Current Eye Research, Early Online, 1–6, 2014 ! Informa Healthcare USA, Inc. ISSN: 0271-3683 print / 1460-2202 online DOI: 10.3109/02713683.2014.961612

RESEARCH REPORT

Comparison of Inferior and Superior Conjunctival Autograft for Primary Pterygium Qi Chen1*, Yun Li1,2*, Fan Xu1*, Yumei Yan1, Kewei Lu1, Ling Cui1, and Min Li1

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Department of Ophthalmology, People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, People’s Republic of China and 2Guangxi Medical University, Nanning, Guangxi, People’s Republic of China

ABSTRACT Purpose: To determine the postoperative symptom by using inferior conjunctival autografting (ICA) rather than superior conjunctival autografting (SCA) after excision of pterygium. Methods: This prospective randomized control study evaluated 80 eyes of 80 consecutive patients undergoing primary pterygium surgery. Patients in each subgroup were then randomized into the ICA (n = 40) or SCA (n = 40) group. All patients were asked to return for follow up on days 1, 2, 3, 5, 7, and 14 then at months 1, 3, 6, and 12 postoperatively. Outcome measures were postoperative patient discomfort, corneal epithelial healing time, complications and recurrence rate. Results: Fluorescein staining revealed complete corneal epithelial healing time was 3.1 ± 0.5 d (range 2–4) in the ICA group and 3.3 ± 0.6 d (range 2–4) in the SCA group (p = 0.11). Pain scores were significantly less in the ICA group than the SCA group on follow-up days 3 and 5 (p50.05). Postoperative foreign body sensation scores on follow-up days 5 and 7 were significantly lower in the ICA group than the SCA group (p50.05). Epiphora scores were significantly less in the ICA group than the SCA group on follow-up days 3, 5, and 7 (p50.05). No statistically significant differences between two groups were found for the overall (conjunctival and corneal) recurrence rates (5% versus 7.5%, p = 0.64). No serious complications were encountered. Conclusion: Pterygium excision with ICA led to less postoperative discomfort for patients with primary pterygium. Keywords: Inferior conjunctival autograft, primary pterygium, superior conjunctival autograft

INTRODUCTION

pterygium excision is the major adjunct treatment for the prevention of pterygium recurrence.1–4 Generally, the conjunctival graft is harvested from the superior bulbar conjunctiva, which has been shown to adversely affect the outcome of future filtration surgery. Thus, inferior bulbar conjunctiva, as an alternative donor site, has been suggested in pterygium surgery.5,6 Our objective was to determine the recurrence rate and postoperative symptom by using inferior conjunctival autografting (ICA) rather than superior conjunctival autografting (SCA) after excision of pterygium.

Pterygium is a common ocular surface disorder characterized by a fibrovascular growth arising from the bulbar conjunctival epithelium and extending onto the cornea. Treatment of choice for pterygium is surgical excision; however, recurrence remains the prime challenge. There are numerous different surgical techniques used to prevent recurrence of pterygium, such as conjunctival autografting, beta-irradiation or topical thiotepa, mitomycin C, or 5-fluorouracil.1 Conjunctival autografting after

Received 20 June 2013; revised 25 August 2014; accepted 26 August 2014; published online 26 September 2014 *The first three authors contributed equally to this work Correspondence: Qi Chen, Department of Ophthalmology, People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, People’s Republic of China. Tel: +86-771-2186320. Fax: +86-771-2102018. E-mail: [email protected]

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MATERIALS AND METHODS This prospective randomized control study evaluated 80 eyes of 80 consecutive patients undergoing primary pterygium surgery from August 2009 to August 2011 at the People’s Hospital of Guangxi Zhuang Autonomous Region in China. The protocol was approved by the ethics committee of the People’s Hospital of Guangxi Zhuang Autonomous Region and full informed consent was obtained in all patients. The study conformed to the provisions of the Declaration of Helsinki. Only primary nasal pterygium (grade 1, 2 or 3) greater than 2 mm in size with a history of change was included. Exclusion criteria included patients with major systemic diseases and a history of an earlier ocular surgery or trauma, glaucoma. Also, patients using artificial tears, topical or systemic steroids, or non-steroidal anti-inflammatory agents were not included. Sample size estimation was determined by power analysis. The following assumptions were made: false positive of 0.05, false negative of 0.95, success rates of the two groups set at 40% and 80%, respectively. Thus, a minimum of 37 patients in each group were needed. Therefore, 80 eyes of 80 consecutive patients were enrolled and patients in each subgroup were then randomized into the ICA (n = 40) or SCA (n = 40) group using a list created by a random number generator. If both eyes were eligible for the study, one eye of the patient was included randomly.

