CASE SERIES

Sequential pterygium excision with conjunctival autograft in the management of primary double-headed pterygia Sonia N. Yeung, MD, PhD, FRCSC,*,† Darya Rubenstein, BA,† Aryeh J. Price, BSc,† Uri Elbaz, MD,† Angela Q. Zhang, MD,† Elie Côté, BSc,† Allan R. Slomovic, MA, MD, FRCSC† ABSTRACT ● RÉSUMÉ Objective: The purpose of this study was to evaluate the efficacy of sequential pterygium excision with conjunctival autograft (PECA) in the management of double-headed pterygia. Methods: All patients who underwent a sequential PECA procedure for double-headed pterygia from 2004 to 2009 were included in this retrospective, noncomparative, interventional case series. The recurrence rate and visual outcomes after this procedure were determined. Results: Nine eyes of 8 patients with doubled-headed pterygia undergoing sequential PECA were identified. Of 18 PECA procedures, 1 recurrence (5.56%) was found. The single recurrence was observed nasally in the right eye (first site operated) of a female patient 55 months after the second PECA procedure. None of the operated eyes lost any lines of corrected distance visual acuity, and 22% gained at least 1 line of corrected distance visual acuity. Conclusions: In this series, harvesting the conjunctival autograft from the same site several months later does not appear to increase the rate of recurrence. Sequential PECA is a safe and effective method of addressing double-headed pterygia. Objet : Évaluation de l’efficacité de l’excision séquentielle du ptérygion avec autogreffe conjonctivale (EPAC) dans la gestion du ptérygion à double tête. Méthodes : Tous les patients qui ont subi une procédure EPAC séquentielle pour un ptérygion à double tête, de 2004 à 2009, ont été inclus dans cette rétrospection non comparative d'une série de cas d'intervention. Le taux de récurrence et les résultats individuels suivant cette procédure ont été déterminés. Résultats : L’on a identifié 9 yeux de 8 patients qui, atteints de ptérygion à double tête, ont subi une EPAC. Sur 18 procédures EPAC, l'on a trouvé 1 récurrence (5,56 %). Celle-ci a été trouvée du côté nasal dans l’œil droit (premier site opéré) d'une patiente 55 mois après la deuxième procédure EPAC. Aucun des yeux opérés n'a perdu de ligne d'acuité visuelle distante corrigée (AVDC) et 22 % ont gagné au moins une ligne de AVDC. Conclusions : Dans cette série, le prélèvement de l’autogreffe conjonctivale dans le même site plusieurs mois après ne semble pas avoir augmenté le taux de récurrence. L’EPAC séquentielle présente une méthode sécuritaire et efficace pour aborder le ptérygion à double tête.

membrane transplantation,4 split graft,5 bare sclera,6 and conjunctival rotational autograft combined.7 Currently, PECA is one of the most commonly used techniques for single-headed pterygia because of its low postoperative recurrence rate.8 The purpose of this study is to report our experience with the use of sequential PECA for doubleheaded pterygia, and to evaluate the postoperative outcomes and recurrence rates.

Pterygium is a common ocular surface disorder characterized by a wing-shaped overgrowth of the bulbar conjunctiva over the limbus, often nasally. The presence of both nasal and temporal pterygia in the same eye, termed double-headed pterygia, is rare with a reported incidence rate of less than 2.5%.1 Pterygium excision with conjunctival autograft (PECA) is a widely performed procedure for single-headed pterygia, with recurrence rates varying from 2% to 39%.2,3 The management of double-headed pterygia poses a significant challenge because a large amount of conjunctival donor tissue is required to cover both bare scleral defects. Various surgical techniques have been described to address the paucity of conjunctival donor tissue in cases of doubleheaded pterygia, whereas also reducing the risk for recurrence. Some of these techniques include the following in combination with conjunctival autograft: amniotic

This retrospective, noncomparative, interventional study of all sequential PECA procedures for doubleheaded pterygia was approved by the Institutional Research Ethics Board of the University Health Network, University of Toronto (Toronto, Ont.).

