Original Paper Ophthalmic Res 2014;51:52–58 DOI: 10.1159/000355075
Received: May 6, 2013 Accepted after revision: August 2, 2013 Published online: November 20, 2013
Pterygium Recurrence, Astigmatism and Visual Acuity following Bare-Sclera Excision and Conjunctival Autograft with or without Additional Phototherapeutic Keratectomy Julia Promesberger Sharmila Kohli Holger Busse Constantin E. Uhlig Department of Ophthalmology, University Clinics, Münster, Germany
Abstract Background: Treatment outcome in patients with pterygium following bare-sclera excision and conjunctival autograft (CAG) with and without phototherapeutic keratectomy (PTK). Methods: Retrospective comparative analysis of 81 eyes, with primary and recurrent pterygia, that were analyzed for recurrence, best-corrected visual acuity (BCVA) and astigmatism in primary (P1 without PTK, P2 with PTK) and recurrent pterygia (R1 without PTK, R2 with PTK). BCVA and astigmatism were compared in patients with simple CAG alone (group I) or in combination with PTK (group II). Results: Recurrence rates were 4.7, 11.6, 16.2, 23.2 and 32.5% at 3, 6, 12, 24 and >24 months (P1), 7.1% at >24 months (P2). Recurrence rates were 5.3, 10.5, 21.1, 21.1 and 26.3% at 3, 6, 12, 24 and >24 months (R1) and 1 recurrence (7.7%) till month 24, and 3 (23.1%) thereafter (R2). BCVA increased from logarithm of the minimal angle of resolution 0.095 ± 0.141 (mean ± SD) at baseline to 0.066 ± 0.09 (group I), and from 0.090 ± 0.164 to 0.054 ± 0.124 (group II). Astigmatism decreased
© 2013 S. Karger AG, Basel 0030–3747/14/0511–0052$39.50/0 E-Mail [email protected] www.karger.com/ore
from –1.01 ± 0.90 dpt at baseline to –0.97 ± 1.24 dpt (group I), and from –1.19 ± 1.55 to –0.75 ± 0.87 dpt (group II). Conclusion: In comparison to CAG alone, additional excimer smoothing with PTK tends to increase BCVA and reduces recurrence rates in patients with primary pterygia. © 2013 S. Karger AG, Basel
Introduction
Pterygium is a fibrovascular conjunctival degeneration that is characterized by invasive centripetal growth and associated inflammation and neovascularization [1], which progressively induces astigmatism and decreases visual acuity. Although attributed to chronic ultraviolet B exposure, defective regulation of apoptosis and presumably immunological mechanisms may also be involved [2]. The hereditary factors are still not clear, and the pathogenesis of this condition remains incompletely understood [2]. Various microsurgical techniques, such as bare-sclera excision with or without autologous conjunc-
J. Promesberger and C.E. Uhlig contributed equally to this paper.
Constantin E. Uhlig University Eye Hospital, University Clinics Münster Albert Schweitzer Campus 1, Building D15 DE–48149 Münster (Germany) E-Mail uhligc @ uni-muenster.de
Downloaded by: NYU Medical Center Library 128.122.253.212 - 5/18/2015 4:25:18 AM
Key Words Pterygium · Bare-sclera resection · Excimer smoothing · Cornea · Astigmatism · Recurrence
Material and Methods This study performed a retrospective analysis of patients suffering from primary pterygium or pterygium recurrence who were treated with pterygium excision and CAG with or without PTK. The inclusion criteria were patient documentation concerning age and gender, ophthalmological diagnosis and having undergone a microsurgical procedure. Photodocumentation of the anterior eye segment including the cornea and bulbar conjunctiva had to be present to enable comparison of the ocular surface before and following surgical treatment as well as follow-up documentation for a minimum of 6 months, with the exception of patients with early recurrence, defined as regrowth of fibrovascular pterygium-like tissue crossing the limbus onto the cornea during the first 6 months following therapy. Further analysis parameters were: onset of pterygium recurrence, best-corrected visual acuity (BCVA) measured with Snellen letters and astigmatism (in diopters) measured with an automatic refractometer (Canon Auto Ref R-22, Canon, Tokyo, Japan). All pterygium excisions had been performed under general anesthesia or subconjunctival anesthesia with 2% lidocaine hydrochloride (Braun, Melsungen, Germany), as follows. The subjacent cornea and sclera were mechanically abraded first with scissors and then smoothed with a hockey knife, and a temporal upper part of the conjunctiva of the same eye – equivalent in both diameters to the dissected conjunctiva – was excised, its Tenon capsule was mechanically discarded, and it was then fixed with interrupted sutures (vicryl 7-0, Ethilon, Ethicon, Norderstedt, Germany) to the borders of the remaining, macroscopically healthy conjunctiva. Following microsurgery, patients were treated with ofloxacin eye drops (4×/day) and dexpanthenol cream (4×/day). A sclera conformer (Huebel, Olfen, Germany) was inserted into the fornix during the first few days following microsurgical intervention to prevent mechanical injury. If PTK (argon-fluoride excimer laser ESIRIS, Schwind, Eye-Tech Solution, Kleinostheim, Germany) was also performed, the laser beam was focused through the central foramen of the conformer and aimed at the abraded corneal area where the pterygium had initially been present. A masking fluid was not used to facilitate smoothing. The PTK wavelength administered was 193 nm, the ablation depth was 10 μm/pulse, the diameter of the optic zone was 8 mm, and automatic treatment length was between 14 and 19 s. Patients undergoing PTK were administered diclofenac-natrium eye drops (5×/day) instead of dexpanthenol cream.
Pterygium Treatment with or without PTK
Table 1. Pterygia: baseline characteristics and follow-up data
Primary pterygia Recurrent pterygia Localization of the primary pterygia Nasal Temporal Nasal and temporal Localization of the recurrent pterygia Nasal Temporal Nasal and temporal Youngson score for primary pterygia Grade 0 Grade 1 Grade 2 Grade 3 Grade 4 Youngson score for recurrent pterygia Grade 0 Grade 1 Grade 2 Grade 3 Grade 4 Follow-up period CAG CAG + PTK
57 (64.7%) 31 (35.2%) 50 (87.7%) 2 (3.5%) 5 (8.8%) 27 (87.1%) 1 (3.2%) 3 (9.7%) 0 7 17 18 15 0 4 7 7 13 1.5 – 216.0 months (mean = 45.3) 3.0 – 77.0 months (mean = 25.9)
Recurrence rates were compared between patients with primary pterygium (P1 without PTK, P2 with PTK) and those who presented with a recurrence (R1 without PTK, R2 with PTK). Visual outcome and the occurrence of astigmatism following microsurgical treatment were compared between patients who underwent simple CAG (group I) and those who were also submitted to PTK (group II). Statistical analysis was performed with Mann-Whitney, Wilcoxon and Fisher exact tests (IBM® SPSS Statistics 21, Ehningen, Germany).