Preoperative At the preoperative visit, patient demographics characteristics, best corrected visual acuity and complete ophthalmic examinations, including slit-lamp biomicroscopy, funduscopy, and intraocular pressure assessment, were recorded by an independent investigator (Yumei Yan). The morphology of the pterygium was graded according to the grading system used by Tan et al.7 as grade 1 (atrophic) with episcleral vessels under the body of the pterygium not obscured and clearly distinguishable; grade 3 (fleshy) with episcleral vessels totally obscured; or grade 2 (intermediate) for all other pterygia not falling into grades 1 or 3.

Surgical Procedure A single surgeon (Qi Chen) performed all surgeries under an operating microscope. The length was measured with a caliper, and the area was recorded. The head of the pterygium is similar in shape to a triangle. The area of the head of the pterygium = (length of limbus  length of vertical line from the apex of pterygium head to limbus)/2. Then, the

involved eye was anesthetized with a combination of topical (0.5% proparacaine hydrochloride, Alcaine, Alcon, Belgium) and subconjunctival (lidocaine hydrochloride 40 mg/2 ml, Hefeng, Shanghai, China) anesthetic. The head of the pterygium was avulsed off the limbal margin up to the central cornea using blunt dissection with tooth forceps and excised with conjunctival scissors. Then, fibrovascular tissue underlying the pterygium was exposed by blunt and sharp dissection up to the semilunar fold. This portion was excised 1 mm away from the lacrimal caruncle. The wound bed was smoothed with a crescent blade and only bleeding vessels were cauterised. The bare sclera is similar in shape to a trapezoid. The area of the bare sclera = length of cross line between limbus and the opposite side  (length of limbus + length of the opposite side)/2. It was not until the pterygium was completed excised that the surgeon was informed the selection of a graft donor site. The dimensions of the bare sclera bed were measured with a caliper. A free conjunctival graft with an additional 1.0 mm of length and width was harvested from the inferior bulbar conjunctiva (ICA group) or superior bulbar conjunctiva (SCA group). Care was taken to include as little of Tenon’s tissue as possible when preparing the graft. The limbal edge of the graft was cut to contain a thin rim of corneal epithelium using a No.15 blade. The graft was then carefully flipped over to the scleral surface in order to maintain the epithelium side facing up and the limbal edge toward the limbus. The graft was welded to the surrounding conjunctiva using an electrocautery pen (YZ-II, Shanmu, Daliang, China), based on one of our group’s previous studies.8 The eye was pressure patched and shielded after application of 0.3% tobramycin and 0.1% dexamethasone ophthalmic ointment (TobraDex, Alcon, Belgium) for 24 h to restrict the eyeball from movement or blinking.

Postoperative After surgery, slit-lamp biomicroscopy examination was performed daily and the corneal epithelial wounded area was stained with fluorescein and measured. The operated eye was patched (3–4 d) with 0.3% tobramycin and 0.1% dexamethasone ophthalmic ointment. After complete corneal epithelial healing, levofloxacin (Cravit, Santen, Osaka, Japan) and 0.1% fluoromethalone (Santen, Osaka, Japan) eye drops were used six times per day for 2 weeks and four times per day for the following 2 weeks. The primary outcome of this study was to evaluate postoperative symptom at study design. Postoperatively, a single investigator (Kewei Lu) examined subjects in both groups without being informed which method was used on each patient. All patients were asked to return for follow up on days 1, 2, 3, 5, 7, and Current Eye Research

