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| REVIEW ARTICLE |
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| Year : 2017 | Volume
: 4
| Issue : 1 | Page : 4-7 |
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Changing trends in pterygium management
Prabhakar Srinivasapuram Krishnacharya, Anuj Singhal, Pooja A Angadi, A Shamsiya Naaz, A Raghavender Reddy
Department of Ophthalmology, JSS Medical College and Hospital, JSS University, Mysore, Karnataka, India
| Date of Web Publication | 8-May-2017 |
Correspondence Address:
Prabhakar Srinivasapuram Krishnacharya
57, 8th Cross, 4th Main, Vinayaka Nagara, Mysore - 570 012, Karnataka
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/1858-6538.205798
Pterygia are progressive unilateral or bilateral ocular surface growths that develop within palpebral aperture area that leads to contour disruption with symptoms ranging from foreign body sensation to cosmetic blemish. Commonly, they appear during the active period of human life, generally between third and fourth decade. Fate of pterygium spans from progressive growth in its earlier stages that undergo diversity of changes such as inflammation, infection, and degeneration ultimately ending in regressive stage during the sixth to eighth decade of life. Pterygium recurrence is the main complication encountered by surgically treating it with or without adjuvant. Not uncommonly pterygium occurrence had been described during childhood that resolved by conservative treatment. Untreated pterygia might grow exuberantly with the invasion of corneal layers, which might result in significant visual loss due to visual axis obstruction and high astigmatism. Therefore, it is justifiable to treat pterygia at any clinical stage of presentation to prevent ocular morbidity and recurrences. Common misbelief in letting the pterygia until corneal encroachment develops should be made understandable to public by conducting awareness programs. Primary objectives of the present review article are to search for the most successful method in terms of nil to low recurrence rates by various modality of treatment and to arrive at promising surgical technique that provided maximum relief in terms of survival rates on the basis of follow-up duration. Secondary objectives are related to intra- and post-operative complications, which have an effect on the ocular surface and final visual gain or loss.
Keywords: Amniotic membrane graft, antivascular endothelial growth factors, conjunctival autograft, limbal conjunctival autograft, mitomycin C
How to cite this article:
Krishnacharya PS, Singhal A, Angadi PA, Naaz A S, Reddy A R. Changing trends in pterygium management. Albasar Int J Ophthalmol 2017;4:4-7 |
| Introduction | |  |
Pterygium recurrence that leads to limbal region destruction may be linked to the locally invasive behavior of benign infiltrating growths in other parts of body. Bare sclera technique, beta irradiation, and buccal mucous membrane grafting in the present era of pterygium management are totally replaced by more promising methods with very low recurrence rates and low incidence of long-term postoperative complications. In our previous two published studies, autologous conjunctival grafting showed reliable results with very low recurrence rate compared to mitomycin C (MMC) that revealed unpredictable ocular surface problems with moderately acceptable success rate.[1] Another was a prospective study that revealed hundred percent success rates and zero recurrence rates with autologous limbal conjunctival grafting for primary pterygium.[2]
The purpose of the present review on pterygium is to identify the most successful method with least recurrence rates and low complications with longer graft survival rates. Pub med literature was searched for published papers within 5 years focusing on recurrence rates and pterygium related complications. Statistical analysis performed on sample size, method chosen, intra- and post-operative complications, recurrence rates, follow-up duration and graft survival rates. Recurrences rates for conjunctival grafting group with or without adjuvant (antimitotic agents), limbal conjunctival group with or without adjuvant (antimitotic agents), and MMC applications only and amniotic membrane transplantation (AMT) were analyzed.
| Results and Discussion | | |
A literature search was performed in PubMed database for the analysis of recurrence rates and complications with respect to various modalities of pterygium treatment are discussed under following subheadings. Best method was selected on the basis of larger sample size, longer graft survival rate with longer follow-up duration, and zero recurrence rates.
Results analyses of prospective studies [Figure 1]
Simple conjunctival autograft as monotherapy
Among four searched prospective research article, Hirst study revealed largest sample size of 1000 pterygia that was followed up for 12 months with only one recurrence implying promising results with conjunctival autograft (CAU). However, a long follow-up is essential before branding this method as sole preferred technique. Another reason for almost nil recurrence in the same study might be meticulous conjunctival epithelial dissection that is devoid of any substantia propria during graft preparation.[3],[4],[5],[6]
Limbal conjunctival autograft as monotherapy
Five prospective research papers described the role of limbal CAU (LCAU) as sole therapy with almost 0 recurrence rate with manageable intra- and post-operative complications although with small sample sizes and shorter follow-up duration could be validated as the most promising method. Young AL study had 10 years follow-up that showed graft survival of LCAU with very low recurrence rate in two cases (6.9%) with small sample size and reported intraoperative MMC use not associated with long-term loss of corneal endothelial cells. Although LCAU method seems to be time-consuming, one can pick up the knack of technique in due course of time with dedicated practice.[7],[8],[9],[10],[11]
Amniotic membrane transplantation grafting as monotherapy
We did not find larger prospective studies on amniotic membrane grafting as sole method for pterygial management despite very low recurrence rates published by previous studies.[12]
Mitomycin C as monotherapy
The role of MMC as for monotherapy is controversial due to unpredictable early and late postoperative complications, large variations in concentration, application time, dose and time of frequency, and route of administration. Five prospective studies employed MMC and reported various complications sometime leading to significant visual and ocular surface problems. Pre- and intra-operative or subpterygial, subconjunctival injection was given, and some studies used topical application during the pre-, intra-, and post-operative course of management.