Results
The follow-up of 145 patients who had pterygia was documented in our clinic archives. According to the exclusion and inclusion criteria, 69 patients were excluded from our analysis, and 88 treatment procedures on 81 eyes of 76 patients (48 males and 28 females; age 28–93 years, mean 53.3 years) were available for analysis. There were 57 cases of primary pterygia, 21 cases with 1 recurrence, and 10 subsequent recurrences (table 1). Simple CAG was performed in 43 eyes with primary pterygia (groups P1 and P2) and in 19 eyes with recurrent Ophthalmic Res 2014;51:52–58 DOI: 10.1159/000355075
53
Downloaded by: NYU Medical Center Library 128.122.253.212 - 5/18/2015 4:25:18 AM
tival transplants (conjunctival autograft, CAG), additional application of antimetabolites, such as mitomycin C, amniotic membrane application, radiation and more recently excimer smoothing [via phototherapeutic keratectomy (PTK)] or locally applied bevacizumab, have been performed with varying results [3]. But excimer smoothing following pterygium resection without or with CAG neither seems to be well known nor to be accepted [4]. The aim of our retrospective analysis was to determine the treatment efficiencies in patients who either had pterygium excision with CAG alone or in combination with phototherapeutic excimer smoothing (i.e. PTK).
Primary pterygia without PTK Primary pterygia with PTK Recurrent pterygia without PTK Recurrent pterygia with PTK
0.8
Survival
0.6
0.4
0.2
0.0 0
50
100
150
200
250
Follow-up (weeks)
Fig. 1. Pterygium recurrence in patients with primary pterygia or
already recurrent pterygia treated with bare-sclera excision and CAG without or with PTK.
pterygia (groups R1 and R2). CAG combined with PTK was performed in 14 eyes with primary pterygia (group P2) and in 12 eyes with recurrent pterygia (group R2; fig. 1, table 1). Comparison of Recurrence Rates for Primary Pterygia Treated with CAG Alone and CAG with PTK In group P1 (bare-sclera excision and CAG without PTK, n = 43), the recurrence rates after 3, 6, 12, 24 and >24 months were 4.7% (n = 2), 11.6% (n = 5), 16.3% (n = 7), 23.2% (n = 10) and 32.5% (n = 14), respectively (fig. 1). In group P2 (bare-sclera excision and CAG with PTK, n = 14), no recurrence was observed during the first 24 months, and 1 recurrence (7.1%) was found after >24 months (fig. 1). At 6 months, the differences in recurrence rates between primary pterygia with and without PTK were not statistically significant (p = 0.185; MannWhitney test). Comparison of Recurrence Rates in Already Recurrent Pterygia Treated with CAG with and without PTK Patients with recurrent pterygia, and who had undergone bare-sclera resection and CAGs without PTK 54
Ophthalmic Res 2014;51:52–58 DOI: 10.1159/000355075
Comparison of Recurrence Rates in Groups I and II Without considering the primary or already recurrent status of the pterygium, patients with CAG alone (group I, n = 62) presented recurrence rates of 4.8% (n = 3), 11.3% (n = 7), 17.7% (n = 11), 22.6% (n = 14) and 30.6% (n = 19) after 3, 6, 12, 24 and >24 months, respectively, and group II (CAG combined with PTK, n = 26) of 3.8% (n = 1) following month 1 till month 24, and 15.4% (n = 4) at >24 months, respectively. Analysis of BCVA It was possible to analyze BCVA in 77 cases. In group I, BCVA increased from logarithm of the minimal angle of resolution (logMAR) 0.095 ± 0.141 (mean ± SD, n = 55) at baseline to 0.066 ± 0.091 (n = 55) following therapy (fig. 2). In group II, BCVA had logMAR 0.090 ± 0.164 at baseline (n = 22) and 0.054 ± 0.124 at follow-up (n = 22, fig. 3). In primary pterygia with CAG, BCVA changed from logMAR 0.107 ± 0.124 (n = 39) to 0.074 ± 0.113 (n = 39), and in primary pterygia with CAG and PTK from logMAR 0.095 ± 0.138 (n = 11) to 0.063 ± 0.130 (n = 11). If recurrent pterygia were analyzed, BCVA changed from logMAR 0.068 ± 0.176 to 0.056 ± 0.083 in cases with CAG (n = 16), and from logMAR 0.095 ± 0.205 to logMAR 0.045 ± 0.068 in cases with CAG and PTK (n = 11). In primary pterygia, BCVA changed from logMAR 0.1043 ± 0.1263 to logMAR 0.0721 ± 0.1155 (n = 50), and in recurrent pterygia from logMAR 0.0791 ± 0.1857 to logMAR 0.5185 ± 0.0767 (n = 27). Analysis of Astigmatism In group I (n = 52), astigmatism (mean ± SD) decreased from –1.01 ± 0.90 to –0.97 ± 1.24 dpt after surgery, while in group II (n = 24), it changed from –1.19 ± 1.55 to –0.75 ± 0.87 dpt, respectively (fig. 3). For all primary and recurrent pterygia, and for those grouped into cases with or without PTK, changes in astigmatism following therapy are listed in table 2. Promesberger/Kohli/Busse/Uhlig
Downloaded by: NYU Medical Center Library 128.122.253.212 - 5/18/2015 4:25:18 AM
1.0
(group R1, n = 19) presented recurrence rates of 5.3% (n = 1), 10.5% (n = 2), 21.1% (n = 4), 21.1% (n = 4) and 26.3% (n = 5) after 3, 6, 12, 24 and >24 months, respectively (fig. 2). Those treated with both CAG and PTK (group R2, n = 12) presented with 1 recurrence (7.7%) between months 3 and 24, and 3 recurrences (23.1%) after >24 months (fig. 1). The comparison of recurrence rates between cases with and without PTK yielded no significant differences at month 6 (p = 0.843; MannWhitney test).
0.8
BCVA following therapy
BCVA at baseline 42
6
11
*
4
*
79
logMAR
0.4
*
84 23
18
84 65 42 83
23
Astigmatism (dpt)
0.6 2
0
–2
0.2 –4 0
–6
–0.2
Fig. 3. Change in astigmatism following treatment with simple CAG without PTK
a
Group II: CAG with PTK (n = 24) Group I: CAG without PTK (n = 52)
CAG with PTK
CAG alone (group I) or in combination with PTK (group II).
Discussion
Fig. 2. a Change in BCVA (logMAR) in patients with CAG without PTK (group I) or with PTK (group II). b Change in BCVA (logMAR) in patients with primary and recurrent pterygia following treatment without or with PTK.
