The effect of different pterygium surgery techniques on the ocular surface parameters in different durations: a systematic review and meta-analysis

PURPOSE

To evaluate the effects of different pterygium surgery techniques on ocular surface (OS) in different follow-up periods.

METHODS

PubMed, Cochrane Library, Web of Science, China National Knowledge Infrastructure, Wan Fang, and China Biology Medicine disc were searched for studies reporting pre- and post-operative OS parameters in pterygium.

RESULTS

A total of 33 articles were finally included. Three OS parameters showed relatively consistent changing trends after surgery including ocular surface disease index (OSDI), tear film break-up time (BUT), and score of corneal fluorescein staining (SCFS). They worsened significantly at 1w post-operation and then gradually improved: OSDI and BUT showed obvious improvement in 1 m post-operation (SMD =  - 0.58, 95%CI = [- 1.04, - 0.13]; SMD = 0.42, 95%CI = [0.06, 0.78]); SCFS was restored to preoperative levels in 3 m after surgery (SMD =  - 0.54, 95%CI = [- 1.16, 0.07]). Another parameter, Schirmer test without anesthesia (SIT), presented transient increase at 1w post-operation (SMD = 0.87, 95%CI = [0.27, 1.47]) and presented a relatively stable improvement after 1 m post-operation (SMD = 0.52, 95%CI = [0.16, 0.89]). All parameters in amniotic membrane graft (AMT) showed better improvement in early stage and they showed non-inferior improvements in the long term compared with conjunctival autograft (CAG). Limbal-conjunctival autograft (LCAG) made excellent improvement to OS in the long term while pterygium excision (PE) showed the worst OS. The type of pterygium (primary and secondary), diabetes mellitus (DM) status, and fixation method had certain effects on the results.

CONCLUSIONS

OS of pterygium is deteriorated at 1w post-operation then gradually improved to preoperative levels after 1 m post-operation. Among various surgery techniques, LCAG had the best improvement to OS which especially displayed in the long-term outcomes.

The Effect of Autografts from the Inferior and Superior Bulbar Conjunctiva on the Ocular Surface in Primary Pterygium Surgery: A Cytology Study

Objectives

This study aimed to evaluate the effect of using an inferior or superior conjunctival autograft in primary pterygium surgery on the postoperative ocular surface.

Materials and Methods

Forty eyes of 40 patients who underwent pterygium surgery with autograft were included in the study. Cytological cell counts were performed on samples taken from the bulbar conjunctiva by impression cytology before and 1 year after the operation. Schirmer 1 test score, lissamine green conjunctival staining score, tear film break-up time (TBUT), and fluorescein corneal staining scores were evaluated. The pain levels of the patients were evaluated with visual analog scale at postoperative 1 day and 1 week.

Results

Corneal and conjunctival staining, TBUT, and Schirmer test results demonstrated significant improvement in all patient groups after surgery, but there was no difference between groups (p>0.05). In both preoperative and postoperative impression cytology, the number of goblet cells in the inferior bulbar conjunctiva was higher than in the superior bulbar conjunctiva (p<0.001), while there was no such difference in epithelial cell or mucin staining. There were no significant cytological changes postoperatively in either group (p>0.05).

Conclusion

Pterygium surgery with autografting improved tear function tests regardless of graft location. Goblet cell count was higher in the inferior bulbar conjunctiva than in the superior bulbar conjunctiva in both postoperative and preoperative impression cytology. However, there was no significant difference in postoperative epithelial and goblet cell counts or mucin staining between the groups before and after surgery. We think that using the inferior bulbar conjunctiva is an appropriate choice in cases where the superior conjunctiva cannot be used as a graft or when future glaucoma surgery is possible.

Multi-drug resistant Klebsiella-induced corneal ulcer following pterygium surgery: a case report

BACKGROUND

Management of pterygium is dependent on the grading of pterygium and its clinical presentation (inflamed or quiescent), and surgical excision is the final choice of treatment for the pterygium extending beyond the limbus. Infectious keratitis is one of the most commonly reported complications in recent years. To the best of our knowledge, Klebsiella keratitis after pterygium surgery has not been described in the current literature. Here, we report a patient with corneal ulcer formation following pterygium surgical excision.

