Superior Conjunctiva Research Articles

MANAGEMENT OF CONJUNCTIVAL MELANOMA ARISING FROM PRIMARY ACQUIRED MELANOMA (PAM) : A CASE REPORT

Introduction : Conjunctival melanoma (CMM) is a rare but potentially a life threatening ocular malignancy. It is an aggressive pigmented tumor and the recurrence rate may be as high as 51% over 10 years.1,2 Surgical wide local excision of the tumour and cryotherapy are current standard treatment of CMM.3,4 The purpose of this case is to report our successful management of conjunctival melanoma using wide excision and cryotherapy.
 Case Illustration : A 67-year-old man who presented to our hospital with a large, pigmented lesion arising from inferior and superior fornix conjunctiva in his left eye since 6 months ago. On examination, a massive pigmented tumor sized 25 x 10 x 15 mm, protruding from inferior fornix conjunctiva and sized 7 x 5x 3 mm arising from superior fornix conjunctiva of left eye. The mass was excised with 3 mm free margin from the tumour border confirmed with negative frozen section and followed by cryotherapy and conjunctival reconstruction using oral mucous graft. Histopathology confirmed with invasive conjunctival melanoma arising in PAM with severe atypia and no lymphovascular and perineural metastasis
 Discussion : Two months after we performed wide excision, cryotherapy and oral mucous graft, no recurrence and conjunctival necrosis at primary site were reported.
 Conclusion : A local wide excision with ‘no touch technique’, cryotherapy and oral mucous graft confirmed with negative frozen section are the mainstay treatment of CMM and has achieved satisfying functional outcomes. Since the high recurrence rate of CMM, we have to close follow up for the next 3 years

COMBINED PAPILLECTOMY AND AUTOLOGOUS CONJUNCTIVAL MEMBRANE GRAFT AS MANAGEMENT FOR SEVERE, REFRACTORY PALPEBRAL VERNAL KERATOCONJUNCTIVITIS: A CASE REPORT

Introduction : Vernal keratoconjunctivitis (VKC) is a type of allergic conjunctivitis which often occurs repeatedly and chronically. It is unusual compared to other types of conjunctivitis due to its giant papillae (GP) manifestation that may cause serious complication on cornea and eventually lead to permanent vision loss. We present a surgical treatment—resection of GP—in conjunction with autologous conjunctival membrane graft to manage a severe case of VKC.
 Case Illustration : An 18-year-old male came with a prior history of recurrent acute allergic keratoconjunctivitis since seven years before. His GP had caused shield-like ulcer, which leads to corneal scar and interferes with his visual acuity. He also had mechanical ptosis due to the giant cobblestones. His symptoms were then managed by performing combined papillectomy and autologous conjunctival membrane graft.
 Discussion : During surgery, the GP on both of his eyes were excised until tarsus was visible. Autologous conjunctival membrane was grafted from superior quadrant of each eye, and sutured tightly onto the excised tarsus. Six month postoperatively, his superior tarsal conjunctiva remain relatively smooth, with well-controlled symptoms of keratoconjunctivitis.
 Conclusion : Combined papillectomy and autologous conjunctival membrane graft can be considered as an adjunctive intervention to medications, in patients with severe, refractory cases of palpebral vernal conjunctivitis. It can alleviate symptoms and reduce the possibility of permanent damage on corneal tissue.

Correlative microscopy (CLEM) of tarsal conjunctival scraping: A new opportunity in the diagnosis of microbial keratitis

