Pterygium Surgery

Pterygium surgery: Conjunctival rotation autograft versus conjunctival autograft Dadeya, Subhash;Malik, K P S;Gulliani, B P

Ophthalmic Surgery and Lasers; Jul/Aug 2002; 33, 4; ProQuest Medical Library pg. 269

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Figure 2. A diagram showing (A) The pterygium along the other structures of the eye. (B) An autograft from the super- otemporal quadrant (EFGH) and the dissected and rolled back area of the pterygium head. (C) A sutured autograft in place.

Figure 1. A diagram showing (A) The pterygium along with the eye and lids. (B) The dissected head of the pterygium, and the rolled back and conjunctival area marked for rotational graft (ABCD). (C) The rotated graft in place (DCBA).

C L I N I C A L

S C I E N C E

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Pterygium Surgery: Conjunctival Rotation Autograft Versus Conjunctival Autograft

Subhash Dadeya, MD; K.P.S. Malik, MS, MNAMS; B.P. Gulliani, MS ■ BACKGROUND AND believed to be caused by increased OBJECTIVES: To compare the safety and efficacy of conjunctival rotation autograft to conjunctival autograft in primary pterygium surgery.

■ PATIENTS AND METHODS: A

prospective randomized study was performed of 39 eyes in 31 patients who had undergone pterygium surgery. Nineteen eyes were treated by conjunctival rotation autograft (Group A). Twenty eyes were treated by conjunctival autograft (Group B). Follow up ranged from 8 to 12 months (mean 11 months). Recurrence was defined as postoperative regrowth of 2 mm fibrovas- cular tissue onto clear cornea in the area of previous pterygium excision.

■ RESULTS: Recurrence was observed in 5.88% (1/17) in Group A and in 5.55% (1/18) in Group B.

INTRODUCTION Pterygium is a triangular-shaped growth of abnormal subconjunctival tissue that extends horizontally from the bulbar conjunctive, across the limbus, and onto the cornea1

From the Department of Ophthalmology, Safdarjung Hospital, New Delhi, India. Accepted for publication October 29. 2001. Address reprint requests to Subhash Dadeya, MD, G-172 Nanak Pura, New Delhi-21, India.

Four eyes were excluded from the study. Delayed wound healing occurred in 11.76% of eyes, and 5.88% of eyes had persistent congestion in Group A. A loose graft was present in 5.55% of eyes, and 5.55% of eyes had dellen formation in Group B.

■ CONCLUSION:

"We conclude that conjunctival rotation autograft and conjunctival autograft are both equally effective methods to reduce the recurrence rate after pterygium surgery. Conjunctival rotation autograft can be tried as an alternative attractive procedure for pterygium surgery to reduce the chances of recurrence. However, a larger, randomized, prospective double masked study with more patients and a longer follow up will eventually demonstrate the superiority of one procedure over the other. [Ophthalmic Surg Lasers 2002;33:269-274]

CONJUNCTIVAL ROTATION AUTOGRAFT vs CONJUNCTIVAL AUTOGRAFT • Dadeya et al

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exposure to ultraviolet light.2 Since the era of Susruta, surgery remains the principal mode of treatment.3 Over the years, different treatment strategies like simple excision with or without adjunctive measures like postoperative betairradiation, thiotepa, intraoperative and postoperative mitomycin-C, and various techniques of conjunctival grafting have been tried to develop a recurrence free pterygium surgery.4"9 Despite the availability of several techniques, recurrence still remains the most enigmatic complication of pterygium.10"11 Conjunctival autografting and intraoperative mitomycin-C are the most commonly used adjunctive therapies to prevent the recurrence of pterygium.12 Recently, conjunctival rotation auto- grafting, as an alternative to conjunctival autografting, has been used successfully in pterygium surgery.13 To the best of our knowledge, no study so far has compared the effectiveness of conjunctival autograft and conjunctival rotation autograft as adjunctive therapies for pterygium surgery. The present prospective study was aimed to compare the results of both the procedures in pterygium surgery.