From the *Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, B.C.; and †Department of Ophthalmology, Toronto Western Hospital, University of Toronto, Toronto, Ont

Can J Ophthalmol 2013;48:521–523 0008-4182/13/$-see front matter & 2013 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2013.05.014

METHODS

Originally received Jan. 1, 2013. Final revision May 12, 2013. Accepted May 23, 2013 Correspondence to Sonia N. Yeung, MD, Department of Ophthalmology and Visual Sciences, University of British Columbia, Eye Care Centre, Vancouver Hospital, 2550 Willow Street, Vancouver BC V5Z 3N9; [email protected] CAN J OPHTHALMOL — VOL. 48, NO. 6, DECEMBER 2013

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Sequential pterygium excision with conjunctival autograft—Yeung et al. Sequential PECA procedures for double-headed pterygia were performed over a 6-year period from 2004 to 2009. All cases included in this study were primary double-headed pterygia. The indications for surgery included vision loss and/or discomfort attributable to pterygium, as well as cosmesis. Data collected included demographics, preoperative visual acuity, length of followup, time between sequential procedures, postoperative visual acuity, early postoperative complications, recurrence, and other late postoperative complications. Recurrence was defined as any fibrovascular growth measuring ≥1 mm across the limbus onto the cornea. Patients were followed at 1 week, 1 month, 3 months, 6 months, and yearly. If a patient was followed elsewhere, a report from the patient’s ophthalmologist or optometrist was obtained. All patients in this study completed a minimum of 5 months of follow-up after the second procedure. Institutional Review Board approval at the University of Toronto and affiliated hospitals was obtained for this study. In all cases, PECA secured by fibrin glue (Tisseel) was performed, as described previously by Koranyi et al.9 After surgery, TobraDex (Alcon Laboratories, Fort Worth, Tex.) eye drops were prescribed 4 times daily for 1 week. Dexamethasone 0.1% (Maxidex, Alcon, Fort Worth, Tex.) eye drops were then given 4 times daily, followed by a slow taper over 6 weeks. Sequential PECA procedures were conducted no earlier than 3 months apart (mean 5 ⫾ 2.1 months). In all cases, the larger of the 2 pterygia was excised first (nasal site in 8/9 eyes). All specimens were submitted for routine histopathologic analysis. Data were expressed as mean ⫾ SD. Snellen values for preoperative and postoperative visual acuity data were converted to logarithm of the minimal angle of resolution units for analysis. Paired t test for continuous variables was used. Proportions were compared using Fisher’s exact test. A p value less than 0.05 was considered statistically significant for all analyses. Results

The population of Southern Ontario is heterogeneous, composed of many different ethnicities because of a large immigrant population. Between 2004 and 2009, 9 cases of primary double-headed pterygia were noted in 1486 total cases of pterygia evaluated (0.6%). During this time, 9 eyes of 8 patients (4 male and 4 female) underwent PECA secured by fibrin glue for primary double-headed pterygia. The mean age of the cohort was 51.9 ⫾ 12.14 years (range, 38–69 years). All patients reported redness and irritation. Three patients reported blurring of vision. Of 9 eyes undergoing sequential procedures, 8 had the nasal pterygium removed first (the larger of the 2 sites). Nasal pterygia had a mean surface area of 10.04 ⫾ 5.20 mm2, whereas temporal pterygia had a mean surface area of 9.13 ⫾ 5.33 mm2. No intraoperative complications were noted. The mean preoperative best corrected distance visual acuity (BDVA) was 0.63 ⫾ 1.06 (mean 20/85), which did

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not change significantly after surgery (0.19 ⫾ 0.33; mean 20/31; p ¼ 0.18). None of the operated eyes lost any lines of BDVA, and 22% gained at least 1 line of BDVA. At an average follow-up of 24 months (range, 5–55 months), 1 recurrence (5.56%) was noted in 18 procedures (9 eyes with double-headed pterygia requiring sequential excisions with conjunctival autograft). This was a small localized recurrence, observed nasally in the right eye (first site operated) of a female patient 55 months after the second PECA procedure. No further surgery was required. Other than this case, no other late complications were noted in this series.

