Treatment of pterygium.
TL;DR: In conclusion, excision and adjunctive treatment with mitomycin C or conjunctival autograft is the most acceptable and most popular mode of treating both primary and recurrent pterygium.
Abstract: The treatment of ocular pterygium has been subjected to the development and application of various new strategies in the last few years. The worrisome problem of recurrence seems to have been significantly reduced with the newer methods of treatment. The field is however, still evolving. This review sets out to examine the various newer approaches to treating pterygium and in spite of the recent developments, to highlight the remaining challenges thereby suggesting the possible direction of future research. Also, to suggest treatment options for Ophthalmologists working in environments with limited resources. A library search and Internet search of PubMed and Google was conducted in 2010. Search terms included "pterygium in combination with surgery", "radiotherapy", "chemotherapy", "graft", and "recurrence." Abstracts were reviewed and relevant articles especially those published from the year 2000 to date were given more attention and when possible, reviewed in full. The relevant references in such articles were also reviewed. In conclusion, excision and adjunctive treatment with mitomycin C or conjunctival autograft is the most acceptable and most popular mode of treating both primary and recurrent pterygium. Outcomes seem to have been further improved with adjuvant combination therapy and the introduction of newer approaches to treatment.
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TL;DR: Evidence indicates that bare sclera excision of pterygium results in a significantly higher recurrence rate than excision accompanied by use of certain adjuvants, and there is evidence that mitomycin C and conjunctival or limbal autografts reduce the recurrence rates after surgical excision.
202 citations
TL;DR: Although pterygium management has traditionally involved surgery, often enhanced by the use of antimetabolites, recent advancements in the understanding of molecular and biochemical events underlying pteryGium pathogenesis may enable theUse of less invasive treatment methods.
Abstract: Pterygium is a fibrovascular lesion of the ocular surface that can display an aggressive clinical behavior and, occasionally, threaten vision. Although there is no consensus on its pathogenesis, recent evidence suggests that it is a proliferative, rather than degenerative condition strongly correlated with exposure to ultraviolet radiation (UVR) of solar light. Molecular genetic alterations reported in association with pterygium include loss of heterozygosity (LOH), point mutations of proto-oncogenes, such as K-ras and alterations in the expression of tumor suppressor genes, such as p53 or p63. Other findings in pterygium include the frequent detection of HPV DNA, ocular surface changes such as the overexpression of various proteins, including defensins and phospolipases D, as well as the up-regulation of growth factors, such as bFGF or VEGF. Although pterygium management has traditionally involved surgery, often enhanced by the use of antimetabolites, recent advancements in the understanding of molecular and biochemical events underlying pterygium pathogenesis may enable the use of less invasive treatment methods.
147 citations
Journal Article•
TL;DR: Intraoperative application of mitomycin C is an effective means to reduce chronic and deep-seated conjunctival inflammation, and helps amniotic membrane restore a deep fornix after symblepharon lysis, even in eyes that had a failed MMG.
Abstract: PURPOSE
To investigate whether intraoperative application of mitomycin C may enhance the success of amniotic membrane transplantation in symblepharon lysis and fornix reconstruction in severe cicatricial ocular surface diseases.
DESIGN
Noncomparative interventional case series.
PARTICIPANTS
Sixteen patients (8 female, 8 male; 18 eyes) with a mean age of 41+/-23.4 years (range, 3-79) and suffering from severe chemical/thermal burns (7 eyes), multiple recurrent pterygia and pseudopterygia (5 eyes), Stevens-Johnson syndrome (4 eyes), and ocular cicatricial pemphigoid (2 eyes) were consecutively enrolled. All except for 2 eyes had had prior surgical attempts of surgical reconstruction, including 6 eyes with a mucous membrane graft (MMG), but still presented with symblepharon and persistent ocular surface inflammation.
INTERVENTION
After excision of subconjunctival fibrovascular tissues, 0.04% mitomycin C was applied for 5 minutes in the deep fornix before amniotic membrane transplantation.
MAIN OUTCOME MEASURES
Deeper fornix, noninflamed ocular surface, and full motility.
RESULTS
The mean epithelial healing time was 4.2+/-1.9 weeks. During the follow-up of 14.16+/-5.2 months, all eyes showed a marked reduction of conjunctival inflammation, a deep fornix, and a continuous tear meniscus. Of 12 eyes with motility restriction, 2 eyes with multiple recurrent pterygia and 1 eye with severe thermal burn showed recurrence of partial motility restriction 2 months after surgery. The vision of 9 eyes was successfully restored by an additional keratolimbal allograft with subsequent penetrating keratoplasty (6 eyes).
CONCLUSION
Intraoperative application of mitomycin C is an effective means to reduce chronic and deep-seated conjunctival inflammation, and helps amniotic membrane restore a deep fornix after symblepharon lysis, even in eyes that had a failed MMG. Restoration of deep fornix and tear meniscus is an important prerequisite to achieve successful reconstruction by subsequent limbal stem cell transplantation.
