Korean J Ophthalmol.  2017 Dec;31(6):469-478. 10.3341/kjo.2016.0135.

Efficacy and Safety of a Large Conjunctival Autograft for Recurrent Pterygium

• Lee JS
• Ha SW
• Yu S
• Lee GJ
• Park YJ

• KMID: 2396697
• DOI: http://doi.org/10.3341/kjo.2016.0135

Abstract

PURPOSE
To evaluate the efficacy and safety of pterygium excision using a large conjunctival autograft for the treatment of recurrent pterygium.
METHODS
The medical records of 120 patients (126 eyes) with recurrent pterygium were reviewed. For each affected eye, pterygium excision with a large conjunctival autograft was performed. The graft was harvested from the superior bulbar area and measured more than 8 × 10 mm in size. Only patients who completed at least six months of follow-up were included. Postoperative clinical outcomes, recurrence rate, and complications were analyzed. Patients with any evidence of recurrence after surgery received a subconjunctival bevacizumab injection.
RESULTS
The average patient age was 56.5 ± 10.2 years, and 45 out of 120 patients were male. The mean study follow-up period was 17.7 ± 17.6 months. Most patients were satisfied with the cosmetic outcome. Postoperative visual acuity improved from 0.69 to 0.75 (p < 0.05). Postoperative refractive astigmatism and corneal astigmatism decreased by 0.55 and 2.73 diopters, respectively (p < 0.05). The postoperative recurrence rate was 4.0%, and the average recurrence period was 7.4 ± 0.6 weeks. A subconjunctival injection of 5 mg bevacizumab was performed in cases of recurrence; no progression of the pterygium was observed following the injection. Postoperative complications included 2 cases of conjunctival graft edema in 2 eyes, 5 donor site scars in 5 eyes, 13 pyogenic granulomas in 13 eyes, and a conjunctival epithelial inclusion cyst in 7 eyes.
CONCLUSIONS
Pterygium excision with a large conjunctival autograft for the treatment of recurrent pterygium produced an excellent cosmetic outcome, a low recurrence rate, and minimal complications. A subconjunctival bevacizumab injection given in cases of recurrence following surgery might be effective in preventing progression of the pterygium.

Keyword

Autografts; Bevacizumab; Pterygium

MeSH Terms

Astigmatism
Autografts*
Bevacizumab
Cicatrix
Edema
Follow-Up Studies
Granuloma, Pyogenic
Humans
Male
Medical Records
Postoperative Complications
Pterygium*
Recurrence
Tissue Donors
Transplants
Visual Acuity
Bevacizumab

Figure

• 

  Fig. 1 Surgical conjunctival autograft procedures in pterygium surgery. (A) Preoperative recurrent nasal pterygium. (B) The pterygium head was excised, the conjunctiva allowed to retract, and the subconjunctival fibrovascular tissue excised en bloc. (C) The superior conjunctival autograft was flipped over the cornea and the limbal attachment, and then the head of the palisades of Vogt was cleaned with a blade. (D) The conjunctival autograft was placed over the cornea. The graft was rotated toward the defect site by spreading the conjunctiva while being mindful of orienting the limbal stem cell population toward the limbus. (E) Fibrin glue was applied over the bare sclera and conjunctival autograft. A drop of fibrinogen solution was placed on the bare sclera, and a drop of thrombin solution was applied to the conjunctival autograft. (F) The conjunctival autograft was spread over the bare sclera, and the edges were bonded to the surrounding health conjunctiva using McPherson forceps. (G) The donor conjunctival tissue was sutured to the recipient site using several simple interrupted sutures with 10-0 nylon (Ethilon; Johnson & Johnson Medical, Cincinnati, OH, USA) at the tissue margins. (H) After the conjunctival autograft was secured, temporary amniotic membrane transplantation was performed.

• 

  Fig. 2 Change in conjunctival injection after pterygium surgery. (A) Hypervascularized recurrent pterygium in a left eye. (B) Decreased conjunctival injection after pterygium excision with a conjunctival autograft.

• 

  Fig. 3 A change in fibrous tissue contraction after pterygium surgery. (A) Thick fibrovascular tissue on the cornea induced ocular motility limitations. (B) Resolution of the thick fibrovascular tissue and ocular motility limitation after pterygium excision with a conjunctival autograft.

• 

  Fig. 4 Complications after pterygium surgery. (A) Graft edema. (B) Donor site scarring. (C) Pyogenic granuloma. (D) Conjunctival epithelial inclusion cyst.

