Journal of the College of Physicians and Surgeons Pakistan 2013, Vol. 23 (3): 199-202 199

INTRODUCTIONPterygium is a fibro vascular wing shaped encroachmentof conjunctiva on the cornea.1 Mostly, it occurs nasally,but can occur temporally, or on both sides of the eyeglobe. Although the pathogenesis is not clear but ultra-violet light, hot, dry, windy, dusty, smoky environmentsand hereditary are considered as risk factors.2-4 Themain histopathological change in primary pterygium isan elastotic degeneration of conjunctival collagenfibers.5 The chief complaints are foreign bodysensations in eye, decreased vision, fleshy growth overthe pupil and cosmetic blemish. Anti-inflammatoryagents and lubricants play an important role inminimizing the patient's discomfort, but do not cure thedisease.Surgical excision of pterygium with bare scleratechnique is widely practised, because it is a safe and

simple procedure.6 However, with time, it becomesapparent that the recurrence rate is un-acceptablyhigh with this procedure, ranging from 24% to 89%.7Several other methods are now implemented with theaim of improving the success rate and decreasing therecurrence rate, for example, low dose Mitomycin C(MMC), conjunctival autograft (CAG), rotational conjunc-tival flap, lamellar keratoplasty, amniotic membranetransplant, beta radiation, ablation with YAG laser andsmoothening of the cornea with the Excimer laser.8Mitomycin C is an antineoplastic antibiotic agent isolatedfrom the fermentation filtrate of Streptomyces caespitosus.It alkylates and cross links DNA and, in addition, maygenerate superoxide and hydroxyl radicals in solution.It also inhibits DNA, RNA, and protein synthesis. Allthese actions affect cellular proliferation for long-time.However, the combination of limbal CAG and local lowdose MMC seems to be the best treatment, giving bothlow recurrence rate and high safety.9 This has not beenwidely tested locally.The objective of this study was to determine the re-recurrence and the postoperative complications inrecurrent pterygium cases treated by intraoperative0.02% Mitomycin C (MMC) and conjunctival autograft(CAG).

ORIGINAL ARTICLE

Outcome of Recurrent Pterygium with Intraoperative 0.02%Mitomycin C and Free Flap Limbal Conjunctival Autograft

Ashok Kumar Narsani1, Partab Rai Nagdev2 and Maria Nazish Memon1

ABSTRACTObjective: To determine the re-recurrence and the postoperative complications in recurrent pterygium cases treated byintraoperative 0.02% Mitomycin C (MMC) and conjunctival autograft (CAG).Study Design: Quasi-experimental.Place and Duration of Study: Department of Ophthalmology, Liaquat University of Medical and Health Sciences,Jamshoro, Hyderabad and Chandka Medical College Hospital, Larkana, from January to December 2010.Methodology: Cases with recurrent pterygium were included in this study. Cases with history of first time pterygium andpterygium with conjunctival scaring, dry eye, glaucoma and vitreoretinal disease were excluded. After topical and sub-conjunctival anaesthesia, pterygium was excised in single piece. Intraoperative 0.02% MMC was applied on bare sclerafor 2 minutes. CAG was excised from supero-temporal conjunctiva, and implanted on bare sclera. All cases were followed-up for 6 months. Re-recurrence was defined as postoperative fibrovascular re-growth of 1.0 mm or more crossing thecorneo-scleral limbus. Data was analysed as descriptive statistics.Results: A total of 65 eyes of 65 cases were studied having mean age of 43.26 12.81 years. Among those, 41 (63.1%)were males and 48 (73.8%) belonged to rural area. The size of pterygium on cornea was 2-3 mm in 44 (67.7%) cases and4-5 mm in 21 (32.3%) cases. Re-recurrence of pterygium was seen in 3 (4.6%) cases. Postoperative complicationsincluded conjunctival granuloma in 2 (3.1%) cases, graft necrosis in 2 (3.1%) cases, graft oedema in 3 (4.6%) cases andgraft displacement in 3 (4.6%) cases.Conclusion: The intraoperative application of 0.02% MMC with CAG markedly reduces the risk of re-recurrence ofpterygium and postoperative complications.

