corneal morphological parameters, including central corneal thickness (CCT), flat-axis keratometry (K1), steep-axis keratometry (K2), corneal astigmatism, irregular astigmatism, and spherical aberration. CD was subdivided into four concentric radial regions based on corneal diameter and three layers according to depth. Results CD values at 0-12 mm of the anterior 120 μm layer, 0-10 mm of the center layer and full thickness, and 2-6 mm of the posterior 60 μm layer were significantly higher in eyes affected by pterygium than in the contralateral unaffected eyes (all P < 0.05). CD values were significantly higher in the severe pterygium group than in the mild to moderate pterygium group (all P < 0.05). Corneal astigmatism, irregular astigmatism, K1, K2, CCT, and spherical aberration correlated with CD values in eyes with pterygium (all P < 0.05). CD values at 6-10, 0-12 mm in the anterior 120 μm layer and full thickness, 10-12 and 0-12 mm in the center layer were significantly decreased 1 month after pterygium surgery compared with those before surgery (all P < 0.05). Conclusion Patients with pterygium had increased CD values, particularly in the anterior and central layers. CD values were correlated with pterygium severity grading and corneal parameters. Pterygium surgery partially reduced the CD values.
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Affiliation(s)
- Jing Zhang
- Shenzhen Eye Hospital, Jinan University, Shenzhen Eye Institute, Shenzhen, Guangdong, China
| | - Liyun Zhang
- Shenzhen Eye Hospital, Jinan University, Shenzhen Eye Institute, Shenzhen, Guangdong, China
- Shenzhen Key Laboratory of Ophthalmology, Shenzhen Eye Hospital, Postgraduate Training Base of Jinzhou Medical University, Shenzhen, Guangdong, China
| | - Huiling Hu
- Shenzhen Eye Hospital, Jinan University, Shenzhen Eye Institute, Shenzhen, Guangdong, China
| | - Liangnan Sun
- Shenzhen Eye Hospital, Jinan University, Shenzhen Eye Institute, Shenzhen, Guangdong, China
| | - Wenling He
- Shenzhen Eye Hospital, Jinan University, Shenzhen Eye Institute, Shenzhen, Guangdong, China
| | - Zhe Zhang
- Shenzhen Eye Hospital, Jinan University, Shenzhen Eye Institute, Shenzhen, Guangdong, China
| | - Jiantao Wang
- Shenzhen Eye Hospital, Jinan University, Shenzhen Eye Institute, Shenzhen, Guangdong, China
| | - Danyao Nie
- Shenzhen Eye Hospital, Jinan University, Shenzhen Eye Institute, Shenzhen, Guangdong, China
| | - Xinhua Liu
- Shenzhen Eye Hospital, Jinan University, Shenzhen Eye Institute, Shenzhen, Guangdong, China
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Neale RE, Lucas RM, Byrne SN, Hollestein L, Rhodes LE, Yazar S, Young AR, Berwick M, Ireland RA, Olsen CM. The effects of exposure to solar radiation on human health. Photochem Photobiol Sci 2023:10.1007/s43630-023-00375-8. [PMID: 36856971 PMCID: PMC9976694 DOI: 10.1007/s43630-023-00375-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 01/13/2023] [Indexed: 03/02/2023]
Abstract
This assessment by the Environmental Effects Assessment Panel (EEAP) of the Montreal Protocol under the United Nations Environment Programme (UNEP) evaluates the effects of ultraviolet (UV) radiation on human health within the context of the Montreal Protocol and its Amendments. We assess work published since our last comprehensive assessment in 2018. Over the last four years gains have been made in knowledge of the links between sun exposure and health outcomes, mechanisms, and estimates of disease burden, including economic impacts. Of particular note, there is new information about the way in which exposure to UV radiation modulates the immune system, causing both harms and benefits for health. The burden of skin cancer remains high, with many lives lost to melanoma and many more people treated for keratinocyte cancer, but it has been estimated that the Montreal Protocol will prevent 11 million cases of melanoma and 432 million cases of keratinocyte cancer that would otherwise have occurred in the United States in people born between 1890 and 2100. While the incidence of skin cancer continues to rise, rates have stabilised in younger populations in some countries. Mortality has also plateaued, partly due to the use of systemic therapies for advanced disease. However, these therapies are very expensive, contributing to the extremely high economic burden of skin cancer, and emphasising the importance and comparative cost-effectiveness of prevention. Photodermatoses, inflammatory skin conditions induced by exposure to UV radiation, can have a marked detrimental impact on the quality of life of sufferers. More information is emerging about their potential link with commonly used drugs, particularly anti-hypertensives. The eyes are also harmed by over-exposure to UV radiation. The incidence of cataract and pterygium is continuing to rise, and there is now evidence of a link between intraocular melanoma and sun exposure. It has been estimated that the Montreal Protocol will prevent 63 million cases of cataract that would otherwise have occurred in the United States in people born between 1890 and 2100. Despite the clearly established harms, exposure to UV radiation also has benefits for human health. While the best recognised benefit is production of vitamin D, beneficial effects mediated by factors other than vitamin D are emerging. For both sun exposure and vitamin D, there is increasingly convincing evidence of a positive role in diseases related to immune function, including both autoimmune diseases and infection. With its influence on the intensity of UV radiation and global warming, the Montreal Protocol has, and will have, both direct and indirect effects on human health, potentially changing the balance of the risks and benefits of spending time outdoors.
