Outcomes of Vertical Split Conjunctival Autograft Using Fibrin Glue in Treatment of Primary Double-Headed Pterygia

Management of pterygium: our experience and a simplified treatment algorithm

Aim: To explore various approaches in the management of pterygium and to propose a simplified treatment algorithm for its surgical management. Methods: A retrospective analysis of 9219 eyes was done. Group I included patients with primary single-head pterygium, most undergoing pterygium excision with conjunctival autograft (CAG). CTG-P (Conjunctival tissue graft from pterygium), AMG (Amniotic membrane graft), and inferior CAG were done in the remaining patients in this group in which conventional conjunctival autograft was a relative contraindication. Group II included patients with primary double-head pterygium who underwent vertical/horizontal split CAG, with/without limbal orientation, Inferior + Superior CAG, CTG-P, and CAG + CTG-P. Group III included patients with recurrent single-head pterygium who underwent ER (Extended resection) + LCAG (Limbal conjunctival autograft), LCAG + MMC (Mitomycin-C), CAG + MMC (Mitomycin-C) and CAG. Group IV included patients with recurrent double-head pterygium who underwent split LCAG and CAG + SLET. Results: All the four groups reported a low incidence of pterygium recurrence. Recurrence was observed at a rate of 0.47%, 3.63%, 2.86%, and 7.69% in Group I, Group II, Group III and Group IV respectively. Discussion: We mainly aimed to get minimal recurrence and good cosmetic outcomes. In double-head pterygium, we could achieve good and comparable outcomes with horizontal or vertical split CAG, with or without maintaining limbal orientation. Similarly, Inferior + Superior CAG, CTG-P, CAG+CTG-P, and AMG also showed low recurrence rates. In recurrent pterygium, ER + LCAG/CAG, with/without adjuncts like MMC showed low recurrence rates. Thus, all of these methods were found to be viable options. The main strength of our study, compared to previous studies on pterygium was its large sample size and long duration of follow-up. Conclusion: All the methods we studied had a low recurrence rate. We have formulated a treatment algorithm for pterygium management based on our outcomes. Abbreviations: CAG = Conjunctival autograft, CTG-P = Conjunctival tissue graft from pterygium, ER = Extended resection, MMC = Mitomycin-C.

Clinical and Autofluorescence Findings in Eyes with Pinguecula and Pterygium

Purpose

To assess the autofluorescence size and properties of pterygium and pinguecula by anterior segment autofluorescence (AS-AF) imaging and demonstrate the difference of autofluorescence size presented in AS-AF imaging compared to the extend size of the conjunctival lesion measured by anterior segment slit-lamp photography (AS-SLE).

Methods

Twenty-five patients with primary pterygium and twenty-five with pinguecula were included in the study. In addition, 25 normal subjects were also enrolled as the control group. The AS-AF characteristics of pterygium and pinguecula lesions were analyzed. The size of lesions displayed in the AS-SLE photography versus the AS-AF images were also compared. AS-AF images were obtained using a Heidelberg retina angiograph which focused on the anterior segment. AS-SLE photography was acquired using a digital imaging system (BX900 HAAG-STREIT).

Results

There were 44 (58.7%) male and 31 (41.3%) female patients; 19 (76%) and 20 (80%) patients had bilateral pterygium and pinguecula, respectively. All pinguecula lesions reflected hyperautofluorescence pattern in the AS-AF imaging. In 24 (96%) patients, the hyperautofluoresecence pattern was larger than the size of the clinical lesions displayed with the AS-SLE photography. Twenty-one (84%) patients with pterygium reflected a hyperautofluorescence pattern in AS-AF images; in one (4%) patient, the hyperautofluorescence pattern was larger than the clinical lesion size and four (16%) patients had no autofluorescence patterns in the AS-AF images. In the control group, in 14 (56%) subjects, a hypoautofluorescent pattern was revealed in the conjunctiva in AS-AF images. However, in 11 (44%) patients, hyperautofluorescence patterns were detected.

Conclusion

AS-AF is a useful modality to monitor vascularization in conjunctival lesions. Pingueculae and pterygium show hyperautofluorescence in AS-AF imaging. The real size of the pinguecula lesions may be estimated with AS-AF characteristics, mostly presenting larger than the area size in AS-SLE photography. The autofluorescence size of the pterygium is smaller than the extent of visible pterygium in slit-lamp photography.

Impact of fibrin glue versus suture closure on double-headed pterygia in Asian eyes - a 7-year study in a tertiary institution

BACKGROUND

To compare the recurrence rate and outcomes of double-headed pterygia using fibrin glue versus suture closure of conjunctival autograft.

METHODS

All patients with double-headed pterygia who underwent pterygia excision with conjunctival autograft from January 2012 to January 2019 in the National University Hospital of Singapore were included. Patients were divided into 2 groups depending on whether fibrin glue or sutures were used to secure the conjunctival autograft in place. All patients had a minimum of 6 months follow-up.

RESULTS

A total (26 patients) of 22 eyes had fibrin glue, while eight eyes underwent suture closure of their conjunctival autograft. Fibrin glue group had 4.5% recurrence rate, while suture group had 37.5% recurrence rate (p = .021). There is statistically significant improvement for overall visual acuity (p = .009) and cylinder (p = .002). There is also statistically significant improvement for visual acuity in the glue group (p = .026), but not in the suture group. Fibrin glue group had a shorter operation duration time compared to suture group (p < .001).There were no cases of graft dislocation, contraction or limbal stem cell deficiency.