One of the most often used microsurgical procedures is the bare-sclera technique [3], but the rates of recurrence associated with this procedure are variously reported to be between 21 and 89% [5–9]. If the bare-sclera technique is combined with CAG, the recurrence rates reportedly fall to between 5.3 and 21% [8, 10]. However, Dadeya et al. [11] did not find any significant difference in recurrence outcome with rotated autografts. Furthermore, as for the use of amniotic membrane as an alternative to CAGs, Küçükerdönmez et al. [12] did not yield any significant difference in recurrence rates in a prospective randomized clinical trial of 78 patients, and both Tananuvat and Martin [13] and Liang et al. [14] demonstrated lower recurrent rates while using CAGs. With CAGs including the limbal areas, Han et al. [15] and Torres et al. [16] reported recurrence rates of 1.9 and 7.9%, respectively. Further treatment options include the additional use of antimetabolites (e.g. 5-fluorouracil or mitomycin C) before, during or following pterygium resection, as first described by Kunitomo and Mori [17] in 1963. Recurrence rates for such interventions were reported to be between 4 and 8% [7, 18], and the administration of cyclosporine 0.05% at 6-hour intervals for 6 months following the bare-sclera technique alone reduced the recurrence rate from 44.4 to 22.2% [19]. Another suggested treat-
Pterygium Treatment with or without PTK
Ophthalmic Res 2014;51:52–58 DOI: 10.1159/000355075
*
*
0.6 *
logMAR
0.4
0.2
*
0
Pr
b
im a w ry p ith t ou ery t P gia TK Pr im ar y p w ter ith yg PT ia K Re cu rre w nt p ith t ou ery t P gia TK Re cu rre nt p w ter ith yg PT ia K
–0.2
55
Downloaded by: NYU Medical Center Library 128.122.253.212 - 5/18/2015 4:25:18 AM
0.8
BCVA following therapy
BCVA at baseline
Table 2. Change in astigmatism following treatment without or with PTK in primary and recurrent pterygia
Astigmatism SD at baseline
Mini- Maxi- Astigmatism SD mum mum following therapy
Mini- Maximum mum
52 24 40 53 23 13 12 11
–1.0144 –1.1875 –1.0875 –1.2453 –0.6630 –1.7308 –1.1875 –0.5455
0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
0.0 0.0 0.0 0.0 0.0 0.0 0.75 0.0
0.89855 1.54154 0.92430 1.25909 0.61979 1.93773 1.79369 0.35032
ment option is the use of β-irradiation. Viani et al. [20, 21] reported a recurrence rate of 9.2% following CAG with β-irradiation, and Mourits et al. [22] reported a decrease from 76 to 11% in a similar trial with 86 primary pterygia. Glues and different suture materials have been proposed to enable sutureless fixation of transplants and to reduce both inflammation and recurrence rates, with varying results [23–26]. Concerning the use of anti-vascular endothelial growth factor agents, Shenasi et al. [27] determined that subconjunctival injection of bevacizumab following bare-sclera resection of primary pterygia did not decrease the rate of recurrence, while Fallah et al. [28] reported efficient delayed recurrence of impending recurrent pterygia if bevacizumab was applied locally after the bare-sclera procedure. Krag and Ehlers [29] were among the first to suggest excimer smoothing following bare-sclera excision. They reported a recurrence rate of 91% while 3 years later, Förster et al. [30, 31] reported about 33–57% in two series of 50 and 46 eyes. Talu et al. [32] reported a 4.5% recurrence rate, while Walkow et al. [33] observed a significantly reduced astigmatism in a series of 60 eyes that had undergone bare-sclera resection combined with excimer smoothing. They also suggested the postoperative use of locally applied mitomycin C, which they report yielded a recurrence rate of 5% [34, 35]. In another series they reported recurrence rates of 2.9% for primary pterygia and 6.4% for already recurrent pterygia, while the mean astigmatism was observed to decrease from 1.54 dpt preoperatively to 0.61 dpt postoperatively [35]. Jandrasits et al. [36] compared the outcome of excimer and manual smoothing with a diamond knife, and found no significant differences regarding astigmatism and BCVA in a study of 32 eyes suffering from primary pte56
Ophthalmic Res 2014;51:52–58 DOI: 10.1159/000355075
–3.75 –5.25 –3.75 –5.25 –2.5 –5.25 –6.5 –1.25
–0.9663 –0.7396 –0.9000 –0.9198 –0.8370 –0.9808 –0.3750 –0.4545
1.24462 0.87065 1.04820 1.04556 1.35388 1.07752 1.56851 0.43038
–6.5 –3.0 –5.75 –5.75 –6.5 –3.0 –5.25 –1.5
rygia. We used iron hockey knifes to abrade the cornea. Therefore, our investigations compare pterygium resection followed by mechanically smoothing with an ordinary microsurgical instrument and CAG with the same procedure and additional PTK, and we cannot exclude that diamond knife abrasion might present better results. Haider et al. [37] found that if the transplants were rotated by 90° there was a further reduction in the recurrence rate to 3%, and Müller et al. [38] observed a recurrence rate of 6.9% if the transplants were slid. Because our surgeons were not specifically requested to rotate the autologous transplants, this does not exclude such procedures and we cannot absolutely exclude a bias in one or more of our presented treatment goups. Nevertheless, none of the colleagues had been specifically taught or was known to perform such techniques. We retrospectively investigated the efficacies of different treatments in patients who had already presented with primary or recurrent pterygium: either bare-sclera resection with a CAG or bare-sclera resection with CAG and additional excimer, PTK smoothing. We did not use antimetabolites, since melting of the cornea has been described as a serious side effect and because Rubinfeld [39] and Sinha et al. [40] reported an improvement in BCVA with bare-sclera excision without adjuvant mitomycin C. We do not know whether such adjuncts would have influenced our results, especially recurrence rates. The usefulness of our study is limited by its retrospective character (e.g. possible bias due to the study design), the relatively small number of patients and the limited ability to compare the calculated recurrence rates with already published results, in part because the follow-up and definition of pterygium recurrences vary among previous studies [41]. Additionally, a direct comparison of our results with already published data is difficult due to wide variation in protocols [4]. Promesberger/Kohli/Busse/Uhlig
Downloaded by: NYU Medical Center Library 128.122.253.212 - 5/18/2015 4:25:18 AM
Group I (CAG) Group II (CAG + PTK) Primary pterygia with CAG Primary pterygia Recurrent pterygia Primary pterygia with CAG + PTK Recurrent pterygia with CAG Recurrent pterygia with CAG + PTK
n
As regards BCVA and astigmatism, we did not observe any significant developments following pterygium treatment with adjuvant PTK. Nevertheless, our results suggest that, in comparison with bare-sclera excision combined with CAG, additional excimer smoothing increases BCVA and reduces recurrence rates in patients with primary pterygium. Since the use of excimer lasers is time consuming and expensive, larger prospective and ran-
domized studies are warranted to investigate whether the use of excimer laser significantly reduces recurrence rates, and especially in comparison to manual smoothing.
Disclosure Statement No conflict of interest.
1 Di Girolamo N, Chui J, Coroneo MT, et al: Pathogenesis of pterygia: role of cytokines, growth factors, and matrix metalloproteinases. Prog Retin Eye Res 2004;23:195–228. 2 Bradley JC, Yang W, Bradley RH, et al: The science of pterygia. Br J Ophthalmol 210; 94: 815–820. 3 Sekundo W, Droutsas K, Cursiefen C: Operative Techniken bei chirurgischer Behandlung primärer und rezidivierender Pterygien. Ophthalmologe 2010;107:525–528. 4 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. 5 Cardillo JA, Alves MR, Ambrosio LE, et al: Single intraoperative application versus postoperative mitomycin C eye drops in pterygium surgery. Ophthalmology 1995; 102: 1949– 1952. 6 Chen PP, Ariyasu RG, Kaza V, et al: A randomized trial comparing mitomycin C and conjunctival autograft after excision of primary pterygium. Am J Ophthalmol 1995;120: 151–160. 7 Fakhry AM: The use of mitomycin C with autologous limbal-conjunctival autograft transplantation for management of recurrent pterygium. Clin Ophthalmol 2011;5:123–127. 8 Lewallen S: A randomized trial of conjunctival autografting for pterygium in the tropics. Ophthalmology 1989;96:1612–1614. 9 Singh G, Wilson MR, Foster CS: Mitomycin eye drops as treatment for pterygium. Ophthalmology 1988;95:813–821. 10 Kenyon KR, Wagoner MD, Hettinger ME: Conjunctival autograft transplantation for advanced and recurrent pterygium. Ophthalmology 1985;92:1461–1470. 11 Dadeya S, Malik KP, Gullian BP: Pterygium surgery: conjunctival rotation autograft versus conjunctival autograft. Ophthalmic Surg Lasers 2002;33:269–274. 12 Küçükerdönmez C, Akova YA, Altinörs DD: Comparison of conjunctival autograft with amniotic membrane transplantation for pterygium surgery: surgical and cosmetic outcome. Cornea 2007;26:407–413.