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Inferior and Superior Conjunctival Autograft 3 14 then at months 1, 3, 6, and 12 postoperatively. Best corrected visual acuity, slit-lamp, intraocular pressure, and funduscopy examinations were performed during each postoperative visit. Complaints and complications were noted. A recurrence grading system devised by Prabhasawat et al.4 was used. Following this grading system, grade 1 indicated a normal appearance of the operated site; grade 2 indicated the presence of fine episcleral vessels without fibrous tissue in the excised area that extended to but not past the limbus; grade 3 indicated a conjunctival recurrence with additional fibrovascular tissue in the excised area that did not invade the cornea; and grade 4 indicated a corneal recurrence with fibrovascular tissue invading the cornea. The postoperative symptom evaluations were assessed by an ophthalmologist (Ling Cui) at each postoperative examination until the second week. The evaluation included a grading of their symptoms (pain, foreign body sensation, and epiphora) using a five-point scale developed by Lim-Bon-Siong et al.9 The five-point scale is a simple scale of 0–4: 0 = no symptom at all; 1 = presence of the symptom but easily tolerated; 2 = presence of the symptom causing some discomfort; 3 = presence of the symptom causing discomfort that interferes with usual activity or sleep; 4 = presence of the symptom that completely interferes with usual activity or sleep.

Statistical Analysis Statistical analyses were carried out with SPSS software (SPSS, version 13.0, SPSS, Chicago). The Mann– Whitney U and chi-square tests were applied, as appropriate, to compare the variables. A p value less than 0.05 was considered statistically significant.

RESULTS All patients completed the 12-month follow-up period. Demographic data of patients in both groups

were summarized in Table 1. Mean age of the patients (±SD) was 55.4 ± 10.1 years in the ICA group and 56.2 ± 9.7 years in the SCA group. There were 18 men and 22 women in both groups. There was no statistically significant difference between the two groups in terms of age, gender or pterygium types (Table 1). Also, the difference between groups with respect to the area of the pterygium head (9.8 ± 2.0 mm2 versus 10.2 ± 1.5 mm2, p = 0.31) and scleral defect (34.8 ± 3.9 mm2 versus 34.6 ± 4.3 mm2, p = 0.83) was not significant. Figure 1 shows the preoperative appearance as well as early postoperative appearances of the patients in the ICA and SCA groups. There were no intraoperative complications in any eyes. Fluorescein staining revealed that the complete corneal epithelial healing time was 3.1 ± 0.5 d (range 2–4) in the ICA group and 3.3 ± 0.6 d (range 2–4) in the SCA group (p = 0.11). In the ICA group, one patient (2.0%) developed an inferior donor site granuloma 1 week after surgery, which was resolved after treatment with 0.3% tobramycin and 0.1% dexamethasone ophthalmic suspension for 1 week. None of the patients developed complications such as graft dehiscence, symblepharon, infection, pannus formation, giant papillary conjunctivitis, significant tissue shrinkage, or corneal defects. Conjunctival recurrence (grade 3) was observed in one patient (2.5%) in the ICA group and in two patients (5%) in the SCA group during the 12month follow-up period. One corneal recurrence (grade 4) in the both groups (2.5%) was recorded. No statistically significant differences between two groups were found for the overall (conjunctival and corneal) recurrence rates (5% versus 7.5%, p = 0.64). Pain scores were significantly less in the ICA group than the SCA group on follow-up days 3 and 5 (p50.01, p = 0.04, respectively), but no significant differences were found on days 1, 2, 7, and 14 (p = 0.76, p = 0.81, p = 1.00, p = 1.00, respectively) (Figure 2). Postoperative foreign body sensation scores on follow-up days 5 and 7 were significantly

TABLE 1. Patient characteristics in the ICA and SCA groups.

Mean (SD) age, years Sex Male (%) Female (%) Pterygium grade Grade 1 (%) Grade 2 (%) Grade 3 (%) Area of the pterygium head (mm2) Area of the scleral defect (mm2)

ICA group, n = 40

SCA group, n = 40

p Value

55.4 (10.1)

56.2 (9.7)

0.72

18 (45.0%) 22 (55.0%)

18 (45.0%) 22 (55.0%)

1.00 1.00

0 (0%) 14 (35.0%) 26 (65.0%) 9.8 (2.0) 34.8 (3.9)

0 (0%) 15 (37.5%) 25 (62.5%) 10.2 (1.5) 34.6 (4.3)

1.00 0.82 0.82 0.31 0.83

ICA: inferior conjunctival autografting; SCA: superior conjunctival autografting. !

