Management Of Primary Pterygium Research Articles

Conjunctival and Limbal Conjunctival Autograft vs. Amniotic Membrane Graft in Primary Pterygium Surgery: A 30-Year Comprehensive Review.

The purpose of this study is to compare the "real-life" effectiveness of amniotic membrane graft (AMG) and conjunctival (CAT) or limbal conjunctival (LCA) autograft in the management of primary pterygium. Human-based studies on primary pterygium surgery that were published between 1993 and 2022 with at least 3months of follow-up were identified, and only those that were retrospective were included. The global recurrence rate of pterygium was assessed for each surgical technique separately. Specific recurrence rates taking into consideration the fixation technique (glue versus sutures) were also measured. 35 real-life retrospective subgroups comprising a total of 3747 eyes were included in the final review. The mean global recurrence rates for CAT, LCA and AMG were 7.61%, 5.50% and 9.0%, respectively. Recurrences were less common for patients who received fibrin glue (5.92%, 2.56% and 3.60%) than for those who received sutures (8.99%, 6.03% and 23.0%) for the three groups, respectively. Surgical techniques combining CAT or LCA with AMG yielded an even lower global recurrence rate (1.83%). AMG seems like a reasonable option that could be considered in primary pterygium surgery, especially when glued to the underlying sclera. Combining AMG with other treatment modalities such as CAT or LCA seems to offer an interesting alternative in terms of recurrence.

Study of visual outcome and complications following conjunctival autograft transplant in management of primary pterygium

Introduction: Pterygium is a common degenerative disease of the anterior segment of the eye characterized by a wedge-shaped fibrovascular dysplasia of the bulbar conjunctiva with a prevalence of 12%. Exact etiology is unknown; risk factors include, long term exposure of ultraviolet B rays, dust, wind, chemicals and air pollution. To minimize recurrence after the traditional bare sclera surgical technique, adjuvant therapies and modifications to the surgical technique are being adopted. Geographically, Vijayapura is located close to the equator with inherent risk of higher ultraviolet radiation exposures. Of late there is an upsurge in the number of patients with diagnosed with pterygium opting for surgical correction. Conjunctival autograft transplant is promising modification of bare sclera technique is associated with significant reduction in pterygium-induced astigmatism thereby improved visual acuity, decreased postoperative complications and decreased recurrence rates. Objective: To evaluate the visual outcome and complications following conjunctival autograft transplant in management of primary pterygium. Methods: The present study was conducted in the department of Ophthalmology, B.L.D.E. deemed to be university Shri B.M. Patil Medical College, Hospital and Research Centre, Vijayapura between October 2019 to April 2021. A total of 52 patients above 18 years with a diagnosis of primary pterygium were included in the study. Age, gender, occupation, side and severity of pterygium was recorded. Preoperative visual acuity and corresponding decimal pin whole equivalent was calculated for each patient. Upon surgery with conjunctival autograft under local anaesthesia, postoperatively, visual acuity, corresponding decimal pin hole equivalent and complications were evaluated at day 1, day 7 and day 30. Comparison of pre and postoperative data was done using appropriate statistical tests. Results: Mean age of patients was 54.38±10.70 years and 69.3% belonged to the age group of 50-70 years. Slight female predominance was noted with female to male ratio of 1.17:1. Most of the patients were farmers (48.5%) followed by housewives (23.1%). All patients had nasal pterygium prominently on the left side than right (61.5% vs 38.5%). 76.9% patients had grade 2 pterygia. Preoperatively, most patients had a visual acuity of 6/24 (25%), followed by 6/36 (19.2%) and 6/60 (17.3%). The mean decimal equivalent value was 0.35±0.21. Compared to preoperative visual acuity, significant improvement was seen at postoperative day 1 (p=0.000), postoperative day 7 (p=0.001) and at postoperative day 30 (p=0.001). Similarly significant increase in the decimal equivalent postoperatively (0.001) than preoperative values. Factors including age, gender, occupation, side and severity had significant association on the visual outcome based on visual acuity at all follow ups. Most common postoperative complication at day1 was subconjunctival haemorrhage (36%) is the common one followed by graft edema (36%) and graft retraction (13.5%). Resolution of complications was seen by day 30.Conclusion: Conjunctival autograft is a feasible and safe option in patients with primary pterygium with severe grading.