Pterygium Treatment with or without PTK
13 Tananuvat N, Martin T: The results of amniotic membrane transplantation for primary pterygium compared with conjunctival autograft. Cornea 2004;23:458–463. 14 Liang WH, Li RR, Deng XY: Comparison of the efficacy of pterygium resection combined with conjunctival autograft versus pterygium resection combined with amniotic membrane transplantation. Yan Ke Xue Bao 2012; 27: 102–105. 15 Han SB, Hyon JY, Hwang JM, et al: Efficacy and safety of limbal-conjunctival autografting with limbal fixation sutures after pterygium excision. Ophthalmologica 2012; 227: 210– 214. 16 Torres J, Fernández I, Quadrado MJ, et al: Estudio multicéntrico retrospectivo sobre trasplante de limbo. Arch Soc Esp Oftalmol 2008;83:417–422. 17 Kunitomo N, Mori S: Studies on pterygium. Report IV. A treatment of the pterygium by mitomycin C installation. Acta Soc Ophthalmol Jpn 1963;67:601–607. 18 Zaky KS, Khalifa YM: Efficacy of preoperative injection versus intraoperative application of mitomycin in recurrent pterygium surgery. Indian J Ophthalmol 2012;60:273–276. 19 Turan-Vural E, Torun-Acar B, Kivanc SA, et al: The effect of topical 0.05% cyclosporine on recurrence following pterygium surgery. Clin Ophthalmol 2011;5:881–885. 20 Viani GA, Fonseca EC, De Fendi LI, et al: Conjunctival autograft alone or combined with adjuvant beta-radiation? A randomized clinical trial. Int J Radiat Oncol Biol Phys 2012;82:e507–e511. 21 Viani GA, Stefano EJ, De Fendi LI, et al: Longterm results and prognostic factors of fractionated strontium-90 eye applicator for pterygium. Int J Radiat Oncol Biol Phys 2008;72: 1174–1179. 22 Mourits MP, Wyrdeman HK, JurgenliemkSchulz IM, et al: Favorable long-term results of primary pterygium removal by bare sclera extirpation followed by a single 90strontium application. Eur J Ophthalmol 2008; 18: 327– 331. 23 Por YM, Tan DT: Assessment of fibrin glue in pterygium surgery. Cornea 2010;29:1–4.
24 Jiang J, Yang Y, Zhang M, et al: Comparison of fibrin sealant and sutures for conjunctival autograft fixation in pterygium surgery: oneyear follow-up. Ophthalmologica 2008; 222: 105–111. 25 Pan HW, Zhong JX, Jing CX: Comparison of fibrin glue versus suture for conjunctival autografting in pterygium surgery: a meta-analysis. Ophthalmology 2011;118:1049–1054. 26 Srinivasan S, Dollin M, McAllum P, et al: Fibrin glue versus sutures for attaching the conjunctival autograft in pterygium surgery: a prospective observed masked clinical trial. Br J Ophthalmol 2009;93:215–218. 27 Shenasi A, Mousavi F, Shoa-Ahari A, et al: Subconjunctival bevacizumab immediately after excision of primary pterygium: the first clinical trial. Cornea 2011;30:1219–1222. 28 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. 29 Krag S, Ehlers N: Excimer laser treatment of pterygium. Acta Ophthalmol (Copenh) 1992; 70:530–533. 30 Förster W, Atzler U, Ratkay I, et al: Excimerlaser-phototherapeutische Keratektomie (PTK) und modifizierte Bare-Sklera-Technik zur Behandlung von Pterygien. Ophthalmologe 1995;92:424–426. 31 Förster W, Atzler U, Ratkay I, et al: Therapeutic use of the 193-nm excimer laser in corneal pathologies. Graefe’s Arch Clin Exp Ophthalmol 1997;235:296–305. 32 Talu H, Taşindi E, Ciftci F, et al: Excimer laser phototherapeutic keratectomy for recurrent pterygium. J Cataract Refract Surg 1998; 24: 1326–1332. 33 Walkow T, Anders N, Wollensak J: Kornealer Astigmatismus nach Pterygiumexzision und nachfolgender phototherapeutischer Keratektomie mit dem Excimerlaser (193 nm). Klin Monatsbl Augenheilkd 1996; 209: 199– 204. 34 Walkow T, Anders N, Antoni HJ, et al: Die Rezidivhäufigkeit nach primärer Pterygiumexzision, phototherapeutischer Keratektomie (PTK) mit dem ArD:Excimerlaser und lokaler Mitomycin-C-Applikation. Klin Monatsbl Augenheilkd 1996;208:406–409.
Ophthalmic Res 2014;51:52–58 DOI: 10.1159/000355075
57
Downloaded by: NYU Medical Center Library 128.122.253.212 - 5/18/2015 4:25:18 AM
References
58
37 Haider TA, Al-Amin LM, Bamashnus MA, et al: Ninety degree conjunctival rotation autograft versus zero and 180 degree rotation autograft for pterygium surgery. Saudi Med J 2009;30:519–523. 38 Müller S, Stahn J, Schmitz K, et al: Rezidivraten nach Pterygiumoperation mit Bindehautschwenklappen versus freies autologes Transplantat. Ophthalmologe 2007;104: 480– 483. 39 Rubinfeld RS: Letter to the editor: long-term results after bare sclera pterygium resection with excimer smoothing and local application of mitomycin C. Cornea 2006;25:758.
Ophthalmic Res 2014;51:52–58 DOI: 10.1159/000355075
40 Sinha R, Sharma N, Vaipayee RB: Letter to the editor: long-term results after bare sclera pterygium resection with excimer smoothing and local application of mitomycin C. Cornea 2006;20:757. 41 Ang LP, Chua JL, Tan DT: Current concepts and techniques in pterygium treatment. Curr Opin Ophthalmol 2007;18:308–313.
Promesberger/Kohli/Busse/Uhlig
Downloaded by: NYU Medical Center Library 128.122.253.212 - 5/18/2015 4:25:18 AM
35 Walkow T, Daniel J, Meyer CA, et al: Longterm results after bare sclera pterygium resection with excimer smoothing and local application of mitomycin C. Cornea 2005;24:378– 381. 36 Jandrasits K, Schauersberger J, Nepp J, et al: Excimer-Laser versus Diamantschleifer: Gleichwertige Kurzzeitergebnisse bei Hornhautglättung nach Pterygiumoperationen. Klin Monatsbl Augenheilkd 2001;218:418–423.
