|Year : 2013 | Volume
| Issue : 3 | Page : 217-221
Temporarily attached conjunctival flap for primary pterygium surgery
Sameh Saleh, Ayman A Ghafar
Department of Ophthalmology, Mansoura University, Mansoura, Egypt
|Date of Submission||13-Jun-2013|
|Date of Acceptance||15-Jul-2013|
|Date of Web Publication||28-Feb-2014|
Ayman A Ghafar
Department of Ophthalmology, Mansoura University, Mansoura
Source of Support: None, Conflict of Interest: None
The aim of the study was to evaluate the safety and outcomes of recurrent pterygium excision with a temporarily attached rotational conjunctival flap.
Patients and methods
In an interventional case series, consecutive patients with recurrent pterygium underwent surgical excision with temporary attachment of a rotational conjunctival flap onto bare sclera. Patients were followed up for 6-12 months and the results were evaluated in terms of recurrent pterygium growth and complications.
Thirty eyes from 30 consecutive patients (19 male and 11 female) of a mean age of 43.3 10.8 years were operated upon. The pterygia extended 4.6 1.2 mm (range 3-6 mm) onto the corneas. Two eyes (6.6%) showed recurrent pterygium growth. One eye (3.3%) developed conjunctival granuloma, which eventually required excision, leading to complete resolution.
Pterygium excision with a temporarily attached rotational conjunctival flap is a safe, easy, and effective surgical technique in the management of recurrent pterygium and has a low recurrence rate.
Keywords: Conjunctival flap-Pterygium Surgery
|How to cite this article:|
Saleh S, Ghafar AA. Temporarily attached conjunctival flap for primary pterygium surgery. J Egypt Ophthalmol Soc 2013;106:217-21
| Introduction|| |
Pterygium is an excessive proliferation of fibrovascular tissue over the exposed ocular surface. It is prevalent worldwide, being particularly common in tropical and subtropical regions such as Egypt. Exposure to ultraviolet light is the most important risk factor for its development . It can result in visual deterioration due to encroachment on the visual axis, irregular astigmatism, and progressive scarring . When it is associated with ocular irritation, visual impairment, or cosmetic failure, surgical excision may be considered using the most appropriate technique ,,. A variety of methods have been utilized in its treatment, with the aim of ensuring proper cosmetic appearance of the eye, reducing recurrence risk, and minimizing complications . These methods include bare sclera excision with or without the use of adjuncts such as intraoperative or postoperative administration of topical mitomycin C or β-irradiation, amniotic membrane transplantation, and conjunctival transplantation . Recurrence after excision remains a great challenge. Both mitomycin C and 5-fluorouracil have been shown to cause a reduction in the recurrence rate of pterygium, but both are potentially toxic to ocular tissues and have been associated with complications . Nowadays, conjunctival autograft surgery has been accepted as the procedure of choice for the treatment of recurrent pterygium ,. Some surgeons perform grafting for the treatment of recurrent pterygium. This is because of the associated low recurrence rate, efficient limbal reconstruction, and long-term safety compared with other techniques such as mitomycin C application and β radiation ,,. However, major limitations include difficulty in closing large defects and the inability to preserve the conjunctiva for glaucoma surgery ,. The main objective of this study was to evaluate the efficacy and safety of a new technique for conjunctival autograft transplantation using a temporarily attached rotational conjunctival flap.
| Patients and methods|| |
This randomized retrospective study was carried out at the Department of Ophthalmology, Ophthalmic Center, Mansoura University, between October 2011 and September 2012. Informed consent was obtained from all patients.
Inclusion criteria included recurrent pterygium encroaching at least 2 mm onto the cornea and age more than 16 years. Individuals with major systemic conditions such as diabetes mellitus or collagen vascular disease, pregnant women, those with dry eyes, cicatricial pemphigoid, glaucoma, or vitreoretinal diseases, and monocular patients were excluded. Patients with bilateral pterygium (seven patients) had their worse eye included, and the contralateral eye was excluded from the study.
Demographic information obtained from all patients included age, sex, occupation, laterality, location, morphology, size of the pterygium (measured with a slit lamp from the limbus), and record of previous pterygium surgery. A complete ophthalmologic examination including measurement of visual acuity, slit-lamp biomicroscopy, autorefraction, intraocular pressure measurement, and funduscopy was performed.