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PATIENTS AND METHODS This study included 39 eyes in 31 patients meeting eligibility criteria and undergoing excision of pterygium in the department of ophthalmology at Safdarjung Hospital. The departmental ethics committee approved the clinical trial protocol and informed written consent was obtained before the surgery. The inclusion criteria included: (1) patient was more than 20 years of age; (2) primary progressive pterygium (fleshy, vascularized, and more than 2 mm encroachment onto cornea) was present; (3) there was no other ocular surface pathology; (4) no systemic pathology was present; (5) there was follow up of at least 6 months; and (6) nasal pterygium was present. Patients more than 60 years of age and/or having atrophic or recurrent pterygium were excluded from the study. Patients having collagen vascular disease, ocular surface disorder, dry eye, or who had undergone any ocular surgery were excluded from the study. Pregnant women and one-eyed patients were also excluded from the study. All patients underwent complete ocular examination prior to surgery. Eyes were randomly divided into 2 groups: Group A was treated by conjunctival rotation autograft and Group B was treated by conjunctival autograft. All cases were operated on by one of us on an outpatient basis. The conjunctival rotation autograft was performed using the technique described by Jap et al.13 The head of the pterygium was dissected from corneal surface to the limbus. A and B represents the conjunctival tissue near the pterygium head, while C and D represents the conjunctival tissue away from the pterygium head. The epithelial layer along with the minimal subepithelial tissue is dissected free, taking care not to include the underlying fibrovascular pterygium tissue. This epithelial layer is rotated 180° so that D and C come close to the limbus (Figure 1A-C). The conjunctival autograft was performed using the technique developed by Kenyon et al9 of transfering a free graft of conjunctiva (EFGH) from a donor site in the superotemporal quadrant of the operative eye to cover the exposed sclera from the pterygium excision (Figure 2A-C). All eyes received postoperative treatment of 0.1% dexamethasone sodium and 0.3% tobramycin 4 times a day for 4 weeks, tapered over 8 weeks. All patients were evaluated on the 1st, 7th, and 15 th postoperative day, and thereafter every month for 6 months, and then every 2 months until the last follow up. The follow up ranged from 8 to 12 months (mean 11 months). Recurrence was defined as the postoperative growth of 2 mm fibrovascular tissue onto the cornea and was confirmed by two surgeons. At each visit, patients were evaluated for visual acuity, the presence or absence of recurrence, injection, graft edema, wound healing, dellen, loose graft, and symblepharon.

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DISCUSSION

Table 1. Demographic Data Characteristics

Group A

Group B

Total No. of patients

13

15

No. of eyes

17

18

Male

9

11

Female

4

4

Age (range)

20-60 years

20-60 years

Age (mean)

45.3 years

47.8 years

Pterygium size (range)

2-4.1 mm

2-4.3 mm

Pterygium size (mean)

3.6 mm

Recurrence rate

5.88% 8-12 months

8-12 months

3.1 months

6.9 months

Follow up Time of recurrence

Pterygium, a worldwide elastotic degeneration of subconjunctival tissue with a multifactorial etiology, is particularly common in tropical countries such as

Table 2. Complications After Pterygium Excision Followed by Conjunctival Autograft and Conjunctival Rotation Autograft Complications

Group A

3.7 mm

Delayed wound healing

11.76%

5.55%

Loose graft Persistent congestion after 6 months

RESULTS This study included 39 eyes of 31 patients afflicted with primary progressive pterygium. Twenty patients were male and 8 patients were female. Their ages ranged from 20 to 60 years (mean 46 years). The size of the pterygium ranged from 2 mm to 4.3 mm (Table 1) and was nasal in location for all patients. Group A consisted of 17 eyes of 13 patients who underwent pterygium excision with conjunctival rotation autograft. Group B consisted of 18 eyes of 15 patients who underwent pterygium excision with conjunctival autografting. Demographic characteristics of patients are shown in Table 1. No significant difference existed between the 2 groups in preoperative characteristics or duration of follow up. Follow up ranged from 8 to 12 months (mean 11 months). All the recurrence occurred within the first 7 months postoperatively. Recurrence rate was 5.88% and 5.55% in Group A and Group B, but when compared statistically, it was found to be nonsignificant (see the Kaplan-Meier curve for survival analysis shown in Figure 3). All recurrences occurred in patients under the age of 30 years in both groups. No intraoperative complication occurred in either group. Patients in both groups had mild symptoms of slight ocular pain, foreign body sensation, lacrimation, and photophobia that disappeared in the first week after surgery. Healing did not occur until 2 weeks in 11.76% of the eyes. Since these patients were young, the cautry used to stop bleeding during surgery may have been the reason for delayed wound healing. Moreover, the ptery gium was more aggressive in these patients. Healing occurred within 3 weeks in both the patients. One patient had a normal postoperative course after that, while the other patient had recurrence, was treated with excision and intraoperative application of 0.02% daunorubicin, and remained recurrence free. Persistent congestion (congestion persisting beyond 3 weeks) occurred in 5.88% eyes in Group A. The cause could not be ascertained; it disappeared 5 weeks after the conventional treatment with no recurrence seen in the patient. Because of an oversized graft, 5-55% eyes in Group B had a loose graft. The extra graft was cut and resutured without recurrence. Dellen formation was present in 5.55% eyes in Group B, and was resolved with antibiotic ointment and pressure bandage (Table 2).