Received: May 6, 2013 Accepted after revision: August 2, 2013 Published online: November 20, 2013
Pterygium Recurrence, Astigmatism and Visual Acuity following Bare-Sclera Excision and Conjunctival Autograft with or without Additional Phototherapeutic Keratectomy Julia Promesberger Sharmila Kohli Holger Busse Constantin E. Uhlig Department of Ophthalmology, University Clinics, Münster, Germany
Abstract Background: Treatment outcome in patients with pterygium following bare-sclera excision and conjunctival autograft (CAG) with and without phototherapeutic keratectomy (PTK). Methods: Retrospective comparative analysis of 81 eyes, with primary and recurrent pterygia, that were analyzed for recurrence, best-corrected visual acuity (BCVA) and astigmatism in primary (P1 without PTK, P2 with PTK) and recurrent pterygia (R1 without PTK, R2 with PTK). BCVA and astigmatism were compared in patients with simple CAG alone (group I) or in combination with PTK (group II). Results: Recurrence rates were 4.7, 11.6, 16.2, 23.2 and 32.5% at 3, 6, 12, 24 and >24 months (P1), 7.1% at >24 months (P2). Recurrence rates were 5.3, 10.5, 21.1, 21.1 and 26.3% at 3, 6, 12, 24 and >24 months (R1) and 1 recurrence (7.7%) till month 24, and 3 (23.1%) thereafter (R2). BCVA increased from logarithm of the minimal angle of resolution 0.095 ± 0.141 (mean ± SD) at baseline to 0.066 ± 0.09 (group I), and from 0.090 ± 0.164 to 0.054 ± 0.124 (group II). Astigmatism decreased
© 2013 S. Karger AG, Basel 0030–3747/14/0511–0052$39.50/0 E-Mail [email protected] www.karger.com/ore
from –1.01 ± 0.90 dpt at baseline to –0.97 ± 1.24 dpt (group I), and from –1.19 ± 1.55 to –0.75 ± 0.87 dpt (group II). Conclusion: In comparison to CAG alone, additional excimer smoothing with PTK tends to increase BCVA and reduces recurrence rates in patients with primary pterygia. © 2013 S. Karger AG, Basel
Introduction
Pterygium is a fibrovascular conjunctival degeneration that is characterized by invasive centripetal growth and associated inflammation and neovascularization [1], which progressively induces astigmatism and decreases visual acuity. Although attributed to chronic ultraviolet B exposure, defective regulation of apoptosis and presumably immunological mechanisms may also be involved [2]. The hereditary factors are still not clear, and the pathogenesis of this condition remains incompletely understood [2]. Various microsurgical techniques, such as bare-sclera excision with or without autologous conjunc-
J. Promesberger and C.E. Uhlig contributed equally to this paper.
Constantin E. Uhlig University Eye Hospital, University Clinics Münster Albert Schweitzer Campus 1, Building D15 DE–48149 Münster (Germany) E-Mail uhligc @ uni-muenster.de
Downloaded by: NYU Medical Center Library 128.122.253.212 - 5/18/2015 4:25:18 AM
Key Words Pterygium · Bare-sclera resection · Excimer smoothing · Cornea · Astigmatism · Recurrence
Material and Methods This study performed a retrospective analysis of patients suffering from primary pterygium or pterygium recurrence who were treated with pterygium excision and CAG with or without PTK. The inclusion criteria were patient documentation concerning age and gender, ophthalmological diagnosis and having undergone a microsurgical procedure. Photodocumentation of the anterior eye segment including the cornea and bulbar conjunctiva had to be present to enable comparison of the ocular surface before and following surgical treatment as well as follow-up documentation for a minimum of 6 months, with the exception of patients with early recurrence, defined as regrowth of fibrovascular pterygium-like tissue crossing the limbus onto the cornea during the first 6 months following therapy. Further analysis parameters were: onset of pterygium recurrence, best-corrected visual acuity (BCVA) measured with Snellen letters and astigmatism (in diopters) measured with an automatic refractometer (Canon Auto Ref R-22, Canon, Tokyo, Japan). All pterygium excisions had been performed under general anesthesia or subconjunctival anesthesia with 2% lidocaine hydrochloride (Braun, Melsungen, Germany), as follows. The subjacent cornea and sclera were mechanically abraded first with scissors and then smoothed with a hockey knife, and a temporal upper part of the conjunctiva of the same eye – equivalent in both diameters to the dissected conjunctiva – was excised, its Tenon capsule was mechanically discarded, and it was then fixed with interrupted sutures (vicryl 7-0, Ethilon, Ethicon, Norderstedt, Germany) to the borders of the remaining, macroscopically healthy conjunctiva. Following microsurgery, patients were treated with ofloxacin eye drops (4×/day) and dexpanthenol cream (4×/day). A sclera conformer (Huebel, Olfen, Germany) was inserted into the fornix during the first few days following microsurgical intervention to prevent mechanical injury. If PTK (argon-fluoride excimer laser ESIRIS, Schwind, Eye-Tech Solution, Kleinostheim, Germany) was also performed, the laser beam was focused through the central foramen of the conformer and aimed at the abraded corneal area where the pterygium had initially been present. A masking fluid was not used to facilitate smoothing. The PTK wavelength administered was 193 nm, the ablation depth was 10 μm/pulse, the diameter of the optic zone was 8 mm, and automatic treatment length was between 14 and 19 s. Patients undergoing PTK were administered diclofenac-natrium eye drops (5×/day) instead of dexpanthenol cream.
Pterygium Treatment with or without PTK
Table 1. Pterygia: baseline characteristics and follow-up data
Primary pterygia Recurrent pterygia Localization of the primary pterygia Nasal Temporal Nasal and temporal Localization of the recurrent pterygia Nasal Temporal Nasal and temporal Youngson score for primary pterygia Grade 0 Grade 1 Grade 2 Grade 3 Grade 4 Youngson score for recurrent pterygia Grade 0 Grade 1 Grade 2 Grade 3 Grade 4 Follow-up period CAG CAG + PTK
57 (64.7%) 31 (35.2%) 50 (87.7%) 2 (3.5%) 5 (8.8%) 27 (87.1%) 1 (3.2%) 3 (9.7%) 0 7 17 18 15 0 4 7 7 13 1.5 – 216.0 months (mean = 45.3) 3.0 – 77.0 months (mean = 25.9)
Recurrence rates were compared between patients with primary pterygium (P1 without PTK, P2 with PTK) and those who presented with a recurrence (R1 without PTK, R2 with PTK). Visual outcome and the occurrence of astigmatism following microsurgical treatment were compared between patients who underwent simple CAG (group I) and those who were also submitted to PTK (group II). Statistical analysis was performed with Mann-Whitney, Wilcoxon and Fisher exact tests (IBM® SPSS Statistics 21, Ehningen, Germany).
