A Comparative Study of Treatment of Pterygium by Excision and Limbal Autograft or Augmented withPost-Op Mitomycin C

Abstract

Pterygium is a cause of diminution of vision when it encroaches on the pupillary area. It typically develops in patients who have been living in hot climates and may represent a response to chronic dryness and exposure to ultraviolet light, dust and hot winds. It is rarely seen in patients younger than the age of 20 years. The study was conducted to study the clinical profile of pterygium and to compare results of recurrence by excision with limbal conjunctival autografts or postoperative topical Mitomycin Cdrops. The present study was conducted at the Department Of Ophthalmology at Agartala Government Medical college and GB Pant Hospital over a period of 18 months (October 2016 to May 2018). One of the main aims of the study was to compare the effectiveness of conjunctival limbal autografting and mitomycin C in preventing the recurrence of pterygium. In the present study it was found that recurrence of pterygium occurred in 2 (5%) out of 40 eyes treated with limbal conjunctival autograft and 3 (7.5%) out of 40 eyes in whom pterygium excision was followed by postoperative mitomycin C.

Full text

IOSR Journal of Dental and Medical Sciences (IOSR-JDMS)
e-ISSN: 2279-0853, p-ISSN: 2279-0861.Volume 17, Issue 11 Ver. 10 (November. 2018), PP 45-48
www.iosrjournals.org
DOI: 10.9790/0853-1711104548 www.iosrjournals.org 45 | Page
A Comparative Study of Treatment of Pterygium by Excision and
Limbal Autograft or Augmented withPost-Op Mitomycin C
Dr. Anurag Majumdar, Dr. Abhijit Ray, Dr. Shivam Gupta
Dept. of Ophthalmology, Agartala Govt. Medical College, Agartala, Tripura(West)
Corresponding Author: Dr. Abhijit Ray
Abstract:Pterygium is a cause of diminution of vision when it encroaches on the pupillary area. It typically
develops in patients who have been living in hot climates and may represent a response to chronic dryness and
exposure to ultraviolet light, dust and hot winds. It is rarely seen in patients younger than the age of 20 years.
The study was conducted to study the clinical profile of pterygium and to compare results of recurrence by
excision with limbal conjunctival autografts or postoperative topical Mitomycin Cdrops.
The present study was conducted at the Department Of Ophthalmology at Agartala Government Medical
college and GB Pant Hospital over a period of 18 months (October 2016 to May 2018).
One of the main aims of the study was to compare the effectiveness of conjunctival limbal autografting and
mitomycin C in preventing the recurrence of pterygium. In the present study it was found that recurrence of
pterygium occurred in 2 (5%) out of 40 eyes treated with limbal conjunctival autograft and 3 (7.5%) out of 40
eyes in whom pterygium excision was followed by postoperative mitomycin C.
Keywords:Pterygium, Mitomycin-C, Recurrence, Limbal autograft, Vascularisation
--------------------------------------------------------------------------------------------------------------------------------------
Date of Submission: 14-11-2018 Date of acceptance: 29-11-2018
--------------------------------------------------------------------------------------------------------------------------------------
I. Introduction
Pterygium is a cause of diminution of vision when it encroaches on the pupillary area. The patient also
has cosmetic problems. Epidemiological surveys indicate that the prevalence rates of pterygium vary depending
on the exact population [1-6]. Overall prevalence rates range from 0.7 to 31% in various populations of the
world [1-6]. As a general rule, prevalence rates for a pterygium increase with age although a decline in
prevalence rates has been reported for patients over 60 to 70 years old [1,3].It typically develops in patients who
have been living in hot climates and may represent a response to chronic dryness and exposure to ultraviolet
light, dust and hot winds. It is rarely seen in patients younger than the age of 20 years. With the development of
new methods of treatment, frequency and severity of pterygium have declined. The study was conducted to
study the clinical profile of pterygium and to compare results of recurrence by excision with limbal conjunctival
autografts or postoperative topical Mitomycin Cdrops.
II. Aim And Objectives
To prospectively analyze a clinical study of pterygium and results of treatment by excision and limbal autograft
surgery or augmented with post operative topical mitomycin C.
III. Material And Methods
Present study was a prospective, comparative case study involving 80 eyes of 40 patients who
attended the attended the Department of Ophthalmology at Agartala Government Medical College and GB Pant
Hospital .The duration of the study was 2 years. The study was reviewed by the institutional review board. Each
eligible patient provided informed consent prior to the enrollment in thestudy.
InclusionCriteria
All cases of pterygium attending the OPD including recurrent pterygium .
ExclusionCriteria
Patients coming from far away places who were not able to come for regular follow up were excluded from this
study
A detailed history was taken and recorded regarding the disease which included age, occupation, residence,
exposure to dust and hot wind. The extent of corneal involvement by the pterygium was also noted.
Patient were assigned to two groups (A and B) randomly. Group A underwent limbal conjunctival autograft.
Group B underwent pterygium excision augmented with postoperative topical mitomycin C application (Figure