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Affiliation(s)
- R. E. Neale
- Population Health Program, QIMR Berghofer Medical Research Institute, Brisbane, QLD Australia ,School of Public Health, University of Queensland, Brisbane, QLD Australia
| | - R. M. Lucas
- National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT Australia
| | - S. N. Byrne
- School of Medical Science, Faculty of Medicine and Health, University of Sydney, Sydney, NSW Australia
| | - L. Hollestein
- Erasmus MC Cancer Institute, Rotterdam, The Netherlands ,Netherlands Comprehensive Cancer Organisation, Utrecht, The Netherlands
| | - L. E. Rhodes
- Dermatology Research Centre, School of Biological Sciences, University of Manchester, Salford Royal Hospital, Northern Care Alliance NHS Trust, Manchester, UK
| | - S. Yazar
- Garvan Medical Research Institute, Sydney, NSW Australia
| | | | - M. Berwick
- University of New Mexico Comprehensive Cancer Center, Albuquerque, USA
| | - R. A. Ireland
- School of Medical Science, Faculty of Medicine and Health, University of Sydney, Sydney, NSW Australia
| | - C. M. Olsen
- Population Health Program, QIMR Berghofer Medical Research Institute, Brisbane, QLD Australia ,Frazer Institute, University of Queensland, Brisbane, QLD Australia
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Furtado JM, Fernandes AG, Silva JC, Del Pino S, Hommes C. Indigenous Eye Health in the Americas: The Burden of Vision Impairment and Ocular Diseases. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3820. [PMID: 36900846 PMCID: PMC10000964 DOI: 10.3390/ijerph20053820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 02/13/2023] [Accepted: 02/18/2023] [Indexed: 06/18/2023]
Abstract
Review of the burden of vision impairment and blindness and ocular disease occurrence in Indigenous Peoples of the Americas. We systematically reviewed findings of the frequency of vision impairment and blindness and/or frequency of ocular findings in Indigenous groups. The database search yielded 2829 citations, of which 2747 were excluded. We screened the full texts of 82 records for relevance and excluded 16. The remaining 66 articles were examined thoroughly, and 25 presented sufficient data to be included. Another 7 articles derived from references were included, summing a total of 32 studies selected. When considering adults over 40 years old, the highest frequencies of vision impairment and blindness in Indigenous Peoples varied from 11.1% in high-income North America to 28.5% in tropical Latin America, whose rates are considerably higher than those in the general population. Most of the ocular diseases reported were preventable and/or treatable, so blindness prevention programs should focus on accessibility to eye examinations, cataract surgeries, control of infectious diseases, and spectacles distribution. Finally, we recommend actions in six areas of attention towards improving the eye health in Indigenous Peoples: access and integration of eye services with primary care; telemedicine; customized propaedeutics; education on eye health; and quality of data.
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Affiliation(s)
- João Marcello Furtado
- Pan American Health Organization, Washington, DC 20037, USA
- Division of Ophthalmology, Ribeirão Preto Medical School, University of São Paulo, Ribeirao Preto 14015-010, Brazil
| | - Arthur Gustavo Fernandes
- Department of Ophthalmology and Visual Sciences, Federal University of São Paulo, Sao Paulo 04023-062, Brazil
- Department of Anthropology and Archaeology, University of Calgary, Calgary, AB T2N 4N1, Canada
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11
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Dotto PG, Salomão SR, Fernandes AG, Mitsuhiro MRKH, Ferraz NN, Furtado JM, Watanabe SS, Cypel M, Sacai PY, Cunha CC, Vasconcelos GC, Morales PH, Cohen MJ, Cohen JM, Campos M, Muñoz S, Belfort R, Berezovsky A. Impact of pterygium on central corneal thickness measured by optical coherence tomography in older adults. Eur J Ophthalmol 2023:11206721231154433. [PMID: 36726300 DOI: 10.1177/11206721231154433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE To measure the central corneal thickness (CCT) using anterior segment optical coherence tomography (AS-OCT) in older adults with and without pterygium from the Brazilian Amazon Region Eye Survey (BARES). METHODS BARES is a population-based epidemiological cross-sectional study conducted in Parintins city. Participants were residents ≥45 years of age identified through a door-to-door interview. Eligible participants were invited for a comprehensive eye exam. Pterygium occurrence and severity were assessed by ophthalmologists through slit-lamp examination considering its location (nasal or/and temporal) and severity (lesion with extension <3 mm, ≥3 mm not reaching the pupillary margin or ≥3 mm reaching the pupillary margin). CCTs were obtained and measurements from the more severely affected eye were included. Images were analyzed offline by masked observers. RESULTS A total of 671 subjects, 533 (79.4%) with pterygium in at least one eye and 138 (20.6%) without pterygium in either eye, were examined. The mean CCT evaluated by multiple linear regression and adjusted for demographic variables and pterygium severity was 521 ± 34 μm (median = 521; range = 304-665). Decreased CCT was significantly associated with age and pterygium severity. Individuals aged 65-74 years had CCT 7 μm thinner than those aged 45-54 years (p = 0.044), individuals aged 75 years and older had CCT 15 μm thinner than those aged 45-54 years (p = 0.001), and eyes with severe pterygium had CCT 33 μm thinner than eyes without pterygium (p < 0.001). CONCLUSIONS The CCT analysis in this population-based sample shows that a thinner cornea is associated with pterygium severity and older age.
