|Year : 2022 | Volume
| Issue : 2 | Page : 59-64
Pterygium conjunctival autograft: A 5-year review
Mayor Orezime Atima, Douglas Jah Pam
ECWA Eye Hospital, Kano, Nigeria
|Date of Submission||09-Aug-2021|
|Date of Acceptance||10-Jan-2022|
|Date of Web Publication||27-Dec-2022|
Mayor Orezime Atima
ECWA Eye Hospital, P. O. BOX 14, Kano
Source of Support: None, Conflict of Interest: None
Background: The treatment of ocular pterygium overtime has been subjected to the development and application of various new strategies towards simpler, quicker, and more comfortable surgical procedures that have foster the development suture-less technique with conjunctival autograft to reduce recurrent rate. Aims: To evaluate the long-term follow-up of recurrent rate and immediate complication in primary pterygium excision with Inferior Limbal Conjunctival Autograft (ILCA) a 5 years follow-up in a Tertiary Ophthalmic Centre. Materials and Methods: The medical record of 68 patients (80 eyes) who underwent pterygium excision and free ILCA for primary nasal pterygium who completed the 5 years follow-up were retrospectively reviewed for recurrence and immediate postoperative complication, of these 59 patients met the criteria. Result: In this study, 59 patients (71 eyes) completed the 5 years follow-up that account for 86.8%, 9 patients defaulted accounting for 13.2%. Two (3.4%) out of the 59 patients had recurrence, one male at 3 months and a female at 2 months that were 21 and 40 years old, respectively. The early complication that was seen in this study was mild conjunctival hyperemia secondary to suture irritation. Conclusions: After a long follow-up period for ILCA for primary pterygium surgery, the success of conjunctival autograft was high with little or no complication seen, this may be related to a significant learning curve or differing surgical techniques for this procedure. The greatest risk factors for recurrence were young age and type of pterygium.
Keywords: Complication, inferior conjunctival autograft, primary pterygium, recurrence
|How to cite this article:|
Atima MO, Pam DJ. Pterygium conjunctival autograft: A 5-year review. J Niger Acad Med 2022;1:59-64
| Introduction|| |
A pterygium that takes its name from the Greek word wing (pterygos) is a vascular, flesh horizontally oriented triangular growth of abnormal tissue that invades the cornea from the canthal region of the bulbar conjunctiva. Chronic exposure to ultraviolent rays plays a role in the pathogenesis of pterygium by damaging both limbal stems cells and corneal nerve plexus,,, which are relatively common in the tropics and in individual that do outdoor activity that are exposed to radiation in the general population., This may typically follow an aggressive or indolent course, with changes in appearance that has effect on vision and poor cosmetic appearance on the eye itself. These tumor-like characteristics of pterygium are expressed when proliferation occurs after bare sclera excision surgery., Although various surgical procedures, including adjunctive treatments, have been proposed for the treatment of pterygium, recurrence remains a significant problem after surgical excision.,, In a comprehensive report, Kenyon et al. first described the use of conjunctival autografts for the management of recurrent or advanced pterygium and reported a low recurrence rate of 5.3% with this method. Since this report, conjunctival autografts have been found to be a safe and effective option in pterygium surgery and have become the primary choice for the surgical management of this disorder.,, However, the procedure in question is technically demanding and the recurrence rates are variable, sometimes considerably, among different reports.,,
Associated epidemiological factors such as age, gender, race, and region may have influenced the possibility of recurrence after this type of pterygium treatment.,, The aim of this study was to observe the recurrence rate after inferior limbal conjunctival autograft associated with primary pterygium surgery in cases treated with sutures while preserving the superior conjunctival area for future glaucoma surgeries should it occur.
This long-term follow-up is meant to show whether some epidemiological factors could be associated with recurrence.
| Materials and Methods|| |
A retrospective review involving a total of 59 patients who underwent ILCA for primary nasal pterygium excision from January to December 2013 at the ECWA Eye Hospital, Kano, Nigeria were identified from the theatre records, and those who had up to 5-year follow-up were included in the study. During the review, patients who had less than 5-year follow-up were contacted by phone; 3 of the 5 reached responded, the rest 4 were unreachable, though they and the rest 5 that were reached were not included in the study accounting for 13.2% loss to follow-up. The presence or absence of recurrence was documented as seen in the patients note with time of recurrence after surgery, so as to estimate the minimum period of follow-up that is required to know if surgery had been successful [Figure 6].
|Figure 6: Number of males and females that were operated at ECWA Eye Hospital, Kano from January to December 2013 and the age range with the highest prevalence|
Click here to view
In this study, recurrence was defined as conjunctival growth at the limbus at the site of excised primary pterygium.
