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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 108  |  Issue : 2  |  Page : 43-46

Inferior limbal conjunctival autografting in primary pterygium


Department of Ophthalmology, El Minia University Hospital, Faculty of Medicine, El Minia University, El Minia

Date of Submission25-Sep-2014
Date of Acceptance29-Apr-2015
Date of Web Publication23-Jul-2015

Correspondence Address:
Farouk M Othman
Ophthalmology Department, El Minia University Hospital, Faculty of Medicine, El Minia University, El Minia 61111

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2090-0686.161385

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  Abstract 

Objective
The aim of this study was to evaluate the outcome of pterygium excision with conjunctival limbal autografting from the lower bulbar conjunctiva for the treatment of primary pterygium.
Patients and methods
This prospective analysis study included 60 eyes of 60 patients with primary pterygium treated by means of pterygium excision with conjunctival limbal autograft from the lower bulbar conjunctiva in El-Minia University Hospital. Patients were examined on the first day, the first week, at 2 weeks, and every month until the 12th month postoperatively. Outcomes were evaluated in terms of complications and recurrence.
Results
During the 12 months of follow-up, postoperative complications occurred in 18 (30%) patients. Recurrence occurred in one (1.7%) eye during the follow-up period.
Conclusion
In patients with primary pterygium, conjunctival limbal autografting from the lower bulbar conjunctiva is an effective technique with a low recurrence rate. It can be a suitable treatment for glaucomatous patients with pterygium to leave the upper bulbar conjunctiva untouched.

Keywords: Autograft, excision, glaucoma, pterygium, recurrence


How to cite this article:
Othman FM. Inferior limbal conjunctival autografting in primary pterygium. J Egypt Ophthalmol Soc 2015;108:43-6

How to cite this URL:
Othman FM. Inferior limbal conjunctival autografting in primary pterygium. J Egypt Ophthalmol Soc [serial online] 2015 [cited 2017 Jun 24];108:43-6. Available from: http://www.jeos.eg.net/text.asp?2015/108/2/43/161385


  Introduction Top


Pterygium is a degenerative ocular surface disorder with wing-shaped fibrovascular growth of the bulbar conjunctiva onto the cornea, which is strongly correlated with ultraviolet light exposure, dryness, and exposure to wind, dust, and heat [1]. The main method of treating a pterygium is by means of surgical excision. Any conservative treatment is mainly symptomatic and temporary, usually for the early stages of the disease [2]. Surgical treatment of pterygium is directed towards excision, prevention of recurrence, and restoration of ocular surface integrity [3]. The main complication of these procedures is the recurrence rate, which has been estimated to be as high as 30-70% in simple excision [4].

In 1985, Kenyon et al. [5] introduced conjunctival autograft as a technique for the treatment of recurrent or advanced pterygium. Conjunctival autograft transplantation following pterygium excision presents the advantage of re-establishing the structure of the limbus. The limbus serves as a generative organ for corneal epithelial stem cells, which facilitate corneal epithelial healing [6]. Several studies have shown that conjunctival autografting has a low recurrence rate, and in all these studies the graft was taken from the superior bulbar conjunctiva [7],[8].

Conjunctival autografting is widely used in pterygium surgery, because it is a safe and effective surgical technique with good esthetic results [9]. Therefore, the purpose of this study was to evaluate the success rates of pterygium excision with conjunctival autografting with graft from the inferior bulbar conjunctiva taking with it the peripheral part of the limbus.


  Patients and methods Top


A total of 60 eyes of 60 patients with primary pterygium were evaluated and operated on. This prospective analysis study was conducted between January 2011 and January 2013 in El-Minia University Hospital. An ethical approval was obtained from the local ethical committee and all patients signed informed consent for the surgical procedure. Only primary pterygium cases were included. Patients with recurrent pterygium, a major systemic disease, ocular surface disease, and ocular surgery or trauma were excluded. Patients with glaucoma were also excluded.

Indications for surgery were classified as follows: symptomatic pterygium if causing redness or irritation; visually threatening pterygium if very close to the pupillary border; and cosmetic pterygium if small and the patient wanted surgery.

The pterygium was graded on the basis of the extent of corneal involvement as follows: grade I, between the limbus and a point midway between the limbus and the pupillary margin [Figure 1]; grade II, the head of the pterygium present between a point midway between the limbus and the pupillary margin and the pupillary margin (nasal papillary margin in case of nasal pterygium and temporal margin in case of temporal pterygium) [Figure 2]; and grade III, crossing the pupillary margin [10].
Figure 1: Grade I pterygium before surgery and at the 12th month postoperatively.

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Figure 2: Grade II pterygium before and at the 12th month postoperatively.

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The patients were treated by means of pterygium excision with conjunctival autografting with the graft taken from the inferior bulbar conjunctiva with the peripheral part of the limbus.