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Affiliation(s)
- Pedro Gabriel Dotto
- Departamento de Oftalmologia e Ciências Visuais, Escola Paulista de Medicina, 28105Universidade Federal de São Paulo - UNIFESP, São Paulo, SP, Brasil
| | - Solange Rios Salomão
- Departamento de Oftalmologia e Ciências Visuais, Escola Paulista de Medicina, 28105Universidade Federal de São Paulo - UNIFESP, São Paulo, SP, Brasil
| | - Arthur Gustavo Fernandes
- Departamento de Oftalmologia e Ciências Visuais, Escola Paulista de Medicina, 28105Universidade Federal de São Paulo - UNIFESP, São Paulo, SP, Brasil
| | - Marcia Regina Kimie Higashi Mitsuhiro
- Departamento de Oftalmologia e Ciências Visuais, Escola Paulista de Medicina, 28105Universidade Federal de São Paulo - UNIFESP, São Paulo, SP, Brasil
| | - Nívea Nunes Ferraz
- Departamento de Oftalmologia e Ciências Visuais, Escola Paulista de Medicina, 28105Universidade Federal de São Paulo - UNIFESP, São Paulo, SP, Brasil
| | - João Marcello Furtado
- Departamento de Oftalmologia e Ciências Visuais, Escola Paulista de Medicina, 28105Universidade Federal de São Paulo - UNIFESP, São Paulo, SP, Brasil.,Departamento de Oftalmologia, Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, 544243Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - Sung Song Watanabe
- Departamento de Oftalmologia e Ciências Visuais, Escola Paulista de Medicina, 28105Universidade Federal de São Paulo - UNIFESP, São Paulo, SP, Brasil
| | - Marcela Cypel
- Departamento de Oftalmologia e Ciências Visuais, Escola Paulista de Medicina, 28105Universidade Federal de São Paulo - UNIFESP, São Paulo, SP, Brasil
| | - Paula Yuri Sacai
- Departamento de Oftalmologia e Ciências Visuais, Escola Paulista de Medicina, 28105Universidade Federal de São Paulo - UNIFESP, São Paulo, SP, Brasil
| | - Cristina Coimbra Cunha
- Departamento de Oftalmologia e Ciências Visuais, Escola Paulista de Medicina, 28105Universidade Federal de São Paulo - UNIFESP, São Paulo, SP, Brasil.,37871Faculdade de Medicina da Universidade Federal do Pará - UFPA, Belém, PA, Brasil
| | - Galton Carvalho Vasconcelos
- Departamento de Oftalmologia e Ciências Visuais, Escola Paulista de Medicina, 28105Universidade Federal de São Paulo - UNIFESP, São Paulo, SP, Brasil.,Departamento de Oftalmologia e Otorrinolaringologia, 28114Faculdade de Medicina da Universidade Federal de Minas Gerais - UFMG, Belo Horizonte, MG, Brasil
| | - Paulo Henrique Morales
- Departamento de Oftalmologia e Ciências Visuais, Escola Paulista de Medicina, 28105Universidade Federal de São Paulo - UNIFESP, São Paulo, SP, Brasil
| | - Marcos Jacob Cohen
- Departamento de Oftalmologia e Ciências Visuais, Escola Paulista de Medicina, 28105Universidade Federal de São Paulo - UNIFESP, São Paulo, SP, Brasil.,Divisão de Oftalmologia, Departamento de Cirurgia, 67892Faculdade de Medicina da Universidade Federal do Amazonas - UFAM, Manaus, AM, Brasil
| | - Jacob Moysés Cohen
- Departamento de Oftalmologia e Ciências Visuais, Escola Paulista de Medicina, 28105Universidade Federal de São Paulo - UNIFESP, São Paulo, SP, Brasil.,Divisão de Oftalmologia, Departamento de Cirurgia, 67892Faculdade de Medicina da Universidade Federal do Amazonas - UFAM, Manaus, AM, Brasil
| | - Mauro Campos
- Departamento de Oftalmologia e Ciências Visuais, Escola Paulista de Medicina, 28105Universidade Federal de São Paulo - UNIFESP, São Paulo, SP, Brasil
| | - Sergio Muñoz
- Departamento de Oftalmologia e Ciências Visuais, Escola Paulista de Medicina, 28105Universidade Federal de São Paulo - UNIFESP, São Paulo, SP, Brasil.,Departamento de Salud Publica, 469458Universidad de La Frontera, Temuco, Chile
| | - Rubens Belfort
- Departamento de Oftalmologia e Ciências Visuais, Escola Paulista de Medicina, 28105Universidade Federal de São Paulo - UNIFESP, São Paulo, SP, Brasil
| | - Adriana Berezovsky
- Departamento de Oftalmologia e Ciências Visuais, Escola Paulista de Medicina, 28105Universidade Federal de São Paulo - UNIFESP, São Paulo, SP, Brasil
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12
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Zhang J, Qin B, Liu B, Sun D, Liang C, Wang S, Yang M, Zhu R. Prevalence and associated factors for pterygium in a Chinese rural population with type 2 diabetes in a cross-sectional study: Jiangsu Diabetic Eye Disease Study (JDEDS). Int Ophthalmol 2023; 43:411-422. [PMID: 35947253 DOI: 10.1007/s10792-022-02438-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 07/05/2022] [Indexed: 12/01/2022]
Abstract
