Clinical Practice JOHN E. SUTPHIN, MD,

EDITOR

Surgical Management of Pterygium BEN J. JANSON, BS ,1

AND

ABSTRACT Pterygia are noncancerous growths of conjunctiva that may require surgical removal because of discomfort, cosmesis, or obstruction of vision. Pterygia often recur after excision. The major goal of pterygium treatment is avoiding recurrence, but complication rates and cosmetic results are also considered. Despite the number of techniques available, there is no consensus on the best procedure. Even the best techniques carry risk of recurrence and complications. In this review, different surgical techniques, graft attachment methods, and adjuvant therapies in current use are discussed. Also discussed are newer techniques that early studies have shown to be promising, but require more investigation before becoming a recommended treatment. The review is intended to provide an overview of the current research to inform surgeons with regard to their decisions and aid researchers in hypothesis generation. KEY WORDS adjuvant therapy, conjunctival disease, graft attachment, pterygium, recurrence

I. INTRODUCTION terygia are fibrovascular growths of eye tissue that can cause numerous problems for patients. As pterygia progress, decreased vision, discomfort, and restricted ocular motility can result. A well-known association between astigmatism and pterygium is documented in the literature.1-5 Greater degrees of astigmatism arise due to mechanical forces or tear film buildup as pterygia

P

Accepted for publication January 2014. From 1Johns Hopkins University School of Medicine, and 2Wilmer Ophthalmological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. Supported by Research to Prevent Blindness. Ben Janson acknowledges the support of the Johns Hopkins Scholarly Concentration program. The authors have no proprietary or commercial interests in any concept or product discussed in this article. Single-copy reprint requests to Shameema Sikder, MD (address below). Corresponding author: Shameema Sikder, MD, 7315 Wisconsin Avenue, West Tower, Suite 610, Bethesda, MD 20814. Tel: 240-482-1100. E-mail address: [email protected] © 2014 Elsevier Inc. All rights reserved. The Ocular Surface ISSN: 15420124. Janson BJ, Sikder S. Surgical management of pterygium. 2014;12(2):112-119.

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SHAMEEMA SIKDER, MD 2 progress.1,4,5 When a pterygium is removed, astigmatism and topographic irregularity often are reversed and visual acuity improves.3,5-7 With this in mind, surgeons should consider excising the pterygium before performing other procedures, as this may alter the need for other ophthalmic surgeries (e.g., cataract) in addition to changing measurements needed for surgical planning. In some cases, patients may elect to have the pterygium excised for cosmetic reasons before any major effects on vision take place. Pterygia can cause significant discomfort, and surgical excision may be indicated for symptom relief.8-11 Interestingly, size and discomfort scores are inversely related. The lesser discomfort experienced with large pterygia is hypothesized to be due to a damaged corneal nerve from chronic inflammation.8 Discomfort from dry eye syndrome may also present with pterygia, and excision can improve these symptoms as well.12 While surgical excision often can effectively reduce or remove symptoms, the number of techniques available attests to the complexity of achieving safe, desirable cosmesis and permanent pterygium removal. II. RECURRENCE OF EXCISED PTERYGIA The tendency of pterygia to recur after surgical removal is frustrating to both patients and surgeons. Many studies have evaluated risk factors for recurrence. Younger age is often associated with recurrence,13-17 although some studies found no association with age, and the issue remains controversial.6,18 Additionally, the morphology of pterygium may affect likeliness of recurrence. Fleshy, nontranslucent, and higher-grade pterygia have higher recurrence rates.14,19,20 Evidence also shows greater recurrence risk with the increased inflammation caused by thicker (6-0 to 8-0) sutures or by letting postoperative inflammation go untreated.13,21 Pterygia tend to recur relatively quickly after excision. Hirst et al found a 50% chance of recurrence within 4 months and a 97% chance within 12 months, suggesting a 1-year follow-up as adequate.22 This study also found that with each subsequent recurrence, the time between excision and recurrence decreased, with intervals starting at 123
113 days for the first recurrence and decreasing to 67
47 days for the third recurrence.22 In addition to the shorter interval to recurrence, recurrent pterygia have higher rates of subsequent recurrence than primary pterygia. This is one of the major reasons why avoiding recurrence is an important