CASE PRESENTATION

A 62-year-old woman presented with complaints of pain, blurred vision, photophobia and redness in her left eye for a month. She had a history of pterygium surgical excision two months ago. Slit-lamp examination showed conjunctival congestion, a central whitish corneal ulcer with a central epithelial defect, and hypopyon. Corneal scraped sample revealed multidrug resistant (MDR) Klebsiella pneumonia and the strain was found to be sensitive to cefoxitin and ciprofloxacin. Intracameral cefuroxime (1 mg/0.1 mL) injection, fortified cefuroxime ophthalmic suspension (50 mg/mL) and moxifloxacin ophthalmic suspension (0.5%) were successfully administered to control the infection. Since residual central stromal opacification remained persistent, final visual acuity did not improve beyond finger counting at two meters.

CONCLUSIONS

Klebsiella keratitis is a rare and sight-threatening complication following pterygium excision. This report emphasizes the importance of close follow-up examination following pterygium surgeries.

Development of a valid and reliable pterygium surgery assessment scale for ophthalmology residents

BACKGROUND

Microsurgery training has become an important part of ophthalmology teaching and one of the main topics of examination. Accurate and effective evaluation of microsurgery skills is vital for the training and teaching of residents. In this study, we aimed to establish a pterygium surgery assessment scale for use by ophthalmic residents and evaluate its reliability and validity.

METHODS

Based on a literature search, experienced pterygium surgeons developed the preliminary scale according to the standard surgical procedure. The preliminary scale and a questionnaire were sent to teaching and research experts in the field for feedback. Face and content validity and reliability of the scale were determined by rounds of modifications based on expert feedback. For construct validity, existing assessment scales were obtained and a range of factors were tested.

RESULTS

Nineteen expert surgeons completed the questionnaire and modifications were made until all surgeons agreed on the final scale. Good construct validity was found by evaluation against 257 existing scales. For reliability, 280 evaluation scales were completed. Inter- and intra-rater reliability analysis both found Intraclass Correlation Coefficient (ICC) > 0.8 for all items and total scores.

CONCLUSION

The pterygium surgery assessment scale developed in this study has good reliability and validity, and is an effective measurement tool for the evaluation of ophthalmology residents' pterygium surgical skills.

Cosmetic outcome of femtosecond laser-assisted pterygium surgery

Background

To examine the cosmetic outcome of femtosecond laser-assisted pterygium surgery (FLAPS) with conjunctival autograft (CAG) and its potential predictive factors.

Methods

This was a prospective interventional case series (NCT02866968). We included 29 patients (29 eyes) with primary pterygium who underwent FLAPS. Cosmetic outcome was graded by two graders (an ophthalmology resident and an experienced ophthalmologist) using Hirst classification system (1–4 = excellent–poor). Weighted Cohen’s kappa analysis was performed to examine the intra- and inter-rater reliability. The relationship between cosmetic outcome and various factors were determined by Spearman’s correlation coefficients (r).

Results

The preoperative severity of pterygium (Tan grading system) was mild/atrophic (7%), moderate/intermediate (62%), and severe/fleshy (31%). An ultrathin CAG (mean thickness of 74.5 ± 9.8 μm) was fashioned intraoperatively. An excellent cosmetic outcome of FLAPS (median ± IQR) was observed at 3 months (1.0 ± 1.0) and remained similar at 6 months (1.0 ± 0.0) and 12 months (1.0 ± 0.0) postoperatively. At final follow-up, 27 (93%) patients achieved good-to-excellent cosmetic outcome, with 1 (3%) patient having a poor outcome due to incomplete pterygium removal. Weighted kappa analysis of Hirst grading system showed excellent intra-rater (κ = 0.86–0.95) and inter-rater reliability (κ = 0.84–0.88). There was a weak and borderline significant correlation between good cosmetic outcome and reduced postoperative CAG thickness (r = 0.38, P = 0.06) but not with age, gender, preoperative pterygium severity, or intraoperative CAG thickness.

Conclusions

FLAPS can result in an excellent cosmetic outcome, which may be attributed to the beneficial effect of an ultrathin CAG.

Trial registration

ClinicalTrials.gov, NCT02866968. Registered in July 2016,

Supplementary Information

The online version contains supplementary material available at 10.1186/s40662-021-00230-w.

A unique case of Paracentral Acute Middle Maculopathy with associated cystoid macular oedema post uncomplicated pterygium surgery

Purpose

To present a unique and unusual case of Paracentral Acute Middle Maculopathy (PAMM) with associated cystoid macular oedema (CMO) following ocular surface surgery in a low risk patient.