Selected patients underwent pterygium excision and temporary attachment of a conjunctival flap.
During surgery, all patients received local anesthesia by means of subconjunctival administration of 2% lidocaine HCL (lignocaine) with adrenaline 1 : 100 000 in the case of most patients. Peribulbar anesthesia was reserved for patients demonstrating limited cooperation. The head of the pterygium was first separated at the limbus and dissected toward the central cornea with a pair of spring scissors. After separation of the head and most of the body, the tenon and subconjunctival fibrovascular tissue were separated from the overlying conjunctiva, undermined, and excised extensively upward and downward toward the fornices and medially toward but not reaching the caruncle; caution was taken not to damage the medial rectus. Cautery was gently applied to bleeding vessels [Figure 1]. The conjunctiva above and below the pterygium was trimmed to create a rectangular area of bare sclera of ∼5×8 mm. Residual fibrovascular tissue over the cornea was detached using toothed forceps or by gentle scraping using a #15 surgical blade [Figure 2]. Following initial pterygium excision, a conjunctival flap of a size equivalent to the bare area was excised from the nearby superior (12 o'clock) bulbar conjunctiva. This conjunctival flap was then rotated and sutured to the recipient bed with interrupted inverted 10-0 nylon silk sutures, taking care to ensure proper orientation of the ends of the flap [Figure 3]. The base of the flap was then excised to convert it into a free graft. All surgical procedures were conducted and supervised by two surgeons. Postoperatively, all patients received tobramycin antibiotic eyedrops three times daily for 2 weeks, dexamethasone eyedrops four times daily for 3 weeks, which was gradually withdrawn over 2 weeks, and cicloplegic eyedrops three times daily for 3 days. They were also advised to wear dark glasses to reduce exposure to sunlight and other environmental irritants after 3 days of wearing a patch. Postoperative follow-up visits were at 1, 4, 10, 30, and 60 days and every 3 months subsequently.
Recurrence of pterygium was defined as any regrowth of fibrovascular tissue across the limbus, as observed using a slit lamp. No patient was lost to follow-up and all patients were followed up for 10-36 weeks. Data analysis was performed using statistical package for social sciences version 14. Pterygium recurrence and the complications arising from treatment were documented using frequency distribution tables.
| Results|| |
Thirty eyes from 30 patients (male to female ratio 1.72 : 1) with recurrent pterygia were included in this study, retrospectively analyzed, and operated upon. The mean age of the patients was 43.3 ± 10.8 (range: 32-55). Twenty-four (80%) patients were engaged in occupations that subjected them to considerable exposure to actinic damage. Preoperative refractive errors consisted of −0.75 to +3.25 D (mean of +1.25 D) for the spherical component and −1.00 to +3.50 D (mean of −0.5 D) for the cylindrical component. The extent of pterygium invasion beyond the limbus ranged from 3 to 6 mm (mean 4.6 ± 1.2 mm). The follow-up period was 9 months (range 6-12 months). Patients' data are shown in [Table 1].
The patients in this study underwent pterygium excision and temporary attachment of a conjunctival flap. On the first postoperative day, all patients had corneal epithelial defects that healed within 4 days with no conjunctival staining with fluorescein. None of the patients showed any significant change in intraocular pressure at any time during the follow-up. All grafts showed mild transient edema that resolved completely within 7 days. No intraoperative complications were encountered apart from minimal subconjunctival hemorrhage. Postoperative complications that required corrective surgical revision occurred in four cases and are presented in [Table 2]. Visual acuities were not affected by surgery in the majority of patients [Figure 4]. Visual acuity was seen to have remained unchanged in 23 patients (76.3%) at the end of follow-up. Visual acuity at 3 months improved in 20% of patients (six cases) and deteriorated in only one patient (3.3%).