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OUTLINE I. Introduction II. Recurrence of Excised Pterygia III. Excision Techniques A. Bare Sclera Excision B. Primary Closure C. Conjunctival Autograft D. Limbal Conjunctival Autograft E. Conjunctival Flaps F. Amniotic Membrane Graft IV. Graft Attachment A. Fibrin Glue Vs Sutures B. Autologous Blood C. Electrocautery Pen V. Adjuvant Therapies A. Mitomycin C B. 5-Fluorouracil C. b-irradiation D. Dobesilate, Ranibizumab, and Bevacizumab VI. Summary and Conclusion

outcome in pterygium surgery. Varssano et al found that 90% of recurrences occurred within the first year, but Kaplan-Meier curve estimates showed that recurrence may be underestimated, with a calculated mean time to recurrence of 104.5
4.9 months.13 III. EXCISION TECHNIQUES The number of surgical procedures for the management of pterygia has increased tremendously. The ideal treatment has low recurrence and complication rates and excellent cosmesis. While a large variety of techniques are described in the literature, no single procedure is considered to be best for all situations. Table 1 summarizes recurrence rates for these procedures. A. Bare Sclera Excision Bare sclera excision is one of the oldest techniques for pterygium surgery. It is a quick procedure, which involves excising the pterygium and leaving the defect open. It has the highest recurrence rates, which are reported to range from 38% to 88%.11,17,19,23,24 Given the other techniques in current use, bare sclera excision is no longer recommended because of the high recurrence rates. Bare sclera excision has more favorable results when it is paired with use of mitomycin C; the effects of mitomycin C and its use with pterygium surgery are reviewed in Section V.A. B. Primary Closure Another simple procedure is bare sclera excision followed by primary closure. Also known as simple conjunctival closure, this procedure involves closing the conjunctiva over the bare sclera by suturing it together. Although not well documented, the reported recurrence

rates are unfavorable, ranging from 45% to 70%.6,25 For this reason, primary conjunctival closure is not a preferred surgical technique. C. Conjunctival Autograft Grafts have become an important part of the surgical management of pterygia. One of the most studied techniques is the conjunctival autograft, attached with either sutures or fibrin glue. The first major paper to describe the technique reported a 5.3% recurrence rate on primary and recurrent pterygium and no serious complications.26 Other recent studies have reported 2% to 20% recurrence rates.7,11,13,15,19,27-33 A meta-analysis found conjunctival autografts to have fewer recurrences than amniotic membrane (AM) grafts for primary pterygium, but the recurrence rate was equal in recurrent pterygium cases.34 Another meta-analysis found conjunctival autografts (including limbal conjunctival autografts) to have lower recurrence rates than AM grafts. For this reason, conjunctival autografts are emerging as the superior procedure, despite newer techniques reported in the literature. In regard to cosmetic appearance, the conjunctival autograft shows results superior to bare sclera, mitomycin C on bare sclera, or conjunctival flaps.11,34 Complications of conjunctival autografting include dellen, steroid-induced ocular hypertension, irritation, photophobia, foreign body sensation, hyperemia, and granuloma.11,19 One study reported surgically induced necrotizing scleritis (SINS) following autografting.35 Recent studies have investigated outcomes of conjunctival autograft using fibrin glue instead of sutures. The recurrence rates ranged between 0% and 9.8%.15,20,30-33,36-39 Many studies comparing fibrin glue and sutures in conjunctival autografts have found that use of fibrin glue was associated with a statistically significant decrease in recurrence, faster operation times, less postoperative pain, and complication rates equal to those found with sutures.15,31-33,38,40-42 It is speculated that decreased inflammation with the glue may help avoid recurrence.15,31-33,40 It was also noted that for surgeons, performing the technique with fibrin glue had no learning curve based on perceived ease, recurrence rates, operative time, and complications. The benefits and risks of fibrin glue are further discussed in Section IV.A. Hirst introduced a variation of the conjunctival autograft procedure: Pterygium Extended Removal Followed by Extended Conjunctival Transplant (PERFECT). Unlike other procedures, PERFECT uses extensive dissection. It has one of the lowest recurrence rates reported– 0.1% for 1000 patients, including primary and recurrent cases.43 It also achieved outstanding cosmesis, and laypersons could not distinguish the operated eye.43-46 Some drawbacks of the PERFECT technique include significant pain and transient diplopia.43-45 Corneal ulcers causing loss of four lines of visual acuity following the procedure have been reported.44 Hirst mentions a probable steep learning curve based on the longer operative time, requirement of peribulbar or general anesthetic, and need

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Table

1.

