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Case Reports
. 2020 May 21:13:201-209.
doi: 10.2147/IMCRJ.S245256. eCollection 2020.

Management of Recurrent Pterygium with Severe Symblepharon Using Mitomycin C, Double Amniotic Membrane Transplantation, Cryopreserved Limbal Allograft, and a Conjunctival Flap

Yu Monden  1 , Chikako Nagashima  1 , Noriko Yokote  1 , Fumi Hotokezaka  1 , Satoshi Maeda  1 , Kensuke Sasaki  1 , Ryoji Yamakawa  1 , Shigeo Yoshida  1
Affiliations
Case Reports

Management of Recurrent Pterygium with Severe Symblepharon Using Mitomycin C, Double Amniotic Membrane Transplantation, Cryopreserved Limbal Allograft, and a Conjunctival Flap

Yu Monden et al. Int Med Case Rep J. .

Abstract

Purpose: The aim of this study was to evaluate the clinical outcomes of management of recurrent pterygium with severe symblepharon using mitomycin C, double amniotic membrane transplantation, cryopreserved limbal allograft, and a conjunctival flap.

Patients and methods: This retrospective case series included 10 eyes of 10 patients with recurrent pterygium with severe symblepharon. Eight patients have diplopia in primary gaze. All patients underwent pterygium excision, application of mitomycin C (MMC), double amniotic membrane transplantation (AMT), cryopreserved limbal allograft (CLA) transplantation, and placement of a conjunctival flap. Outcome measures were visual acuity, astigmatism, and recurrence. Recurrence was defined as the presence of fibrovascular proliferative tissue crossing the limbus.

Results: The patients' mean age was 73.8 years. The mean follow-up period was 3.0 years. The mean preoperative and postoperative best-corrected visual acuities (logMAR conversion) were 0.43 and 0.30, respectively. The mean preoperative and postoperative astigmatism were -3.89 diopters and -1.54 diopters, respectively, and there was a significant difference. No recurrence occurred in any of the eyes. Symblepharon was released in all eyes. Diplopia in primary gaze was resolved in all eyes.

Conclusion: Management of recurrent pterygium with severe symblepharon using MMC, double AMT, CLA, and a conjunctival flap was an effective treatment.

Keywords: amnion; limbal allograft; mitomycin C; pterygium; symblepharon.

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Conflict of interest statement

The authors report no conflicts of interest in this work.

Figures

Figure 1
Figure 1
Surgical procedure (schema). (A) Removal of the pterygium head and subconjunctival tissue, and application of pieces of sponge soaked in 0.04% mitomycin C. (B) The CLA was trimmed and placed on the bare limbus and sclera. (C) Amniotic membrane was placed over the bare sclera to reach the fornix, and the sclera of CLA. (D) Large pedicle conjunctival epithelium flap excluding the limbal area (1–2 mm). (E) Amniotic membrane transplantation on the ocular surface. Abbreviations: MMC, mitomycin C; CLA, cryopreserved limbal allograft, AM, amniotic membrane; CF, conjunctival flap; LA, limbal area.
Figure 2
Figure 2
Surgical procedure (photographs). (A) Application of pieces of sponge (arrows) soaked in 0.04% mitomycin C. (B) The cryopreserved limbal allograft was trimmed. (C) The cryopreserved limbal allograft (between arrows) was placed on the bare limbus and sclera with 10–0 nylon sutures. (D) Amniotic membrane (between arrows) transplantation on the bare sclera and the sclera of the cryopreserved limbal allograft. (E) A conjunctival epithelium flap (between arrows) from the superior area was rotated, positioned, and secured on the amniotic membrane with 9–0 Vicryl sutures. (F) Amniotic membrane was placed on the ocular surface.
Figure 3
Figure 3
Preoperative and postoperative appearances. Upper column, Case 1 and lower column, Case 2. (A) Case 1. Before excision of a recurrent pterygium combined with application of mitomycin C, double amniotic membrane transplantation, and a large conjunctival flap. (B) Before the surgery. (C) At 5.6 years after the surgery. Symblepharon was released and the center of CLA became thinner (arrow), but there has been no recurrence. (D) Case 2. Before the surgery. (E) Scleral stromalysis was observed 6 months after the surgery (arrow). (F) Scleral transplantation was performed for the scleral stromalysis 2 years after the surgery (arrow).
Figure 4
Figure 4
Preoperative and postoperative appearances in other cases. Left column, eyes before surgery and right column, after surgery. (A) A 63-year-old female had undergone pterygium surgery two times in the past. Before the surgery. (B) At 5.5 years after the surgery. Symblepharon was released and the center of the CLA became thinner (arrow), but there has been no recurrence. (C) A 72-year-old male had undergone pterygium surgery four times in the past. Before the surgery. (D) At 3 years after the surgery. (E) An 82-year-old male had undergone pterygium surgery three times in the past. Before the surgery. (F) At 2.5 years after the surgery. The conjunctival sac was shortened. (G) A 73-year-old male had undergone pterygium surgery once in the past. Before the surgery. (H) At 1 year after the surgery.
Figure 5
Figure 5
Preoperative and postoperative appearances in other cases. Left column, eyes before surgery and right column, after surgery. (A) A 73-year-old male had undergone pterygium surgery two times in the past. Before the surgery. (B) At 2 years after the surgery. (C) A 70-year-old female had undergone pterygium surgery once in the past. Before the surgery. (D) At 2 years after the surgery. (E) An 81-year-old female had undergone pterygium surgery once in the past. Before the surgery. (F) At 1 year after the surgery. (G) A 76-year-old male had undergone pterygium surgery once in the past. Before the surgery. (H) At 11 months after the surgery. The conjunctival sac was shortened.
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