Observations

This observational case report describes the presentation of a single case of Paracentral Acute Middle Maculopathy following pterygium surgery. The patient harboured no risk factors and underwent uncomplicated pterygium surgery with no perioperative complications. Post-operatively the patient demonstrated marked visual acuity loss to count fingers only to the operated eye. Optical Coherence Tomography demonstrated hyper-reflective band-like lesions affecting the middle layers of the retina, pathognomonic for PAMM. Unusually, cystoid macular oedema was also evident. He was managed on topical and oral therapy, with limited visual recovery.

Conclusions and importance

We report a rare and unique case of PAMM with associated cystoid macular oedema occurring in a patient deemed low risk following pterygium surgery resulting in significant permanent visual loss. To our knowledge, this is the first reported incidence of PAMM following ocular surface surgery.

A rare case of corneal keloid occurred 30 years after pterygium surgery and 3 years after cataract surgery

Purpose

We report a case of corneal keloid occurring 30 years after pterygium surgery and 3 years after cataract surgery.

Observations

The case of a 72-year-old man was referred because of blurred vision and corneal opacity in the right eye. Pterygium surgery had been performed on the right eye 30 years earlier, and bilateral cataract surgery had been done uneventfully via a temporal corneal incision 3 years ago. Deterioration of vision occurred in the right eye from 2 years ago. At the initial visit, his best corrected visual acuity (BCVA) was 20/2000 on the right. A white nodule that was well demarcated from the underlying stroma was seen on the right cornea. The nodule was excised by superficial keratectomy, with BCVA being 180/200 at 1 week after surgery. Pathological examination of the resected specimen revealed proliferation of fibroblasts and haphazard arrangement of collagen bundles, leading to a diagnosis of corneal keloid. Keloid-like lesion was also later noted in temporal corneal incision site of cataract surgery.

Conclusions and importance

This rare case of corneal keloid occurred as a late complication of pterygium surgery.

A surgical skills assessment rubric for pterygium surgery

PURPOSE

To introduce an assessment tool (rubric) for evaluating ophthalmology residents' competency in pterygium surgery.

METHODS

A panel of experienced international surgeons collaborated and developed the rubric. After describing various stages of the procedure, the Dreyfus scale of skill acquisition was used for scoring each stage. After finalizing the rubric, two surgeons independently evaluated 20 masked pterygium surgery videos of 10 residents and scored the videos according to the rubric. The agreement between the scores of them was examined with the intra-class correlation coefficient test.

RESULTS

This rubric divides pterygium surgery into 13 different stages and covers the two most common techniques of pterygium surgery; conjunctival autograft and amniotic membrane transplant. The rubric showed face and content validity. Overall, an intraclass correlation coefficient of 0.90 (95% confidence interval 0.76-0.96, P < 0.001) was achieved between the two surgeons. The residents scored significantly higher on surgeries performed later in their rotation compared to the earlier surgeries (4.32 ± 0.35 vs 3.96 ± 0.31, P = 0.006). Certain stages of pterygium surgery were more strongly correlated with the residents' past pterygium surgical experience.

CONCLUSION

This study introduces an international rubric for assessing competency in pterygium surgery. In addition to face and content validity, this rubric shows high inter-rater reliability. This may be a useful tool for teaching and measuring competency in pterygium surgery.

Evaluation of antimitotic and antiangiogenic effect of preoperative subconjunctival application of mitomycin C in primary pterygium: a randomized trial

PURPOSE

To evaluate the influence of preoperative mitomycin C (MMC) on the proliferative behavior of fibroblasts and fibrovascular tissue derived from the primary pterygium using the immunohistochemical method (Ki67 and CD34).

DESIGN

Randomized clinical trial.

SUBJECTS, PARTICIPANTS AND/OR CONTROLS

Sixty-five patients with primary pterygium were randomly selected and divided into one of three groups. The control group had 29 patients that were only submitted to pterygium removal. The group that received the MMC injection a month before surgery had 16 patients, and the group that received the MMC 2 weeks before surgery had 20 patients. Each patient only had one eye operated on.

METHODS

Sixty-five patients were selected to undergo pterygium excision surgery. We randomly placed the patients into three groups: one without MMC (n = 29), one with MMC application 1 month before surgery (n = 16) and another with MMC application 2 weeks before surgery (n = 20). Subconjunctival injection was applied with 0.1 ml of 0.02% MMC in the pterygium body, and patients were followed for 2 years.

MAIN OUTCOME MEASURES

Proliferative behavior of fibroblasts and fibrovascular tissue using the immunohistochemical method (Ki67 and CD34) comparing the three groups.