Surgical Preferences in the Management of Primary Pterygium among Anterior Segment Specialists

Purpose: The purpose of this study is to reflect anterior segment specialists’ current practice pattern regarding the management of primary pterygium. Methods: A 24-item survey regarding indications for surgery, different surgical techniques, use of adjuvant pharmacological therapy, type of intraoperative and postoperative pharmacological therapy, and the preferred treatment of early recurrences was sent to members of the Saudi Ophthalmological Society (SOS) and practicing cornea experts including consultants, specialists, and fellows in Saudi Arabia. Results: A total of 61 cornea specialists completed the questionnaire (response rate 49%). More than 95% considered the proximity of the pterygium to the visual axis an indication for excision. The most frequent technique for pterygium excision was extensive head and conjunctival resection, including the base (69%) and intermediate resection of the Tenon's capsule (53%). For conjunctival replacement, conjunctival autograft was preferred by 79%, amniotic membrane (54%), and simple conjunctival closure (46%). Interrupted vicryl sutures, fibrin glue, and combined sutures and tissue adhesive were the preferred graft fixation conveyed by 85%, 46%, and 34% of our experts, respectively. An estimated recurrence rate of 1-5% was stated by 29% of respondents and 46% reported recurrence within 6 to 12 months. Half of the respondents specified using mitomycin C intraoperatively to prevent early pterygium recurrences. When recurrence occurred, corticosteroid was the agent of choice. Conclusion: This study set out to reflect the practice pattern of anterior segment specialists regarding the management of primary pterygium, and it may serve as an insight for further studies to define the optimal management of pterygium.

The efficacy of intralesional injection of bevacizumab (Avastin) in the management of primary pterygium

Background Pterygium is a triangular encroachment of the conjunctiva onto the cornea. Objectives This study aimed to assess the role of anti-vascular endothelial growth factor (Avastin) in the management of primary pterygium. Patients and methods This was an interventional study. This study was carried out at the Ophthalmology Department of AL-Zahraa University Hospital. The study period was from October 2019 to September 2020. Thirty eyes from 30 patients with primary pterygia were included in this study. Results There was a difference in visual acuity between preinjection of Avastin and 3 months postinjection by mean −0.10±0.10; 16 patients showed an improvement (53.3%), while 14 patients were stable (46.7%). There is a difference in astigmatism between preinjection of Avastin and 3 months postinjection by mean (−0.15±0.33); 10 patients showed an improvement (33.3%), while 20 patients did not show an improvement (66.7%). No increase in astigmatism occurred in any patient postinjection. There was a highly significant decrease in color intensity starting from the 2nd week till the end of the 3rd month postinjection. There was no significant change in ocular tension postinjection. Conclusion Our results showed that Avastin injection is a viable option in arresting the progress of pterygium and improving the cosmetic appearance, with a slight decrease in pterygium dimensions, which in turn improved the degree of astigmatism produced by pterygium.

English

BACKGROUND Pterygium excision with conjunctival limbal autograft (CAU) is one of the most frequently used modalities in the treatment of pterygium. The graft has traditionally been harvested from the superior bulbar conjunctiva, but this may not be possible in all patients. The purpose of this study was to compare the intraoperative difficulties and early postoperative outcomes between superior and inferior CAU in the management of primary pterygium. METHODS This hospital based cross sectional study evaluated 58 eyes of 50 patients with primary pterygium who underwent pterygium excision with conjunctival limbal autograft secured with the help of sutures over a period of 2 years from March 2018 to March 2020. In 28 eyes, the superior bulbar conjunctiva was used for grafting whereas in 30 eyes, the inferior conjunctiva was used for the same. The outcome measured was in terms of the mean surgical time, clinical symptoms and signs in the early postoperative period and recurrence rate. RESULTS The mean age of the patients was 44.14 ± 12.71 years in the superior CAU group and 45.76 ± 14.51 years in the inferior CAU group. There was no statistically significant difference between the two groups in terms of the mean surgical time (68.39 ± 31.51 in superior group, 2.60 ± 0.79 in inferior group; P value 0.712). The duration of follow-up after surgery was significantly more (P = 0.048) in the inferior CAU group (42.60 ± 11.71 days) as compared to the superior CAU group (37.39 ± 7.52 days). Postoperative symptoms were comparable, and no recurrence was observed in either of the two groups. CONCLUSIONS Pterygium excision with inferior conjunctival limbal autograft is safe and effective in the management of primary pterygia and may be considered as an alternative to superior graft in cases where harvesting the superior conjunctiva is not possible or not advisable. KEYWORDS Primary Pterygium, Conjunctival Limbal Autograft, Inferior Graft

Practice Patterns in the Management of Primary Pterygium: A Survey Study.

