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

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.     

纤维蛋白胶在兔眼翼状胬肉自体结膜瓣转移手术中的应用

背景 翼状胬肉为临床常见的眼表疾病.为降低其术后复发率,众多学者进行了广泛的研究.近年来,纤维蛋白胶的应用逐渐受到人们的重视. 目的 探讨利用纤维蛋白胶粘合翼状胬肉自体结膜瓣转移对于减少术后刺激的作用机制.方法 取12只清洁级家兔采用角巩膜缘组织切除和质量分数1.25％稀盐酸点眼法制作兔眼翼状胬肉模型并行翼状胬肉自体结膜瓣转移手术,其中左眼利用手术缝线缝合结膜瓣(缝线组),右眼利用纤维蛋白胶封闭结膜瓣(蛋白胶组),比较两组手术的持续时间.分别于术后1周和4周检查两组兔眼的刺激症状,采用免疫组织化学染色和逆转录聚合酶链反应( RT-PCR)法观察血管内皮生长因子(VEGF)和碱性成纤维细胞生长因子(bFGF)蛋白及其mRNA在结膜组织中的表达情况. 结果 缝线组手术持续时间为(21.3±0.2)min,而纤维蛋白胶组为(10.1±0.1)min,纤维蛋白胶组较缝线组手术时间明显缩短(t=102.242,P＜0.05).术后1周及术后4周,纤维蛋白胶组的结膜充血程度为(+)～(++),缝线组为(++)～(+++),纤维蛋白胶组充血程度明显较轻.免疫组织化学染色显示,VEGF和bFGF主要在结膜上皮细胞层表达,棕黄色颗粒沉积于上皮细胞的细胞质.术后1周时,纤维蛋白胶组的VEGF和bFGF表达强度明显弱于缝线组;术后4周时,两组VEGF和bFGF的表达较术后1周时有所减弱,但纤维蛋白胶组仍明显弱于同期缝线组.RT-PCR检测显示,术后纤维蛋白胶组VEGF mRNA在结膜上皮组织中的表达明显低于缝线组,VEGFmRNA表达量随着术后时间的延长而下降,差异均有统计学意义(F组别=174.443,P=0.000;F时间=231.459,P=0.000);bFGF mRNA的表达遵循同样的模式,差异均有统计学意义(F组别=41.727,P=0.000;F时间=55.417,P=0.000).结论 纤维蛋白胶粘合可以免去缝合环节,节省手术时间,避免缝线的刺激,并可减轻炎症反应.通过减少VEGF和bFGF的表达,可能有助于降低翼状胬肉的复发率.     

自体结膜瓣移植术和角膜缘干细胞移植术对原发性翼状胬肉术后泪膜的影响

目的：比较自体结膜瓣移植术(CAT)和角膜缘干细胞移植术(LCAT)对原发性翼状胬肉患者术后泪膜的影响。

方法：前瞻性研究。收集2018-09/2019-05在新疆军区总医院北京路医疗区眼科诊断为原发性翼状胬肉患者共150例150眼,依次纳入本研究,奇数者行CAT,偶数者行LCAT,术前,术后1、3、6mo,1a完成泪膜破裂时间(TBUT)、SchirmerⅠ试验(SⅠt)和眼表疾病指数(OSDI),结果进行统计学分析。

结果：患者129例129眼完成术后1a随访,CAT组64例64眼,复发4眼(6.2%); LCAT组65例65眼,复发3眼(4.6%),两组复发率无差异(P=0.718)。CAT组和LCAT组TBUT、SⅠt和OSDI评分术前和术后1、3、6mo,1a均有差异(P<0.05),术后1mo和术后3、6mo,1a均有差异(P<0.05),术后3、6mo和术后1a均无差异(P>0.05)。CAT组和LCAT组不同时间点TBUT、SⅠt和OSDI评分均无差异(P>0.05)。