RESULTS

Of the total 29 patients (44.6%) in the control group (without MMC application), 11 cases had recurrence (37.9%), of which seven (63.6%) were within 3 months of follow-up and four (36.3%) within 6 months of follow-up. The mean proliferation index of the recurrent cases was 4.5%, and of the cases without recurrence, it was 6.1%. There were 16 patients (24.6%) in the MMC application group 1 month before surgery, in which one case (6.25%) recurred at 6 months. In the group with MMC application 2 weeks before surgery, of the total of 20 patients (30.7%), there was one case of recurrence (5%) at 6 months. The proliferation index of the group that had MMC administered and did not have a recurrence was 7.2%, and in the group with recurrence, it was 6.4%. The CD34-labeled cell count was 5.8% among cases with recurrence and 5.6% in cases without recurrence. No side effects of MMC application were reported during the study follow-up period.

CONCLUSION

MMC was efficient to reduce the recurrence index despite the absence of a direct relation with its antimitotic and antiangiogenic effect in the samples that were analyzed.

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.

[Pterygium surgery by conjunctiva autograft with autologous blood fixation]

INTRODUCTION

Pterygium surgery is marked by the possibility of recurrences; one of the techniques which results in the least recurrences is conjunctival autograft. Fixation of the conjunctiva had traditionally been accomplished with sutures. In recent years, conjunctival grafting has also been performed with fibrin glue. Even more recently, with a view towards improving the quality of postoperative results, some surgeons recommend the use of autologous blood. This study aims to evaluate the stability of this latest method of graft fixation, while assessing its postoperative results.

METHODOLOGY

After diagnosis of pterygium, the patients underwent pterygium surgery with a conjunctival graft fixated with autologous blood. They were then monitored for one year, at 24h postoperatively, then seven days, 15 days, one month 3months, and every 3months thereafter.

RESULTS

In totl, 84.21 % of the patients demonstrated stable postoperative fixation; 5.26 % of patients experienced significant displacement of the graft. After one year of follow-up, 15.79 % of patients experienced recurrent pterygium. Recurrences were more frequent in younger patients and in patients with previous recurrence.

CONCLUSION

Pterygium surgery by conjunctival graft fixated with autologous blood is a safe surgery, with results similar to other pterygium surgery techniques with conjunctival autograft. However, this technique has the advantage less irritation, no risk of transmitting infection and lower cost.

Serratia marcescens endophthalmitis after pterygium surgery: a case report

Background

To report a case of Serratia marcescens endophthalmitis after pterygium surgery using the bare sclera technique with mitomycin C (MMC).

Case presentation

A 69-year-old male patient underwent pterygium excision surgery using the bare sclera technique and 0.02% MMC. The patient presented with decreased visual acuity and pain from the day after the operation. Trans pars plana vitrectomy was performed and intravitreal antibiotics were administered. Cultures from the aqueous humor and intraocular lens were all positive for S. marcescens, which was sensitive to an empiric antibiotic regimen. The best corrected distant visual acuity, 1 month after treatment, was a finger count/50 cm, but the retinal layer structure and the vasculature were relatively well preserved.

Conclusions

This is the first reported case of S. marcescens endophthalmitis after pterygium surgery. Endophthalmitis caused by S. marcescens has a devastating visual prognosis and may show a high clinical risk-benefit ratio for the application of MMC in pterygium surgery.

Comparison of free conjunctival autograft versus amniotic membrane transplantation for pterygium surgery

Purpose

To compare the recurrence rate and surgical outcomes of amniotic membrane transplantation (AMT) and free conjunctival autograft (CAT) for pterygium surgery.

Methods

In this prospective study, 60 patients with primary pterygium were randomly assigned to two groups of CAT or AMT and were compared in terms of recurrence rate, mean healing time of corneal epithelial defects, the mean level of inflammation, and complications.

Results

The mean ± SD age of patients was 48.98 ± 9.8 years (range, 27–71 years). 73.3% were men, and 26.7% were women. The groups did not differ with respect to demographic characteristics (P > 0.05). Patients were followed for an average of 12.6 ± 1.3 months. The recurrence rates were 6.7% and 3.3% in the AMT and CAT groups, respectively (P > 0.05). Comparison of mean inflammation score showed higher inflammation in the AMT group in the first, third, and sixth postoperative month (P < 0.05). Mean healing times of corneal epithelial defects were 2.5 ± 0.572 and 2.67 ± 0.479 days in the CAT and AMT groups, respectively (P = 0.173).