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FIGURE 1. Pterygium excision with superior conjunctival autograft (A–C) and inferior conjunctival autograft (D–F). (A) Preoperative grade 2 primary pterygium. (B) The graft site, 1 day postoperatively. (C) The superior donor site, 1 day postoperatively. (D) Preoperative grade 2 primary pterygium. (E) The graft site, 1 day postoperatively. (F) The inferior donor site, 1 day postoperatively.

FIGURE 2. Five-point scale assessment of postoperative pain at 1, 2, 3, 5, 7, and 14 d after pterygium surgery.

lower in the ICA group than the SCA group (p50.01, p = 0.03, respectively), but there were no statistically significant difference in the scores on days 1, 2, 3, and 14 (p = 0.22, p = 0.50, p = 0.18, p = 0.32, respectively) (Figure 3). Epiphora scores were significantly less in the ICA group than the SCA group on follow-up days 3, 5, and 7 (p50.01, p50.01, p50.01, respectively), but there were no statistically significant difference in the scores on days 1, 2, and 14 (p = 0.40, p = 0.13, p = 1.00, respectively) (Figure 4).

FIGURE 3. Five-point scale assessment of postoperative foreign-body sensation at 1, 2, 3, 5, 7, and 14 d after pterygium surgery.

DISCUSSION After surgery, the surgeon should aim to decrease patient discomfort in the postoperative period.10 The ICA method described here was devised to address patient’s discomfort, especially postoperative pain, foreign body sensation, and epiphora. In addition, postoperative corneal epithelial defect and recurrence rate were of concern. Current Eye Research

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Inferior and Superior Conjunctival Autograft 5

FIGURE 4. Five-point scale assessment of postoperative epiphora at 1, 2, 3, 5, 7, and 14 d after pterygium surgery.

This study confirmed the benefits of using ICA over SCA with regard to postoperative discomfort. There were no significant differences in the symptoms scores between the two groups in the first 48 postoperative hours: this is probably due to the cornea epithelial defect created during the pterygium excision.11,12 However, the postoperative patient symptoms were much less in the ICA group on follow-up days 3 to 7, especially in terms of the epiphora. Blink-related microtrauma has been implicated as a cause for ocular surface disorder, such as superior limbic keratoconjunctivitis.13,14 We speculated that the upper eyelid had a greater range of motion than lower eyelid, which might produce more ocular surface inflammation due to friction on the upper bulbar conjunctiva defect area during blinking. Ocular surface inflammation plays an important role as both a cause and a consequence in the development of early postoperative tear film instability. This leads to a series of physiopthaological alterations and dry eye symptoms.15 Meanwhile, more early postoperative ocular surface inflammation and tear film instability may contribute to longer corneal epithelial healing time in the SCA group that also increased postoperative discomfort.15–17 The exact mechanisms for each factor needs further research. It should be noted that the absolute decreases in post-operative symptoms were small. According to our previous study, this was due to the fact that postoperative discomfort was significantly lower by an electrocautery pen rather than sutures when attaching the graft.8 However, pterygium excision with ICA still seems to help to reduce postoperative discomfort. Prospective series in literature report recurrence rates of 0–5.25% after primary pterygium surgery using ICA,5,6,18,19 and a follow-up period for as long as 1 year was recommended for clinical studies to identify recurrence of pterygium.20 Our study has !

