Management of Recurrent Pterygium With Intraoperative Mitomycin C and Conjunctival Autograft With Fibrin Glue




Purpose


To evaluate the safety and efficacy of using fibrin glue in cases of recurrent pterygium treated with pterygium excision and conjunctival autograft combined with mitomycin C.


Design


Retrospective, interventional case series.


Methods


The charts of 28 patients with recurrent pterygium who had undergone pterygium excision and conjunctival autograft using fibrin glue to secure the graft combined with intraoperative mitomycin C at a corneal service in a university teaching hospital were reviewed. Inclusion criteria were recurrent pterygium that had undergone at least 1 previous surgical excision and patients who had completed a regular postoperative follow-up of at least 12 months. Outcome measures included mean best-corrected visual acuity (BCVA) and intraoperative and postoperative complications.


Results


The mean age of the cohort was 49.7 years. There were no intraoperative complications. Early postoperative total graft dehiscence developed in 1 eye that underwent repositioning with glue and sutures. One eye had mild graft dehiscence and required no surgical intervention. One eye had a conjunctival cyst on the graft that did not require intervention. No significant change was observed in BCVA. At a mean follow-up of 26.5 months, there was 1 case of recurrence.


Conclusions


Pterygium excision and conjunctival autograft using fibrin glue to secure the graft combined with intraoperative mitomycin C seems to be a safe and effective surgical option for treating recurrent pterygium. However, a larger cohort with longer follow-up may be required to assess the recurrence rate of this method.


The primary long-term outcome measure to a successful pterygium excision surgery is recurrence. Over the years, many surgical techniques have evolved to lower the risk of recurrence. In many studies, pterygium excision with conjunctival autograft has been associated with the lowest recurrence rates. In addition, the use of fibrin tissue glue instead of sutures was associated with further reduction of recurrence rates in several studies of primary pterygium surgery.


Reports on the outcomes of recurrent pterygium surgery usually are difficult to assess as a separate category because they frequently are reported simultaneously with cases of primary pterygium surgery or comprise a small number of cases. Nevertheless, they frequently demonstrate a higher recurrence rate than when the same specific method of removal for primary pterygium is used. Consequently, there is a tendency for more aggressive or combined methods of removal for recurrent pterygium. Mitomycin C (MMC) has been shown to be a useful adjunct to pterygium surgery, especially in preventing recurrence. Our current approach to managing recurrent pterygium is to perform a pterygium excision with a conjunctival autograft combined with intraoperative application of MMC 0.02% for 2 minutes. We use fibrin glue to adhere the conjunctival autograft after the MMC has been applied, followed by copious irrigation with balanced salt solution. The goal of this study was to evaluate the safety and efficacy of using fibrin glue (Tisseel; Baxter, Wostlabo village, California, USA) in cases of recurrent pterygium treated with conjunctival autograft combined with MMC 0.02%.


Methods


The medical records of all patients who underwent pterygium excision with the use of MMC and conjunctival autograft secured with fibrin glue tissue adhesive for the treatment of recurrent pterygium between October 2005 and November 2008 in one corneal practice at the Toronto Western Hospital were reviewed retrospectively. Patients who had at least 1 year of follow-up after the surgery were included in this study. Preoperative data collected included demographics, number of previous pterygium excision surgeries, and preoperative visual acuity.


Pterygium excision with conjunctival autograft secured by fibrin glue (Tisseel) was performed in all cases, as described before by Koranyi and associates. The application of the intraoperative MMC was performed after excision of the head and body of the pterygium by applying a surgical sponge soaked with MMC 0.02% on the exposed sclera for 2 minutes. Thereafter, the sclera was irrigated thoroughly with balance salt solution and surgery was completed. After surgery, TobraDex (Alcon Laboratories, Fort Worth, Texas, USA) eye drops were prescribed 4 times daily for 1 month.


The postoperative data collected included length of follow-up, postoperative visual acuity, early postoperative complications, recurrence, and other late postoperative complications. Recurrence was defined as any fibrovascular growth 1 mm or more on the cornea past the corneoscleral limbus.


Statistical Analysis


Snellen values were converted to logarithm of the minimal angle of resolution units to calculate the mean preoperative and postoperative visual acuity. Change in visual acuity after surgery was compared using the paired Student t test. Results are presented as mean ± standard deviation. The recurrence rate was calculated from total number of patients at 1 year.




Results


Between October 2005 and November 2008, 28 eyes of 28 patients (19 men and 9 women) underwent pterygium excision and conjunctival autograft with the use of fibrin glue and MMC for recurrent pterygium. The mean age of the cohort was 49.7 years (range, 28 to 71 years). All eyes had undergone at least 1 previous pterygium excision and conjunctival autograft surgery (performed elsewhere) without the use of intraoperative or postoperative MMC. Two of the 28 eyes (7.14%) had at least 2 previous pterygium excisions and conjunctival autograft without intraoperative or postoperative MMC. There were no intraoperative complications. In 1 eye, early postoperative total graft dehiscence developed that was repositioned and secured with a combination of Tisseel and 10-0 nylon interrupted sutures. One eye had mild graft dehiscence (inferior quadrant of the graft only) and required no intervention. One eye had a conjunctival cyst on the graft that did not require surgical intervention.


The mean best-corrected visual acuity before surgery was 0.2 ± 0.14 (mean, 20/30; range, 20/20 to 20/60) and did not change significantly after surgery (0.2 ± 0.16). At a mean follow-up of 26.5 months, there was 1 case of recurrence, for an incidence rate of 3.5%.




Results


Between October 2005 and November 2008, 28 eyes of 28 patients (19 men and 9 women) underwent pterygium excision and conjunctival autograft with the use of fibrin glue and MMC for recurrent pterygium. The mean age of the cohort was 49.7 years (range, 28 to 71 years). All eyes had undergone at least 1 previous pterygium excision and conjunctival autograft surgery (performed elsewhere) without the use of intraoperative or postoperative MMC. Two of the 28 eyes (7.14%) had at least 2 previous pterygium excisions and conjunctival autograft without intraoperative or postoperative MMC. There were no intraoperative complications. In 1 eye, early postoperative total graft dehiscence developed that was repositioned and secured with a combination of Tisseel and 10-0 nylon interrupted sutures. One eye had mild graft dehiscence (inferior quadrant of the graft only) and required no intervention. One eye had a conjunctival cyst on the graft that did not require surgical intervention.


The mean best-corrected visual acuity before surgery was 0.2 ± 0.14 (mean, 20/30; range, 20/20 to 20/60) and did not change significantly after surgery (0.2 ± 0.16). At a mean follow-up of 26.5 months, there was 1 case of recurrence, for an incidence rate of 3.5%.

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Jan 16, 2017 | Posted by in OPHTHALMOLOGY | Comments Off on Management of Recurrent Pterygium With Intraoperative Mitomycin C and Conjunctival Autograft With Fibrin Glue
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