Aims/Purpose: To evaluate the efficacy of correlated Scanning Electron Microscopy (SEM)/Optical Microscopy (OM) analysis of conjunctival scrapings in diagnosing infectious keratitis with prior negative culture tests or ineffective broad‐spectrum antibiotic therapy.Methods: 102 eyes of 87 patients (45M, 42F) affected by keratitis were evaluated by cytological examination of scrapings of the superior tarsal conjunctiva in OM (Nikon Eclipse 50i) and SEM (JEOL), after 72 h of wash‐out. Inclusion criteria: age > 18 years, corneal epithelial defects from suspected infection, ineffectiveness of previous broad‐spectrum antimicrobial therapy or negative conjunctival swab. Exclusion criteria: ocular surgery <3 months, immunosuppression, allergic keratitis, severe dry eye, ocular herpes, ulcer >3 mm, anterior chamber involvement. Identification of inflammatory infiltrate (OM) and microorganisms (SEM) was performed by two independent operators with the same devices and methodology. Weekly clinical control with new conjunctival scraping for OM and SEM after cycles of therapy were carried out.Results: Pathogenic microorganisms were detected in 94/102 eyes: Acanthamoeba (22), Candida (18), Mycoplasma (15), Mycobacteria (13), Chlamydia (12), Micrococci (11), Pseudomonas (6), Cocci (6), Aspergillus (5), Fusarium (2); in 14 cases 2 or more different forms coexisted; in 2 cases a subsequent PCR test revealed the presence of HSV‐1; 3 cases showed signs of severe dry eye; other 3 marked eosinophilia. Operator agreement: 99%. The specific treatment for the germs detected determined in all cases clinical and microbiological resolution in 14–49 days (mean 27.6 ± 2.4).Conclusions: CLEM put in evidence the correlation between phlogistic cells and pathogens, allowing the diagnosis and the treatment of different forms of infectious keratitis and other pathological conditions. The interpretation and repeatability, however, require appropriate training and dedicated equipment.

Third surgery of Ahmed valve tube exposure: A case report

Aims/Purpose: Exposure of the glaucoma drainage devices tube is one of the main postsurgical complications, and it is important not to delay treatment in order to avoid serious situations such as endophthalmitis. Our aim is to report a case of a patient with an Ahmed valve tube exposure who had undergone two previous surgeries unsuccessfully.Methods: We present the case of a 71‐year‐old male patient with diabetic retinopathy with an Ahmed valve in his left eye for 4 years due to neovascular glaucoma. In the first surgery the tube was positioned in the posterior chamber. After two months, displacement of the tube was observed so it was repositioned in anterior chamber with apposition of Ologen® on temporal, superior sclera. Three years later, exposure of the valve tube was seen and it was covered with Tutopatch® and conjunctiva. Recently, on examination, exposure of the valve tube was observed once again. We removed the epithelial cells from the scleral bed with absolute alcohol, after that we revitalized the conjunctival borders of the wound and covered the tube with fascia lata. Finally, we sutured the conjunctiva without tension.Results: At the moment, the tube remains covered and the superior temporal conjunctiva has a good appearance.Conclusions: Different repair techniques are described in the bibliography, such as conjunctiva covering, grafting of different materials, repositioning of the tube with grafting, valve removal and implantation in a different quadrant and even definitive removal of the valve. In our case we used a fascia lata graft, which is associated with a lower risk of subsequent exposure. The previous preparation of the scleral bed and the edges of the conjunctiva, as well as a conjunctival suture free of tension and traction are key to obtaining a good result.

Accuracy, acceptability and feasibility of photography for use in trachoma surveys: a mixed methods study in Tanzania.

Photography could be used to train individuals to diagnose trachomatous inflammation-follicular (TF) as trachoma prevalence decreases and to ensure accurate field TF grading in trachoma prevalence surveys. We compared photograph and field TF grading and determined the acceptability and feasibility of eyelid photography to community members and trachoma survey trainers. A total of 100 children ages 1-9y were examined for TF in two Maasai villages in Tanzania. Two images of the right everted superior tarsal conjunctiva of each child were taken with a smartphone and a digital single-lens reflex (DSLR) camera. Two graders independently graded all photos. Focus group discussions (FGDs) were conducted with community members and Tropical Data trainers. Of 391 photos, one-fifth were discarded as ungradable. Compared with field grading, photo grading consistently underdiagnosed TF. Compared with field grading, DSLR photo grading resulted in a higher prevalence and sensitivity than smartphone photo grading. FGDs indicated that communities and trainers found photography acceptable and preferred smartphones to DSLR in terms of practicalities, but image quality was of paramount importance for trainers. Photography is acceptable and feasible, but further work is needed to ensure high-quality images that enable accurate and consistent grading before being routinely implemented in trachoma surveys.