Results
The follow-up of 145 patients who had pterygia was documented in our clinic archives. According to the exclusion and inclusion criteria, 69 patients were excluded from our analysis, and 88 treatment procedures on 81 eyes of 76 patients (48 males and 28 females; age 28–93 years, mean 53.3 years) were available for analysis. There were 57 cases of primary pterygia, 21 cases with 1 recurrence, and 10 subsequent recurrences (table 1). Simple CAG was performed in 43 eyes with primary pterygia (groups P1 and P2) and in 19 eyes with recurrent Ophthalmic Res 2014;51:52–58 DOI: 10.1159/000355075
53
Downloaded by: NYU Medical Center Library 128.122.253.212 - 5/18/2015 4:25:18 AM
tival transplants (conjunctival autograft, CAG), additional application of antimetabolites, such as mitomycin C, amniotic membrane application, radiation and more recently excimer smoothing [via phototherapeutic keratectomy (PTK)] or locally applied bevacizumab, have been performed with varying results [3]. But excimer smoothing following pterygium resection without or with CAG neither seems to be well known nor to be accepted [4]. The aim of our retrospective analysis was to determine the treatment efficiencies in patients who either had pterygium excision with CAG alone or in combination with phototherapeutic excimer smoothing (i.e. PTK).
Primary pterygia without PTK Primary pterygia with PTK Recurrent pterygia without PTK Recurrent pterygia with PTK
0.8
Survival
0.6
0.4
0.2
0.0 0
50
100
150
200
250
Follow-up (weeks)
Fig. 1. Pterygium recurrence in patients with primary pterygia or
already recurrent pterygia treated with bare-sclera excision and CAG without or with PTK.
pterygia (groups R1 and R2). CAG combined with PTK was performed in 14 eyes with primary pterygia (group P2) and in 12 eyes with recurrent pterygia (group R2; fig. 1, table 1). Comparison of Recurrence Rates for Primary Pterygia Treated with CAG Alone and CAG with PTK In group P1 (bare-sclera excision and CAG without PTK, n = 43), the recurrence rates after 3, 6, 12, 24 and >24 months were 4.7% (n = 2), 11.6% (n = 5), 16.3% (n = 7), 23.2% (n = 10) and 32.5% (n = 14), respectively (fig. 1). In group P2 (bare-sclera excision and CAG with PTK, n = 14), no recurrence was observed during the first 24 months, and 1 recurrence (7.1%) was found after >24 months (fig. 1). At 6 months, the differences in recurrence rates between primary pterygia with and without PTK were not statistically significant (p = 0.185; MannWhitney test). Comparison of Recurrence Rates in Already Recurrent Pterygia Treated with CAG with and without PTK Patients with recurrent pterygia, and who had undergone bare-sclera resection and CAGs without PTK 54
Ophthalmic Res 2014;51:52–58 DOI: 10.1159/000355075
Comparison of Recurrence Rates in Groups I and II Without considering the primary or already recurrent status of the pterygium, patients with CAG alone (group I, n = 62) presented recurrence rates of 4.8% (n = 3), 11.3% (n = 7), 17.7% (n = 11), 22.6% (n = 14) and 30.6% (n = 19) after 3, 6, 12, 24 and >24 months, respectively, and group II (CAG combined with PTK, n = 26) of 3.8% (n = 1) following month 1 till month 24, and 15.4% (n = 4) at >24 months, respectively. Analysis of BCVA It was possible to analyze BCVA in 77 cases. In group I, BCVA increased from logarithm of the minimal angle of resolution (logMAR) 0.095 ± 0.141 (mean ± SD, n = 55) at baseline to 0.066 ± 0.091 (n = 55) following therapy (fig. 2). In group II, BCVA had logMAR 0.090 ± 0.164 at baseline (n = 22) and 0.054 ± 0.124 at follow-up (n = 22, fig. 3). In primary pterygia with CAG, BCVA changed from logMAR 0.107 ± 0.124 (n = 39) to 0.074 ± 0.113 (n = 39), and in primary pterygia with CAG and PTK from logMAR 0.095 ± 0.138 (n = 11) to 0.063 ± 0.130 (n = 11). If recurrent pterygia were analyzed, BCVA changed from logMAR 0.068 ± 0.176 to 0.056 ± 0.083 in cases with CAG (n = 16), and from logMAR 0.095 ± 0.205 to logMAR 0.045 ± 0.068 in cases with CAG and PTK (n = 11). In primary pterygia, BCVA changed from logMAR 0.1043 ± 0.1263 to logMAR 0.0721 ± 0.1155 (n = 50), and in recurrent pterygia from logMAR 0.0791 ± 0.1857 to logMAR 0.5185 ± 0.0767 (n = 27). Analysis of Astigmatism In group I (n = 52), astigmatism (mean ± SD) decreased from –1.01 ± 0.90 to –0.97 ± 1.24 dpt after surgery, while in group II (n = 24), it changed from –1.19 ± 1.55 to –0.75 ± 0.87 dpt, respectively (fig. 3). For all primary and recurrent pterygia, and for those grouped into cases with or without PTK, changes in astigmatism following therapy are listed in table 2. Promesberger/Kohli/Busse/Uhlig
Downloaded by: NYU Medical Center Library 128.122.253.212 - 5/18/2015 4:25:18 AM
1.0
(group R1, n = 19) presented recurrence rates of 5.3% (n = 1), 10.5% (n = 2), 21.1% (n = 4), 21.1% (n = 4) and 26.3% (n = 5) after 3, 6, 12, 24 and >24 months, respectively (fig. 2). Those treated with both CAG and PTK (group R2, n = 12) presented with 1 recurrence (7.7%) between months 3 and 24, and 3 recurrences (23.1%) after >24 months (fig. 1). The comparison of recurrence rates between cases with and without PTK yielded no significant differences at month 6 (p = 0.843; MannWhitney test).
0.8
BCVA following therapy
BCVA at baseline 42
6
11
*
4
*
79
logMAR
0.4
*
84 23
18
84 65 42 83
23
Astigmatism (dpt)
0.6 2
0
–2
0.2 –4 0
–6
–0.2
Fig. 3. Change in astigmatism following treatment with simple CAG without PTK
a
Group II: CAG with PTK (n = 24) Group I: CAG without PTK (n = 52)
CAG with PTK
CAG alone (group I) or in combination with PTK (group II).
Discussion
Fig. 2. a Change in BCVA (logMAR) in patients with CAG without PTK (group I) or with PTK (group II). b Change in BCVA (logMAR) in patients with primary and recurrent pterygia following treatment without or with PTK.