Twelve patients had bilateral pterygium excision done; the patient’s personal particulars and details of clinical history were obtained from their clinical notes (e.g., age, sex, grade, morphology, recurrence, and early complication).
The conjunctival autograft was harvested from inferior limbal conjunctival area and secured to the bare area by a buried 10/0 Nylon suture.
Postoperatively the patients were placed on 0.05% dexamethasone and 0.3% ciprofloxacin eye drops four times a day for 4–6 weeks, then they are tailed down thereafter. Pain reliever was given to patients with pain without photophobia.
In this study, the surgical procedure was carried out by the author. The study was approved by the Hospital Ethical Committee and the Management Board.
| Surgical Technique|| |
The surgical technique employed in this case was similar to others that have been reported,, with slight modification. All pterygia were primary in nature situated nasally and patients with recurrent pterygium were not included in this study.
In each case, 3 mL of 2% xylocaine and 0.01% of adrenaline peribulbar anesthesia was given and the periorbital area was cleaned with 10% povidone iodine and draped; a lid speculum was inserted to part the lid. The pterygium body was inflated with 1/2 mL of saline using a 30-G needle; the head of the pterygium was then detached from the surface of the cornea with tooth forceps and the subconjunctival fibrous tissue was removed completely from the cornea with a razor blade fragment. The conjunctival area was excised with a scissors preserving the adjacent tenon capsule and the sheath of the medial rectus muscle. A dental role pressure was applied on bleeding vessels by the assistant when present. The surgeon who performed the surgeries has more than 20 years of experience.
The size of the graft was determined by measuring the exposed sclera area and transferred to the site where the graft is to be taken and marked out as shown in [Figure 1]. The free graft is taken after the injection of a 1/2 mL of saline in the area. This helps to obtain the thinnest conjunctiva by dissecting the conjunctival from the tenon as shown in [Figure 2]. The limbal side of the graft is placed on the limbal area of the defect, if clotted blood had formed while taking the graft this is removed by the application of a dental role and light cauterization done to prevent further bleeding. [Figure 3] shows the transplanted conjunctival graft at the right position with buried stitches.
|Figure 1: Marked out area of inferior conjunctival tissue from where the graft was taken|
Click here to view
|Figure 2: Thin layer of dissected conjunctiva from the inferior limbal area without tenon|
Click here to view
| Results|| |
In the year 2013, a total of 68 (80 eyes) patients had ILCA for primary pterygium excision. A total of 59 (86.8%) patients who completed the 5-year follow-up with mean age of 49.9 years and standard deviation (SD) of 12.25 years were included in the study. Nine (13.2%) of the 68 patients did not complete the 5-year period and were not included in the study. All the patients were Blacks and live in the tropics (Nigeria).
There were 32 males with a mean age of 51.75 years and SD of 13.40 years; and 27 females with mean age of 47.72 years and SD of 10.30 years. The male-to-female ratio was 1.2:1 as shown in [Table 1]. There were 6 males and 6 females that had bilateral, 26 males and 21 females had unilateral, the morphological types seen in this study were 32 atrophic of which 18 were males and 14 females; 39 were fleshy of which 18 were males and 21 females as shown in [Figure 4].
|Table 1: Age range, gender, and the number of patients with pterygium in each age range that had pterygium surgeries with ILCA done from January to December 2013|
Click here to view
|Figure 4: Sex variations, morphology, and the laterality of the types of pterygium seen in this study|
Click here to view
In this review study, 2 (2.8%), one female and one male at 2 and 3 months, respectively, of the 59 patients developed recurrence after surgery, as shown in [Table 1] with the age range given in the bracket.
The grades (G) of pterygium seen in this study are shown in [Table 1]. There were 34 of grade II and 25 of grade III. Of the 34 with grade II, there were 26 males and 8 females. Of the 25 patients with grade III, 6 were males and 19 were females.
The age range that had frequent pterygium in this study was the same for both male and female, as shown in [Figure 4] and [Figure 5].