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

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

Utility of Scanning Electron Microscopy (SEM) for Suspected Microbial Keratoconjunctivitis Unresponsive to Broad-Spectrum Antibiotic Therapy

The aim of this work is to evaluate the sensitivity and efficacy of a diagnostic approach based on scrapings of the superior tarsal conjunctiva examined by scanning electron microscopy (SEM). We examined 30 eyes of 26 consecutive patients with presumed microbial keratitis, who had no improvement after local broad-spectrum antibiotic therapy performed for at least 7 days at an effective dosage. 13 patients had negative culture tests for bacteria and fungi obtained from corneal curettage. After 72 hours of wash-out, scrapings of the upper tarsal conjunctiva for cytological examination of cell morphology by scanning electron microscope (SEM) were performed. With this method, the presence of pathogenic microorganisms was detected in 26/30 eyes and specific therapy was carried out on the basis of these results. Clinical improvement and eradication of organisms previously detected by SEM were observed in all positive patients within 1-7 weeks. No organisms were detected in four patients; in two of them the presence of inflammatory cells indicative of an allergic reaction (eosinophils and mast cells) was detected, in the other two there were signs of severe dry eye. The efficacy of this diagnostic technique is confirmed by the clinical response to treatment based on the microorganisms identified by SEM and by the eradication of previously detected microorganisms, verified by subsequent scanning electron microscopic (SEM) control examination. The results obtained support the validity of the proposed method and we believe that it constitutes a very useful tool for distinguishing, on the basis of the inflammatory infiltrate, the infectious forms from those of other nature and for detecting the presence of microorganisms resistant to the usual therapies.

Surgical application of Ong speculum in simple limbal epithelial transplantation and pterygium surgery.

Ong speculum is used in glaucoma surgeries such as trabeculectomy to expose the superior part of the globe. The large inferior blade pushes the inferior conjunctival fornix, due to which the eyeball rotates downwards. It has not been used in other anterior segment surgeries before. We used this speculum in simple limbal epithelial transplantation (SLET) and pterygium surgery to expose superior bulbar conjunctiva for harvesting limbal and conjunctival grafts, respectively. As the superior conjunctiva and sclera become exposed, it facilitates the steps of harvesting limbal biopsy and conjunctival graft in SLET and pterygium surgery. This eliminated the need for a superior rectus suture or an assistant who would keep the globe rotated downwards. Its position could also be maneuvered to adjust the site of exposure when dissecting the area of pannus in SLET. Thus, it makes the superior conjunctiva more accessible.

Scanning Electron Microscopy of Conjunctival Scraping: Our Experience in the Diagnosis of Infectious Keratitis with Negative Culture Tests

65 consecutive patients with presumed microbial keratitis and negative culture tests for bacteria and fungi obtained by corneal curettage were evaluated. All patients had undergone local broad spectrum antibiotic therapy for at least 5 days with no clinical improvement. After 48–72 h of wash-out they underwent scraping of the superior tarsal conjunctiva for cytological examination of cellular morphology in Scanning Electron Microscopy (SEM). The presence of pathogenic microorganisms was detected with this method in 62 of these patients, towards which specific therapy was carried out. Clinical improvement and eradication of microorganisms previously detected by SEM examination were observed in all positive patients over a time between 10 and 49 days. In three patients, no microorganisms were detected, but the presence of inflammatory cells (eosinophils and mast cells) or dry eye findings. This method could be useful to detect the presence of non-isolated microorganisms at common culture tests. The resolution of the infectious keratitis and the eradication of the pathogens at the subsequent cytological examination of cellular morphology in Scanning Electron Microscopy support the validity of the proposed method.

Comparison of topical 0.03% tacrolimus and homologous injectable platelet-rich plasma in the treatment of keratoconjunctivitis sicca in dogs.

