Efficacy and Safety of a Large Conjunctival Autograft for Recurrent Pterygium

Abstract

Purpose: To evaluate the efficacy and safety of pterygium excision using a large conjunctival autograft for the treatment of recurrent pterygium.

Methods: The medical records of 120 patients (126 eyes) with recurrent pterygium were reviewed. For each affected eye, pterygium excision with a large conjunctival autograft was performed. The graft was harvested from the superior bulbar area and measured more than 8 × 10 mm in size. Only patients who completed at least six months of follow-up were included. Postoperative clinical outcomes, recurrence rate, and complications were analyzed. Patients with any evidence of recurrence after surgery received a subconjunctival bevacizumab injection.

Results: The average patient age was 56.5 ± 10.2 years, and 45 out of 120 patients were male. The mean study follow-up period was 17.7 ± 17.6 months. Most patients were satisfied with the cosmetic outcome. Postoperative visual acuity improved from 0.69 to 0.75 (p < 0.05). Postoperative refractive astigmatism and corneal astigmatism decreased by 0.55 and 2.73 diopters, respectively (p < 0.05). The postoperative recurrence rate was 4.0%, and the average recurrence period was 7.4 ± 0.6 weeks. A subconjunctival injection of 5 mg bevacizumab was performed in cases of recurrence; no progression of the pterygium was observed following the injection. Postoperative complications included 2 cases of conjunctival graft edema in 2 eyes, 5 donor site scars in 5 eyes, 13 pyogenic granulomas in 13 eyes, and a conjunctival epithelial inclusion cyst in 7 eyes.

Conclusions: Pterygium excision with a large conjunctival autograft for the treatment of recurrent pterygium produced an excellent cosmetic outcome, a low recurrence rate, and minimal complications. A subconjunctival bevacizumab injection given in cases of recurrence following surgery might be effective in preventing progression of the pterygium.

Keywords: Autografts; Bevacizumab; Pterygium.

Fig. 1. Surgical conjunctival autograft procedures in pterygium surgery. (A) Preoperative recurrent nasal pterygium. (B) The pterygium head was excised, the conjunctiva allowed to retract, and the subconjunctival fibrovascular tissue excised en bloc. (C) The superior conjunctival autograft was flipped over the cornea and the limbal attachment, and then the head of the palisades of Vogt was cleaned with a blade. (D) The conjunctival autograft was placed over the cornea. The graft was rotated toward the defect site by spreading the conjunctiva while being mindful of orienting the limbal stem cell population toward the limbus. (E) Fibrin glue was applied over the bare sclera and conjunctival autograft. A drop of fibrinogen solution was placed on the bare sclera, and a drop of thrombin solution was applied to the conjunctival autograft. (F) The conjunctival autograft was spread over the bare sclera, and the edges were bonded to the surrounding health conjunctiva using McPherson forceps. (G) The donor conjunctival tissue was sutured to the recipient site using several simple interrupted sutures with 10-0 nylon (Ethilon; Johnson & Johnson Medical, Cincinnati, OH, USA) at the tissue margins. (H) After the conjunctival autograft was secured, temporary amniotic membrane transplantation was performed.

Fig. 2. Change in conjunctival injection after pterygium surgery. (A) Hypervascularized recurrent pterygium in a left eye. (B) Decreased conjunctival injection after pterygium excision with a conjunctival autograft.

Fig. 3. A change in fibrous tissue contraction after pterygium surgery. (A) Thick fibrovascular tissue on the cornea induced ocular motility limitations. (B) Resolution of the thick fibrovascular tissue and ocular motility limitation after pterygium excision with a conjunctival autograft.

Fig. 4. Complications after pterygium surgery. (A) Graft edema. (B) Donor site scarring. (C) Pyogenic granuloma. (D) Conjunctival epithelial inclusion cyst.

Fig. 5. A 45-year-old male experienced pterygium recurrence after pterygium surgery and received two subconjunctival bevacizumab injections. (A) Recurrent pterygium before the surgery. (B) Pterygium recurrence eight weeks postoperatively. (C) No progression of fibrovascular proliferation after two subconjunctival bevacizumab injections for six months.