The IBM SPSS Statistics 25 and MS Excel were used for the data compilation, description, and analysis.
| Discussion|| |
Surgical excision of pterygium has been the form of treatment for many years but the development of recurrence has led to newer methods so as to reduce recurrent rate. Though this area is still undergoing evolution, adjunctive treatment with conjunctival autograft or mitomycin C application are accepted methods of treating both primary and recurrent pterygium. The surgeon’s experience also plays a role in the recurrent rate, which may range from 0% to 39% in the case of conjunctival autograft.,, Although even in the hand of experience surgeon graft suturing has the disadvantage of requiring more time than bare sclera technique, that also carried the risk of complication such as granuloma formation and patient discomfort that are associated with exposed sutures will require removal if non-absorbable stitches are used. Although polyglactin and nylon suture are good materials for autograft suturing in pterygium surgery and causes postoperative discomfort, polyglactin causes slightly more reactions in early postoperative period than nylon. The surgical management of primary conjunctival autograft with glue has reduced surgical time and conjunctival hyperemia with ocular discomfort compared with fixation with 10/0 nylon or with vicryl sutures. It is an excellent option for conjunctival autograft in primary pterygium surgery.,, However, its role with respect to traditional suturing is still a matter of debate. A metanalysis to compare the safety and the clinical efficacy of fibrin glue with that of suture for conjunctival autograft attachment in pterygium surgery showed that fibrin glue was associated with reduction in operation time and was more effective than suture in reducing recurrent rate. This metanalysis evaluated 342 participants with 366 eyes from seven studies. The use of fibrin glue can decrease the recurrent rate through its ability to reduce inflammation. Postoperatively inflammation is closely associated with surgical outcome and risk of pterygium recurrence. The use of suture can induce inflammation and migration of Langerhans cells to the cornea. A retrospective study and a prospective comparative study showed statistically significant less degree of inflammation and decreased recurrent rate with fibrin glue used than suture. The recurrent rate was not evaluated in many of the studies cited in which fibrin glue was used.,,,, However, some studies have reported lower rate of recurrence with the use of fibrin glue,,,, whereas others reported the same rate of recurrence with suture.,, The majority of these studies have not been subjected to long time follow-up and when such studies have been conducted most of them have focus on a period of less than 1 year. The longest period published after using fibrin glue showed a mean recurrence of 4.5% in a series of 111 operated pterygia over a follow-up period of 2 years.
Having reviewed the published literature, we presented in this study a review of 5-year follow-up of primary pterygium with ILCA. The number of patients who completed the 5 years study were 59 (71 eyes), of which 32 were males and 27 females which was also reported by Mahar who had more males than females. The reason been that more males are exposed to radiation compared to females as they do more of outdoor activities as seen.,, The average age in this study was 49.9 years that ranged between 21 and 72 years. This average age was similar to that in the literature with 50.8 years old in Hong Kong. In Zarrouki et al.’s study the mean ages were 51.5 and 54 years.
The recurrent rate after pterygium excision and autograft varied as seen in the literature ranged from 0% to 39%.,, In our review, the recurrent rate was 2.8% after 5-year follow-up. The age at which recurrence occurred was between 21 and 30 years in both sex, one in each. The period at which recurrent occurred was 6 months after surgery, although this could occurred much earlier at about 3 months postoperative period.
The grade of pterygium seen in this study is as shown in [Table 1]. There were 34 patients with grade II and 25 with grade III. Of the 34 patients with grade II, 26 were males and 8 were females. The grade III had 6 males and 19 females. The increase in the number of females with grade III can be explained from the economic and social prevailing circumstances in the region of study in which females are not economically viable because they are made to care for the home and must have approval with the release of funds before surgery can be done.
In this review, there was no complication seen except for mild conjunctival hyperemia, which is usually seen in pterygium excision with conjunctival autograft, though the use of glue is reported to be associated with low postoperative inflammation, but placed more cost on the patients. As seen in this study that 10/0 Nylon buried sutures used was associated with low conjunctival inflammation and recurrence.