Key words: Excision. Recurrent pterygium. 0.02% Mitomycin C (MMC). Conjunctival autograft (CAG).

1 Department of Ophthalmology, Liaquat University of Medicaland Health Sciences, Jamshoro, Hyderabad.

2 Department of Ophthalmology, Chandka Medical CollegeHospital, SMBBM University, Larkana.

Correspondence: Dr. Partab Rai Nagdev, Bungalow 13,Doctor Colony, VIP Road, Larkana.E-mail: dr_partab_rai@yahoo.com

Received July 15, 2011; accepted January 08, 2013.

METHODOLOGYThis study was conducted at the Department ofOphthalmology, Liaquat University of Medical andHealth Sciences, Jamshoro, Hyderabad and ChandkaMedical College Hospital, Larkana, from January 2010to December 2010. It was a quasi-experimental studywhere cases presenting with history of recurrentpterygium were included. Cases with history of first timepterygium and pterygium with conjunctival scaring, dryeye, glaucoma, and vitreoretinal disease were excluded.All cases were informed about the study and a writtenconsent was taken from them. After admission in theward, the detailed history and eye examination wasrecorded on a specific proforma. After topical and sub-conjunctival anaesthesia, pterygium was excised insingle piece. Intraoperative 0.02% MMC was applied onbare sclera for 2 minutes. CAG was excised fromsupero-temporal conjunctiva, and implanted on baresclera. At the end of surgery, topical combined steroid-antibiotic eye ointment was used and eye pad wasapplied for 24 hours. Postoperatively oral antibiotic,(cephradine 500 mg, 3 times/day) and analgesic,(diclofenac potassium 50 mg, 2 times/day) were used for5 days. The topical combined steroid-antibiotic eyedrops (dexamethasone 0.1% + tobramycin 0.3%), onedrop one hourly during awaking hours and eye ointmentat night was used for first week and then tapered to4 times/day for a further 8 weeks (Figures 1 3). Post-operatively, all the cases were followed after first 1 week,first 2 weeks and then in every month for 6 months.Re-recurrence was defined as postoperative fibro-vascular re-growth of 1.0 mm size or more crossing thecorneo-scleral limbus. Any complications in the graftwere noted.Frequencies and percentages were determined forgender, area of origin of population, size of pterygium,follow-up and postoperative complications. Chi-squaretest was used for comparision of re-recurrence.A p-value of 0.05 was considered statisticallysignificant. Statistical Package for Social Sciences(SPSS) version 10 was used for statistical analysis ofthe data.

RESULTSWe evaluated 65 eyes of 65 cases with mean age of43.26 12.81 years (range 21 to 72 years). Amongthose, 41 (63.1%) were males and 24 (36.9%) werefemales with male to female ratio of 2:1; 48 (73.8%)cases belonged to rural area and 17 (26.2%) to urbanarea. The size of pterygium on cornea was 2-3 mm in 44(67.7%) cases and 4-5 mm in 21 (32.3%) cases(Table I). The re-recurrence of pterygium was seen in 3(4.6%) cases. The postoperative complications noticedwere conjunctival granuloma in 2 (3.1%) cases, graftnecrosis in 2 (3.1%) cases, graft displacement in3 (4.6%) cases, and graft oedema in 3 (4.6%) cases.

Ashok Kumar Narsani, Partab Rai Nagdev and Maria Nazish Memon

200 Journal of the College of Physicians and Surgeons Pakistan 2013, Vol. 23 (3): 199-202

Figure 1: Photograph showing measurement ofsize of pterygium.

Figure 3: Complete attachment of free flap limbalconjunctival autograft.

Figure 2: Application of MMC with cotton tipapplicator after excision of pterygium.

Table I: A summary of demographics, pterygim size, follow-up, post-operative complications and re-recurrence (n = 65).