Summary recurrence technique

rates

by

surgical

Recurrence Rate

Literature Reports

Bare sclera

38-88%

11,17,19,23,24

Primary closure

45-70%

6,25

Conjunctival autograft

5.3-20%

7,11,13,15,19,27e33

Conjunctival autograft with fibrin glue

0-9.8%

15,20,30e33,36e39

0.1%

43

Limbal conjunctival autograft

0-14.29%

23,47e49

Conjunctival flap

13-33.3%

11,53

Mini conjunctival flap

6.1%

27

Limbal conjunctival flap

7.1%

6

Amniotic membrane graft

14.5-27.3%

6,28,56,57

Amniotic membrane graft with steroid injections

3-9.5%

55

Amniotic membrane graft with fibrin glue

10-10.5%

58,59

Technique

PERFECT

PERFECT ¼ Pterygium Extended Removal Followed by Extended Conjunctival Transplant.

for a surgical assistant.43,44 It is important to discuss with the patient the benefit of a near-zero recurrence rate with the PERFECT technique weighed against the increased risks of severe complications. The technique needs to be studied more extensively when performed by different surgeons in other health centers to determine if the reported recurrence rates apply broadly. D. Limbal Conjunctival Autograft A procedure related to the conjunctival autograft is the limbal conjunctival autograft, in which limbal tissue is included in the graft source and then transferred to the destination. It is hypothesized that grafts prevent the residual tissue from proliferating, and the addition of limbal stem cells may promote faster healing and reconstruct the area anatomically.23,47 Recurrence rates for sutured limbal autografts range from 0% to 14.29%.23,47-49 In the long term, pterygium recurrence rates after limbal conjunctival autograft showed a statistically significant advantage over AM grafts and bare sclera.23 Fibrin glue has been used to maintain a stable limbal conjunctival autograft, and studies found a statistically significant decrease in recurrence and procedure time when fibrin glue was used.48,50 Complications can include hematoma, Tenon’s granuloma, pannus formation, and pseudopterygium.47,49,51 114

While limbal conjunctival autografts are superior to techniques such as bare sclera, primary conjunctival closure, or AM grafts, it is controversial whether limbal conjunctival autografts are superior to conjunctival autografts. Some have found statistically significant differences in recurrence rates, without added complications or procedure time.7,24 The analysis of surgical techniques by Kaufman et al and Li et al showed that limbal conjunctival autografts and conjunctival autografts did not have statistically significant differences from each other, but had recurrence rates that were statistically significantly superior to AM grafts.17,34 By meta-analysis, limbal conjunctival autografts were better than mitomycin C alone, but more studies are needed to determine any differences between conjunctival autografts and limbal conjunctival autografts.52 E. Conjunctival Flaps Another procedure related to the conjunctival autograft is the conjunctival flap. Instead of completely removing the conjunctiva at the donor site, part of the conjunctiva remains attached and the surgeon rotates or slides the flap into position. In a study comparing four pterygium excision techniques, Alpay et al found the conjunctival flap technique to have a recurrence rate of 33.3%, which was statistically worse than the conjunctival autograft, and it also had a poor cosmetic appearance.11 In a study by Aslan et al, the conjunctival flap technique had a recurrence rate of 13%. It was not statistically different from conjunctival autografts in recurrence rates or complications, and it was a shorter procedure.53 Another study found the mini-flap had a statistically lower recurrence rate at 6.1% versus 17.1% for the conjunctival autograft. The authors reasoned that this could be due to lower levels of trauma inflicted, which may decrease the induction of fibroblast activity, thus decreasing recurrence.27 A study of limbal conjunctival flaps found a statistically lower recurrence rate (7.1%) than with amniotic grafts (27.3%) or primary closure (56%).6 However, while these conjunctival flap studies typically use the same surgeon consistently, different procedures were not always performed within a short time period. Thus, the differences in recurrence or complications may reflect changes in physician experience over the years and not solely a superiority of the flap procedure. Flap procedures require more clinical trials before they are determined to be superior to the conjunctival autograft. Complaints with the flap techniques included irritation, photophobia, foreign body sensation, and hyperemia.11 Unfortunately, in trials with flaps and fibrin glue, 1/19 (5.3%) of rotation flaps and 4/15 (26%) of double sliding flaps were lost, although none of the 34 patients had pterygium recurrence.54 F. Amniotic Membrane Graft An AM graft is commonly used to cover the bare sclera. These grafts may help prevent recurrence through their antiinflammatory properties, promotion of epithelial growth, suppression of transforming growth factor (TGF)-b