PURPOSE To investigate the pterygium prevalence and evaluate risk factors of pterygium in rural type 2 diabetic (D2M) patients aged 50 years and above in Funing Country, Jiangsu Province, China. METHODS A cross-sectional ophthalmic survey was conducted in type 2 diabetes mellitus (D2M) patients aged ≥ 50 years in Funing County, Jiangsu Province, China, which was named Jiangsu Diabetic Eye Disease Study (JDEDS). All participants underwent a comprehensive questionnaire and ocular examination. Pterygium was diagnosed by slit lamp examination. The risk factors associated with pterygium were evaluated with logistic regression models. RESULTS The prevalence of pterygium was 22.37% (n = 427) and 95% confidence interval (CI) (20.50-24.24%) in D2M patients aged 50 years and above in JDEDS. The prevalence of pterygium was 18.32% (95% CI 15.33-21.32%) in men and 24.43% (95% CI 22.06-26.80%) in women. Women had a higher prevalence than men (p = 0.001). Multivariate analysis showed, for male participants with D2M, pterygium was independently associated with increasing age [70-79 years: OR and 95% CI 2.49(1.20-5.18), p = 0.014; ≥ 80 years: 4.84(2.04-11.47), p < 0.001], while cigarette smoking was the protective factors, especially in current smoker [OR and 95% CI 0.79(0.67-0.92); p = 0.003]. For female participants with D2M, age [60-69 years OR and 95% CI 1.68(1.07-2.62), p = 0.023; 70-79 years: 2.62(1.69-4.06), p < 0.001; ≥ 80 years:3.24(1.70-5.90), p < 0.001], hypertension [OR and 95% CI 1.40(1.05-1.87), p = 0.024], BMI 24-27.9 [OR and 95% CI 1.20(1.00-1.44), p = 0.047], higher HbA1c [(5.6-7.9) % OR and 95% CI 1.42(1.10-1.82), p = 0.006; (8.0-9.9) %: 1.32(1.10-1.58), p = 0.003] were risk factors. CONCLUSIONS D2M patients aged over 50 years has a high prevalence of pterygium in JDEDS. The pterygium prevalence is higher in female D2M participants. Diabetes and related factors may be risk factors of pterygium in female D2M patients. Further studies are needed to explore the gender difference in the pathogenesis of pterygium in D2M subjects.
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Affiliation(s)
- Junfang Zhang
- Department of Ophthalmology, Affiliated Hospital of Nantong University, Nantong, 226001, China
| | - Bai Qin
- Department of Ophthalmology, Affiliated Hospital of Nantong University, Nantong, 226001, China
| | - Bihong Liu
- Funing Shizhuang Eye Hospital, Yancheng, 224000, China
| | - Dajun Sun
- Funing Shizhuang Eye Hospital, Yancheng, 224000, China
| | - Congkai Liang
- Funing County Center for Disease Prevention and Control, Yancheng, 224000, China
| | - Shiyi Wang
- Department of Ophthalmology, Affiliated Hospital of Nantong University, Nantong, 226001, China
| | - Mei Yang
- Department of Ophthalmology, Affiliated Hospital of Nantong University, Nantong, 226001, China
| | - Rongrong Zhu
- Department of Ophthalmology, Affiliated Hospital of Nantong University, Nantong, 226001, China.
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Key Genes of Immunity Associated with Pterygium and Primary Sjögren's Syndrome. Int J Mol Sci 2023; 24:ijms24032047. [PMID: 36768371 PMCID: PMC9916617 DOI: 10.3390/ijms24032047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/05/2023] [Accepted: 01/19/2023] [Indexed: 01/22/2023] Open
Abstract
Pterygium and primary Sjögren's Syndrome (pSS) share many similarities in clinical symptoms and ocular pathophysiological changes, but their etiology is unclear. To identify the potential genes and pathways related to immunity, two published datasets, GSE2513 containing pterygium information and GSE176510 containing pSS information, were selected from the Gene Expression Omnibus (GEO) database. Differentially expressed genes (DEGs) of pterygium or pSS patients compared with healthy control conjunctiva, and the common DEGs between them were analyzed. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analysis were conducted for common DEGs. The protein-protein interaction (PPI) network was constructed using the STRING database to find the hub genes, which were verified in clinical samples. There were 14 co-upregulated DEGs. The GO and KEGG analyses showed that these common DEGs were enriched in pathways correlated with virus infection, antigen processing and presentation, nuclear factor-kappa B (NF-κB) and Th17 cell differentiation. The hub genes (IL1R1, ICAM1, IRAK1, S100A9, and S100A8) were selected by PPI construction. In the era of the COVID-19 epidemic, the relationship between virus infection, vaccination, and the incidence of pSS and pterygium growth deserves more attention.
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14
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Moscovici BK, Rodrigues PF, Freitas MMS, e Silva FB, Felberg S, Dantas PEC. Donor graft harvesting with air in pterygium surgery. Eur J Ophthalmol 2022; 32:3103-3109. [DOI: 10.1177/11206721221090802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose Report a new technique for improvement of pterygium surgery: donor graft harvesting with air. Case reports We describe a technique that was used with 138 patients who underwent surgery that included a conjunctival autograft and fibrin glue with air injection to dissect the Tenon capsule from the conjunctiva. Results No complications occurred with this technique and all patients achieved good results. Discussion The surgical time with this new technique was similar to that reported in the literature. In addition, the graft thickness was close to that reported with femtosecond laser dissection and it was thinner than that reported with aesthetic/saline dissection (unable to determine statistical significance). Conclusions and importance With the injection of an air bubble, we could easily dissect the conjunctiva from the Tenon capsule and quickly acquire thin grafts without any additional costs or complications.