The surgery was performed under peribulbar anesthesia. The outline of the pterygium was defined with gentian violet marker. The bulbar portion (body) of the pterygium was excised carefully down to the sclera using Westcott scissors, removing all of the underlying tenon's capsule [Figure 3]. The body of the pterygium was reflected towards the cornea, and the head of the pterygium was dissected using a no. 15 blade in a direction from the limbus towards the center of the cornea [Figure 4]. Subconjunctival fibrous tissue under the pterygium was excised much more widely compared with the area covered by the pterygium. The conjunctival defect was measured with calipers and gentian violet marker was used to outline the margins of the graft to be created from the inferior bulbar conjunctiva with peripheral part of the limbus. The graft was dissected from the underlying tenon's tissue by injecting 2% lidocaine, followed by blunt and sharp dissection with Westcott scissors and none-toothed forceps [Figure 5]. The graft was sutured to the edges of bulbar conjunctiva with continuous 10-0 nylon ensuring that the epithelial side was up and the limbal edges corresponded [Figure 6]. The sutures were removed at the third week. Postoperatively, topical corticosteroids and antibiotics were administered for ∼3-4 weeks and tear substitutes for 6 weeks.
Figure 3: Excision of the pterygium from the sclera bed.

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Figure 4: Excision of the head of the pterygium from the cornea.

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Figure 5: Taking the conjunctival limbal graft from lower bulbar conjunctiva.

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Figure 6: Suturing the graft in place.

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Patients were examined on the first day, first week, at 2 weeks, first month, and then monthly until the 12th month postoperatively. Outcomes were evaluated in terms of complications and recurrence after pterygium excision. The criterion for recurrence was determined to be fibrovascular tissue invasion of the cornea more than 1 mm in diameter beginning from the limbus at the operation site [11].

Data were entered into SPSS (version 11; SPSS Inc., Chicago, Illinois, USA) and were expressed as frequency, percentage, mean, and SD as applicable.


  Results Top


There were 44 (73%) male and 16 (27%) female patients, with a mean age of 47.5±7.5 years. A total of 46 (77%) eyes were of farmers', and 14 (23%) eyes were of laborers'. Grade II pterygium was diagnosed in 42 (70%) eyes, grade III in 14 (23%) eyes, and grade I in four (6.6%) eyes. The indications of surgery were symptomatic pterygium in 42 (70%) cases, vision threatening pterygium in 14 (23%) eyes, and cosmetic in four (6.6%) eyes [Table 1].
Table 1: Demographic and basic characteristics of the studied patients

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During the follow-up period, postoperative complications occurred in 18 (30%) patients. The reported complications were photophobia in eight (13.3%) eyes, blepharospasm in two (3.3%) eyes, foreign body sensations in 16 (26.6%) eyes, and subconjunctival hemorrhage in two (3.3%) eyes, and postoperative graft edema was observed in 12 (20%) eyes, as some patients showed more than one complication at the same time. All these complications occurred during the first postoperative month and resolved later on. Recurrence occurred in one (1.7%) eye in the third month [Table 2] and [Figure 7].
Figure 7: Postoperative complications.

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Table 2: Postoperative complications

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  Discussion Top


Since its introduction by Kenyon et al. [5], conjunctival autografting has gradually come to be a popular treatment for pterygium. Covering the bare sclera using autologous conjunctival tissue could be performed with a free conjunctival autograft [5]. The free graft is typically harvested from the superior bulbar conjunctiva and sutured to the bare sclera defect after pterygium excision [2]. However, taking the conjunctival autograft from the inferior bulbar conjunctiva may be beneficial to leave the superior bulbar conjunctiva intact for further glaucoma filtering surgery if needed in the future. This makes this technique useful for surgical removal of pterygium in a known glaucoma patient. Moreover, combining the peripheral part of the limbus with the conjunctival graft, which is rich in stem cells may add to the success of the procedure and decrease the recurrence rate.

The current study enrolled 60 patients with primary pterygium, all of whom were farmers and laborers who worked outdoors for long periods and were exposed to the hazardous effects of radiations present in sunlight. These findings were similar to those of most of the published studies [1],[12],[13]. The indication for surgery in this study was mainly symptomatic pterygium, which was consistent with the findings of Nazzulah et al. [14] and Shrestha et al. [1], who reported a similar indication.

