Recurrence of the pterygium after excision: What factors do relate

it?

Hong Kyun KimDept. of Ophthalmology

Kyungpook National University School of medicine

Purpose• To evaluate the factors that influence the re-

currence of the pterygium after excision

Patients and Methods• 37 eyes of patients including 14 males and 23 females

pterygium in the age range of 22 – 66 years (mean age 52.4 years ± 12.1)

• There were 20 eyes of primary pterygium and 17 re-current pterygium.

• Each eyes underwent a complete ocular examination and were taken photograph to evaluate the molpho-logic severity of pterygium

Patients and Methods – Exclusion Criteria

• patients with pseudopterygium• patients with severe dry eye syndrome, meibo-

mian gland dysfunction, neurotrophic keratitis.• if the patients did not follow up at least 6months

Patients and Methods - Preoperaitve morphologic severity grading by Slit lamp Photography

Evaluate the thickness, vascularity, the amount of encroachment on cornea of the fibrovascular pro-liferation - Thickness (T) - Vascularity (V) - Location(L)

Grade of Thickness (T) • T0 : no elevation

• T1 : minimal elevation with definite con-firmation of episcleral vessel in most of the elevated area.

• T2 : moderate elevation, episcleral ves-sel can be found in some of the elevated area.

• T3 : marked elevation, episcleral vessel cannot be found because of the pterygial fleshiness.

Grade of Vascularity (V)• We use the computer program (Adobe Photo-

shop ver.9.0) to compare the vascularity of each pterygial proliferation

equalized and in-verted photo from original photo

original photograph

Grade of Vascularity (V)

• V0 : no directional vascular pattern

• V1 : minimal vascu-larization with uni-directional patterm

• V2 : moderate vas-cularization with unidirectional and enlarged vessels

• V3 : marked vascu-larization with uni-directional, en-gorged vessels

V0

V2

V1

V3

Location (L)• L1 : abnormal fibrovascular tissue were con-

fined conjunctival area• L2 : abnormal fibrovascular tissue were lo-

cated in limbal area. • L3 : abnormal fibrovascular tissue were en-

croached over limbal area. (> 1.0 mm from limbus)

Surgical TechniquePterygial Excision Method• Subconjunctival 2% lidocaine• Mark the incision line with the gentian violet • The head of Pterygium was avulsed with a 0.3mm toothed

forceps• Wescott scissors was used to dissect the underlying con-

junctiva and Tenon’s capsule and excised the Tenon.• with or without 0.04% MMC sub Tenon’s soaking for 2min.• excise additional exposed Tenon’s capsuleCovering methods over pterygium excised area• Conjunctival Autograft• Conjuntival Autograft + Amniotic membrane graft• Amniotic membrane graft

Patient F/U• include who completely followed up over

6months• Definition of Recurrence “a certain amount of fibrous reproliferation with unidi-

rectional vascularity after excisional operation” - Recurrence that need the Re-operation 1. Recurrence over the > 1mm past the limbus (L3) with

T3 or V3 2. fibrovascular proliferation over L2 with adhesive trac-

tion that results in diplopia - Conjuntival Recurrence Recurrence within L2 and do not cause the diplopia

Evaluation of Risk factor for Recurrence• Univariate Analysis (Chi-squre test, SPSS for Windows ver.12.0,

P<0.05) comparison of the incidence of the recurrence in following variables Preoperative morphologic feature 1. primary / recurrence 2. preoperative fibrous thickness (T2 /T3) 3. preoprative vascularity 4. symblepharous fibrous traction Operation technique 1. amniotic membrane 2. conjunctive autograft

Adjunctive Treatment 1. preopeative TA subconjunctival injection 2. preoperative MMC injection 3. intraoperative 0.04% MMC soaking

• Multivariate analysis (Logistic Regression Analysis, SPSS for Win-dows ver. 12.0, p<0.05))

Results• follow-up period - mean 8.4 ±4.6 (6-18 months)• Recurrence rate - total recurrence rate 14/37 eyes (37.8%) - conjunctival recurrence rate 10/37 (27.0%) - Recurrence that need the Re-operation 4/37 (10.8%

• There were no statistic significance in preoperative mophologic variables and Adjunctive treatment

• Conjunctival Autograft was the only statistically significant vari-able.

- Fisher’s exact test, p=0.015; OR 7.08; 95% CI 1.60-31.33 - Multiple logistic regression analysis, p=0.028; OR 5.42; 95% CI 1.20-24.52)

Conclusion• preoperative morphologic factors or adjunc-

tive treatment did not affect the recurrence of the pterygium

• conjunctival autograft was significantly de-creased the risk of the reccurence of the pterygium