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Affiliation(s)
| | | | | | | | - Sérgio Felberg
- Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
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15
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Zhong X, Xu P, Chen K, Yang D, Wang F, Ni H, Wu Y, Xia D, Ye J, Wu H. A novel lncRNA lnc-PPRL promotes pterygium development by activating PI3K/PDK1 signaling pathway. Exp Eye Res 2022; 219:109034. [PMID: 35304111 DOI: 10.1016/j.exer.2022.109034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 03/05/2022] [Accepted: 03/09/2022] [Indexed: 11/16/2022]
Abstract
A sight threatening, pterygium is a common proliferative and degenerative disease of the ocular surface. LncRNAs have been widely studied in the occurrence and development of various diseases, however, the study of lncRNAs in pterygium has just relatively lacking. In the present study, we performed the high-throughput RNA sequencing (HTS) technology to identify differentially expressed lncRNAs in pterygium. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses were carried out to forecast the regulatory and functional role of lncRNAs in pterygium. Notably, we identified a novel lncRNA, LOC102724238, which we named pterygium positively-related lncRNA (lnc-PPRL), was up-regulated in pterygium. Lnc-PPRL showed to be preferentially accumulated in cytoplasm, and it can promote cell proliferation, migration and invasion of human pterygium epithelium cells (hPECs). Further study of underlying mechanisms demonstrated that lnc-PPRL may exert its biological effect by activating canonical PI3K/PDK1 pathway, and subsequently promoting the activation of Akt/mTOR signaling pathway and its downstream effectors. Interestingly, lnc-PPRL was also proved to influence YAP nuclear localization. Taken together, our study firstly suggested that the "big molecule" lnc-PPRL have potential as a novel therapeutic target for the prevention and treatment of pterygium.
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Affiliation(s)
- Xincao Zhong
- Department of Ophthalmology, The Second Affiliated Hospital of Zhejiang University, College of Medicine, Hangzhou, Zhejiang, China
| | - Peifang Xu
- Department of Ophthalmology, The Second Affiliated Hospital of Zhejiang University, College of Medicine, Hangzhou, Zhejiang, China
| | - Kelie Chen
- Department of Toxicology of School of Public Health, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China; Department of Gynecologic Oncology of Women's Hospital of Zhejiang University, College of Medicine, Hangzhou, Zhejiang, China
| | - Dexin Yang
- Department of Toxicology of School of Public Health, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Fang Wang
- Department of Toxicology of School of Public Health, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Heng Ni
- Department of Thoracic Surgery, The First Affiliated Hospital of Zhejiang University, College of Medicine, Hangzhou, Zhejiang, China
| | - Yihua Wu
- Department of Toxicology of School of Public Health, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China; Department of Gynecologic Oncology of Women's Hospital of Zhejiang University, College of Medicine, Hangzhou, Zhejiang, China
| | - Dajing Xia
- Department of Toxicology of School of Public Health, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China; Department of Gynecologic Oncology of Women's Hospital of Zhejiang University, College of Medicine, Hangzhou, Zhejiang, China
| | - Juan Ye
- Department of Ophthalmology, The Second Affiliated Hospital of Zhejiang University, College of Medicine, Hangzhou, Zhejiang, China.
| | - Han Wu
- Department of Ophthalmology, The Second Affiliated Hospital of Zhejiang University, College of Medicine, Hangzhou, Zhejiang, China.
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16
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Prevalence of ocular findings regardless of visual acuity status in older adults from the Brazilian Amazon Region. Sci Rep 2021; 11:23710. [PMID: 34887482 PMCID: PMC8660780 DOI: 10.1038/s41598-021-03172-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 11/22/2021] [Indexed: 01/19/2023] Open
Abstract
Recently, it has been recommended that population-based studies report not only frequencies of vision impairment and blindness but also any ocular abnormalities that might lead an individual to seek for eyecare services. The current study aimed to determine prevalence of ocular findings regardless of visual acuity (VA) status in older adults from the Brazilian Amazon Region. Disturbances were grouped into: Eyelids; Anterior Segment; Posterior Segment; Increased intraocular pressure; and Overall Globe. The presence of an ocular finding was considered positive when any abnormality was noted, regardless of VA. Refractive errors were not considered. A total 2384 eligible persons were enumerated and 2041 (85.6%) examined. The prevalence of ocular disturbances in either eye was 87.0% and was associated with male gender, older age, lower education, and rural residence. Overall, main findings were pterygium, cataract, and pinguecula, occurring in 58.8%, 45.4% and 17.4%, respectively. Among individuals with 20/20 VA in both eyes, the most frequent findings were pterygium, pinguecula, and glaucoma cupping, occurring in 47.4%, 31.2% and 6.5%, respectively. The high prevalence of ocular findings observed in this population reinforces that different conditions might not immediately decrease VA but can indicate risk and/or discomfort symptoms and should be considered when planning public health ophthalmic services.