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shown that the total recurrence rate in the ICA group was 5%, and all of the recurrences occurred within 6 months after surgery. Compared with the SCA, the use of ICA seemed to have no additional lowering effect on pterygium recurrence. Except for a low incidence (2.0%) of granuloma, we did not find any serious complication in the ICA group during the follow-up period. Complications were defined as any corneal defects, significant tissue shrinkage, giant papillary conjunctivitis, pannus formation, symblepharon, graft dehiscence, or infection. Another advantage of ICA was that it helped preserve the superior conjunctiva for filtering glaucoma surgery in patients with suspected or proven glaucoma.5 There were some limitations to this study that need to be acknowledged. First, the electrocautery pen used for the attachment of conjunctival autograft had not been widely adopted in pterygium surgery, thus limiting the universal translatability of our results. Second, besides blinding the postoperative observer to the patient randomization, the site of harvesting graft would have been obvious. It may affect the objectivity of postoperative outcome measures. Third, 40 patients in each group were enrolled, but it did not have enough statistical power to pick up recurrence accurately as risk is 5%. Further studies with a larger sample size are needed to confirm the results of this study. In summary, pterygium excision with ICA led to less postoperative discomfort for patients with primary pterygium. This technique should be viewed as a useful method for all patients with primary pterygium, especially when there is a potential filtering glaucoma surgery. Further confirmation of the benefits of this technique will be carried out with a multicenter prospective trial.

DECLARATION OF INTEREST The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article. This study was supported by Health Department of Guangxi Zhuang Autonomous Region (No. Z2009123) and Science Fund Project of People’s Hospital of Guangxi Zhuang Autonomous Region (No. qn2014-1).

REFERENCES 1. Mohammed I. Treatment of pterygium. Ann Afr Med 2011; 10:197–203. 2. Kenyon KR, Wagoner MD, Hettinger ME. Conjunctival autograft transplantation for advanced and recurrent pterygium. Ophthalmology 1985;92:1461–1470. 3. 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;120:151–160.

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4. 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. 5. Syam PP, Eleftheriadis H, Liu CS. Inferior conjunctival autograft for primary pterygia. Ophthalmology 2003;110: 806–810. 6. 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: 315–319. 7. 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. 8. Xu F, Li M, Yan Y, Lu K, Cui L, Chen Q. A novel technique of sutureless and glueless conjunctival autografting in pterygium surgery by electrocautery pen. Cornea 2013;32: 290–295. 9. Lim-Bon-Siong R, Valluri S, Gordon ME, Pepose JS. Efficacy and safety of the ProTek (Vifilcon A) therapeutic soft contact lens after photorefractive keratectomy. Am J Ophthalmol 1998;125:169–176. 10. Julio G, Lluch S, Pujol P, Merindano D. Ocular discomfort in pterygium patients. Optom Vis Sci 2013;90:269–274. 11. Dushku N, John MK, Schultz GS, Reid TW. Pterygia pathogenesis: corneal invasion by matrix

12.

13.

14. 15.

16.

17.

18.

19.

20.

metalloproteinase expressing altered limbal epithelial basal cells. Arch Ophthalmol 2001;119:695–706. Al-Aqaba MA, Fares U, Suleman H, Lowe J, Dua HS. Architecture and distribution of human corneal nerves. Br J Ophthalmol 2010;94:784–789. Sangwan VS, Tseng SC. New perspectives in ocular surface disorders. An integrated approach for diagnosis and management. Indian J Ophthalmol 2001;49:153–168. Cher I. Blink-related microtrauma: when the ocular surface harms itself. Clin Exp Ophthalmol 2003;31:183–190. Stevenson W, Chauhan SK, Dana R. Dry eye disease: an immune-mediated ocular surface disorder. Arch Ophthalmol 2012;130:90–100. Sakimoto T, Sawa M. Metalloproteinases in corneal diseases: degradation and processing. Cornea 2012;31: S50–S56. Lan W, Petznick A, Heryati S, Rifada M, Tong L. Nuclear Factor-kappaB: central regulator in ocular surface inflammation and diseases. Ocul Surf 2012;10:137–148. Massaoutis P, Khemka S, Ayliffe W. Clinical outcome study of a modified surgical technique for pterygium excision. Can J Ophthalmol 2006;41:704–708. Kawano H, Kawano K, Sakamoto T. Separate limbalconjunctival autograft transplantation using the inferior conjunctiva for primary pterygium. Oman J Ophthalmol 2011;4:120–124. Avisar R, Arnon A, Avisar E, Weinberger D. Primary pterygium recurrence time. Isr Med Assoc J 2001;3: 836–837.

Current Eye Research

Comparison of Inferior and Superior Conjunctival Autograft for Primary Pterygium.

To determine the postoperative symptom by using inferior conjunctival autografting (ICA) rather than superior conjunctival autografting (SCA) after ex...
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