To characterize cornea specialists' current practice preferences in the management of primary pterygium. A 25-item survey regarding indications for surgery, surgical technique, use of adjuvant therapy, type and duration of postoperative therapy, and treatment of early recurrences was designed and sent to members of the Cornea Society through the kera-net listserv. In total, 199 cornea specialists completed the questionnaire. More than 90% considered that surgery should be performed when there is proximity of the pterygium to the visual axis, pain or redness, eye movement restriction, or induction of astigmatism. Cosmesis was considered as an indication by 41.7% of the participants. The most frequent technique for pterygium excision was complete resection including the base and a moderate quantity of Tenon capsule followed by autologous conjunctival or limbal-conjunctival graft. The preferred graft fixation method in this survey was fibrin glue (61.2%). Most respondents reported a recurrence rate of less than 5% and no use of adjuvant agents to prevent recurrence. When early recurrence did occur, the preferred agents were corticosteroids. This study reflects the preferences of cornea experts regarding primary pterygium treatment and may serve as a guide for the management of this pathology.

Management of primary pterygium with intra-lesional injection of 5 flurouracil and bevacizumab (Avastin).

To assess the efficacy of combined 5FU and Avastin injections in the treatment of primary pterygium METHODS: Sixteen eyes with primary pterygium received intralesional 5 fluorouracil and Avastin (2.5-5 mg) injections every 2 weeks for a maximum of five injections. Fourteen eyes of 14 patients received five injections, one eye received three injections and one eye received two injections. All eyes were followed at monthly intervals for 3 months after last injection. Tissue was obtained by surgical excision of primary pterygium from four eyes who received injections and three eyes with primary pterygium who did not receive injections (control) and subjected to immunohistological examination for beta fibroblast growth factor (bFGF), vascular endothelial growth factor (VEGF), epidermal growth factor (EGF), von-Willebrand factor (vWF), lymphatic vessel endothelial hyaluronan receptor (LYVE-1) and collagen-I. Pterygium progression was arrested in all patients. Sixty-two percent of patients had improvement of redness while 89% had reduced thickness of the lesion. VEGF, bFGF, EGF, vWF, LYVE-1 and collagen-I were all reduced in the injected samples. The injection of 5 fluorouracil and Avastin act synergistically to arrest progression and induce atrophy in primary pterygium. This is related to the effect of agents on fibroblasts, collagen, and vascular tissues. Such medical intervention is a safe and viable option in the management of primary pterygium though excision of residual tissue is still required in some cases. Longer follow up is needed to ascertain whether this will reduce the recurrence rate following excision.

Primary nasal pterygium excision with sutureless and glue-free technique of conjunctival autograft

Aim: To evaluate the efficacy and complication of sutureless and glue-free conjunctival autograft for the management of primary pterygium over a period of one year.
 Methods: Prospective, interventional, hospital-based study. Twenty-four eyes of 24 patients with primary nasal pterygium were graded, and excision was performed by a single surgeon. To prevent recurrence, a free conjunctival autograft was taken from the superior quadrant from the same eye and the bare sclera was covered without the use of sutures or fibrin glue, allowing natural autologous coagulum of the recipient bed to act as a bioadhesive. The eye was patched for 24 hours. Postoperatively, patients were put on topical eye drops (polymixin 0.5%, neomycin 0.5%, and dexamethasone 1%) four times daily for four weeks, and oral antibiotics and methyl prednisolone 3x4 mg per day for 5 days. Patients were followed up postoperatively on day 1, 1 week, 6 weeks, 6 months, and 12 months. They were examined for haemorrhage, wound gape, graft shrinkage, granuloma, graft dehiscence, recurrence, or any other complication.
 Results: The mean age of the patients was 56.96 ± 11.51 years (range 35-81 years). There were 18 females (75%) and 6 males (25%). The following complications were noted: granuloma in three eyes (12.5 %), overriding graft onto the cornea in three eyes (4.17%), and recurrence in one eye (4.17%). No other complications were noted. Average surgical time was 16 ± 2 minutes. 
 Conclusion: Sutureless and glue-free limbal conjunctival autografting is a treatment modality for primary nasal pterygium with no additional cost and has only one recurrence case in 24 cases.