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SURGICAL MANAGEMENT OF PTERYGIUM / Janson and Sikder signaling, and fibroblast suppression.23,28,55 The AM graft also benefits patients with heavily scarred conjunctival donor sites who require large grafts or need to keep the conjunctiva preserved in case the patient needs future glaucoma surgery.23,55 Pterygium recurrence rates with AM grafts fall between 14.5% and 27.3% in recent reports.6,28,56,57 The AM graft alone will not produce recurrence rates comparable to those of conjunctival autografts. However, when steroid injections are used to control inflammation after AM grafts, the recurrence rate in primary pterygium has been reported at 3% and in recurrent cases 9.5%.55 When fibrin glue is used instead of sutures, rates of 10% and 10.5% have been reported.58,59 Meta-analyses and clinical trials have both found higher recurrence rates with AM grafts than conjunctival autografts.23,28,34,57 Study reports describe no serious complications, but document higher rates of foreign body sensation, eyelid edema, and conjunctival hyperemia.21,28,56 Postoperative complications can include pyogenic granuloma and symblepharon.55 In our opinion, conjunctival autografts, with their lower complication rate, should be favored over AM grafts unless special circumstances, e.g., extensive scarring or possible future glaucoma surgery, indicate AM grafts. AMs can also be important for the reconstruction of the conjunctiva. A recent variation of the amniotic graft uses a procedure combining a conjunctival graft and an AM graft. Shimazaki et al used AM and a limbal conjunctival autograft in cases with severe symblepharon from multiple recurrent pterygia and concluded that the combination prevented some recurrences (recurrence rate 25%) and improved ocular motility.60 In another study of primary pterygium cases, Sekeroglu et al used fibrin glue to attach a graft of AM combined with a conjunctival autograft, achieving a 6.7% recurrence rate.61 One other recent variation used AM transplant with conjunctival limbal autograft, mitomycin C, and e-PFTE (Gore-Tex) with micropores. This statistically significantly lowered recurrence from 25% to 3.3% and also reduced symblepharon, motility restriction, and hyperemia.62 This study of e-PFTE is promising, as it was a prospective trial with a control group, and it achieved very low recurrence rates in patients who all had at least two previous pterygium excisions. IV. GRAFT ATTACHMENT A. Fibrin Glue Vs Sutures Nylon and vicryl sutures have long been the favorite for attaching grafts to the bare sclera, but new methods also show promise. Fibrin glue creates an adhesive fibrin network to hold the graft in place when the fibrinogen and thrombin components combine.40 Many studies compare outcomes of sutures and fibrin glue. Some studies have found lower recurrence rates with use of fibrin glue.15,31-33,40,48,59 Others have found no difference in recurrence and indicate that the glue is at least equivalent to sutures in avoiding recurrence.16,30,36,58,63 Complication rates with fibrin glue and sutures are comparable.30,33,40 Graft stability is also comparable, but cases

of dehiscence and displacement have occurred following intensive eye rubbing.31,32,40,42,64 Benefits of fibrin glue include statistically shorter operation time, need for less surgical skill, and lower postoperative discomfort.30,32,36,40,41,48,58,59,63-65 Fibrin glue does, however, still require training and experience, as its use does carry risk of dehiscences and dislocations when used improperly. The major drawback of fibrin glue is the higher cost, but this can sometimes be reduced to equal the cost of vicryl sutures if multiple patients can be scheduled to share the same tube of glue.32,39,48 Fibrin glue has been reported to be associated with the transmission of infection. While such adverse events have not been reported with ophthalmic use, symptomatic B19 infection and anaphylaxis leading to multi-organ failure have been reported in other specialties.40,66,67 With limbal conjunctival autografts, conjunctival autografts, and AM grafts, the use of fibrin glue has results equal to or better than results with sutures.15,16,30-33,36,41,48,58,59,63-65 However, fibrin glue may not be appropriate for all pterygium surgeries; for example, fibrin glue could not withstand the tangential force produced by double sliding flaps.54 B. Autologous Blood Autologous blood presents an alternative to fibrin glue, while avoiding the cost and potential infectious agent transmission of fibrin glue. With this technique, blood collects on the eye and, through clotting, promotes adherence of the graft. As with fibrin glue, complications include graft displacement and retraction with large grafts.68 Total graft dehiscence or retraction was reported in one case, but the complication rate was not statistically significantly different from that with sutures.69 Evidence comparing autologous blood to fibrin glue or sutures is sparse. Small, randomized controlled trials have shown recurrence rates between autologous blood and fibrin glue or sutures to be equal. These studies have also reported that autologous blood takes longer than fibrin glue to produce adherence, but autologous blood attaches the graft faster than sutures.68,69 Larger clinical trials are needed to assess the benefits and risk of autologous blood before it its use is recommended. C. Electrocautery Pen A newer technique that may prove useful with further study is the use of an electrocautery pen. Xu et al described a procedure of thermal welding 8-10 times around the graft with the electrocautery pen and in a randomized controlled trial found statistically significant decreases in operating time, postoperative pain, and irritation. This procedure had a pterygium recurrence rate of 5% and did not show a learning curve based on duration of surgery times in order of date of a single surgeon. The only reported complication was two graft losses out of 40 eyes.70 V. ADJUVANT THERAPIES Adjuvant therapies have become an important part of pterygium surgical management. Adjuvants studied include