Conclusions

No significant complication was observed during or after both surgical methods. No statistically significant difference was seen in visual acuity changes and epithelial healing in CAT and AMT groups, but more inflammation and recurrence rate were seen in AMT group.

When an Easy Thing Goes Wrong: Foreign Body Induced Granuloma-Associated Scleritis Following Pterygium Surgery

PURPOSE

To report a case of pterygium surgery with conjunctival autograft followed by focal necrotizing scleritis due to foreign body entrapment in the scleral bed.

CASE REPORT/RESULTS

This is a case report of a 76-years-old male patient who underwent nasal pterygium surgery and developed focal necrotizing scleritis secondary to foreign body entrapment under conjunctival autograft. One month following surgery, slit-lamp examination demonstrated a progressive thinning of the surgical area with focal inflammatory signs. A small synthetic fiber was identified to be trapped under the graft. A second intervention was performed with foreign body removal and a new conjunctival graft. Despite the surgery, focal scleral melting continued to progress and the patient was placed under systemic corticotherapy and submitted to amniotic membrane graft with epithelial side up. During the follow-up period there was a good tissue response.

CONCLUSION

Despite being a safe and quick procedure, pterygium surgery can sometimes elicit new challenges.

Large pterygium surgery: When coverage of the scleral bed justifies graft rotation

OBJECTIVE

To perform a 12 month follow-up study to assess the safety and effectiveness of resection and conjunctival autograft fixed with Tissucol® in selected cases of large pterygium. The orientation of the graft was adapted to the morphology of the scleral bed for a better coverage free of traction, with limbal position being lost.

METHODS

A prospective, non-comparative study of 10 cases of grade II or superior pterygium (7 primary, 3 recurrent) with at least 8mm of limbal extension. A wide scleral bed was obtained after pterygium and Tenon resection, with larger grafts being required to cover the defects. A superior conjunctival autograft was harvested and fixed to bare sclera using Tissucol. The orientation was adapted to the morphology of the scleral bed and limbal position was lost. Patients were periodically assessed for recurrence and complications for a period of 12 months.

RESULTS

Minor complications occurred in 4 eyes. In one case a buttonhole was formed during dissection of the graft. Two presented with small limbal dehiscence, but epithelialisation was completed in the first week. In a third case, it was necessary to increase topical corticosteroids for pyogenic granuloma on the donor site, with secondary increased intraocular pressure (IOP). There were no recurrences after 12 months follow-up.

CONCLUSIONS

A conjunctival graft of appropriate size adapted to the morphology of the scleral bed to ensure good coverage free of tension, provides good surgical results in selected cases of pterygium, regardless of the conservation the limbal orientation, with no recurrences after one year follow-up.

Comparison between sutureless and glue free versus sutured limbal conjunctival autograft in primary pterygium surgery

PURPOSE

To compare and evaluate the safety and efficacy of two surgical techniques for the management of primary pterygium.

DESIGN

Prospective randomized clinical trial using the CONSORT 2010 Statement (Consolidated Standards of Reporting Trials) for parallel group randomized trials.

SETTING

Department of Ophthalmology, Al-Minya University, Faculty of Medicine, Egypt.

METHODS

The study included 150 eyes of 150 patients with primary pterygium. The mean age was 49 ± 12 years (range 24-74 years). Simple excision under local anesthesia was performed followed by closure of the bare sclera by suture less and glue free conjunctival autograft in 50 eyes of 50 patients (group 1), versus the conventional method of a sutured conjunctival autograft in 100 eyes of 100 patients (group 2).

RESULTS

The pterygium recurrence rate was 6% for group 1, 8% for group 2. Graft dehiscence occurred in 4 eyes out of 50 (8%) in group 1. Graft retraction occurred in 6 (12%) out of 50 eyes for group 1 versus 6 eyes (6%) in group 2. Pyogenic granuloma occurred in 3 (3%) eyes out of 100 in group 2. No other serious complications were noted. At the 3 week visit the overall patient satisfaction score was statistically significantly higher for group 1 (P < 0.002) compared to group 2. At 3 months postoperatively, the gain in uncorrected visual acuity (UCVA) ranged from 0.2 to 0.5 Log MAR in 10 eyes.

CONCLUSION

Sutureless and glue free conjunctival autograft technique is easy, safe, effective, prevents potential adverse reactions encountered with the use of foreign materials. This technique has an acceptable pterygium recurrence rate that is comparable to conventional sutured conjunctival autograft for primary pterygium.