One of the most often used microsurgical procedures is the bare-sclera technique [3], but the rates of recurrence associated with this procedure are variously reported to be between 21 and 89% [5–9]. If the bare-sclera technique is combined with CAG, the recurrence rates reportedly fall to between 5.3 and 21% [8, 10]. However, Dadeya et al. [11] did not find any significant difference in recurrence outcome with rotated autografts. Furthermore, as for the use of amniotic membrane as an alternative to CAGs, Küçükerdönmez et al. [12] did not yield any significant difference in recurrence rates in a prospective randomized clinical trial of 78 patients, and both Tananuvat and Martin [13] and Liang et al. [14] demonstrated lower recurrent rates while using CAGs. With CAGs including the limbal areas, Han et al. [15] and Torres et al. [16] reported recurrence rates of 1.9 and 7.9%, respectively. Further treatment options include the additional use of antimetabolites (e.g. 5-fluorouracil or mitomycin C) before, during or following pterygium resection, as first described by Kunitomo and Mori [17] in 1963. Recurrence rates for such interventions were reported to be between 4 and 8% [7, 18], and the administration of cyclosporine 0.05% at 6-hour intervals for 6 months following the bare-sclera technique alone reduced the recurrence rate from 44.4 to 22.2% [19]. Another suggested treat-
Pterygium Treatment with or without PTK
Ophthalmic Res 2014;51:52–58 DOI: 10.1159/000355075
*
*
0.6 *
logMAR
0.4
0.2
*
0
Pr
b
im a w ry p ith t ou ery t P gia TK Pr im ar y p w ter ith yg PT ia K Re cu rre w nt p ith t ou ery t P gia TK Re cu rre nt p w ter ith yg PT ia K
–0.2
55
Downloaded by: NYU Medical Center Library 128.122.253.212 - 5/18/2015 4:25:18 AM
0.8
BCVA following therapy
BCVA at baseline
Table 2. Change in astigmatism following treatment without or with PTK in primary and recurrent pterygia
Astigmatism SD at baseline
Mini- Maxi- Astigmatism SD mum mum following therapy
Mini- Maximum mum
52 24 40 53 23 13 12 11
–1.0144 –1.1875 –1.0875 –1.2453 –0.6630 –1.7308 –1.1875 –0.5455
0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
0.0 0.0 0.0 0.0 0.0 0.0 0.75 0.0
0.89855 1.54154 0.92430 1.25909 0.61979 1.93773 1.79369 0.35032
ment option is the use of β-irradiation. Viani et al. [20, 21] reported a recurrence rate of 9.2% following CAG with β-irradiation, and Mourits et al. [22] reported a decrease from 76 to 11% in a similar trial with 86 primary pterygia. Glues and different suture materials have been proposed to enable sutureless fixation of transplants and to reduce both inflammation and recurrence rates, with varying results [23–26]. Concerning the use of anti-vascular endothelial growth factor agents, Shenasi et al. [27] determined that subconjunctival injection of bevacizumab following bare-sclera resection of primary pterygia did not decrease the rate of recurrence, while Fallah et al. [28] reported efficient delayed recurrence of impending recurrent pterygia if bevacizumab was applied locally after the bare-sclera procedure. Krag and Ehlers [29] were among the first to suggest excimer smoothing following bare-sclera excision. They reported a recurrence rate of 91% while 3 years later, Förster et al. [30, 31] reported about 33–57% in two series of 50 and 46 eyes. Talu et al. [32] reported a 4.5% recurrence rate, while Walkow et al. [33] observed a significantly reduced astigmatism in a series of 60 eyes that had undergone bare-sclera resection combined with excimer smoothing. They also suggested the postoperative use of locally applied mitomycin C, which they report yielded a recurrence rate of 5% [34, 35]. In another series they reported recurrence rates of 2.9% for primary pterygia and 6.4% for already recurrent pterygia, while the mean astigmatism was observed to decrease from 1.54 dpt preoperatively to 0.61 dpt postoperatively [35]. Jandrasits et al. [36] compared the outcome of excimer and manual smoothing with a diamond knife, and found no significant differences regarding astigmatism and BCVA in a study of 32 eyes suffering from primary pte56
Ophthalmic Res 2014;51:52–58 DOI: 10.1159/000355075
–3.75 –5.25 –3.75 –5.25 –2.5 –5.25 –6.5 –1.25
–0.9663 –0.7396 –0.9000 –0.9198 –0.8370 –0.9808 –0.3750 –0.4545
1.24462 0.87065 1.04820 1.04556 1.35388 1.07752 1.56851 0.43038
–6.5 –3.0 –5.75 –5.75 –6.5 –3.0 –5.25 –1.5
rygia. We used iron hockey knifes to abrade the cornea. Therefore, our investigations compare pterygium resection followed by mechanically smoothing with an ordinary microsurgical instrument and CAG with the same procedure and additional PTK, and we cannot exclude that diamond knife abrasion might present better results. Haider et al. [37] found that if the transplants were rotated by 90° there was a further reduction in the recurrence rate to 3%, and Müller et al. [38] observed a recurrence rate of 6.9% if the transplants were slid. Because our surgeons were not specifically requested to rotate the autologous transplants, this does not exclude such procedures and we cannot absolutely exclude a bias in one or more of our presented treatment goups. Nevertheless, none of the colleagues had been specifically taught or was known to perform such techniques. We retrospectively investigated the efficacies of different treatments in patients who had already presented with primary or recurrent pterygium: either bare-sclera resection with a CAG or bare-sclera resection with CAG and additional excimer, PTK smoothing. We did not use antimetabolites, since melting of the cornea has been described as a serious side effect and because Rubinfeld [39] and Sinha et al. [40] reported an improvement in BCVA with bare-sclera excision without adjuvant mitomycin C. We do not know whether such adjuncts would have influenced our results, especially recurrence rates. The usefulness of our study is limited by its retrospective character (e.g. possible bias due to the study design), the relatively small number of patients and the limited ability to compare the calculated recurrence rates with already published results, in part because the follow-up and definition of pterygium recurrences vary among previous studies [41]. Additionally, a direct comparison of our results with already published data is difficult due to wide variation in protocols [4]. Promesberger/Kohli/Busse/Uhlig
Downloaded by: NYU Medical Center Library 128.122.253.212 - 5/18/2015 4:25:18 AM
Group I (CAG) Group II (CAG + PTK) Primary pterygia with CAG Primary pterygia Recurrent pterygia Primary pterygia with CAG + PTK Recurrent pterygia with CAG Recurrent pterygia with CAG + PTK
n
As regards BCVA and astigmatism, we did not observe any significant developments following pterygium treatment with adjuvant PTK. Nevertheless, our results suggest that, in comparison with bare-sclera excision combined with CAG, additional excimer smoothing increases BCVA and reduces recurrence rates in patients with primary pterygium. Since the use of excimer lasers is time consuming and expensive, larger prospective and ran-
domized studies are warranted to investigate whether the use of excimer laser significantly reduces recurrence rates, and especially in comparison to manual smoothing.
Disclosure Statement No conflict of interest.
1 Di Girolamo N, Chui J, Coroneo MT, et al: Pathogenesis of pterygia: role of cytokines, growth factors, and matrix metalloproteinases. Prog Retin Eye Res 2004;23:195–228. 2 Bradley JC, Yang W, Bradley RH, et al: The science of pterygia. Br J Ophthalmol 210; 94: 815–820. 3 Sekundo W, Droutsas K, Cursiefen C: Operative Techniken bei chirurgischer Behandlung primärer und rezidivierender Pterygien. Ophthalmologe 2010;107:525–528. 4 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. 5 Cardillo JA, Alves MR, Ambrosio LE, et al: Single intraoperative application versus postoperative mitomycin C eye drops in pterygium surgery. Ophthalmology 1995; 102: 1949– 1952. 6 Chen PP, Ariyasu RG, Kaza V, et al: A randomized trial comparing mitomycin C and conjunctival autograft after excision of primary pterygium. Am J Ophthalmol 1995;120: 151–160. 7 Fakhry AM: The use of mitomycin C with autologous limbal-conjunctival autograft transplantation for management of recurrent pterygium. Clin Ophthalmol 2011;5:123–127. 8 Lewallen S: A randomized trial of conjunctival autografting for pterygium in the tropics. Ophthalmology 1989;96:1612–1614. 9 Singh G, Wilson MR, Foster CS: Mitomycin eye drops as treatment for pterygium. Ophthalmology 1988;95:813–821. 10 Kenyon KR, Wagoner MD, Hettinger ME: Conjunctival autograft transplantation for advanced and recurrent pterygium. Ophthalmology 1985;92:1461–1470. 11 Dadeya S, Malik KP, Gullian BP: Pterygium surgery: conjunctival rotation autograft versus conjunctival autograft. Ophthalmic Surg Lasers 2002;33:269–274. 12 Küçükerdönmez C, Akova YA, Altinörs DD: Comparison of conjunctival autograft with amniotic membrane transplantation for pterygium surgery: surgical and cosmetic outcome. Cornea 2007;26:407–413.