Keratoconjunctivitis sicca (KCS) is predominantly an immune-mediated chronic inflammatory ocular disease that is commonly diagnosed in dogs. This study aimed to compare the conventional use of topical immunosuppressant tacrolimus 0.03% eye drops and a new therapy injectable homologous platelet-rich plasma (HPRP) into the third eyelid gland and inferior and superior palpebral conjunctiva of dogs with KCS. A total of 66 eyes from 33 dogs were evaluated. The eyes were divided into three equal groups: Negative control group, tacrolimus group (TG), and homologous platelet-rich plasma group (HPRPG). The animals were evaluated using the Schirmer's tear test-1 (STT-1), osmolarity test (OT), strip meniscometry test (SMT), tear film break-up test (TBUT), fluorescein test, lissamine green test (LGT), and cytological and histopathological analyses. In TG, there was a significant increase (p < 0.05) in the STT-1 and SMT values, and goblet cell count in the palpebral conjunctiva by the end of the study. In HPRPG, 36% (four dogs) received three applications, 55% (six dogs) received two applications, and 9% (one dog) received one application before the initial ocular signs improved. There was a significant decrease (p < 0.05) in the lymphocyte and neutrophil counts of the palpebral conjunctiva in HPRPG than in TG. Both groups showed equivalent improvements in TBUT, OT, and LGT values. Tacrolimus 0.03% eye drops were more efficient than HPRP in increasing tear production and the number of goblet cells. However, injectable HPRP was more efficient than tacrolimus in decreasing the number of conjunctival inflammatory cells. Treatment with injectable HPRP requires an average of two to three applications, is safe and feasible, and can be used as a cheaper alternative or as an adjuvant to conventional treatment with topical immunosuppressants.

A modified surgical technique of fibrin glue-assisted double bipedicle conjunctival flaps for patients with ocular surface diseases.

This study aimed to describe and investigate the surgical outcome and complications of fibrin glue-assisted double bipedicle conjunctival flaps (CFs) (FADCOF), an alternative surgical technique that restores a stable ocular surface in patients with painful blinding ocular surface disease combined with a shortage of bulbar conjunctiva. Six eyes of six patients with painful blinding ocular surface disease were enrolled in this study. All patients had inadequate superior or inferior conjunctiva tissue to cover the whole corneal surface owing to previous surgeries or ocular surface diseases. These patients received FADCOF between 2009 and 2019. The main outcome included surgical success rate, visual analog scale (VAS) pain score, ocular inflammation score, and postoperative complications. Surgical success was defined as resolution of initial ocular complaints and restoration of a stable ocular surface with no flap melting, retraction, or dehiscence resulting in re-exposure of the corneal surface. All of the six eyes (100%) achieved surgical success. All patients reported significant improvement in subjective symptoms and complete resolution of ocular pain after the surgery (VAS pain score: 6.5 ± 0.5 preoperatively to 0.0 ± 0.0 at 1 month). Ocular inflammation score decreased significantly from a presurgical value of 1.83 ± 0.69 to 0.33 ± 0.47 1 month after the surgery. No postoperative complication was found during the long-term follow-up (range: 12-82 months). FADCOF is a reliable alternative for patients with painful blinding ocular surface diseases unsuitable for single total CF surgery. This surgical technique yields fast ocular surface stabilization, satisfactory recovery, and low complication rates.

Minocycline-induced Conjunctival Hyperpigmentation.

A 73-year-old woman presented with a 1-year history of pigmented conjunctival lesions in both eyes. She had been taking minocycline for decades for recurrent facial cysts. On examination, she had a larger pigmented cystic lesion of her right inferior fornix conjunctiva, and several smaller hyperpigmented lesions in her right inferior, left superior, and left inferior palpebral conjunctivae (Panel A; external photograph). She underwent an excisional biopsy of the large cyst. Pathology showed exogenous brownish-gray pigment granules (circle) deposited in macrophages surrounding vessels in the substantia propia (Panel B; hematoxylin & eosin-stained image at 40× magnification). The pigment granules were stained black (arrow) with Fontana-Masson stain (Panel C; image at 40×). There was no evidence of an atypical melanocytic proliferation. A diagnosis of minocycline-induced hyperpigmentation was made. Minocycline, a tetracycline antibiotic, can be used to treat dermatologic conditions. Extended use can lead to hyperpigmentation of the skin, nails, teeth, oral mucosa, sclera, and conjunctiva. There is a wide range of reported doses and duration of therapy associated with mucosal or cutaneous hyperpigmentation varying by type and site, occurring as early as days to weeks, with a median onset of 1–2 years. Cosmetic concerns should prompt discontinuation, although hyperpigmentation is likely permanent. These lesions were not visually significant nor bothersome, and therefore no additional treatment was recommended.