结论：CAT和LCAT均能有效治疗原发性翼状胬肉,术后复发率低且相近,两种手术方式改善原发性翼状胬肉术后泪膜功能的程度相近。     

两种方法治疗原发性翼状胬肉的疗效观察

目的：比较自体结膜瓣移植术( conjunctival autograft transplant, CAT )和角膜缘干细胞移植术( limbal conjunctival autograft transplant, LCAT)治疗原发性翼状胬肉的临床效果。
　　方法：前瞻性、随机、对照病例研究。收集2014-01/2015-01在解放军第四七四医院诊断为原发性翼状胬肉患者共120例120眼,依次纳入本研究,奇数者行 CAT,偶数者行LCAT。
　　结果：术后随访1a,完成随访107例107眼,CAT 组患者54例54眼,术后复发4眼,复发率7.4%;LCAT 组患者53例53眼,术后复发2眼,复发率3.8%。两组间复发率无统计学意义(P=0.678)。
　　结论：CAT 组和 LCAT 组均能有效治疗原发性翼状胬肉,降低术后翼状胬肉复发率,但 LCAT 是治疗原发性翼状胬肉的最优术式。     

Conjunctival autograft for primary and recurrent pterygia: surgical technique and problem management

The surgical technique and postoperative problem management of conjunctival autograft transplantation for advanced primary and recurrent pterygium are reviewed. Problems such as graft edema, corneoscleral dellen, and epithelial inclusion cysts infrequently occur. Corneal astigmatism, Tenon's granuloma, retraction and/or necrosis of the graft, and muscular disinsertion are even less frequently encountered. Limbal-conjunctival autograft for recalcitrant recurrent cases is proposed.     

Pterygium surgery: conjunctival rotation autograft versus conjunctival autograft

BACKGROUND AND OBJECTIVES: To compare the safety and efficacy of conjunctival rotation autograft to conjunctival autograft in primary pterygium surgery. PATIENTS AND METHODS: A prospective randomized study was performed of 39 eyes in 31 patients who had undergone pterygium surgery. Nineteen eyes were treated by conjunctival rotation autograft (Group A). Twenty eyes were treated by conjunctival autograft (Group B). Follow up ranged from 8 to 12 months (mean 11 months). Recurrence was defined as postoperative regrowth of 2 mm fibrovascular tissue onto clear cornea in the area of previous pterygium excision. Four eyes were excluded from the study. Delayed wound healing occurred in 11.76% of eyes, and 5.88% of eyes had persistent congestion in Group A. A loose graft was present in 5.55% of eyes, and 5.55% of eyes had dellen formation in Group B. CONCLUSION: We conclude that conjunctival rotation autograft and conjunctival autograft are both equally effective methods to reduce the recurrence rate after pterygium surgery. Conjunctival rotation autograft can be tried as an alternative attractive procedure for pterygium surgery to reduce the chances of recurrence. However, a larger, randomized, prospective double masked study with more patients and a longer follow up will eventually demonstrate the superiority of one procedure over the other.     

Management of primary pterygia using free conjunctival and limbal-conjunctival autografts without antimetabolites

PURPOSE: To report the incidence of recurrence after primary pterygium surgery using either a free conjunctival or limbal-conjunctival autograft without antimetabolites. METHODS: One hundred eleven eyes of 90 patients underwent pterygium resection; a free conjunctival autograft was used in 88 surgeries and a free limbal-conjunctival autograft in 24; the latter technique was reserved for dark-skinned patients, under age 30, and with a history of recurrent pterygium in the contralateral eye. RESULTS: Mean age was 42.5 years (range, 23-75), and 50% of the patients were male. Mean follow-up was 9 months (range, 3-12). There were 2 recurrences (1.8%), both observed in the third postoperative month. CONCLUSIONS: With a good surgical technique, the incidence of recurrence after primary pterygium surgery is very low, making the use of antimetabolites unnecessary.     

翼状胬肉切除联合自体球结膜或干细胞移植疗效的Meta分析

目的：探究翼状胬肉切除联合自体球结膜移植(CAG)或干细胞移植(LCAG)的疗效对比分析。

方法：系统性检索美国国立图书馆医学文献检索系统(PubMed)、荷兰医学文摘数据库(EMBASE)、科克伦图书馆(The Cochrane Library)、美国临床试验注册中心(The US trial registry),从建库起至2021-09所有的文献。对复发率、角膜上皮愈合时间、基础泪液分泌试验(SⅠt)和泪膜破裂时间(BUT)进行分析。应用Review Manager 5.3进行统计学分析,计数资料以相对危险度(RR)、计量资料以标准化均数差(SMD)及其95%可信区间(CI)表示。

结果：共计纳入15项研究,接受手术眼数共1 883眼,其中897眼行LCAG术,986眼行CAG术。在复发率方面,LCAG组显著低于CAG组(RR=0.33,95%CI：0.15～0.71,P=0.004); 在角膜上皮愈合时间方面,LCAG组显著短于CAG组(SMD=-0.87,95%CI：-1.64～-0.11,P=0.02); 在SⅠt方面,两组结果变化值相近(SMD=0.03,95%CI：-0.33～0.40,P=0.86); 在BUT方面,LCAG组较CAG组显著延长(SMD=0.40,95%CI：0.09～0.70,P=0.01)。