Pterygium Treatment with or without PTK
13 Tananuvat N, Martin T: The results of amniotic membrane transplantation for primary pterygium compared with conjunctival autograft. Cornea 2004;23:458–463. 14 Liang WH, Li RR, Deng XY: Comparison of the efficacy of pterygium resection combined with conjunctival autograft versus pterygium resection combined with amniotic membrane transplantation. Yan Ke Xue Bao 2012; 27: 102–105. 15 Han SB, Hyon JY, Hwang JM, et al: Efficacy and safety of limbal-conjunctival autografting with limbal fixation sutures after pterygium excision. Ophthalmologica 2012; 227: 210– 214. 16 Torres J, Fernández I, Quadrado MJ, et al: Estudio multicéntrico retrospectivo sobre trasplante de limbo. Arch Soc Esp Oftalmol 2008;83:417–422. 17 Kunitomo N, Mori S: Studies on pterygium. Report IV. A treatment of the pterygium by mitomycin C installation. Acta Soc Ophthalmol Jpn 1963;67:601–607. 18 Zaky KS, Khalifa YM: Efficacy of preoperative injection versus intraoperative application of mitomycin in recurrent pterygium surgery. Indian J Ophthalmol 2012;60:273–276. 19 Turan-Vural E, Torun-Acar B, Kivanc SA, et al: The effect of topical 0.05% cyclosporine on recurrence following pterygium surgery. Clin Ophthalmol 2011;5:881–885. 20 Viani GA, Fonseca EC, De Fendi LI, et al: Conjunctival autograft alone or combined with adjuvant beta-radiation? A randomized clinical trial. Int J Radiat Oncol Biol Phys 2012;82:e507–e511. 21 Viani GA, Stefano EJ, De Fendi LI, et al: Longterm results and prognostic factors of fractionated strontium-90 eye applicator for pterygium. Int J Radiat Oncol Biol Phys 2008;72: 1174–1179. 22 Mourits MP, Wyrdeman HK, JurgenliemkSchulz IM, et al: Favorable long-term results of primary pterygium removal by bare sclera extirpation followed by a single 90strontium application. Eur J Ophthalmol 2008; 18: 327– 331. 23 Por YM, Tan DT: Assessment of fibrin glue in pterygium surgery. Cornea 2010;29:1–4.
24 Jiang J, Yang Y, Zhang M, et al: Comparison of fibrin sealant and sutures for conjunctival autograft fixation in pterygium surgery: oneyear follow-up. Ophthalmologica 2008; 222: 105–111. 25 Pan HW, Zhong JX, Jing CX: Comparison of fibrin glue versus suture for conjunctival autografting in pterygium surgery: a meta-analysis. Ophthalmology 2011;118:1049–1054. 26 Srinivasan S, Dollin M, McAllum P, et al: Fibrin glue versus sutures for attaching the conjunctival autograft in pterygium surgery: a prospective observed masked clinical trial. Br J Ophthalmol 2009;93:215–218. 27 Shenasi A, Mousavi F, Shoa-Ahari A, et al: Subconjunctival bevacizumab immediately after excision of primary pterygium: the first clinical trial. Cornea 2011;30:1219–1222. 28 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. 29 Krag S, Ehlers N: Excimer laser treatment of pterygium. Acta Ophthalmol (Copenh) 1992; 70:530–533. 30 Förster W, Atzler U, Ratkay I, et al: Excimerlaser-phototherapeutische Keratektomie (PTK) und modifizierte Bare-Sklera-Technik zur Behandlung von Pterygien. Ophthalmologe 1995;92:424–426. 31 Förster W, Atzler U, Ratkay I, et al: Therapeutic use of the 193-nm excimer laser in corneal pathologies. Graefe’s Arch Clin Exp Ophthalmol 1997;235:296–305. 32 Talu H, Taşindi E, Ciftci F, et al: Excimer laser phototherapeutic keratectomy for recurrent pterygium. J Cataract Refract Surg 1998; 24: 1326–1332. 33 Walkow T, Anders N, Wollensak J: Kornealer Astigmatismus nach Pterygiumexzision und nachfolgender phototherapeutischer Keratektomie mit dem Excimerlaser (193 nm). Klin Monatsbl Augenheilkd 1996; 209: 199– 204. 34 Walkow T, Anders N, Antoni HJ, et al: Die Rezidivhäufigkeit nach primärer Pterygiumexzision, phototherapeutischer Keratektomie (PTK) mit dem ArD:Excimerlaser und lokaler Mitomycin-C-Applikation. Klin Monatsbl Augenheilkd 1996;208:406–409.
Ophthalmic Res 2014;51:52–58 DOI: 10.1159/000355075
57
Downloaded by: NYU Medical Center Library 128.122.253.212 - 5/18/2015 4:25:18 AM
References
58
37 Haider TA, Al-Amin LM, Bamashnus MA, et al: Ninety degree conjunctival rotation autograft versus zero and 180 degree rotation autograft for pterygium surgery. Saudi Med J 2009;30:519–523. 38 Müller S, Stahn J, Schmitz K, et al: Rezidivraten nach Pterygiumoperation mit Bindehautschwenklappen versus freies autologes Transplantat. Ophthalmologe 2007;104: 480– 483. 39 Rubinfeld RS: Letter to the editor: long-term results after bare sclera pterygium resection with excimer smoothing and local application of mitomycin C. Cornea 2006;25:758.
Ophthalmic Res 2014;51:52–58 DOI: 10.1159/000355075
40 Sinha R, Sharma N, Vaipayee RB: Letter to the editor: long-term results after bare sclera pterygium resection with excimer smoothing and local application of mitomycin C. Cornea 2006;20:757. 41 Ang LP, Chua JL, Tan DT: Current concepts and techniques in pterygium treatment. Curr Opin Ophthalmol 2007;18:308–313.
Promesberger/Kohli/Busse/Uhlig
Downloaded by: NYU Medical Center Library 128.122.253.212 - 5/18/2015 4:25:18 AM
35 Walkow T, Daniel J, Meyer CA, et al: Longterm results after bare sclera pterygium resection with excimer smoothing and local application of mitomycin C. Cornea 2005;24:378– 381. 36 Jandrasits K, Schauersberger J, Nepp J, et al: Excimer-Laser versus Diamantschleifer: Gleichwertige Kurzzeitergebnisse bei Hornhautglättung nach Pterygiumoperationen. Klin Monatsbl Augenheilkd 2001;218:418–423.