109 citations
TL;DR: This rate of unsuspected OSSN suggests that all specimens of pterygium should be submitted for histopathologic examination and that patients in whom O SSN is noted should be examined at more frequent intervals so any clinical OSSn that develops can be identified at an early stage.
Abstract: METHODSThis retrospective study examined the patho-logicresultsofexcisedtissuefromallpatientswith pterygium who underwent surgery con-sistingofexcisionandautoconjunctivaltrans-plantation. The procedures were all per-formed by 1 of us (L.W.H.) between April 8,2003, and February 6, 2008. The indicationsforsurgerywereprimarilythepresenceofpte-rygium greater than 3 mm on the cornea, vi-sionlossattributabletopterygium,and,insomepatients,aconcernabouttheappearanceoftheeye.Allspecimensweresubmittedforroutinepathologic examination in formalin fixation,whichinvolvedparaffinembeddingoftheen-tire pterygium specimen. Multiple serial sec-tions, 4 µm thick, were cut. Three or 4 sec-tions stained with hematoxylin-eosin weremounted on each slide, and 4 slides were ex-aminedperspecimen.Onepathologist(R.A.A.)examined all the specimens in an open man-nerbecausetheinterpretationsweremadeanddocumented during the initial pathologic ex-aminationforroutinediagnosisofthesubmit-tedspecimens.Ifapatienthadapterygiumre-movedfromtheoppositeeye,itwasconsideredtobeaseparateevent;ifanasalpterygiumandatemporalpterygiumwereexcisedfrom1eye,only the first pterygium removed was in-cluded in this study. Findings of OSSN werereported as mild dysplasia, moderate dyspla-sia,severedysplasia,andcarcinomainsituac-cording to an accepted classification.
96 citations
TL;DR: A comparison of the groups demonstrated that the recurrence rate was highest in the bare sclera group, and lowest in conjunctival autografting and mitomycin C treatment groups respectively.
Abstract: Purpose:
To compare various techniques of pterygium surgery including bare sclera, intraoperative mitomycin C application, conjunctival flap reconstruction, and conjunctival autografting technique.
92 citations
Cites background from "Treatment of pterygium."
...Minimal to no complications apart from fl ap retraction and cyst formation have been reported.(12) McCoombes...
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References
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TL;DR: If mitomycin is used, the lowest possible concentration should be applied for the shortest time period in an effort to avoid these complications and the authors urge extreme caution in the use of this medication.
639 citations
"Treatment of pterygium." refers background in this paper
...Apart from the potential long-term effects on the cornea, use of MMC like with radiotherapy has been associated with serious complications that could present long after the surgery.[39,44] Although said to be uncommon, these serious complications are sight threatening and may include scleral melting leading to perforation, uveitis, infectious scleritis, and endophthalmitis....
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...Both the intraoperative and postoperative methods of application have similar reported recurrence rates and similar risks of serious potential side effects.[39,40] The main advantage of single dose intraoperative administration has been the control it gives to the surgeon over usage of the drug thereby avoiding the possible problem of poor patient compliance....
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TL;DR: The relatively low recurrence rate for primary pterygia allows one to use amniotic membrane transplantation as an alternative first choice, especially for advanced cases with bilateral heads or those who might need glaucoma surgery later.
575 citations
"Treatment of pterygium." refers background in this paper
...[51] However, in terms of preventing pterygium recurrence, most studies[51-53] have shown that it is not as effective as conjunctival grafting and have documented recurrence rates above 10% using AMT alone....
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TL;DR: Free conjunctival grafts from the superotemporal bulbar conjunctiva of the same eye were used to resurface exposed sclera and extraocular muscle and, in all 14 patients with diplopia, extraocular movement was restored and the surgical approach is recommended as a safe and effective means of treating pterygia complicated by Conjunctival scarring withextraocular muscle involvement and requiring concurrent fornix reconstruction.
498 citations
"Treatment of pterygium." refers background in this paper
...Since its introduction by Kenyon et al.[57] in 1985, conjunctival autograft has gradually come to be a popular treatment for pterygium....
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...Covering the bare sclera by using autologous conjunctival tissue could be performed by a primary direct closure, a sliding conjunctival flap,[58,59] or by a free conjunctival autograft.[57] The free graft is typically harvested from the superior bulbar conjunctiva and sutured or more preferably, glued to the bare sclera defect after pterygium excision....
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...Conjunctival autograft Since its introduction by Kenyon et al.[57] in 1985, conjunctival autograft has gradually come to be a popular treatment for pterygium....
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TL;DR: The current knowledge on pterygium pathogenesis is summarised, highlighting recent developments and novel data is provided further demonstrating the complexity of this intriguing disease.
311 citations
"Treatment of pterygium." refers background in this paper
...Various theories have been postulated on the aetiopathogenesis[1,2] and its predominantly nasal location on the eye....
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TL;DR: It will be important to develop a grading system, and surgeons will need to be conservative in the treatment of pterygium until such time as a single treatment provides a lower recurrence rate and complication rate.
281 citations