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SURGICAL MANAGEMENT OF PTERYGIUM / Janson and Sikder mitomycin C, 5-fluorouracil, b-irradiation, dobesilate, ranibizumab, and bevacizumab. Not all have been able to effectively reduce recurrence, and many carry serious known and possible unknown side effects. A. Mitomycin C Mitomycin C is one of the commonly used adjuvants in pterygium management. It inhibits RNA, DNA, and protein synthesis, and in the past was used as a systemic anticancer therapy.11 Its use in pterygium management is off-label, according to the FDA. Mitomycin C can be administered preoperatively, intraoperatively, and postoperatively. When used in conjunction with a surgical procedure, it has been shown to lower recurrence rates with limbal conjunctival autografts, conjunctival autografts, amniotic membrane, and bare sclera.17,56,71-73 However, it is not always the best option, as studies using intraoperative mitomycin C after bare sclera excision had statistically significantly higher recurrence rates than the conjunctival autograft and conjunctival limbal autografts that did not use mitomycin C.24,52 When mitomycin C was used with bare sclera techniques, it was found that the higher the dose and/or concentration, the lower the recurrence rate.17,72 Mitomycin C paired with bare sclera excision has shown favorable results in some reports. In one study, 48 patients had mitomycin C injection 1 month before primary pterygia excision, and 43 patients had limbal conjunctival autografts without mitomycin C. The pterygium recurrence rate in the mitomycin C group was 4.2%, which was not statistically significantly different from that of the patients who had had the more complex technique of limbal conjunctival autograft.51 Another study of postoperative topical mitomycin C found a bare sclera excision recurrence rate of 3.7%, which was equal to that of AM grafts and conjunctival autografts. However, Ma et al suggest a single intraoperative dose, as they reported a case of infectious scleritis following scleral ischemia in the postoperative topical mitomycin C group.18 Thus, a single intraoperative dose is strongly recommended over a postoperative dosing regimen of multiple exposures to mitomycin C. Since the recurrence rates with bare sclera paired with mitomycin C are at best equivalent to conjunctival autografts and AM grafts, we recommend using the latter techniques to avoid the adverse effects of mitomycin C use. Tsumi et al recently described a new technique of bare sclera using 20% ethanol in a ring well, followed by pterygium excision and then use of mitomycin C.74 This technique produced a clear separation plane that allowed for easy dissection and avoided corneal scraping and polishing, and had no reported complications and a low 2.9% recurrence rate over a mean 22
7 months follow-up.74 While the technique seems promising, this study lacked a control group. Serious complications have been attributed to mitomycin C use, including scleral melting, conjunctival vascularization, punctate keratitis, infectious scleritis, corneal perforation, severe secondary glaucoma, and 116