• 

  Fig. 5 A 45-year-old male experienced pterygium recurrence after pterygium surgery and received two subconjunctival bevacizumab injections. (A) Recurrent pterygium before the surgery. (B) Pterygium recurrence eight weeks postoperatively. (C) No progression of fibrovascular proliferation after two subconjunctival bevacizumab injections for six months.

Reference

1. Yoon KC, Mun GH, Kim SD, et al. Prevalence of eye diseases in South Korea: data from the Korea National Health and Nutrition Examination Survey 2008-2009. Korean J Ophthalmol. 2011; 25:421–433.

2. Wong WW. A hypothesis on the pathogenesis of pterygiums. Ann Ophthalmol. 1978; 10:303–308.

3. Coroneo MT. Pterygium as an early indicator of ultraviolet insolation: a hypothesis. Br J Ophthalmol. 1993; 77:734–739.

4. Zauberman H. Pterygium and its recurrence. Am J Ophthalmol. 1967; 63:1780–1786.

5. Youngson RM. Recurrence of pterygium after excision. Br J Ophthalmol. 1972; 56:120–125.

6. Hirst LW. Prospective study of primary pterygium surgery using pterygium extended removal followed by extended conjunctival transplantation. Ophthalmology. 2008; 115:1663–1672.

7. Kucukerdonmez C, Akova YA, Altinors DD. Comparison of conjunctival autograft with amniotic membrane transplantation for pterygium surgery: surgical and cosmetic outcome. Cornea. 2007; 26:407–413.

8. Tananuvat N, Martin T. The results of amniotic membrane transplantation for primary pterygium compared with conjunctival autograft. Cornea. 2004; 23:458–463.

9. Shimazaki J, Kosaka K, Shimmura S, Tsubota K. Amniotic membrane transplantation with conjunctival autograft for recurrent pterygium. Ophthalmology. 2003; 110:119–124.

10. Ti SE, Chee SP, Dear KB, Tan DT. Analysis of variation in success rates in conjunctival autografting for primary and recurrent pterygium. Br J Ophthalmol. 2000; 84:385–389.

11. Kaufman SC, Jacobs DS, Lee WB, et al. Options and adjuvants in surgery for pterygium: a report by the American Academy of Ophthalmology. Ophthalmology. 2013; 120:201–208.

12. Tan DT, Chee SP, Dear KB, 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.

13. Ha SW, Park JH, Shin IH, Kim HK. Clinical analysis of risk factors contributing to recurrence of pterygium after excision and graft surgery. Int J Ophthalmol. 2015; 8:522–527.

14. Koranyi G, Artzen 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; 90:266–270.

15. Ozer A, Yildirim N, Erol N, Yurdakul S. Long-term results of bare sclera, limbal-conjunctival autograft and amniotic membrane graft techniques in primary pterygium excisions. Ophthalmologica. 2009; 223:269–273.

16. Luanratanakorn P, Ratanapakorn T, Suwan-Apichon O, Chuck RS. Randomised controlled study of conjunctival autograft versus amniotic membrane graft in pterygium excision. Br J Ophthalmol. 2006; 90:1476–1480.

17. Fallah MR, Golabdar MR, Amozadeh J, et al. Transplantation of conjunctival limbal autograft and amniotic membrane vs mitomycin C and amniotic membrane in treatment of recurrent pterygium. Eye (Lond). 2008; 22:420–424.

18. Ma DH, See LC, Hwang YS, Wang SF. Comparison of amniotic membrane graft alone or combined with intraoperative mitomycin C to prevent recurrence after excision of recurrent pterygia. Cornea. 2005; 24:141–150.

19. Kim YI, Lee GY, Kim EJ, et al. The effect of subconjunctival bevacizumab injection before conjunctival autograft for pterygium. J Korean Ophthalmol Soc. 2015; 56:847–855.

20. Stival LR, Lago AM, Figueiredo MN, et al. Efficacy and safety of subconjunctival bevacizumab for recurrent pterygium. Arq Bras Oftalmol. 2014; 77:4–7.

21. Hu Q, Qiao Y, Nie X, et al. Bevacizumab in the treatment of pterygium: a meta-analysis. Cornea. 2014; 33:154–160.

22. Ozgurhan EB, Agca A, Kara N, et al. Topical application of bevacizumab as an adjunct to recurrent pterygium surgery. Cornea. 2013; 32:835–838.

23. Hurmeric V, Vaddavalli P, Galor A, et al. Single and multiple injections of subconjunctival ranibizumab for early, recurrent pterygium. Clin Ophthalmol. 2013; 7:467–473.