A Comparative Study of Treatment of Pterygium by Excision and Limbal Autograft or Augmented..
DOI: 10.9790/0853-1711104548 www.iosrjournals.org 46 | Page
1 and 2). In patients belonging to Group A excision of pterygium was done followed by limbal conjunctival
autograft taken from upper temporal quadrant and sutured on the bare sclera using 6-0 vicryl sutures (Figure 3
and 4). Patients were given gatifloxacin or moxifloxacin with dexamethasone eye drop 4 times a day for 2
weeks, then3 times a day for 2 weeks, and then 2 times a day for 2 weeks. Gatifloxacin or Moxifloxacin with
dexamethasone ointment was applied at night for 6 weeks. The patients were followed after one week and after
that monthly for a year. Patients belonging to group B were treated with mitomycin C in a strength of 0.01
mg/ml in carboxy methylcellulose. On first and second postoperative day patients were told to use either
gatifloxacin or moxifloxacin eye drops 6 times a day. From third to twenty first postoperative day patients were
given mitomycin C drops 4 times a day and gatifloxacin (3 mg) with dexamethasone (1 mg) eyedrops 4 times
aday.
Patients were followed weekly for three weeks and then monthly for a period of one year. Best corrected visual
acuity were noted on every visit. Patients were asked for any pain, photophobia, redness, lacrimation.
Slit lamp examination was done and eye was looked for:
1) Anyrecurrence.
2) Scleralthinning.
3) Cornealvascularisation.
IV. Results
The present study was conducted at the Department Of Ophthalmology at Agartala Government
Medical college and GB Pant Hospital over a period of 18 months (October 2016 to May 2018).
80 eyes of 40 patients were enrolled in this study. Patients were assigned to two groups (A and B) randomly.
Group A underwent limbal conjunctival autograft, 40 patients. Group B underwent pterygium excision
augmented with postoperative topical mitomycin C application included 40 patients.
AgeDistribution
Out of the 80 patients maximum number of patients were in the age group from 41 to 50 years in which the
youngest patient was 23 years of age and the oldest patient was 70 years of age.
SexDistribution
Out of the 80 patients there was a male preponderance in this study with 47 males (58.75%) as compared to 33
females (41.25%). The higher incidence in males could be attributed to their greater exposure to hot, dry and
dustyclimate.
EyeInvolved
Out of 91 eyes in 80 patients right eye was involved in 54 patients (67.5%), left eye was involved in 37 patients
(46.25%).
Site ofPterygium
The site of pterygium is found to be nasal in 88 eyes (96.70%) of eyes, while temporal in 3 (3.30%) of eyes.
Size ofPterygium
The cornea was encroached by pterygium between 2 - 3 mm in 88 eyes (96.70%) while the cornea was involved
greater than 3 mm by pterygium in 3 eyes (3.30%).
RecurrenceRates
One of the main aims of the study was to compare the effectiveness of conjunctival limbal autografting
and mitomycin C in preventing the recurrence of pterygium. In the present study it was found that recurrence of
pterygium occurred in 2 (5%) out of 40 eyes treated with limbal conjunctival autograft and 3 (7.5%) out of 40
eyes in whom pterygium excision was followed by postoperative mitomycin C.
Recurrence Time afterSurgery
Chen et al. [17] reported the mean time of recurrence varied from 3.7 to 4.8 months with only 6% of
recurrences occurring after the sixth postoperative month.
In the present study, cases where limbalconjunctival autografting was done there was recurrence occurring in
the first and third month whereas in cases where pterygium excision followed by mitomycin was done
recurrence occurred in third, fourth and sixth month of follow up (Table 4). So the present study agrees with
previous studies.
Age of Patients withRecurrence