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Erickson S, Sullivan AG, Abad JC, Alves M, Barabino S, Craig JP, Eid M, Farrant S, Gomes JAP, Heydenrych L, Iyer G, Jarade EF, Kinoshita S, Kobia-Acquah E, Lazreg S, Margolis T, Mechleb N, Navas A, Nsubuga N, Said RB, Shaheen MS, Sotozono C, Stapleton F, Vehof J, Versura P, Sullivan DA. TFOS: Unique challenges and unmet needs for the management of ocular surface diseases throughout the world. Ocul Surf 2021; 22:242-244. [PMID: 34517137 DOI: 10.1016/j.jtos.2021.08.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 08/20/2021] [Accepted: 08/21/2021] [Indexed: 10/20/2022]
Affiliation(s)
| | | | - Juan Carlos Abad
- Department of Ophthalmology, Antioquia Ophthalmology Clinic-Clofan, Medellin, Antioquia, Colombia
| | - Monica Alves
- Department of Ophthalmology and Otorhinolaryngology, Faculty of Medical Sciences, University of Campinas - UNICAMP, São Paulo, Brazil
| | - Stefano Barabino
- Ocular Surface Center and Department of Ophthalmology, Sacco Hospital, Milan University, Milan, Italy
| | - Jennifer P Craig
- Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, Auckland, New Zealand
| | - Maroun Eid
- Ophthalmology Department, Lebanese University, Beirut, Lebanon
| | - Sarah Farrant
- Earlam and Christopher Optometrists and Contact Lens Specialists, Taunton, UK
| | - José A P Gomes
- Department of Ophthalmology and Visual Sciences, Federal University of São Paulo/Paulista School of Medicine, São Paulo, Brazil
| | | | - Geetha Iyer
- Sankara Nethralya, Chennai, Tamil Nadu, India
| | - Elias F Jarade
- Cornea and Refractive Surgery, Beirut Eye and ENT Specialist Hospital, Ophthalmology Department, Lebanese University, Beirut, Lebanon, and Mediclinic Dubai Mall, Dubai, United Arab Emirates
| | - Shigeru Kinoshita
- Department of Frontier Medical Science and Technology for Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Emmanuel Kobia-Acquah
- Department of Optometry and Visual Science, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Sihem Lazreg
- Cabinet Ophthalmologie, Alger Centre, Algiers, Algeria
| | - Todd Margolis
- Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St. Louis, MO, USA
| | - Nicole Mechleb
- Ophthalmology Department, Saint Joseph University, Beirut, Lebanon
| | - Alejandro Navas
- Institute of Ophthalmology, Conde de Valenciana, National Autonomous University of Mexico, UNAM, Mexico City, Mexico
| | - Naomi Nsubuga
- Department of Optometry, School of Health Sciences at the College of Health Sciences, Makerere University, Kampala, Uganda
| | - Reeda Bou Said
- Ophthalmology Department, Lebanese University, Beirut, Lebanon
| | | | - Chie Sotozono
- Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Fiona Stapleton
- School of Optometry and Vision Science, UNSW Sydney, Sydney, Australia
| | - Jelle Vehof
- Section of Academic Ophthalmology, King's College London, London, UK, and Departments of Ophthalmology and Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Piera Versura
- Department of Specialized, Experimental, and Diagnostic Medicine, University of Bologna, Bologna, Italy
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Fernandes AG, Alves M, Nascimento RAE, Valdrighi NY, de Almeida RC, Nakano CT. Visual impairment and blindness in the Xingu Indigenous Park - Brazil. Int J Equity Health 2021; 20:197. [PMID: 34461895 PMCID: PMC8404365 DOI: 10.1186/s12939-021-01536-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 08/16/2021] [Indexed: 12/05/2022] Open
Abstract
Background Most estimates of visual impairment and blindness worldwide do not include data from specific minority groups as indigenous populations. We aimed to evaluate frequencies and causes of visual impairment and blindness in a large population sample from the Xingu Indigenous Park. Methods Cross-sectional study performed at Xingu Indigenous Park, Brazil, from 2016 to 2017. Residents from 16 selected villages were invited to participate and underwent a detailed ocular examination, including uncorrected (UVA) and best-corrected visual acuity (BCVA). The main cause of UVA < 20/32 per eye was determined. Results A total of 2,099 individuals were evaluated. Overall, the frequency of visual impairment and blindness was 10.00% (95% CI: 8.72–11.29%) when considering UVA, decreasing to 7.15% (95% CI: 6.04–8.25%) when considering BCVA. For each increasing year on age, the risk of being in the visually impaired or blind category increased by 9% (p < 0.001). Cataracts (39.1%) and uncorrected refractive errors (29.1%) were the most frequent causes of visual impairment and blindness in this population. The main causes among those aged 45 years and more were cataracts (54.5%) while refractive errors were the main cause in adults aged 18 to 45 years (50.0%) and children up to 18 years old (37.1%). Conclusions A higher frequency of visual impairment and blindness was observed in the indigenous population when compared to worldwide estimates with most of the causes being preventable and/or treatable. Blindness prevention programs should focus on accessibility to eye exam, cataract surgeries and eyeglass distribution.