Conjunctival Extramedullary Plasmacytoma in Dogs and a Cat: Clinical Characteristics and Histopathological Findings.

Extramedullary plasmacytoma (EMP) is a plasma cell tumor that is very rarely reported in ocular and adnexal tissue and is usually solitary and benign. This study evaluated seven cases from different ophthalmology referrals submitted for histopathological analysis between 2013 and 2022. EMPs were diagnosed in a 9-year-old domestic short-haired cat and in six dogs (median age, 10 years): three English Cocker Spaniels, a Golden Retriever, a Maltese, and a Pinscher. EMPs affected the third eyelid conjunctiva in five cases (5/7), followed by the superior bulbar (1/7) and palpebral conjunctivae (1/7), respectively, and were presented mostly as well-defined, salmon-colored nodules. Histopathologically, the masses were composed of sheets and packets of round cells morphologically consistent with mature plasma cells with mild anisocytosis and anisokaryosis; mitosis and binucleated giant cells were rarely observed. Follow up for 6/7 cases ranged from 6 months to 2 years. No signs of recurrence or systemic involvement (multiple myeloma) were observed. EMP should be included in the differential diagnoses of canine and feline conjunctival masses. Staging recommendations should include multiple myeloma diagnostic evaluation. Our results suggest that primary conjunctival EMP does not appear to be locally aggressive and has low systemic involvement behavior. The local surgical excision alone or combined with cryotherapy should be curative.

Comparison of Trehalose/Hyaluronic Acid (HA) vs. 0.001% Hydrocortisone/HA Eyedrops on Signs and Inflammatory Markers in a Desiccating Model of Dry Eye Disease (DED).

Background: Dry eye disease (DED) is a multifactorial disease where ocular surface inflammation and damage play key etiological roles. Purpose: To compare a combination of 3% trehalose (T) and 0.15% hyaluronic acid (HA) (Thealoz duo®, T/HA) with a tear substitute containing 0.001% hydrocortisone (I) and 0.2% HA (Idroflog®, I/HA), with respect to changes on signs and inflammatory markers in a mouse DED model. Methods: Thirty 12-week-old C57BL/6 mice were exposed in a controlled-environment chamber as a desiccating stress model of DED for 35 days. At day 14 (T1), administration of 5 µL T or I in the right eye (RE) or NaCl 0.9% in the left eye (LE) started, twice a day. Animals were sacrificed after 7 (T2), 14 (T3), 21 (T4, endpoint) days from the beginning of treatment. Corneal fluorescein staining ratio (Image J), histological and histochemical assessment of ocular surface tissues (goblet cell GC density and characterization —PAS, Alcian blue pH 2.5, pH 1.0, and MUC4 expression—in the superior and inferior conjunctiva), and levels of inflammatory markers HLA-DR, IL-1β and TNF-α in cornea and conjunctiva were measured. Results: No animal fully recovered from DED signs at the endpoint. Difference between arms was observed at T3 and T4, with T treated eyes showing a higher corneal damage reduction, PAS-positive GC recovery, lower inflammatory marker expression as compared to the I treated ones. Conclusions: Data suggest that 21 days of treatment with T/HA improved signs, GC recovery and inflammatory markers in a DED mouse model, to a greater extent as compared to I/HA. Data suggest that 21 days of treatment with T/HA improved signs, GC recovery and inflammatory markers in a DED mouse model, to a greater extent as compared to I/HA.

Combined nasal goniotomy - temporal trabeculotomy (NGTT) for circumferential angle surgery in primary congenital glaucoma.