A Comparative Study of Treatment of Pterygium by Excision and Limbal Autograft or Augmented..
DOI: 10.9790/0853-1711104548 www.iosrjournals.org 47 | Page
In the study conducted by Figueiredoet al. [18] patients with age less than 50 years had significantly
more recurrences. It has been suggested that lipoid degeneration in the cornea is an inhibiting factor to
pterygium growth, based on observations that pterygium does not cross an arcus senilis to any great extent. The
presence of increasing amounts of lipoid degeneration with age might explain in part, the strong association
between age and recurrence.
The present study (Table 5) shows that there were two recurrences in eyes with pterygium excision
followed by conjunctival autograft with age less than 50 years of age whereas in eyes with pterygium excision
followed by mitomycin C there was one recurrence in patients less than 50 years and two recurrences in patients
greater than 50 years of age which agrees with previous studies.
Table 1. Shows the site of pterygium involved.
Site
No. of eyes
Percentage
Nasal
88
96.70%
Temporal
3
3.30%
Total
91
100%
Table 1. Shows the site of pterygium involved.
Size
No of eyes
Percentage
2 - 3 mm
88
96.70
Greater than 3 mm
3
3.30
Table 3. Shows the recurrence rates.
Pterygium autograft
Pterygium excision
with mitomycinC
No of eyes treated
40
40
Recurrence no. %
2 (5%)
3 (7.5%)
Table 4. Shows the recurrence time after surgery
Time of recurrence
GroupA
(conjuctival
autograft)
Group B (pterygium excision followed by
mitomycin C)
1 month
1
0
2 months
0
0
3 months
1
1
4 months
0
1
5 months
0
0
6 months
0
1
7 months
0
0
8 months
0
0
9 months
0
0
10 months
0
0
11 months
0
0
12 months
0
0
Table 5. Shows the age of patients with recurrence.
Age of the patient
Group A (conjuctival autograft)
Group B (pterygium excision followed by mitomycin C)
Less than or equal to 50 years
2 (5%)
2 (5%)
Greater than 50 years
0
1 (2.5%)
Table 6. Shows the postoperative complications.