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Affiliation(s)
- Arthur Gustavo Fernandes
- Associação Médicos da Floresta, Sao Paulo, Brazil. .,Department of Ophthalmology and Visual Sciences, Federal University of Sao Paulo - Paulista Medical School, Sao Paulo, Brazil.
| | - Monica Alves
- Associação Médicos da Floresta, Sao Paulo, Brazil.,Department of Ophthalmology and Otorhinolaryngology, University of Campinas, Campinas, Brazil
| | - Roberta Andrade E Nascimento
- Associação Médicos da Floresta, Sao Paulo, Brazil.,Department of Ophthalmology and Visual Sciences, Federal University of Sao Paulo - Paulista Medical School, Sao Paulo, Brazil
| | - Natalia Yumi Valdrighi
- Associação Médicos da Floresta, Sao Paulo, Brazil.,Department of Ophthalmology and Visual Sciences, Federal University of Sao Paulo - Paulista Medical School, Sao Paulo, Brazil
| | - Rafael Cunha de Almeida
- Associação Médicos da Floresta, Sao Paulo, Brazil.,Department of Ophthalmology, ABC Medical School, Santo Andre, Brazil
| | - Celso Takashi Nakano
- Associação Médicos da Floresta, Sao Paulo, Brazil.,Department of Ophthalmology, University of Sao Paulo, Sao Paulo, Brazil
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Jiang Y, Zhang X, Zhang X, Zhao K, Zhang J, Yang C, Chen Y. Comprehensive Analysis of the Transcriptome-Wide m6A Methylome in Pterygium by MeRIP Sequencing. Front Cell Dev Biol 2021; 9:670528. [PMID: 34249924 PMCID: PMC8267473 DOI: 10.3389/fcell.2021.670528] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 05/04/2021] [Indexed: 01/08/2023] Open
Abstract
Aim Pterygium is a common ocular surface disease, which is affected by a variety of factors. Invasion of the cornea can cause severe vision loss. N6-methyladenosine (m6A) is a common post-transcriptional modification of eukaryotic mRNA, which can regulate mRNA splicing, stability, nuclear transport, and translation. To our best knowledge, there is no current research on the mechanism of m6A in pterygium. Methods We obtained 24 pterygium tissues and 24 conjunctival tissues from each of 24 pterygium patients recruited from Shanghai Yangpu Hospital, and the level of m6A modification was detected using an m6A RNA Methylation Quantification Kit. Expression and location of METTL3, a key m6A methyltransferase, were identified by immunostaining. Then we used m6A-modified RNA immunoprecipitation sequencing (MeRIP-seq), RNA sequencing (RNA-seq), and bioinformatics analyses to compare the differential expression of m6A methylation in pterygium and normal conjunctival tissue. Results We identified 2,949 dysregulated m6A peaks in pterygium tissue, of which 2,145 were significantly upregulated and 804 were significantly downregulated. The altered m6A peak of genes were found to play a key role in the Hippo signaling pathway and endocytosis. Joint analyses of MeRIP-seq and RNA-seq data identified 72 hypermethylated m6A peaks and 15 hypomethylated m6A peaks in mRNA. After analyzing the differentially methylated m6A peaks and synchronously differentially expressed genes, we searched the Gene Expression Omnibus database and identified five genes related to the development of pterygium (DSP, MXRA5, ARHGAP35, TMEM43, and OLFML2A). Conclusion Our research shows that m6A modification plays an important role in the development of pterygium and can be used as a potential new target for the treatment of pterygium in the future.
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Affiliation(s)
- Yaping Jiang
- Department of Ophthalmology, Yangpu Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xin Zhang
- Department of Ophthalmology, Yangpu Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xiaoyan Zhang
- Department of Ophthalmology, Huashan Hospital, Fudan University, Shanghai, China
| | - Kun Zhao
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jing Zhang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Chuanxi Yang
- Department of Cardiology, Yangpu Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yihui Chen
- Department of Ophthalmology, Yangpu Hospital, Tongji University School of Medicine, Shanghai, China
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Hatsusaka N, Yamamoto N, Miyashita H, Shibuya E, Mita N, Yamazaki M, Shibata T, Ishida H, Ukai Y, Kubo E, Cheng HM, Sasaki H. Association among pterygium, cataracts, and cumulative ocular ultraviolet exposure: A cross-sectional study in Han people in China and Taiwan. PLoS One 2021; 16:e0253093. [PMID: 34129614 PMCID: PMC8205177 DOI: 10.1371/journal.pone.0253093] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 05/27/2021] [Indexed: 12/11/2022] Open
Abstract
Purpose Pterygium is an ocular surface disorder mainly caused by ultraviolet (UV) light exposure. This study explored the relationships between six cataract types with pterygium and UV exposure. Methods We have previously studied cataracts in residents of three regions in China and Taiwan with different UV intensities. From that study, we identified 1,547 subjects with information on the presence or absence of pterygium. Pterygium severity was graded by corneal progress rate. Cataracts were graded by classification systems as three main types (cortical, nuclear, posterior subcapsular) and three subtypes (retrodots, waterclefts, fiber folds) with high prevalence in middle-aged and elderly people. We calculated the cumulative ocular UV exposure (COUV) based on subject data and National Aeronautics and Space Administration data on UV intensities and used logistic regression to calculate odds ratios for the associations of COUV, cataract, and pterygium. Results We found an overall pterygium prevalence of 23.3%, with significant variation among the three regions. Four cataract types (cortical, nuclear, posterior subcapsular, and retrodots) were significantly associated with the presence of pterygium. Conclusions There was a significant association between COUV and pterygium, indicating that COUV is associated with the risk of pterygium development and that pterygium is useful as an index of UV exposure. Furthermore, the type of cataract in eyes with pterygium may indicate the level of UV exposure.