In view of small sample size and shorter follow-up duration with unpredictable ocular side effects, it seems that MMC applicability is associated with very high degree of its use in dosage and duration with and of expectation with postoperative complication although these studies reported very low recurrence rates. Really speaking ocular complications are more difficult to accept than the recurrent pterygium itself.[13],[14]
Role of grafting with adjuvant application
Conjunctival autograft with mitomycin C/5 fluorouracil
MMC and 5-fluorouracil were most commonly used adjuvants along with grafting procedures in pterygium management. Three prospective studies found that showed the difference in concentration and application duration along with CAU. In spite of low recurrence rates sample size and follow-up, duration was inadequate to validate this procedure. However, in view of MMC and 5 Fu in producing adverse effects, still CAU alone could be performed without the use of an adjuvant.[15],[16]
Conjunctival autograft versus amniotic membrane transplantation
Toker reported higher recurrence rate with AMT when fixed with fibrin glue, and Nguyen stated that pterygium surgery with AMT had less conjunctival inflammation and dry eye in patients receiving fibrin glue than those with Vicryl 8–0 sutures.
Antivascular endothelial growth factors in pterygium management
With the advent of antivascular endothelial growth factor (VEGF) agents' diabetic retinopathy induced neovascularization treatment had dramatically changed in recent past years. With successful treatment of posterior segment inflammation now anti-VEGF administration has a questionable role in corneal vascularization, anterior segment inflammation, and pterygium management. Greater risk of subconjunctival hemorrhage was observed in a meta-analyses on randomized controlled trial (RCT) on pterygium treatment with bevacizumab institution. Recurrence rates are still higher with anti-VEGF for pterygium management. Published studies showed limitations in sample size and longer duration of follow-up with higher recurrence compared to CAU and LCAU procedures and no statistical significance with the dose of bevucizumab [17],[18],[19],[20] [Table 1]. | Table 1: Recurrence rates following bevacizumab administration in pterygium management
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Results analyses from retrospective studies [Figure 2] | Figure 2: Analyses of recurrent rates (blue) and odds ratio (red) from retrospective studies
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There were five searched retrospective designed research articles elaborated on investigating recurrence rates following MMC, CAU, AMT, and CAU with MMC as an adjuvant. Limitation was small sample size except in Masuda study of 1482 pterygium eyes subjected for CAU with MMC as an adjuvant with very low recurrence rate (3.96%) and follow-up duration of 1 year with acceptable recurrence rates.[21],[22],[23],[24]
Shi recommended abandoning of MMC for not having any added advantage over LCAU rather it produced long-term adverse effects on ocular surface. Khakshoor observed scleral whitening and hypovascularity as secondary complications. Lindquist studied 16 pterygium eyes and found MMC-induced scleral stromolysis. Risk factors for recurrence found to be pterygium surgery in younger age group and toward higher grade of pterygium growth.[25],[26]
Secondary complications that were managed successfully were Dellen ulcer, tenons cyst, suture granuloma formation, pyogenic granuloma, graft retraction, graft edema, graft hemorrhagic edema, graft bleed graft dehiscence, irritative symptoms, scleral thinning, persistent redness, secondary epithelialization, conjunctival inflammation, infection, scleromalacia, impaired visual acuity, and strabismus.
| Conclusion | | |
Summary of the important results include successful treatment with CAU as monotherapy and CAU with intraoperative MMC as adjuvant followed by LCAU as sole therapy with nil to very low recurrence rates based on RCTs, prospective, meta-analyses retrospective studies. Future implications of this review would be on community-based research with large sample size inclusion and longer follow-up duration to know regarding graft survival period and achieve hundred percent success rates.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 2. | Prabhakar SK. Safety profile and complications of autologous limbal conjunctival transplantation for primary pterygium. Saudi J Ophthalmol 2014;28:262-7. |
| 3. | Hirst LW. Recurrence and complications after 1,000 surgeries using pterygium extended removal followed by extended conjunctival transplant. Ophthalmology 2012;119:2205-10. |
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| 19. | Ozsutcu M, Ayintap E, Akkan JC, Koytak A, Aras C. Repeated bevacizumab injections versus mitomycin C in rotational conjunctival flap for prevention of pterygium recurrence. Indian J Ophthalmol 2014;62:407-11. [ PUBMED] [Full text] |
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| 23. | Chan TC, Wong RL, Li EY, Yuen HK, Yeung EF, Jhanji V, et al. Twelve-year outcomes of pterygium excision with conjunctival autograft versus intraoperative mitomycin C in double-head pterygium surgery. J Ophthalmol 2015;2015:891582. |
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[Figure 1], [Figure 2]
[Table 1]
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