To assess the safety and efficacy of combining nasal goniotomy with temporal trabeculotomy in the management of primary congenital glaucoma. Case series. Fifteen eyes of eleven children (3-12 months old at presentation) were enrolled in this study after the establishment of PCG diagnosis based on the criteria placed by the World Glaucoma Association. Combined nasal goniotomy and temporal trabeculotomy were done on each eye in an attempt to perform almost 360 degrees circumferential angle surgery without disturbing the superior 180 degrees of conjunctiva to preserve it for future filtering glaucoma surgeries. By first month, average IOP was 10.5 ± 4.3 mmHg with a 65.3% reduction from average pre-operative IOP. Almost the same percentage of reduction was maintained at 3rd,6th and 12th months postoperative visits with average IOP of 11.9 ± 4.65, 11.8 ± 2.77 and 13 ± 2.82 mmHg (60.7%, 61.1% and 57.2% reduction from pre-operative average). According to success rates, complete success has been achieved in all eyes but one (93.3%), with minor complications in 4 out of 15 eyes (26.6%) that did not affect IOP outcome. Nine out of fifteen eyes completed 18 months post-operative follow-up visits with a successfully, maintained target average IOP of 13.3 ± 3.0 mmHg (57.2% reduction). All of the mean IOP readings during post-operative follow-up period were significantly lower when compared to pre-operative IOP (p < 0.0001). Only one eye had persistently elevated IOP of 26 mmHg at 1st and 3rd months post-operatively that necessitated a subsequent subscleral trabeculectomy which succeeded in controlling the pressure bringing it down to 15 mmHg on topical medications. Nasal goniotomy - temporal trabeculotomy (NGTT) is the combination of two well established surgeries that exploits the advantages of circumferential angle surgery while sparing the superior conjunctiva completely for future surgeries if needed. This new procedure was safe and effective in lowering IOP by an average of 60% from pre-operative IOP with a sustained effect till 18 months post-operatively. We believe that this surgery might be added to the armentarium of the surgical management of infantile glaucomas with other circumferential angle surgeries.

Inferior Removal of Dislocated Polymethyl Methacrylate Intraocular Lens and Scleral Refixation in Glaucomatous Eyes.

IntroductionThe aim of this study was to report a technique for the removal of dislocated polymethyl methacrylate (PMMA) intraocular lenses (IOLs) in glaucomatous eyes.MethodsDislocated PMMA IOLs were removed from the inferior sclerocorneal incision, and sutureless intrascleral fixation of each IOL was performed to preserve the intact superior conjunctiva and sclera for future trabeculectomy or to maintain a functional filtering bleb of trabeculectomy. ResultsIn two cases, the condition of the bleb did not change, while the intraocular pressure improved or did not change after the procedures. IOL fixation was stable with no complications, such as tilt, decentration, or extrication of the IOL haptics.ConclusionThis procedure of preserving the superior conjunctiva and sclera can maintain the function of the bleb, superior cornea and sclera and may contribute to the success of future trabeculectomy.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40123-022-00477-z.

Inferior Conjunctival Autograft Transplantation for Primary Pterygium

Objective: To evaluate postoperative recurrence rate and complications after inferior conjunctival autograft transplantation for primary pterygium. Materials and Methods: The present study was a retrospective Cohort study on 45 eyes in 45 patients that underwent inferior conjunctival autograft transplantation after pterygium removal in primary pterygium. The results of all patients were reviewed. The success rate was determined in terms of recurrence rate of pterygium. Postoperative complications were also analyzed. Results: The present study comprised 45 patients for 45 eyes, that undergone inferior conjunctival autograft transplantation after pterygium removal in primary pterygium. The mean follow-up was 14.2±10.1 months. Recurrence rate was 7% or three eyes, in one year follow-up. No serious complications were found. Conjunctival buttonhole was a major complication. Conclusion: Inferior conjunctival autograft transplantation after pterygium removal is an effective and safe treatment with low complications. This alternative surgical technique is used to preserve superior conjunctiva for future glaucoma filtering surgery. Keywords: Inferior conjunctival autograft; Primary pterygium; Glaucoma