Group B

-

5.88% -

Dellen formation Recurrence rate

5.88%

—

5.55% —

5.55% 5.55%

Figure 3. The Kaplan-Meier curve for recurrence in both Groups A and B.

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CONJUNCTIVAL ROTATION AUTOGRAFT vs CONJUNCTIVAL AUTOGRAFT • DeuUya et al

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India. A high incidence of recurrence of pterygium following surgical excision alone has been well documented.4 While the definitive management of pterygium is surgical, the ideal adjunctive procedure is still to be determined, though conjunctival autografting and intraoperative mitomycin are the 2 adjunctive treatment methods most commonly used in pterygium surgery. Kenyon et al9 reported 0% and 5.3% recurrence rate in 57 eyes undergoing conjunctival autograft for primary and recurrent pterygium. The drawback of their study was it was not conducted in the pterygium belt. Shaw et al14 reported a 7.1% recurrence rate after conjunctival autografting. Stark et al15 concluded that conjunctival autograft remains the best option in the treatment of advanced primary and recurrent pterygium. Although it is not uncommon to encounter minor problems such as graft edema, corneoscleral dellen, graft retraction, graft necrosis, epithelial cyst, tenon's granuloma, and hematomas, Vrabec et al16 reported subconjunctival fibrosis after conjunctival autograft. Conjunctival autograft technique has proved to be safe and effective; however, complications include a greater degree of technical difficulty with extended operating time and expense, patient discomfort from multiple suture knots, and the need for conjunctival donor tissue that may not be available in eyes with both nasal and temporal pterygia.17 Lawallen18 and Chen et al19 reported a 21% and 39% recurrence rate after conjunctival autografting. Moreover, Simona et al20 concluded that, in view of the high recurrence rate, this method should not be used as standard primary surgery for pterygium. There are conflicting reports about the use of intraoperative mitomycin-C to prevent the recurrence of pterygium after excision. Mastropasqua et al,21 Lam et al,22 and Panda et al23 have successfully used intraoperative mitomycin to reduce the recurrence of pterygium after excision. However, Parra et al24 and Dougherty et al25 have reported serious sight-threatening complications. It must be kept in mind that these complications occurred despite minimum concentration was used for a minimum period. These reports have questioned the safety of mitomycin-C as adjunctive therapy to prevent the recurrence of pterygium after excision. Moreover, the authors do not recommend intraoperative use of mitomycin-C as adjunctive therapy based on their personal experience. Various procedures with variable success, merits, and demerits have been described to reduce the recurrence of pterygium after excision. However, the search for the best adjunctive for pterygium after excision still continues. Most of the surgical techniques for pterygium are based on one or more principles to prevent the recurrence: (1) complete removal of pterygia and leaving a bare area of sclera26; (2) suppressing regrowth of subconjunctival tissue27"29; (3) ways of restoring barrier function of limbus9,30; and (4) biological contact inhibition.31 In 1855, Desmerres32 devised the method of transplantation for the purpose of diverting the growth from the cornea. The pterygium was detached from the cornea and sutured into the adjacent lower fornix of the conjunctiva. It was found that pterygium atrophied after transplantation. Knapp favored splitting the pterygium before suturing it to the conjunctiva.33 McReynold buried the tissue under the conjunctiva.34 Concurrent with the establishment of the techniques of transposition of the pterygium head, newer techniques of excision were evolving and various type of conjunctival flaps have been described to cover the exposed epibulbar defects. Spaeth35 introduced the concept of rotated island graft in 1920. The graft was rotated 90° with the head pointing upwards and base down. This procedure could not

gain popularity because the subconjunctival tissue was not removed. Blott36 modified Spaeth's original technique. He rotated the island of tissue 180° facing the head towards the inner can thus and base at the limbus. However, Jap et al13 concluded that conjunctival rotation autograft is an alternative procedure to conjunctival autograft in cases where the autograft is con- traindicated or not feasible. They reported a 4% recurrence rate in their series. The recurrence rate in our study was 5.88%, which is comparable to one reported by Jap et al.13 The study duration is adequate in our study (8-12 months) given that most recurrences take place within the first 6 months. The follow-up period, time of recurrence, and complication rate are comparable in both the study groups. Moreover, both the studies were conducted in the pterygium belt. However, the indication of surgery in each of the 2 studies was different. Jap et al13 conducted the study in patients wherein conjunctival autografting was not possible. We conducted the study of patients with primary progressive pterygium where autografting was not con- traindicated. The results of our study confirm the findings of Jap et al13 and reasonably assume that recurrence rates may be lower if the abnormal epithe