Preoperative subconjunctival injection of mitomycin C versus conjunctival autografting with fibrin glue fixation in the management of primary pterygium

Aims: To measure the outcome of preoperative subconjunctival mitomycin C 1 month before bare sclera and conjunctival autografting using fibrin glue in terms of recurrence rate and complications. Settings and Design: This was a prospective, randomized, interventional, hospital-based comparative study. Materials and Methods: Sixty eyes of 58 consecutive patients with primary, progressive pterygium were randomly allocated into two equal Groups (A and B) of 30 each. In Group A, subconjunctival injection of mitomycin C (MMC) (0.1 ml of 0.1 mg/ml) 1 month before bare sclera technique and in Group B pterygium excision with conjunctival autografting using fibrin glue were performed. The study period was from December 2010 to October 2012, and patients were followed up for 18 months. The outcome measures were significant corneoscleral complications and recurrence. Results: The mean age of patients in the study was 38.6 ± 12.6 years with females slightly outnumbering males. Majority (58.6%) of patients were pursuing outdoor occupations. The mean follow-up period of MMC group was 10.2 ± 4.49 months, whereas that of conjunctival autograft with glue group was 10.8 ± 3.66 months. The average surgery time was more for conjunctival autografting with fibrin glue than subconjunctival mitomycin before bare sclera. One (3.33%) patient in the MMC group and 2 (6.67%) patients in the fibrin glue group had recurrence within the study period. Both the surgical techniques were not found to be associated with any serious vision-threatening complications. Conclusions: Subconjunctival MMC 1 month before bare sclera is simple, safe, economical, less time-consuming, technically less demanding, and as effective as conjunctival autografting with fibrin glue fixation.

Role of Anti VEGF Agent in Management of Primary Pterygium

Role of Anti VEGF Agent in Management of Primary Pterygium

A comparative evaluation of conjunctival autograft and intra- operative mitomycin-C in the management of primary pterygium- our experience

Background: Surgery is the treatment of choice in the management of primary pterygium. Recurrence following excision is frustrating to both the surgeons and patients alike. India being a tropical country is an ideal home for pterygium.Methods: This study was carried out in a tertiary care hospital. A comparative prospective study was performed in 80 patients presenting with primary pterygium who fulfill inclusion and exclusion criteria were taken for the study for the period from January 2011 to December 2012. They were randomised in two equal groups to undergo primary pterygium surgery with conjunctival autograft and excision of primary pterygium followed by intraoperative use of Mitomycin-C for 3 minutes to study the effectiveness of adjuncts i.e. mitomycin -C and conjunctival autograft in preventing recurrence of pterygium after excision and complications following the procedure. Follow up visits were scheduled for the postoperative days 1, 7, 30 days and 3 and 6 months. mean follow up was for 9 months.Results: No significant intra operative complications were noted except for 2 cases of button holing of the conjunctival graft. Recurrence was noted in 1 case after conjunctival autograft and 1 case in mitomycin C group.Conclusions: The adjuncts in primary pterygium surgery as conjunctival autograft and pterygium excision with mitomycin-C significantly reduces the recurrence rates than bare sclera excision alone.

Superior versus Inferior Conjunctival Autograft Using Fibrin Glue in Management of Primary Pterygium: Clinical and Histopathological Results

Purpose: To evaluate the differences between superior and inferior conjunctival autografts with fibrin glue in management of primary pterygium as regard surgical difficulties, duration, recurrence, complications and stem cell density. Patients and methods: In a prospective one stage randomized controlled study, 36 patients with primary pterygium were included in the study and assigned into 2 groups. Group A received superior and group B received inferior conjunctival auto graft each group comprised 18 patients. All eyes were followed up at day 1 and 3 and at first week, first month, 3 month and finally 6 month post-operatively. All the intraoperative and postoperative data were analyzed. Results: 36 patients with pterygium were included in this study and 17 patients were males and 19 were females with average follow up period of 7.5 ± 0.6 months. Mean age was 52.5 ± 5.9 years and 46.2 ± 11.7 years respectively,the mean size of pterygium was 12.1 ± 3.4 mm2 11.3 ± 2.1 mm2 respectively . Mean size of the autograft was 26.9 ± 6.7 mm2, and 27 ± 5.6 mm2 respectively. The mean surgical time was 17.8 ± 2.0 minutes and 17.5 ± 2.4 minutes respectively. Mean follow up period was 7.4 ± 0.6 months and 7.6 ± 0.7 months respectively. There was one recurrent case in each group. No difference in stem cell density between 2 groups. Conclusions: Inferior autograft with fibrin glue has the same advantages as superior one as regard rate of recurrence and surgical time but superior to it as regard patient discomfort and saving superior conjunctiva sparing it for future glaucoma surgery if needed.

Sutureless and Glue-free Versus Sutures for Limbal Conjunctival Autografting in Primary Pterygium Surgery: A Prospective Comparative Study.