cataract.18,51,56,72,75-78 Corneal and scleral melting have occurred with concentrations of 0.02% for 3 minutes and 0.01% for 5 minutes.75-77 One study found lasting effects on endothelial cells at 1 and 3 months, but another study found no differences in the corneal endothelium or corneal thickness.79,80 It has been noted that in developing countries mitomycin C is more expensive and less available than 5fluorouracil.77 Despite the possible complications, mitomycin C is still used, but should be used judiciously. B. 5-Fluorouracil Like mitomycin C, 5-fluorouracil (5-FU) is used on the excised pterygium region. It acts on the S phase of the cell cycle and has fewer complications than mitomycin C or b-irradiation.81 Kareem et al found that 5-FU did not lower recurrence as much as mitomycin C and produced worse cosmesis with excessive vascularization.73 Bekibele et al found that 5-FU and mitomycin C had recurrence rates of 8.7% and 11.8%, respectively, which were not statistically significantly different; however, this study is limited by only 56.3% completing the 52-week follow-up.77 5-FU has also been studied in the setting of pterygium resection and flap rotation.81 Pterygia recurred in 5.83% of eyes receiving 5-FU adjuvant therapy and in 25.5% of fellow eyes not treated with 5-FU, a statistically significant difference.81 In summary, the evidence to date does not warrant the use of 5-fluorouracil over mitomycin C. C. b-irradiation b-irradiation is less frequently used than other adjuvant therapies because it is less convenient for providers and patients. However, it has been reported to show promising results. In a 10-year follow-up study of 120 eyes treated with strontium-90 three times every other day (total dose 20003000 cGy) following pterygium surgery, Qin et al saw no recurrences.82 Other studies reported low recurrence rates when combining b-irradiation with conjunctival autografts (9.2% recurrence).83 In a review of 16 studies covering 6000 cases over a 30-year period, Ali et al found significant reductions in recurrence when fractionated 30Gy doses in 3 fractions were given over 2-3 weeks following pterygium surgery.84 In a prospective, randomized clinical trial including 108 pterygia treated with conjunctival autograft alone or followed by a low single-dose of b-irradiation of 10 Gy, Viani et al found that adjuvant treatment with b-irradiation reduced the risk of primary pterygium recurrence, improved symptoms after surgery, had a better cosmetic effect than conjunctival autograft alone.83 Reported complications of treatment with b-irradiation include conjunctival congestion and delayed epithelial healing, but these often spontaneously resolve.82 More serious complications include scleral ulcerations, scleromalacia, necrosis, and cataract.84 D. Dobesilate, Ranibizumab, and Bevacizumab Recent studies have reported new medical therapies for pterygia, but none has yet proven to be broadly effective. One of these, dobesilate, was reported in a case report to

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SURGICAL MANAGEMENT OF PTERYGIUM / Janson and Sikder have successfully regressed a fibrovascular mass of invasive pterygium. The success might be due to inhibiting fibroblast growth factor, which has increased expression in pterygium.85 Vascular endothelial growth factor (VEGF) is increased in pterygia,86 and the anti-VEGF antibodies ranibizumab or bevacizumab have been used in treatment. In two studies of ranibizumab, each involving only five patients, there were no adverse effects but no clinical or histological effects on the pterygia.86,87 The authors are uncertain if this lack of effect arises because the ranibizumab has no effect on pterygia or because the dosing/frequency of the subconjunctival injections were not adequate.86,87 Bevacizumab has also been used to reduce pterygium recurrence. Wu et al treated an impending recurrent pterygium with topical bevacizumab eyedrops for 3 weeks and reported that at 6 months it was no longer present.88 Nakasato et al used bevacizumab injection followed by pterygium neck ligation in four patients, and all pterygium heads regressed and disappeared with the bodies also partially regressing.89 However, many trials have found no statistically significant effect of bevacizumab drops on recurrence.90-94 One randomized, prospective clinical trial found a clinically significant result of earlier and more aggressive recurrence in the bevacizumab group.94 Some studies found reduced eye redness, neovascularization, and discharge, but these effects did not appear to last long or did not occur at all.86,93,95 Bevacizumab appeared safe, with no adverse effects reported in many studies.86,88,90,91,96 However, corneal defect and erosion and idiopathic corneal melt have been reported with use of bevacizumab.97,98 VI. SUMMARY AND CONCLUSION Avoiding recurrence is a major goal of pterygium treatment, as recurrences increase the likelihood of future recurrences and decrease the time interval to subsequent occurrence. Preference is therefore given to those procedures with lower risk of recurrence. The trade-off is often a more complicated procedure that may take more operative time. Keeping operative times short is important to minimize the resources used and patient discomfort. While there is no consensus on the best procedure, techniques like bare sclera and primary conjunctival closure are regarded as inferior and should be avoided, given their high rates of recurrence. Current research points to the conjunctival autograft as the recommended treatment. AM grafts can be useful when there is extensive scarring, conjunctival reconstruction, or the need for future glaucoma surgeries. However, AM grafts have not been shown to be equivalent to conjunctival autografts in preventing recurrence. Fibrin glue as an alternative to sutures has demonstrated additional potential benefits. Finally, adjuvants like mitomycin C can also be effective, especially in patients with a history of recurrence or high-grade pterygium. Adjuvants, however, should be used sparingly due to adverse effects. All surgical techniques carry some risk of recurrence and complications, and this should be considered in evaluating cases in which