A Comparative Study of Treatment of Pterygium by Excision and Limbal Autograft or Augmented..
DOI: 10.9790/0853-1711104548 www.iosrjournals.org 48 | Page
Type of complications
Group A (conjunctival autograft)
Group B (pterygium excision followed by mitomycin C)
Scleral thinning
0
2 (5%)
5.9. Postoperative Complications
Lam et al. [19] reported 2 cases (5.57%) of scleral thin- ning in the group in which they applied MMC.
The present study shows (Table 6) 2 cases (5%) of scleral thinning in eyes with pterygium excision followed by
MMC which agrees with previous studies.
V. Conclusion
Conjunctival limbal autograft and postoperative Mitomycin C (0.02%) are both safe and effective
adjuncts to primary pterygium surgery. The main prejudices against auto- grafting are the expertise and time
required for the pro- cedure. Theuse of biologic adhesives to fixate the autograft in place may simplify the
procedure. Age of the patients was strongly associated with recurrence regard- less of which procedure was
used. More research needs to be done to delve into this seemingly innocuous pathology of conjunctiva to
effec- tively manage the disease condition
References
[1]. R. M. Youngson, “Pterygium in Israel,” American Jour- nal of Ophthalmology, Vol. 74, No. 5, 1972, pp.954-959.
[2]. R. Detels and S. P. Dhir, “Pterygium: A Geographical Study,” Archives of Ophthalmology, Vol. 78, No. 4, 1967, pp. 485-
491.http://dx.doi.org/10.1001/archopht.1967.00980030487014
[3]. P. Sivasubramaniam, “Pterygium in Ceylon,” British Jour- nal of Ophthalmology, Vol. 55, 1971, pp. 55-
59.http://dx.doi.org/10.1136/bjo.55.1.55
[4]. M. S. Norn, “Prevalence of Pinguecula in Greenland and in Copenhagen and Its Relation to Pterygium and Sphe- roid
Degeneration,” Acta Ophthalmologica, Vol. 57, No. 1, 1979, pp.96-105.
[5]. http://dx.doi.org/10.1111/j.1755-3768.1979.tb06664.x
[6]. R. T. Rasanayagam, “The Incidence and Racial Distribu- tion of Pterygium in West Malaysia,” Transactions of the
Ophthalmological Society of New Zealand, Vol. 25, 1973, pp.56-59.
[7]. J. R. Rojas and H. Malaga, “Pterygium in Lima, Peru,” Annals of Ophthalmology, Vol. 18, No. 4, 1986, pp. 147- 149.
[8]. A. Meseret, A. Bejiga and M. Ayalew, “Prevalence of Pterygium in Rural Community,” Ethiopian Journal of Health Development,
Vol. 22, No. 2, 2008, pp.191-194.
[9]. J. S. Kwon and O. Choi, “A Study of Pterygium in Cheju Island,” Yonsei Medical Journal, Vol. 18, No. 2, 1977, pp. 151-156.
[10]. S. Duke Elder, “System of Ophthalmology,” Vol. VIII, Part I, Henry Kimpton, London, 1965, pp.573-582.
[11]. S. K. Rao, T. Lekha, B. N. Mukesh, et al., “Conjunctival- Limbal Autograft for Primary and Recurrent Pterygia,” Indian Journal of
Ophthalmology, Vol. 46, No. 4, 1998, pp.203-209.
[12]. J. A. McCoombes, L. W. Hirst and G. P. Isbell, “Sliding Conjuctival Flap for the Treatment of Primary Ptery- gium,”
Ophthalmology, Vol. 101, No. 1, 1994, pp. 169- 173.
[13]. R. Rachmiel, H. Leiba and S. Levartovsky, “Results of Treatment with Topical Mitomycin C 0.02% Following Excision of Primary
Pterygium,” British Journal of Oph- thalmology, Vol. 79, No. 3, 1995, pp. 233-236.http://dx.doi.org/10.1136/bjo.79.3.233
[14]. J. Shimazaki, H. Y. Yang, K. Tsubota, et al., “Limbal Autograft Transplantation for Recurrent and Advanced Pterygia,”
Ophthalmic Surgery Lasers, Vol. 27, No. 11, 1996, pp.917-923.
[15]. R. S. Rubinfeld, R. R. Pfister and R. M. Stein, et al., “Se- rious Complications of Topical Mitomycin C after Ptery- gium Surgery,”
Ophthalmology, Vol. 99, No. 11, 1992, pp.1647-1654.
[16]. B. D. S. Allan, P. Short, G. J. Crawford, et al., “Ptery- gium Excision with Conjunctival Autografting: An Effec- tive and Safe
Technique,” British Journal ofOphthal- mology, Vol. 77, No. 11, 1993, pp. 698-701.http://dx.doi.org/10.1136/bjo.77.11.698
[17]. J. A. Cardillo, M. R. Alves, L. E. Ambrosio, et al., “Sin- gle Intraoperative Application versus Postoperative Mi- tomycin C Eye
Drops in Pterygium Surgery,” Ophthal- mology, Vol. 102, No. 12, 1995, pp.1949-1952.
[18]. P. P. Chen, R. G. Ariyasu, V. Kaza, et al., “A Random- ized Trial Comparing Mitomycin C and Conjuctival Autograft after
Excision of Primary Pterygium,” Ameri- can Journal of Ophthalmology, Vol. 120, No. 2, 1995, pp. 151-160.
[19]. R. S. Figueiredo, E. J. Cohen, J. A. P. Gomes, et al., “Conjunctival Autograft for Pterygium Surgery: How Well Does It Prevent
Recurrence,” Ophthalmic Surgery Lasers, Vol. 28, No. 10, 1997, pp.99-104.
[20]. D.S.C.Lam,A.K.K.WongandD.S.P.Fan,“Intraop-erative Mitomycin C to Prevent Recurrence of Pterygium after Excision. A 30-
Month Follow-Up Study,” Oph- thalmology, Vol. 105, No. 5, 1998, pp. 901-905. http://dx.doi.org/10.1016/S0161-6420(98)95034-
5
Dr. Anurag Majumdar. , “A Comparative Study of Treatment of Pterygium by Excision and
Limbal Autograft or Augmented withPost-Op Mitomycin C..”. ” IOSR Journal of Dental and
Medical Sciences (IOSR-JDMS), vol. 17, no. 11, 2018, pp 45-48.