结论：翼状胬肉切除联合LCAG较CAG的术后复发率更低,角膜上皮愈合更快,泪膜稳定性更好。     

Intraoperative daunorubicin versus conjunctival autograft in primary pterygium surgery

PURPOSE: To evaluate the safety and efficacy of intraoperative daunorubicin during a bare sclera procedure in primary pterygium surgery and to compare with conjunctival autograft. METHODS: The data for 84 patients who underwent pterygium surgery at Safdarjung Hospital and Guru Nanak Eye Center were analyzed retrospectively. The patients were divided into two groups: group A, those who underwent bare sclera excision along with conjunctival autograft, and group B, those who underwent bare sclera excision with intraoperative daunorubicin (0.02%) for 3 minutes. We evaluated pterygium recurrence and postoperative complications for both groups. Recurrence of pterygium was defined as growth of 2 mm of fibrovascular tissue over the corneoscleral limbus into the clear cornea in the area of previous pterygium excision. RESULTS: Follow-up ranged from 18 to 37 months (mean, 27). Recurrence rates of 8.33% (three of 36) and 7.14% (three of 42) were found in groups A and B, respectively. When compared statistically, the difference was not significant. All the recurrences occurred in patients younger than 30 years of age. Pyogenic granuloma, graft edema, loose graft, and dellen formation were seen, respectively, in 5.5% (two of 36), 2.77% (one of 36), 2.77% (one of 36), and 2.77% (one of 36) patients in group A. Nine of 42 (21.42%) patients in group B had chemosis of the conjunctiva and two of 42 (4.76%) had delayed epithelization. CONCLUSION: We conclude that intraoperative daunorubicin (0.02%) and conjunctival autograft are both equally effective adjuncts to pterygium surgery.     

Comparison of conjunctival autograft and conjunctival transposition flap techniques in primary pterygium surgery

Purpose

To investigate and compare the efficacy of conjunctival autograft and conjunctival transpositional flap for the treatment of primary pterygium surgery.

Mitomycin C, amniotic membrane transplantation and limbal conjunctival autograft for treating multirecurrent pterygia with symblepharon and motility restriction

Background Treatment of eyes with multirecurrent pterygia associated with severe symblepharon and motility restriction is challenging. A combined surgical procedure of intraoperative mitomycin C, amniotic membrane transplantation and conjunctival limbal autograft was applied for treating such eyes. Methods Seven eyes of seven patients who had previously undergone an average of four operations for pterygial removal and who manifested recurrent pterygia associated with severe symblepharon and motility restriction were involved in this retrospective study. The surgical procedures involved clearing fibrovascular membrane over the cornea, extensive excision of epibulbar fibrovascular tissue to the bare sclera, application of 0.02% mytomycin C onto the bare sclera for 5 min and transplantation of preserved human amniotic membrane and conjunctival limbal autograft. Results Postoperatively, all seven eyes showed rapid epithelialization on the corneal surface in 3–5 days and, on the conjunctival surface, in 10–18 days. For a mean follow-up period of 22.4±6.1 months, six eyes recovered deep fornices, smooth and stable ocular surface and full ocular motility without recurrence. One eye showed regrowth of fibrovascular tissue and motility restriction but less severe than before surgery. No complication was noted due to mitomycin C. Conclusions Combined intraoperative mitomycin C, amniotic membrane graft and limbal conjunctival autograft are successful approaches for treating multirecurrent pterygia with severe symblepharon to restore the ocular surface integrity and prevent recurrence. S.C.G.T. and his family are more than 5% shareholders of TissueTech, Inc., which owns US Patents nos 6,152,142 and 6,326,019 on the method of preparation and clinical uses of human amniotic membrane.     