the patient’s primary goal is to improve cosmesis when the effect on vision and comfort is minimal. Although recurrence has been studied extensively with regard to the surgical treatments used, there has been little standardization or study on postoperative care. The postoperative care may very well influence recurrence rates, but the degree of the impact has not been reported. REFERENCES 1. Gazzard G, Saw SM, Farook M, et al. Pterygium in Indonesia: prevalence, severity and risk factors. Br J Ophthalmol 2002;86:1341-6 2. Li Z. Prevalence and associated factors for pterygium in a rural adult population (the Southern Harbin Eye Study). Cornea 2013;32:806-9 3. Fotouhi A, Hashemi H, Khabazkhoob M, Mohammad K. Prevalence and risk factors of pterygium and pinguecula: the Tehran Eye Study. Eye 2009;23:1125-9 4. Lin A, Stern G. Correlation between pterygium size and induced corneal astigmatism. Cornea 1998;17:28-30 5. Fong S, Balakrishnan V, Chee S, Tan D. Refractive change following pterygium surgery. CLAO J 1998;24:115-7 6. Kurna SA, Altun A, Aksu B, et al. Comparing treatment options of pterygium: limbal sliding flap transplantation, primary closing, and amniotic membrane grafting. Eur J Ophthalmol 2013;23:480-7 7. Al Fayez MF. Limbal-conjunctival vs conjunctival autograft transplant for recurrent pterygia: a prospective randomized controlled trial. JAMA Ophthalmol 2013;131:11-6 8. Julio G, Lluch S, Pujol P, Merindano D. Ocular discomfort in pterygium patients. Optom Vis Sci 2013;90:269-74 9. Todani A, Melki S. Pterygium current concepts in pathogenesis and treatment. Int Ophthalmol Clin 2009;49:21-30 10. Marcovich A, Bahar I, Srinivasan S, Slomovic A. Surgical management of pterygium. Int Ophthalmol Clin 2010;50:47-61 11. Alpay A, Ugurbas¸ S, Erdogan B. Comparing techniques for pterygium surgery. Clin Ophthalmol 2009;3:69-74 12. Turkyilmaz K, Oner V, Sevin M, et al. Effect of pterygium surgery on tear osmolarity. J Ophthalmol 2013;2013:1-5 13. Varssano D, Shalev H, Lazar M, Fischer N. Pterygium excision with conjunctival autograft: True survival rate statistics. Cornea 2013;32: 1243-50 14. Mahar PS, Manzar N. The study of etiological and demographic characteristics of pterygium recurrence: a consecutive case series study from Pakistan. Int Ophthalmol 2013. June 18:Epub ahead of print 15. Farid M, Pirnazar J. Ptergyium recurrence after excision with conjunctival autograft: a comparison of fibrin tissue adhesive to absorbable sutures. Cornea 2009;28:43-5 16. Huerva V, March A, Martinez-Alonso M, et al. Pterygium surgery by means of conjunctival autograft: long term follow-up. Arq Bras Oftalmol 2012;75:251-5 17. Kaufman S, Jacobs D, Lee W, et al. Options and adjuvants in surgery for pterygium: a report by the American Academy of Ophthalmology. Ophthalmology 2013;120:201-8 18. Ma D, See L-C, Liau S, Tsai R. Amniotic membrane graft for primary pterygium: comparison with conjunctival autograft and topical mitomycin C treatment. Br J Ophthalmol 2000;84:973-8 19. Tan DT, Chee SP, Dear KB, Lim AS. Effect of pterygium morphology on pterygium recurrence in a controlled trial comparing conjunctival autografting with bare sclera excision. Arch Ophthalmol 1997;115: 1235-40 20. Sandra S, Zeljka J, Zeljka VA, et al. The influence of pterygium morphology on fibrin glue conjunctival autografting pterygium surgery. Int Ophthalmol 2013. June 4. Epub ahead of print

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