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OPHTHALMIC SURGERY AND LASERS • JULY/AUGUST 2002 • VOL 33,

lium at the head of pterygium is placed away from the limbus. Rotating the graft also plays a role in preventing pterygium recurrence. A recurrence rate of 5.88% in conjunctival rotation autografting is comparable to 5.55% in the conjunctival autografting group and other studies reported in literature.9,18'19,37 Moreover, no serious complication occurred in either group. The success of conjunctival rotation autograft also questions the validity of the theory that pterygia arise as a result of limbal cell deficiency.38 It might be possible that conjunctival rotation autograft, conjunctival autograft, or limbal autograft prevent recurrence of pterygium by an alternative mode of action. One important finding that we noted was all the recurrences were seen in patients below 30 years of age. We think that the greater risk of pterygium recurrence in younger patients is an under-reported finding in the literature. The exact reason for higher recurrence in younger patients is not exactly known, but may relate to more aggressive tissue growth in younger patients. The conjunctival rotation autograft is a safe, simple, and effective procedure. Conjunctival rotation autograft uses the principle of restoration of barrier function of limbus by placement of normal conjunctiva and suppresses the regrowth of subconjunctival tissue. The advantage of this procedure over the conjunctival autograft is no donor tissue from superotemporal quadrant or other eye is required. It can be attempted in all those circumstances where conjunctival autografting is contraindicated or not feasible. It requires less time as compared to autograft; the approximate time required for auto and rotational grafting was 1 hour and 40 minutes, respectively. Moreover, no serious complications have been reported and the recurrence rate is lower. We conclude that conjunctival rotation autograft and conjunctival autograft appear to be equally effective in reducing the recurrence after pterygium surgery. Conjunctival rotation autograft can be tried as an alternative attractive procedure for pterygium surgery to reduce the recurrence. However, a larger, prospective, double-masked study with more patients and a longer follow up will eventually demonstrate the superiority of one procedure over the other.

9. Kenyon KR, Wagoner MD, Hetlinger ME. Conjunctival autograft transplantation for advanced and recurrent pterygium. Ophthalmology. 1985;92: 1461-1470. 10. Hirst LW, Sebban A, Chant D. Pterygium recurrence time. Ophthalmology. 1994;101:755-758. 11. Jaros PA, DeLuise VP. Pingiculae and pterygia. Sum OphthalmoL 1988;33:41-49. 12. Sharma A, Gupta A, Ram J, Gupta A. Low dose intraoperative mitomycin-C versus conjunctival autograft in primary pterygium surgery: long-term follow up. Ophthalmic Surg Lasers. 2000;31:301-307. 13. Jap A, Chan C, Lim L, Donald TH. Conjunctival rotation autograft for pterygium: an alternative to conjunctival autografting. Ophthalmology 1999; 106:6771. 14. Shaw EL. A modified technique for conjunctival transplant. CLAOJ. 1992;18:112-116. 15. Stark T, Kenyon KR, Serrano F. Conjunctival autograft for primary and recurrent pterygia: surgical technique and problem management. Cornea. 1991; 10(3): 196202. 16. Vrabec MP, Weisenthal RW, Elsing HS. Subconjunctival fibrosis after conjunctival autograft. Cornea. 1993;12(2):181-183. 17. Manning CA, Kloess PM, Diaz MD, Yee RW. Intraoperative mitomycin in primary pterygium excision. A prospective, randomized trial. Ophthalmology. 1997;104:844-848. 18. Lewallen S. A randomized trial of conjunctival auto-