Number of patients Percentage(Frequency)

GenderMale 41 63.1Female 24 36.9Total 65 100

Area of originUrban 17 26.2Rural 48 73.8Total 65 100

Size of pterygium2 3 mm 44 67.74 5 mm 21 32.3Total 65 100

Follow-upPresent 52 80Absent 13 20Total 65 100

Postoperative complicationsGranuloma 2 3.1Graft necrosis 2 3.1Graft oedema 3 4.6Displacment of graft 3 4.6Nill 55 84.6Total 65 100

Recurrence+ VE 3 4.6- VE 62 95.4Total 65 100

The re-recurrence of pterygium was seen in 3 (4.6%)cases (p = 0.003). Postoperatively the common factorsfound in re-recurrence of pterygium were graft necrosisand graft displacement.

DISCUSSIONIt is believed that surgical trauma and subsequentpostoperative inflammation activates sub-conjunctivalfibroblasts, vascular cells, and deposition of extracellular matrix proteins, which in turn contributes to thepterygium recurrence. Various surgical techniques wereemployed for the treatment of pterygium, but the mainproblem encountered in each modality was an un-predictable rate and time of recurrence.10 The simplesttechnique for pterygium excision by bare sclera alonewas proved unsatisfactory because of its highrecurrence rate 24 89%.7 Adjunctive treatment afterbare sclera technique with beta radiation showed therecurrence rate to as low as 0.5 10%,11 but this canproduce serious complications such as scleral melting,keratitis etc. Singh et al. introduced the use of low doseMMC as an adjuvant to pterygium surgery in 1988.12Although MMC significantly reduces the rate ofrecurrence of pterygium to less than 10% but it canproduce serious complications such as scleral melting,ectasia and necrosis, corneal limbal perforation.13 In1985, Kenyon et al. reported limbal CAG as a promisingtechnique in the treatment of pterygium with recurrencerate of 5.3%.14 After that, a number of papers on thelimbal CAG technique are published with varioussuccess rates. However, the surgical factors such as thesurgeon's experience and the surgical technique hasprofound influence on the recurrence rate.The main disadvantage of limbal CAG is that it requiresprolonged per operative time in comparison to baresclera technique. Moreover, limbal CAG including limbalstem cells generally yield better results, because it willhelp to restore its barrier function. In 1989, Lewallenreported a randomized trial of the limbal CAG techniquefor pterygium excision and documented 19% recurrencerate in grafted cases compared with 37% recurrencerate in bare sclera technique cases.15 Riordan-Eva et al.reported 14% recurrence rate following 3 years of limbalCAG for pterygium.16 In 2005, Fahmi et al. reported13.3% recurrence rate with limbal CAG.17 Therecurrence rate in this series of cases was 4.6% which iscomparable with studies by Altiparmak et al. and Segevet al., they reported recurrence rate of 13.3% and 2%respectively.18,19Serious complications occurring after pterygium excisionwith adjunctive treatment has been well reported.However, no serious complications were noted in thisstudy, like study of Frucht-Pery and IIsar.20 A commonrisk factor in toxicity with MMC is a relatively largecumulative dose and duration of application. Therefore,

a single intraoperative low dose of 0.02% MMC andshort (2 minutes) duration of application would reducethe postoperative complication rate. It was also noticedthat the frequency of recurrent pterygium was more inthe third to fifth decade of life, twice more common inmales than females and thrice common in those living inrural area, than urban area. This may be due to moreultraviolet exposed outdoor occupational and re-creational activities of males than females and in ruralarea than in urban area.

CONCLUSIONThe intraoperative application of MMC combined withfree flap limbal CAG significantly reduces the risk of re-recurrence of pterygium and postoperative complications.

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Ashok Kumar Narsani, Partab Rai Nagdev and Maria Nazish Memon

202 Journal of the College of Physicians and Surgeons Pakistan 2013, Vol. 23 (3): 199-202