The most important finding in the current study was that, within a 12-month follow-up period, about 98% of patients with primary pterygium were successfully treated using pterygium excision with inferior limbal conjunctival autograft without recurrence of pterygial growth. Recurrence occurred in about 2% of eyes; this is in agreement with the findings of Syam et al. [15], who reported a success rate of about 97% and a recurrence rate of about 3%. The use of mitomycin c in the technique of pterygium excision with bare sclera may decrease the recurrence rate, but it can cause local scleral necrosis. In the literature, recurrence rates reported for pterygium excision with conjunctival autografting are generally low [9],[14],[16]. The graft success is enhanced by the use of minimal cautery, ensuring the graft is tenon free, countering postoperative graft retraction by using a slightly oversized (by 1 mm) graft, and taking a peripheral part of the limbus [2].

Ideally, pterygium surgery should have a low or no recurrence, minimal adverse events, and be cosmetically acceptable [17]. Limbal conjunctival autograft may yield better results by acting as a barrier against fibrovascular invasion of the cornea and supplying stem cells to the corneal epithelium [18].

In conclusion, the low recurrence rate and few postoperative complications of the inferior limbal conjunctival autograft as shown in the current study renders this procedure suitable for the treatment of primary pterygium, especially in glaucoma patients in whom the superior bulbar conjunctiva is valuable.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Shrestha A, Shrestha A, Bhandari S, Maharjan N, Khadka D, Pant SR, Pant BP. Inferior conjunctival autografting for pterygium surgery: an alternative way of preserving the glaucoma filtration site in far western Nepal. Clin Ophthalmol 2012; 6 :315-9.  Back to cited text no. 1
[PUBMED]    
2.
Mohammed I. Treatment of pterygium. Ann Afr Med 2011; 10 :197-203.  Back to cited text no. 2
    
3.
Mahdy SAE, Bhatia J. Treatment of primary pterygium: role of limbal stem cells and conjunctival autograft transplantation. Oman J Ophthalmol 2009; 2 :23-26.  Back to cited text no. 3
    
4.
Jaros PA, DeLuise VP. Pingueculae and pterygia. Surv Ophthalmol 1988; 33 :41-49.  Back to cited text no. 4
    
5.
Kenyon KR, Wagoner MD, Hettinger ME. Conjunctival autograft transplantation for advanced and recurrent pterygium. Ophthalmology 1985; 92 :1461-1470.  Back to cited text no. 5
[PUBMED]    
6.
Starck T, Kenyon KR, Serrano F. Conjunctival autograft for primary and recurrent pterigia: surgical technique and problem management. Cornea 1991; 10 :196-202.  Back to cited text no. 6
    
7.
Lewallen S. A randomized trial of conjunctival auto grafting for pterygium in the tropics. Ophthalmology 1989; 96 :1612-1614.  Back to cited text no. 7
    
8.
Ozkurt YB, Kocams O, Comez AT, Uslu B, Dogan OK. Treatment of primary pterygium. Optom Vis Sci 2009; 86 :1178-81.  Back to cited text no. 8
    
9.
CelevaMarkovska V, StankovicBabic G, Zdravkovska Jankuloska M. Comparative study of pterygium surgery. Prilozi 2011; 32 :273-287.  Back to cited text no. 9
    
10.
Maheshwari S. Pterygium-induced corneal refractive changes. Indian J Ophthalmol 2007; 55 :383-386.  Back to cited text no. 10
    
11.
Al Fayez MF. Limbal versus conjunctival autograft transplantation for advanced and recurrent pterygium. Ophthalmology 2002; 109 :1752-1755.  Back to cited text no. 11
    
12.
Yanoff M, Duker JS. Conjunctival and corneal degenerations. Ophthalmology 2004; 1 :446-447.  Back to cited text no. 12
    
13.
Threlfall TJ, English DR. Sun exposure and pterygium of the eye: a dose-response curve. Am J Ophthalmol 1999; 128 :280-7.  Back to cited text no. 13
    
14.
Nazzulah, Shah A, Mustaque A, Abdul B, Khan MS, Nasir S. Recurrence rate of pterygium: a comparison of bare sclera and free conjunctival autograft. J Med Sci 2010; 18 :36-39.  Back to cited text no. 14
    
15.
Syam PP, Eleftheriadis H, Liu CS. Inferior conjunctival autograft for primary pterygia. Ophthalmology 2003; 110 :806-10.  Back to cited text no. 15
    
16.
Koch JM, Mellin KB, Waubke TN. Initial experience with autologous conjunctiva/limbus transplantation in pterygium. Klin Monbl Augenheilkd 1990; 197 :106-109.  Back to cited text no. 16
    
17.
Fernandes M, Sangwan VS, Bansal AK, Gangopadhyay N, Sridhar MS, Garg P, et al. Outcome of pterygium surgery: analysis over 14 years. Eye (Lond) 2005; 19 :1182-90.  Back to cited text no. 17
    
18.
Tananuvat N, Martin T. The results of amniotic membrane transplantation for primary pterygium compared with conjunctival autograft. Cornea 2004; 2:458-63.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2]



 

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