Visual acuity at 3 months had deteriorated by one Snellen line in comparison with the preoperative level in the case of one patient. It improved by one line in two patients and by two lines in three patients. One patient, in whom the pterygium had been encroaching upon the visual axis preoperatively, showed a marked improvement in visual acuity (three lines). Of the 30 patients in the study, two with pterygia experienced recurrence (6.6%). A distinct pattern was identified in the form of cross-graft recurrence [Figure 5] in those two patients. The recurrences occurred within the first 6 months and were generally flat and uninflamed. These recurrences remained stationary, with encroachment of 1.5 mm or less into the cornea, and needed no further interference. One eye (3.3%) developed conjunctival granuloma and another eye developed a conjunctival cyst, which eventually required excision, leading to complete resolution. Wound dehiscence occurred in two patients and was secured by simple sutures. None of these patients went on to develop a recurrence.
| Discussion|| |
Pterygium surgery should ideally have low or no recurrence, minimal adverse events, and should be cosmetically acceptable . The gold standard for treatment of pterygium is excision followed by application of a conjunctival autograft. Recurrence after excision remains a great challenge in the management of pterygium . Wu  recently described pterygium excision with a conjunctival rotational autograft in 20 eyes. They harvested the graft and placed it over the bare scleral defect created after removal of the pterygium with a 180° rotation. They reported recurrence in seven eyes. The procedure appeared to be difficult and lengthy .
Use of a conjunctival autograft has shown successful results in the management of recurrent pterygium ,. It is easily available, ready to use as it requires no preoperative processing, has few side effects on the surrounding ocular tissue, and carries no risk of cross-infection. The greatest advantage is the presence of limbal stem cells, which prevents the growth of fibrovascular tissue and hence recurrence . Tananuvat and Martin  suggested that a conjunctival autograft may yield better results by acting as a barrier against fibrovascular invasion of the cornea and by supplying stem cells to the corneal epithelium. Some prospective, randomized studies in which a conjunctival autograft was performed after pterygium excision have shown higher recurrence rates (16-39%) in high-risk populations ,,,. Different investigators have reported variable recurrence rates after performing a conjunctival autograft for treatment against pterygium. In a long-term study, Pulte et al.  observed two recurrences in a group of 70 patients with pterygia (62 primary; eight recurrent) who underwent a conjunctival autograft, with a mean follow-up of 45 months. Shimazaki et al.  noted minimal subconjunctival tissue invasion (<1 mm) in two of 27 patients with advanced and recurrent pterygia followed up for a mean of 11 months after application of a conjunctival autograft.
In this study, the recurrence rate of pterygium following excision and temporary attachment of a conjunctival flap is 6.6% (two cases). This is lower than the recurrence rate of 40% in pterygia using the bare sclera technique only, hence the need for augmenting treatment with a conjunctival autograft, which is cheap, has few side effects, and has minimal recurrence rate .
Pterygia is more common in men than in women ,,,. The female sex has been reported to be associated with lower occupational or recreational exposure to sunlight. However, greater exposure to the sun alone cannot explain the male preponderance to developing pterygia. It is suggested that other unknown factors probably play a role ,. In a paper comparing the outcomes of pterygium surgery, male patients and patients under 40 years of age were seen to face a greater risk for recurrence .
The results of this study indicate that the male sex is also strongly associated with pterygia recurrence after surgery. Postoperative complications in this study were few, minimal, and were treated completely compared with other methods of preventing recurrence, such as β radiation, intraoperative administration of mitomycin C, and use of amniotic membrane grafts .
In this study, visual acuity improved or remained unchanged in 29 patients (96.7%) and deteriorated in only one (3.3%) at the end of follow-up. These results are better than those obtained by some prospective, randomized studies in which a conjunctival autograft was used after pterygium excision ,,,.
The conjunctival autograft reduces the probability of recurrence after pterygium excision because of the following reasons:
- Limbal stem cells are purposefully included in the transplanted conjunctiva.
- The complete closure of the excision site with relatively normal conjunctival tissue provides a 'fire-break' to the proliferation and advancement of residual abnormal tissue toward and across the limbus.
As surgery was performed by two different surgeons there could have arisen the risk of intersurgeon variation, which could have acted as a limitation on the results of the study. To minimize this, the procedure was standardized, and both surgeons were conversant with the protocol before commencement of the study.
Larger sample sizes and longer follow-up are still needed to provide more precise results concerning the efficacy of this technique.
| Conclusion|| |
This study was carried out to identify a treatment option for recurrent pterygium that would result in lower recurrence rate. The study consisted of patients undergoing pterygium excision with temporary attachment of a conjunctival flap and the results showed a lower recurrence rate of 3.3%.
On the basis of the above findings we conclude that pterygium excision with temporary attachment of a conjunctival flap is a safe, easy, and rapid technique for the treatment of recurrent pterygium with lower recurrence rate and minor postoperative complications. Larger controlled studies with longer follow-up are required.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2]