The use of inferior conjunctival tissue is thought to be associated with increase recurrence due to inflammatory deposit on the lower lid and its tendency to radiation exposure.
| Conclusion|| |
In our study, the graft was taken from the inferior limbal conjunctiva. This area is prone to inflammatory deposit and exposure to radiation that is thought to cause conjunctival harvested from this site to recur after pterygium surgery while preserving the superior limbal conjunctival area for future glaucoma surgeries. The low recurrence from this review had showed that ILCA has low recurrent rate and should be an alternative area of conjunctival harvested for pterygium autograft in Blacks who are prone to develop glaucoma later in life more also to give room for a second or a third glaucoma surgery when the first and second fails.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Santosh K, Roohie S Pterygium excision and conjunctival autograft: A comparative study of techniques. Oma J Ophthalmol 2018;11:124-28.
Nitin V, Tarun C, Priyanka A A comparison between fibrin sealant and suture for attaching conjunctival autograft after pterygium excision. Med J Armed Forces India 2013;6:151-55.
Chui J, Coroneo MT, Tat LT, Crouch R, Wakefield D, Di Girolamo N Ophthalmic pterygium: A stem cell disorder with premalignant features. Am J Pathol 2011;178:817-27.
Di Girolamo N, Tedla N, Kumar RK, McCluskey P, Lloyd A, Coroneo MT, et al
. Culture and characterisation of epithelial cells from human pterygia. Br J Ophthalmol 1999;83:1077-82.
Ajayi Iyiade A, Omotoye Olusola J Pattern of eye diseases among welders in a Nigeria community. Afr Health Sci 2012;12:210-6.
Hill JC, Maske R, Pathogenesis of pterygium. Eye 1989;3: 218-26.
Nubile M, Curcio C, Lanzini M, Calienno R, Iezzi M, Mastropasqua A, et al
. Expression of CREB in primary pterygium and correlation with cyclin D1, ki-67, MMP7, p53, p63, survivin and vimentin. Ophthalmic Res 2013;50:99-107.
Young AL, Ho M, Jhanji V, Cheng LL Ten-year results of a randomized controlled trial comparing 0.02% mitomycin C and limbal conjunctival autograft in pterygium surgery. Ophthalmology 2013;120:2390-5.
Prabhasawat P, Barton K, Burkett G, Tseng SC Comparison of conjunctival autografts, amniotic membrane grafts, and primary closure for pterygium excision. Ophthalmology 1997;104:974-85.
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;9:331-4.
Chen PP, Ariyasu RG, Kaza V, LaBree LD, McDonnell PJ A randomized trial comparing mitomycin C and conjunctival autograft after excision of primary pterygium. Am J Ophthalmol 1995;120:151-60.
Kenyon KR, Wagoner MD, Hettinger ME Conjunctival autograft transplantation for advanced and recurrent pterygium. Ophthalmology 1985;92:1461-70.
Starck T, Kenyon KR, Serrano F Conjunctival autograft for primary and recurrent pterygia: Surgical technique and problem management. Cornea 1991;10:196-202.
Allan BD, Short P, Crawford GJ, Barrett GD, Constable IJ Pterygium excision with conjunctival autografting: An effective and safe technique. Br J Ophthalmol 1993;77:698-701.
Mahar PS Conjunctival autograft versus topical mitomycin C in treatment of pterygium. Eye (Lond) 1997;11:790-2.
Manning CA, Kloess PM, Diaz MD, Yee RW Intraoperative mitomycin in primary pterygium excision: A prospective, randomized trial. Ophthalmology 1997;104:844-8.
West S, Muñoz B Prevalence of pterygium in Latinos: Proyecto Ver. Br J Ophthalmol 2009;93:1287-90.
Kandavel R, Kang JJ, Memarzadeh F, Chuck RS Comparison of pterygium recurrence rates in Hispanic and white patients after primary excision and conjunctival autograft. Cornea 2010;29:141-5.
Ayala M Results of pterygium surgery using a biologic adhesive. Cornea 2008;27:663-7.
Mohammed I Treatment of pterygium. Ann Afr Med 2011;10:197-203.
Koranyi G, Artzén D, Seregard S, Kopp ED Intraoperative mitomycin C versus autologous conjunctival autograft in surgery of primary pterygium with four-year follow-up. Acta Ophthalmol 2012;90:266-70.
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;31:301-7.
Rubin MR, Dantas PE, Nishiwaki-Dantas MC, Felberg S [Efficacy of fibrin tissue adhesive in the attachment of autogenous conjuntival graft on primary pterygium surgery]. Arq Bras Oftalmol 2011;74:123-6.
Koranyi G, Seregard S, Kopp ED Cut and paste: A no suture, small incision approach to pterygium surgery. Br J Ophthalmol 2004;88:911-4.