Sutureless and glue-free conjunctival autograft as a treatment modality for primary pterygium is recently gaining popularity but conventional technique of suturing conjunctival autograft is still practised widely. To compare the outcome of sutureless and glue-free technique with sutures for limbal conjunctival autografting in management of primary pterygium. A prospective interventional study was carried out in 50 consecutive eyes with primary nasal pterygium requiring surgical excision. Simple excision under local anaesthesia was performed followed by closure of the bare sclera by sutureless and glue-free conjunctival autograft in 25 eyes of 25 patients (group 1) and by the conventional method of suturing conjunctival autograft using interrupted 10-0 nylon sutures in 25 eyes of 25 patients (group 2), followed by bandaging for 24 hours in both the groups. Surgical time was recorded for both the techniques. Postoperative discomfort was assessed using preformed questionnaires. The patients were followed up for 6 months. During follow up, graft related complications and recurrence if any were noted. Mean surgical time for group 1 (23.20±1.55 minutes) was significantly less as compared to group 2 (37.76±1.89 minutes); (p=0.001). Postoperative symptoms were seen in less number of patients (20%) and were of shorter duration (2 weeks) in group 1 as compared to group 2 with 20 (80%) patients having symptoms lasting for 4 weeks; (p<0.001). Recurrence rate and conjunctival granuloma formation rate for group 1 (0%) and for group 2 (4%) were statistically insignificant. Sutureless and glue-free conjunctival autograft technique is simple, easy, safe, effective and less time consuming than sutured limbal autograft technique with less postoperative discomfort and adverse events encountered with the use of suture material. Postoperative results of both techniques are comparable. Hence sutureless and glue-free conjunctival autografting is a good technique for the treatment of primary pterygium.

Efficacy of Intralesional Bevacizumab Administration in Primary Pterygium

To analyze the regression of the pterygium tissue quantitatively after intralesional bevacizumab administration in patients with primary pterygium. Thirty-three eyes of 33 patients with primary pterygium who underwent intralesional bevacizumab (1.25 mg per 0.05 mL) administration were included in this prospective study. The ocular irritation, best-corrected visual acuity (BCVA), slit-lamp and funduscopic examinations, corneal astigmatism, the horizontal length, and the thickness of the pterygium were assessed before and after 2 months of treatment. To evaluate the corneal astigmatism and the thickness of the pterygium, the Pentacam comprehensive eye scanner (Pentacam CES; Oculus GmbH) was used. After 2 months of bevacizumab administration, the average BCVA was improved (P=0.003). The average ocular irritation score, horizontal length, and the thickness of the pterygium were statistically significantly decreased (P<0.001, P<0.001, P<0.001, respectively). After 2 months of intralesional bevacizumab administration, the average amount of decrease in the horizontal length and thickness of the pterygium was 0.6 mm and 37 μm, respectively. Intralesional bevacizumab administration is useful in the management of primary pterygium without having any local or systemic adverse effects; however, repeated administrations are needed to provide clinically more significant results.

Amniotic Membrane Transplantation in the Treatment of Primary Pterygium: A Comparative Study of Two Techniques

ABSTRACT Purpose To compare two techniques of human amniotic membrane transplantation (AMT) following pterygium excision: (1) end to end suturing of the amniotic membrane graft (AMG) with the conjunctiva versus (2) a new technique of purse-string suturing of the AMG and tucking of AMG under the free edge of conjunctiva. Materials and methods Pterygium surgery with human AMT was done in 42 eyes with primary pterygium. Twenty four eyes (group A) underwent end-to-end suturing of AMG with conjunctiva. Eighteen eyes (group B) underwent purse-string suturing of AMG with underlying sclera with free edge of AMG tucked under conjunctiva on three sides. The two groups were compared in terms of the outcome measures, i.e. complete epithelialization time of AMG and recurrence of pterygium within 1 year. Results The complete epithelialization of AMG occurred in 21 days (range 14 to 28 days) and 14 days (range 7 to 21 days) in groups A and B respectively. In group A, 7 eyes (29.17%) developed recurrence. In group B, 2 eyes (11.11%) developed recurrence. Conclusion Purse string suturing and tucking of AMG resulted in faster epithelization of AMG and lower recurrences in comparison with end to end suturing of AMG in the management of primary pterygium. How to cite this article Bansal R, Jain AK, Sehgal R. Amniotic Membrane Transplantation in the Treatment of Primary Pterygium: A Comparative Study of Two Techniques. J Postgrad Med Edu Res 2014;48(1):1-7.