DISCUSSION PECA is considered to be the gold standard in the management of primary pterygia and is associated with the lowest recurrence rates.10 This in combination with the use of fibrin tissue glue instead of sutures has provided a further reduction in recurrence rates for primary pterygia.9,11,12 Because of the lack of available donor conjunctival tissue, a single procedure involving the excision of both pterygia in double-headed pathology with conjunctival autograft often is not possible. Several techniques have been proposed in the literature to address this surgical challenge. In 11 eyes, Solomon et al.4 used amniotic membrane transplantation in double-headed pterygia and cited a recurrence rate of 9% (1/11 cases). The authors reported motility restriction and symblepharon formation evident in 3 patients, associated with the extensive removal of subconjunctival tissue and local injections of corticosteroid. Furthermore, amniotic membrane may not be readily available at all institutions and is costly. Avisar et al.6 described their experience in 10 eyes with the use of intraoperative mitomycin C after bare sclera excision of primary double-headed pterygia. No recurrences were noted with this technique, and only 1 patient experienced development of a pyogenic granuloma postoperatively. Concerns with the use of mitomycin C must still be considered, such as scleral melt, corneal perforation, iritis, and glaucoma.13,14 Split-conjunctival graft technique has also been used to manage double-headed pterygia.5 In their series of 7 eyes, no recurrences were noted at a mean follow-up of 17 months. With this technique, sufficient superior conjunctival tissue and exposure is not always possible given that both grafts are harvested from the superior quadrant. Wu et al.7 devised a new technique by using a conjunctival rotational autograft in combination with a conventional conjunctival autograft after pterygium surgery. In their series, the recurrence rate was 35% (7/20 cases), and the main postoperative complication was persistent injection over the conjunctival rotational autograft in 45% of cases (9/20 cases). Sequential PECA is simple, safe, effective, and avoids many of the complications described earlier.

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Sequential pterygium excision with conjunctival autograft—Yeung et al. The primary long-term outcome measure for successful pterygium excision surgery is recurrence. PECA is the most commonly performed technique for primary pterygia, with recurrence rates varying from 2% to 39%.2,3,15–18 The recurrence rates after double-headed pterygium excision is reported to be 0% to 35%, depending on the chosen surgical procedure and size of the series published. Our recurrence rate of 5.56% is low and is consistent with reported recurrence rates after excision with conjunctival autograft for primary single-headed pterygia. The main limitation of our study is the retrospective noncomparative design and the limited number of cases. A prospective, randomized study would be instrumental in determining the optimal surgical technique for addressing double-headed pterygia excision. However, the low incidence rate (o2.5%)1 would make recruitment a challenge, as noted in our series (0.6%). The minimum follow-up of 5 months was chosen because previous publications demonstrated that most recurrences occurred within 4 to 5 months.4,17,19,20 A longer follow-up period would be preferable nonetheless. In our study, we present the outcomes for management of nasal and temporal pterygia with sequential conjunctival autograft transplantation with tissue glue. The drawback of this procedure is the 2 separate operations. Patients may not be willing to undergo a second procedure. Also, care must be taken to ensure that Tenon’s is spared so that significant scarring of the donor area is prevented. However, this procedure takes advantage of the low recurrence rate and low complication rate of conjunctival autograft with tissue glue to approach the management challenge of double-headed pterygia. Furthermore, reharvesting the conjunctiva eliminates the concern of having insufficient tissue for grafting, and the aesthetic outcomes are good. Harvesting the conjunctival autograft from the same site several months later did not appear to increase the rate of recurrence. We found sequential excision with conjunctival autograft to be a safe and effective procedure for managing double-headed pterygia.