CONCLUSIONS

Low recurrence rates and good postoperative visual outcomes can be achieved with the split conjunctival autograft technique. Our study suggests that fibrin glue has an additional benefit over the use of sutures in the management of these complex cases.

Comparison of horizontal versus vertical split conjunctival autograft in the management of double head pterygium: A retrospective analysis

Purpose

To compare horizontal and vertical split conjunctival autograft technique in the management of double head pterygium.

Methods

Retrospective analysis of 96 and 99 eyes with double head pterygia that underwent horizontal (Group 1) and vertical (Group 2) split conjunctival autografting, respectively. Comparison of recurrence rates and other complications was done.

Results

Recurrence was seen in 5.2% and 4% of the eyes in Groups 1 and 2, respectively (P > 0.05). Other complications like subconjunctival hemorrhage, graft edema, graft retraction, granuloma, and graft loss were also comparable among the two groups.

Conclusion

Both the techniques provide good results with comparable efficacy in terms of rates of recurrence and complication profiles.

Comparison of vertical split conjunctival autograft with and without limbus to limbus orientation in cases of double-head pterygium-A retrospective analysis

Purpose

The aim of this study is to compare the outcome and complications in patients who underwent double-head pterygium excision with split conjunctival autograft with and without limbus to limbus orientation.

Methods

In this retrospective, comparative study, 99 eyes with double-head pterygium which underwent split conjunctival autograft with limbus to limbus orientation (Group 1) and 93 eyes which underwent without limbus to limbus orientation (Group 2) during the period of 2011-2016 were included in this study. The primary outcome compared was the recurrence rate. Other complications were included as secondary outcomes.

Results

Mean age in group 1 and group 2 were 46.84 +/- 10.78 years and 54.38 +/- 11.44 years respectively. M:F was 36:63 in group 1 and 45:48 in group 2 with a mean follow up of 18.30 +/- 7.48 months in group 1 and 17.04 +/- 9.98 months in group 2. Recurrence was seen in 4 cases in each of the 2 groups with the mean time of recurrence being 7 +/- 2.34 months in group 1 and 6 +/- 2.01 months in group 2. Other complications included graft edema, SCH, graft retraction, granuloma, dellen and graft loss with only graft loss being statistically significant between 2 groups.

Conclusion

This study provides data that recurrence rates are not different among patients who undergo split conjunctival graft with and without limbal orientation. The strict adherence to maintaining limbus to limbus orientation while managing double-headed pterygia may not be necessary in all cases, especially in those with large defects following excision.

The Human Tissue-Engineered Cornea (hTEC): Recent Progress

Each day, about 2000 U.S. workers have a job-related eye injury requiring medical treatment. Corneal diseases are the fifth cause of blindness worldwide. Most of these diseases can be cured using one form or another of corneal transplantation, which is the most successful transplantation in humans. In 2012, it was estimated that 12.7 million people were waiting for a corneal transplantation worldwide. Unfortunately, only 1 in 70 patients received a corneal graft that same year. In order to provide alternatives to the shortage of graftable corneas, considerable progress has been achieved in the development of living corneal substitutes produced by tissue engineering and designed to mimic their in vivo counterpart in terms of cell phenotype and tissue architecture. Most of these substitutes use synthetic biomaterials combined with immortalized cells, which makes them dissimilar from the native cornea. However, studies have emerged that describe the production of tridimensional (3D) tissue-engineered corneas using untransformed human corneal epithelial cells grown on a totally natural stroma synthesized by living corneal fibroblasts, that also show appropriate histology and expression of both extracellular matrix (ECM) components and integrins. This review highlights contributions from laboratories working on the production of human tissue-engineered corneas (hTECs) as future substitutes for grafting purposes. It overviews alternative models to the grafting of cadaveric corneas where cell organization is provided by the substrate, and then focuses on their 3D counterparts that are closer to the native human corneal architecture because of their tissue development and cell arrangement properties. These completely biological hTECs are therefore very promising as models that may help understand many aspects of the molecular and cellular mechanistic response of the cornea toward different types of diseases or wounds, as well as assist in the development of novel drugs that might be promising for therapeutic purposes.

Bilateral Double-headed Recurrent Pterygium: A Case Presentation and Literature Review

Pterygium is a frequent corneal disease characterized by growing of fibrovascular tissue from the bulbar conjunctiva onto the cornea. Although the causes of pterygium are not obvious, sun exposure is closely correlated with its development. Pterygium, especially double-headed pterygium is mostly seen in warm climate and in individuals who work outdoors. A minority of pterygium is double-headed (both temporal and nasal origins). Bilateral recurrent double-headed pterygium is a very rare condition. Here, we reported a 35-year-old male patient with bilateral recurrent double-headed pterygium. A brief review about the recent literature concerning the etiology, associated risk factors, operation types and management of patients with recurrent pterygium was also discussed. The patient was a field worker, smoker and had a family history of pterygium. There was no ocular surgery history except pterygium surgery 15 years ago in both eyes. A successful pterygium excision was performed under local anesthesia with the vertical split conjunctival autograft transplantation (CAT) in both temporal and nasal parts of the right eye (randomly) for cosmetic disfigurement and avoidance of recurrence. The pathological report was consistent with pterygium. At postoperative first week, first and 1.5^th month visits, conjunctival autografts were in place and stable. No complications such as infection, corneal thinning or graft dislocation were seen. The patient was satisfied with his right eye and demanded the same surgery for his left eye. We suggest vertical split simultaneous CAT as a safe and useful surgical method for the treatment of recurrent double-headed pterygium; however, longer follow-up is required to confirm the outcome.