REFERENCES 1. Adamis AP, Starck T, Kenyon KR. The management of pterygium. Ophthalmol Clin North Am. 1990;3:6ll. 2. Moran DJ, Hollows FC. Pterygium and ultraviolet radiation: a positive correlation. Br J OphthalmoL 1984;68:343-346. 3. Rosenthal JW. Chronology of pterygium therapy. Am J OphthalmoL 1953;36:1601. 4. Sebban A, Hirst LW, Kynaston B, Bain C. Pterygium recurrence rate at the Princess Alexandra Hospital. Aust NZ J OphthalmoL 1991;19:203-206. 5. Mackenzie FD, Hist LW, Kynaston B, Bain C. Recurrence rate and complications after beta-irradiation for pterygia. Ophthalmology. 1991;98:1776-1781. 6. Joelson GA, Muller P. Incidence of pterygium recurrence in patients treated with thiotepa. Am ] OphthalmoL CoNjUNcnvAL ROTATION AUTOGRAFT vs CONJUNCTIVAL AUTOGRAFT - Dadeya et al 1976;81:891-892. 7. Singh G, Wilson MR, Foster CS. Long-term follow-up study of mitomycin eye drops as adjunctive treatment of pterygia and its comparison with conjunctival autograft transplantation. Cornea. 1990;9:331-334. 8. Frucht-Pery J, Ilsar M, Home I. Single dose of mitomycin C for prevention of recurrent pterygium: preliminary report. Cornea. 1994;13:411-413.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

273

19.

20.

21.

22.

23.

24.

25.

26. 27.

grafting for pterygium in the tropics. Ophthalmology. 1989;96:1612-1614. Chen PP, Ariyasu RG, Kaza V. A randomized trial comparing mitomycin C and conjunctival autograft after excision of primary pterygium. Am J Ophthalmol. 1995;120:151-160. Simona F, Tabatabay CA, Leuenberger PM. Preliminary results of the pterygium, excision technique with conjunctival autograft. Klin Monatsbl Augenheilkd. 1990;196:295-297. Mastropasqua L, Carpineto P, Ciancaglini M, Gallenga PE. Long-term results of intra-operative mitomycin C in the treatment of recurrent pterygium. Br J Ophthalmol 1996;80:288-291. Lam DSC, Wong AKK, Fan DSP, Chew S, Kwok PSK, Tso MOM. Intra-operative mitomycin-C to prevent the recurrence of pterygium after excision. Ophthalmology. 1998;105:901-905. Panda A, Das GK, Tuli SW, Kumar A Randomized trial of intra-operative mitomycin C in surgery for pterygium. Am J OphthalmoL 1998;125:59-63. Parra JC, Diaz-Llopis M, Maldonado MJ. Prospective trial of intra-operative mitomycin C in the treatment of primary pterygium. Br J OphthalmoL 1995;79:439- 441. Dougherty PJ, Hardten DR, Lindstrom RL. Corneoscleral melt after pterygium surgery using single intraoperative application of mitomycin C. Cornea. 1996; 15(5):537-540. D'Ombrain A. The surgical treatment of pterygium. Br ] OphthalmoL 1948;32:65. Haik GM, Ellis GS, Nowell JF. The management of pterygia with special reference to surgery combined

274

with beta irradiation. Trans Am Acad Ophthalmol Otolaryngol 1962;66:776-784. 28. Mahar PS, Nwokara GE. Role of mitomycin C in pterygium surgery. Br J OphthalmoL 1993;77:433-435. 29. Rubinfeld RS, Pfister RR, Stein RM. Serious complications of topical mitomycin C after pterygium surgery. Ophthalmology. 1992;99(11):1647-1654. 30. Guler M, Sabci G, Ilker S, Ozturk F, Mutlu FM, Yildirim E. Limbal-conjunctival autograft transplantation in cases with recurrent pterygium. Acta Ophthalmol (Cophen). 1994;72:721-726. 31. Hara T, Shoji E, Hara Takako, Obara Y. Pterygium surgery using the principle of contact inhibition and a limbal transplanted pedicle conjunctival strip. Ophthalmic Surg. 1994;25:95-98. 32. Desmarres LA Traite theorique at partique des maladies des yeux. Paris G Baillere. 1855;(March):1935. 33. Knapp H: A new plastic conjunctival operation. Arch F OphthalmoL 1868;14:267. 34. McReynolds JO: The nature and treatment of pterygium. JAMA 1902;39:296. 35- Spaeth E. Rotated island graft operation for pterygium. Am J OphthalmoL 1926;9:649-655. 36. Blott N. Rotation of pterygium as a method of operative for pterygium. Ztsch FAugenh. 1931;76:161. 37. Tan DT, Chee SP, Dear BGO, Lim AS. Effect of pterygium morphology on pterygium recurrence in a controlled trial comparing conjunctival autografting with bare sclera. Excision. Arch OphthalmoL 1997; 115: 1235-1240. 38. Tseng SCG. Concept and application of limbal stem cells. Eye,. 1989;3:141-157.

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