The results of amniotic membrane transplantation for primary pterygium compared with conjunctival autograft

PURPOSE: To study the efficacy and safety of amniotic membrane transplantation as an adjunctive therapy after surgical excision of primary pterygium and to compare the clinical outcome with that of conjunctival autograft. METHODS: Eighty-six eyes of 78 patients with primary pterygium were operated on by a single surgeon (N.T.). All patients were randomized to undergo amniotic membrane or conjunctival autograft transplantation as an adjuvant therapy after pterygium excision. Forty-four eyes in 39 patients were treated with amniotic membrane transplantation (AM group), and 42 eyes of 41 patients were treated with conjunctival autograft (CG group). Patients were followed up at 1 week, 1, 3, 6, and 12 months postoperation. The main outcome measurement was a recurrence rate after surgery. RESULTS: The mean follow-up was 14.40 +/- 5.4 months in the AM group and 12.35 +/- 3.13 months in the CG group. There were 18 recurrences (40.9%) in the AM group and two (4.76%) in the CG group, which was significantly different among both groups (P < 0.007). The cumulative proportion that were recurrence-free at 12 months was 0.6 +/- 0.15 for the AM group and 0.95 +/- 0.07 for the CG group (P = 0.0003, Log-rank test). The cumulative nonrecurrence rate at 6 and 12 months in all patients stratified by age and sex was not significantly different (P = 0.28 and P = 0.9, Log-rank test). No major complications were observed in either group. CONCLUSION: The surgical results of primary pterygium excision followed by amniotic membrane and conjunctival autograft transplantation were compared. It was found that amniotic membrane transplantation for pterygium surgery has an unacceptably high recurrence rate.     

Long-term follow-up study of mitomycin eye drops as adjunctive treatment of pterygia and its comparison with conjunctival autograft transplantation

We observed 48 patients for 7-21 months (mean, 18 months) after pterygium excision and 2 weeks of placebo or mitomycin topical therapy to evaluate whether or not the short-term efficacy of mitomycin in preventing pterygium recurrence would be reflected in long-lasting efficacy as well. Placebo-treated pterygia showed a 73% recurrence rate. One of 58 (1.7%) mitomycin-treated pterygia recurred (p less than 0.05). We also performed a pilot study comparing pterygia treated with excision followed by 0.4 mg/ml of mitomycin to pterygia treated with excision coupled with conjunctival autograft transplantation to estimate the number of patients required for a randomized clinical trial comparing these two treatment modalities and thereby to decide whether or not such a study would be justified. Thirteen primary and two recurrent pterygia were treated with mitomycin, while 14 primary and one recurrent pterygia were treated with conjunctival autograft transplantation. With mean follow-up times of 4 and 6 months, respectively, no recurrences were noted in the mitomycin-treated group, while the conjunctival autograft transplantation group had one recurrence (6.6%). We estimate that 400 patients would be required for a properly designed clinical trial comparing these two effective therapies for prevention of recurrent pterygia. We conclude that such a study is unjustified, and further conclude that the vastly less expensive, simple therapy of mitomycin eye drops is the more appropriate treatment.     

自体角膜缘干细胞移植术治疗复发性翼状胬肉疗效观察

目的:观察自体角膜缘干细胞移植术治疗复发性翼状胬肉疗效。方法:把66例81眼复发性翼状胬肉患者随机分为两组,治疗组:34例44眼行翼状胬肉切除联合自体角膜缘干细胞移植术;对照组:32例37眼行翼状胬肉切除联合带蒂结膜瓣转移术。胬肉复发的定义:血管纤维组织重新侵入角膜。结果:术后随访12~24mo。治疗组治愈率98%,复发率2%;对照组治愈率84%,复发率16%。两组复发率有统计学意义(χ2=4.62,P<0.05),两组均无明显并发症。结论:自体角膜缘干细胞移植术治疗复发性翼状胬肉疗效高,复发率低于带蒂结膜瓣转移术。     

Inferior limbal-conjunctival autograft transplantation for recurrent pterygium

PURPOSE: To study the safety and efficacy of inferior limbal-conjunctival autograft (LCAT) transplantation in the surgical management of recurrent pterygium. METHODS: Prospective non-comparative case series. Inferior limbal-conjunctival autografting was performed on 11 patients (11 eyes) with recurrent pterygium. Pterygium recurrence was considered a surgical failure. RESULTS: Recurrence of pterygium was noted in two (18.2%) eyes, after a mean follow up of 16.2 +/- 0.9 months (range: 10-19 months). Neither recurrence required further surgical treatment. Nonprogressive pseudopterygium formation was noted at the donor site in five (45.5%) eyes. CONCLUSION: Inferior LCAT appears to be a safe and effective option in the management of recurrent pterygium. In patients with suspected or proven glaucoma, this may be the procedure of choice, if mitomycin C is contraindicated.