24. Alhammami H, Farhood Q, Shuber H. Subconjunctival bevacizumab injection in treatment of recurrent pterygium. J Clin Exp Ophthalmol. 2013; 01. 23. DOI: 10.4172/2155-9570.1000267.

25. Lekhanont K, Patarakittam T, Thongphiew P, et al. Randomized controlled trial of subconjunctival bevacizumab injection in impending recurrent pterygium: a pilot study. Cornea. 2012; 31:155–161.

26. Mandalos A, Tsakpinis D, Karayannopoulou G, et al. The effect of subconjunctival ranibizumab on primary pterygium: a pilot study. Cornea. 2010; 29:1373–1379.

27. Fallah MR, Khosravi K, Hashemian MN, et al. Efficacy of topical bevacizumab for inhibiting growth of impending recurrent pterygium. Curr Eye Res. 2010; 35:17–22.

28. Nava-Castaneda A, Ulloa-Orozco I, Garnica-Hayashi L, et al. Triple subconjunctival bevacizumab injection for early corneal recurrent pterygium: one-year follow-up. J Ocul Pharmacol Ther. 2015; 31:106–113.

29. Safianik B, Ben-Zion I, Garzozi HJ. Serious corneoscleral complications after pterygium excision with mitomycin C. Br J Ophthalmol. 2002; 86:357–358.

30. Dougherty PJ, Hardten DR, Lindstrom RL. Corneoscleral melt after pterygium surgery using a single intraoperative application of mitomycin-C. Cornea. 1996; 15:537–540.

31. Bahar I, Kaiserman I, Lange AP, et al. The effect of mitomycin C on corneal endothelium in pterygium surgery. Am J Ophthalmol. 2009; 147:447–452.

32. Kheirkhah A, Izadi A, Kiarudi MY, et al. Effects of mitomycin C on corneal endothelial cell counts in pterygium surgery: role of application location. Am J Ophthalmol. 2011; 151:488–493.

33. Avisar R, Apel I, Avisar I, Weinberger D. Endothelial cell loss during pterygium surgery: importance of timing of mitomycin C application. Cornea. 2009; 28:879–881.

34. Prabhasawat P, Barton K, Burkett G, Tseng SC. Comparison of conjunctival autografts, amniotic membrane grafts, and primary closure for pterygium excision. Ophthalmology. 1997; 104:974–985.

35. Solomon A, Pires RT, Tseng SC. Amniotic membrane transplantation after extensive removal of primary and recurrent pterygia. Ophthalmology. 2001; 108:449–460.

36. Kim HH, Mun HJ, Park YJ, et al. Conjunctivolimbal autograft using a fibrin adhesive in pterygium surgery. Korean J Ophthalmol. 2008; 22:147–154.

37. Fernandes M, Sangwan VS, Bansal AK, et al. Outcome of pterygium surgery: analysis over 14 years. Eye (Lond). 2005; 19:1182–1190.

38. Kria L, Ohira A, Amemiya T. TNP-470 (a fungus-derived inhibitor of angiogenesis) reduces proliferation of cultured fibroblasts isolated from primary pterygia: a possible drug therapy for pterygia. Curr Eye Res. 1998; 17:986–993.

39. Kria L, Ohira A, Amemiya T. Growth factors in cultured pterygium fibroblasts: immunohistochemical and ELISA analysis. Graefes Arch Clin Exp Ophthalmol. 1998; 236:702–708.

40. Barishak RY, Baruh E, Lazar M. Episcleral traumatic conjunctival inclusion cyst. Br J Ophthalmol. 1977; 61:299–301.

41. Song JJ, Finger PT, Kurli M, et al. Giant secondary conjunctival inclusion cysts: a late complication of strabismus surgery. Ophthalmology. 2006; 113:1049.

42. Williams BJ, Durcan FJ, Mamalis N, Veiga J. Conjunctival epithelial inclusion cyst. Arch Ophthalmol. 1997; 115:816–817.

43. Gebhardt M, Mentlein R, Schaudig U, et al. Differential expression of vascular endothelial growth factor implies the limbal origin of pterygia. Ophthalmology. 2005; 112:1023–1030.

44. Jin J, Guan M, Sima J, et al. Decreased pigment epithelium-derived factor and increased vascular endothelial growth factor levels in pterygia. Cornea. 2003; 22:473–477.

45. Marcovich AL, Morad Y, Sandbank J, et al. Angiogenesis in pterygium: morphometric and immunohistochemical study. Curr Eye Res. 2002; 25:17–22.

46. Lee DH, Cho HJ, Kim JT, et al. Expression of vascular endothelial growth factor and inducible nitric oxide synthase in pterygia. Cornea. 2001; 20:738–742.