Comparative Analysis of Tear Film Parameters in Patients Undergoing Pterygium Excision by Conjunctival Autograft or Bare Sclera Technique Augmented by Intraoperative Mitomycin C Application

Introduction: Excision of the pterygium has been shown to enhance tear film stability. The study was designed to assess the effects of pterygium removal utilising two different surgical procedures on tear film parameters: bare sclera with Mitomycin C (MMC) and conjunctival autograft. The bare sclera with MMC application and conjunctival autograft techniques are the two most common treatments for pterygium. Conjunctival autograft is a procedure in which the superior conjunctiva of the patient's eye is removed in one piece and the excised tissue is used to cover the area where the pterygium was removed.The bare sclera with MMC application procedure involves removing the pterygium and intraoperatively applying 0.02% MMC to the scleral bed, leaving it to re-epithelialise. Aim: Comparative analysis of improvement in tear film parameters of patients undergoing pterygium excision by conjunctival autograft or bare sclera technique augmented by intraoperative MMC application. Materials and Methods: The prospective interventional study was conducted in Department of Ophthalmology, SGT University affiliated hospital, Gurugram, Haryana, India, from January 2019 to January 2020. A total of 54 Patients were divided into two groups. Group 1 has 26 patients undergoing pterygium excision with bare sclera technique (with MMC 0.02%), and Group 2 has 28 patients undergoing pterygium excision with conjunctival autograft technique (with MMC). Tear Break-up Time (TBUT) and Schirmer's I were measured in 54 eyes with pterygium before and after surgery. Data analysis was done using Two tail (inequality) test on Statistical Package for the Social Sciences (SPSS) software version 28.0. Patients were randomly divided into two groups by using RAND between software. Results: The mean preoperative Schirmer's I was 9.333 mm which improved to 12.203 mm after pterygium excision, which was a statistically significant change irrespective of the technique used. The mean preoperative Tear Break-up Time (TBUT) was 7.212 seconds which improved to 13.059 seconds after pterygium excision, which was a statistically significant change irrespective of the technique used. In the autograft group, TBUT improved from preoperative mean value of 7.253 seconds to 14.0 seconds and Schirmer's I mean values improved from 9.178mm to 12.678 mm, respectively.In the bare sclera group TBUT improved from preoperative mean value of 7.169 second to 12.046 second and Schirmer's I mean values improved from 9.500 mm to 11.692 mm, respectively. The mean postoperative Schirmer’s1 in autograft technique was 12.678 mm and postoperative Schirmer’s1 in bare sclera technique was 11.692 mm.The postoperative improvement in both groups was statistically similar. The mean postoperative TBUT in autograft technique was 14 seconds and postoperative TBUT in bare sclera technique was 12.046 seconds. Postoperative results in the autograft group were statistically better than the bare sclera group. Conclusion: The tear film stability parameters in pterygium patients improved after surgery in both the groups. Statistical analysis of postoperative Schirmer's I data was similar in both the techniques. Although postoperative TBUT values were statistically better in the autograft group, the mean value in both the techniques were more than ten seconds. The analysis of data indicates that bare sclera technique with MMC can be used as an alternative surgical procedure in patients with scarred conjunctiva or in situations where superior conjunctiva has to be preserved for future use.

Subconjunctival Silicone Oil Causing Giant Papillary Conjunctivitis

A 43-year-old man presented with giant papillary conjunctivitis of the left eye 5 months after retinal detachment repair with silicone oil that was complicated by massive postoperative subconjunctival oil leak. Examination demonstrated clear mobile cysts in Tenon’s capsule for 360 degrees (Fig A), punctate keratopathy, and a giant papillary reaction on the superior tarsal conjunctiva (Fig B). Surgical excision of the cystic lesions was performed. Histopathology demonstrated encysted lipid vacuoles throughout the subconjunctival space with a foreign body reaction (Fig C), consistent with giant papillary conjunctivitis secondary to subconjunctival silicone oil.

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