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Affiliation(s)
- Natsuko Hatsusaka
- Department of Ophthalmology, Kanazawa Medical University, Uchinada, Ishikawa, Japan
- Division of Vision Research for Environmental Health, Project Research Center, Medical Research Institute, Kanazawa Medical University, Uchinada, Ishikawa, Japan
| | - Naoki Yamamoto
- Department of Ophthalmology, Kanazawa Medical University, Uchinada, Ishikawa, Japan
- Division of Vision Research for Environmental Health, Project Research Center, Medical Research Institute, Kanazawa Medical University, Uchinada, Ishikawa, Japan
| | - Hisanori Miyashita
- Department of Ophthalmology, Kanazawa Medical University, Uchinada, Ishikawa, Japan
| | - Eri Shibuya
- Department of Ophthalmology, Kanazawa Medical University, Uchinada, Ishikawa, Japan
| | - Norihiro Mita
- Department of Ophthalmology, Kanazawa Medical University, Uchinada, Ishikawa, Japan
| | - Mai Yamazaki
- Department of Ophthalmology, Kanazawa Medical University, Uchinada, Ishikawa, Japan
| | - Teppei Shibata
- Department of Ophthalmology, Kanazawa Medical University, Uchinada, Ishikawa, Japan
| | - Hidetoshi Ishida
- Department of Ophthalmology, Kanazawa Medical University, Uchinada, Ishikawa, Japan
| | - Yuki Ukai
- Department of Ophthalmology, Kanazawa Medical University, Uchinada, Ishikawa, Japan
| | - Eri Kubo
- Department of Ophthalmology, Kanazawa Medical University, Uchinada, Ishikawa, Japan
| | | | - Hiroshi Sasaki
- Department of Ophthalmology, Kanazawa Medical University, Uchinada, Ishikawa, Japan
- Division of Vision Research for Environmental Health, Project Research Center, Medical Research Institute, Kanazawa Medical University, Uchinada, Ishikawa, Japan
- * E-mail:
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21
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Histopathological Variability and Concomitant Lesions in Pterygium in a Large Case Series. J Ophthalmol 2021; 2021:6623794. [PMID: 33828861 PMCID: PMC8004360 DOI: 10.1155/2021/6623794] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 03/08/2021] [Accepted: 03/12/2021] [Indexed: 01/02/2023] Open
Abstract
Pterygium is a common lesion consisting of fleshy conjunctival growth extending towards the cornea. There is no documented risk of malignant transformation; however, concomitant disease is not rare, and its link to sunlight exposure indicates a risk of other malignancies. The purpose of our study is to describe histopathological features of resected pterygiums and to recognize patients at risk of other conjunctival diseases. One hundred and forty-nine formalin-fixed and paraffin-embedded pterygium samples were subjected to histopathological analysis. Histological H&E sections were obtained and digitalized using a Zeiss Axio Scan.Z1 slide scanner. Thirteen predefined morphological features were used to record histopathological changes in the epithelium and substantia propria. Neovascularization was observed in 54% of the samples. Sun damage, comprising solar elastosis and stromal plaque, was present in 81% of the samples. Variation in epithelial thickness was the most common change, with acanthosis and atrophy being observed in 62% and 26% of the samples, respectively. In our series, 21% (31/149) of pterygiums showed mild to moderate dysplasia, a finding that may be associated to ocular surface squamous neoplasia (OSSN). Moreover, 32% (47/149) of the cases showed melanocytic hyperplasia, which could represent primary acquired melanosis (PAM). There is a positive correlation between dysplasia and chronic inflammation (p=0.012) and an inverse correlation with epithelial atrophy (p=0.001) and neovascularization (p=0.05). Similarly, a positive correlation is observed between goblet cell hyperplasia and melanocytic hyperplasia (p=0.02). Our findings show that pterygiums harbour histological features that may be suggestive of OSSN or PAM in 53% of our patients. Whilst being on the benign side of the spectrum, these two entities are known for their potential progression to malignancy. A recommendation is made for all surgically excised pterygiums to be sent for histopathological diagnosis, and clear guidelines for reporting of these lesions should be established. Associated histopathological findings suggestive of other concomitant diseases should be identified to insure adequate follow-up of these patients.
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Costa FQ, Costa RQ, Barbosa JB, Gomes JÁP. Pterygium Surgery with Conjunctival Autograft Fixation Using Bipolar Electrocauterization. Eur J Ophthalmol 2020; 31:1458-1462. [PMID: 33111555 DOI: 10.1177/1120672120965488] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To report a case series of pterygium surgery with conjunctival autograft fixation using bipolar electrocautery. DESIGN A noncomparative, retrospective, interventional case series of pterygium surgery with follow-up longer than 12 months to assess recurrence and other complication rates. PARTICIPANTS Fifty-six eyes of 37 patients were treated between April 2011 and January 2018, either for primary (n = 53 cases) or recurrent (n = 3 cases) pterygia. INTERVENTION After pterygium excision, free conjunctival grafts from the inferior bulbar conjunctiva of the same eye were harvested and fixated with the use of bipolar electrocautery. MAIN OUTCOME MEASURE Recurrence of the pterygium and complications. RESULTS The mean follow-up was 41 months (range 12 to 81 months). There were no intraoperative complications. Recurrence of the lesion was seen in three eyes (5.36%). There were no other postoperative complications such as graft detachment, or formation of dellen or granulomas. CONCLUSION Conjunctival autograft fixation using bipolar electrocautery seems to be a fast, costly and safe procedure that can be applied in most cases of pterygium surgery.
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Affiliation(s)
| | | | | | - José Álvaro Pereira Gomes
- Department of Ophthalmology and Visual Sciences, Paulista School of Medicine/Federal University of São Paulo (EPM/UNIFESP), São Paulo/SP, Brazil
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