Bahar I, Weinberger D, Dan G, Avisar R Pterygium surgery: Fibrin glue versus vicryl sutures for conjunctival closure. Cornea 2006;25:1168-72.
Bahar I, Weinberger D, Gaton DD, Avisar R Fibrin glue versus vicryl sutures for primary conjunctival closure in pterygium surgery: Long-term results. Curr Eye Res 2007;32:399-405.
Pan HW, Zhong JX, Jing CX Comparison of fibrin glue versus suture for conjunctival autografting in pterygium surgery: A meta-analysis. Ophthalmology 2011;118:1049-54.
Ti SE, Tseng SC Management of primary and recurrent pterygium using amniotic membrane transplantation. Curr Opin Ophthalmol 2002;13:204-12.
Hirst LW, Sebban A, Chant D Pterygium recurrence time. Ophthalmology 1994;101:755-8.
Koranyi G, Seregard S, Kopp ED The cut-and-paste method for primary pterygium surgery: Long-term follow-up. Acta Ophthalmol Scand 2005;83:298-301.
Srinivasan S, Dollin M, McAllum P, Berger Y, Rootman DS, Slomovic AR Fibrin glue versus sutures for attaching the conjunctival autograft in pterygium surgery: A prospective observer masked clinical trial. Br J Ophthalmol 2009;93:215-8.
Uy HS, Reyes JM, Flores JD, Lim-Bon-Siong R Comparison of fibrin glue and sutures for attaching conjunctival autografts after pterygium excision. Ophthalmology 2005;112:667-71.
Wong VW, Rao SK, Lam DS Polyglactin sutures versus nylon sutures for suturing of conjunctival autograft in pterygium surgery: A randomized, controlled trial. Acta Ophthalmol Scand 2007;85:658-61.
Ozdamar Y, Mutevelli S, Han U, Ileri D, Onal B, Ilhan O, et al
. A comparative study of tissue glue and vicryl suture for closing limbal-conjunctival autografts and histologic evaluation after pterygium excision. Cornea 2008;27:552-8.
Miranda-Rollón MD, Pérez-González LE, Sentieri-Omarrementería A, Martínez-Rodríguez R, Parente-Hernández B, Junceda-Moreno J Pterygium surgery: Comparative study of conjunctival autograft with suture versus fibrin adhesive. Arch Soc Esp Oftalmol 2009;84:179-84.
Karalezli A, Kucukerdonmez C, Akova YA, Altan-Yaycioglu R, Borazan M Fibrin glue versus sutures for conjunctival autografting in pterygium surgery: A prospective comparative study. Br J Ophthalmol 2008;92:1206-10.
Nieuwendaal CP, van der Meulen IJ, Mourits M, Lapid-Gortzak R Long-term follow-up of pterygium surgery using a conjunctival autograft and tissucol. Cornea 2011;30:34-6.
Hall RC, Logan AJ, Wells AP Comparison of fibrin glue with sutures for pterygium excision surgery with conjunctival autografts. Clin Exp Ophthalmol 2009;37:584-9.
Coral-Ghanem R, Oliveira RF, Furlanetto E, Ghanem MA, Ghanem VC Conjunctival autologous transplantation using fibrin glue in primary pterygium. Arq Bras Oftalmol 2010;73:350-3.
Sarnicola V, Vannozzi L, Motolese PA Recurrence rate using fibrin glue-assisted ipsilateral conjunctival autograft in pterygium surgery: 2-year follow-up. Cornea 2010;29:1211-4.
Mackenzie FD, Hirst LW, Battistutta D, Green A Risk analysis in the development of pterygia. Ophthalmology 1992;99:1056-61.
MacKenzie FD, Hirst LW, Kynaston B, Bain C. Recurrence rate and complications after beta irradiation for pterygia. Ophthalmology 1991;98:1776-80; discussion 1781.
Zarrouki M, Elyadari M, Jebbar Z, Azennoud S, Serghini L, Elorch H, et al
. Limbal conjunctival autograft in pterygium surgery: Suture versus fibrin glue in 30 cases. J Fr Ophtalmol 2017;40:e293-5.
MacKenzie FD, Hirst LW, Kynaston B, Bain C Recurrence rate and complications after beta irradiation for pterygia. Ophthalmology 1991;98:1776-80; discussion 1781.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]