Disclosure: The authors have no proprietary or commercial interest in any materials discussed in this article. REFERENCES 1. Dolezalova V. Is the occurrence of a temporal pterygium really so rare? Ophthalmologica. 1977;174:88-91.

2. Kenyon KR, Wagoner MD, Hettinger ME. Conjunctival autograft transplantation for advanced and recurrent pterygium. Ophthalmology. 1985;92:1461-70. 3. Lewallen SA. randomized trial of conjunctival autografting for pterygium in the tropics. Ophthalmology. 1989;96:1612-4. 4. Solomon A, Pires RT, Tseng SC. Amniotic membrane transplantation after extensive removal of primary and recurrent pterygia Ophthalmology. 2001;108:449-60. 5. Maheshwari S. Split-conjunctival grafts for double-head pterygium. Indian J Ophthalmol. 2005;53:53-5. 6. Avisar R, Snir M, Weinberger D. Outcome of double-headed pterygium surgery. Cornea. 2003;22:501-3. 7. Wu WK, Wong VW, Chi SC, Lam DS. Surgical management of double-head pterygium by using a novel technique: conjunctival rotational autograft combined with conjunctival autograft. Cornea. 2007;26:1056-9. 8. Shehadeh-Mashor R, Srinivasan S, Boimer C, Lee K, Tomkins O, Slomovic AR. Management of recurrent pterygium with intraoperative mitomycin C and conjunctival autograft with fibrin glue. Am J Ophthalmol. 2011;152:730-2. 9. Koranyi G, Seregard S, Kopp ED. Cut and paste: a no suture, small incision approach to pterygium surgery. Br J Ophthalmol. 2004;88:911-4. 10. Sanchez-Thorin JC, Rocha G, Yelin JB. Meta-analysis on the recurrence rates after bare sclera resection with and without mitomycin C use and conjunctival autograft placement in surgery for primary pterygium. Br J Ophthalmol. 1998;82:661-5. 11. Farid M, Pirnazar JR. Pterygium recurrence after excision with conjunctival autograft: a comparison of fibrin tissue adhesive to absorbable sutures. Cornea. 2009;28:43-5. 12. Karalezli A, Kucukerdonmez C, Akova YA, Altan-Yaycioglu R, Borazan M. Fibrin glue versus sutures for conjunctival autografting in pterygium surgery: a prospective comparative study. Br J Ophthalmol. 2008;92:1206-10. 13. Rubinfeld RS, Pfister RR, Stein RM, et al. Serious complications of topical mitomycin-C after pterygium surgery. Ophthalmology. 1992;99:1647-54. 14. Safianik B, Ben-Zion I, Garzozi HJ. Serious corneoscleral complications after pterygium excision with mitomycin C. Br J Ophthalmol. 2002;86:357-8. 15. 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;115:1235-40. 16. Bahar I, Kaiserman I, Weisbrod M, McAllum P, Slomovic A. Extensive versus limited pterygium excision with conjunctival autograft: outcomes and recurrence rates. Curr Eye Res. 2008; 33:435-40. 17. 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; 120:151-60. 18. Prabhasawat P, Barton K, Burkett G, Tseng SC. Comparison of conjunctival autografts, amniotic membrane grafts, and primary closure for pterygium excision. Ophthalmology. 1997;104:974-85. 19. Ma DH, See LC, Liau SB, Tsai RJ. Amniotic membrane graft for primary pterygium: comparison with conjunctival autograft and topical mitomycin C treatment. Br J Ophthalmol. 2000;84:973-8. 20. Memarzadeh F, Fahd AK, Shamie N, Chuck RS. Comparison of deepithelialized amniotic membrane transplantation and conjunctival autograft after primary pterygium excision. Eye (Lond). 2008;22:107-12.

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Sequential pterygium excision with conjunctival autograft in the management of primary double-headed pterygia.

The purpose of this study was to evaluate the efficacy of sequential pterygium excision with conjunctival autograft (PECA) in the management of double...
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