EDITORIAL
The Use of Conjunctival Rotational Autograft in the Management of Pterygium Alvin L. Young, MMedSc(Hons), FRCS(Irel)
P
terygium is a condition commonly found within the ‘‘pterygium belt’’ between the latitudes 30 degrees north and south of the equator.1 The major risk for its development is believed to be related to environmental UV radiation.2 Many surgical treatment modalities have been tried, but the main concern after any surgery is recurrence, which can be as high as greater than 80% for primary excision alone.3 The goals of pterygium surgery should address the following issues including the restoration of a smooth ocular surface, complete removal of reactive fibrovascular tissue and active pterygium cells, and restoration of a normal limbal barrier. Clinically used surgical adjuvants include antimetabolites such as mitomycin C (MMC),4 limbal conjunctival autograft,5 amniotic membrane transplantation,6 conjunctival autografts,7 and more recently even antiangiogenic agents.8 In everyday clinical practice, prevention of recurrence postYpterygium excision is usually managed by either some form of conjunctival autografts (different variations), or some form of antimetabolites (with different modes of application and frequencies), of which MMC is probably the most commonly used or combining the two together. Surgeons may tend to favor conjunctival autograft because of the lack of potential melting risks associated with MMC, the smoother appearance of the postoperative bed, and the generally lower recurrence rates reported.9 However, in patients with glaucoma and/or multiple recurrences with extensive areas of scarred conjunctiva, harvesting a healthy and large conjunctival autograft may simply not be feasible, and further disturbing the already delicate ocular surface is surely undesirable. One variant of the conjunctival autograft is the conjunctival rotational autograft.10 Conjunctival rotational autograft confers the benefits of conventional conjunctival autograft, namely, the reconstitution of the tissue barrier and reconstruction of the limbal barrier yet without the need to disturb the rest of the remaining ocular surface. In this issue, Sune and Sune are reporting their noncomparative case series of conjunctival rotational autograft outcome in 47 Indian patients, followed up for roughly 9 months. Contrary to earlier studies in predominately Chinese eyes, they have described lower postoperative injection and pigmentation rates.10,11 It is uncertain if these differences in observation are more related to racial factors or to the degree of meticulous dissection or otherwise. Even though the earlier studies in predominately Chinese eyes indeed had higher injection (and pigmentation) rates, the actual pterygium recurrence rates were still quite comparable to the very impressive 1.8% reported in the current series (defined as 91.5 mm across the limbus).10,11 The authors have also correctly reemphasizing the fact that harvesting a satisfactory conjunctival rotational autograft is technically more demanding, and it is not always easy to obtain a reasonable graft from the pterygium. One should try his/her best to aim for as large a graft as possible (targeting for oversize) to cover the postexcision bare sclera; otherwise, resultant graft shrinkage and retraction may be inevitable. Because conjunctival rotational autograft is harvested from an unhealthy source of previously ‘‘diseased’’ origin, as one of the reasons for persistent postoperative injection, it would be worthwhile to conduct longer-term studies to examine if the low recurrence rates achieved with conjunctival rotational autograft are sustainable over time. The value of modification to any techniques needs to be subjected to stringent scientific scrutiny. Ultimately, the patients’ long-term safety, visual outcome, and recurrence rates are of prime importance for any pterygium excision. In the meantime, the surgeon and the patient must make an informed choice in an individual tailored approach, based on the current known advantages and limits of each of the adjuvant modalities.
Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital & Alice Ho Miu Ling Nethersole Hospital, Hong Kong SAR. Received for publication May 7, 2013; accepted July 21, 2013. The author has no funding or conflicts of interest to declare. Reprints: Alvin L. Young, MMedSc(Hons), FRCS(Irel), Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong. E-mail: [email protected]. Copyright * 2013 by Asia Pacific Academy of Ophthalmology ISSN: 2162-0989 DOI: 10.1097/APO.0b013e31829d3ddb
Asia-Pacific Journal of Ophthalmology
&
Volume 2, Number 4, July/August 2013
www.apjo.org
Copyright © 2013 Asia Pacific Academy of Ophthalmology. Unauthorized reproduction of this article is prohibited.
209
Asia-Pacific Journal of Ophthalmology
Editorial
REFERENCES 1. Cameron ME. Pterygium Throughout the World. Springfield, IL: Charles C Thomas; 1965. 2. Moran DJ, Hollows FC. Pterygium and ultraviolet radiation: a positive correlation. Br J Ophthalmol. 1984;68:343Y346. 3. Jaros PA, DeLuise VP. Pingueculae and pterygia. Surv Ophthalmol. 1988;33:41Y49. 4. Lam DS, Wong AK, Fan DS, et al. Intraoperative mitomycin C to prevent recurrence of pterygium after excision: a 30-month follow-up study. Ophthalmology. 1998;105:901Y904. 5. Young AL, Leung GY, Wong AK, et al. A randomised trial comparing 0.02% mitomycin C and limbal conjunctival autograft after excision of primary pterygium. Br J Ophthalmol. 2004;88:995Y997. 6. Ma DH, See LC, Liau SB, et al. Amniotic membrane graft for primary pterygium: comparison with conjunctival autograft and topical mitomycin C treatment. Br J Ophthalmol. 2000;84:973Y978.
&
Volume 2, Number 4, July/August 2013
7. Tan DT, Chee SP, Dear KB, et al. Effect of pterygium morphology on pterygium recurrence in a controlled trial comparing conjunctival autografting with bare sclera excision. Arch Ophthalmol. 1997;115:1235Y1240. 8. Galor A, Yoo SH, Piccoli FV, et al. Phase I study of subconjunctival ranibizumab in patients with primary pterygium undergoing pterygium surgery [published online ahead of print April 24, 2010]. Am J Ophthalmol. 2010;149:926Y931. 9. Hirst LW. Prospective study of primary pterygium surgery using pterygium extended removal followed by extended conjunctival transplantation. Ophthalmology. 2008;115:1663Y1672. 10. Jap A, Chan C, Lim L, et al. Conjunctival rotation autograft for pterygium. An alternative to conjunctival autografting. Ophthalmology 1999;106:67Y71. 11. Young AL, Tam PM, Leung GY, et al. Prospective study on the safety and efficacy of combined conjunctival rotational autograft with intraoperative 0.02% mitomycin C in primary pterygium excision. Cornea. 2009;28:166Y169.
‘‘You can’t depend on your eyes when your imagination is out of focus.’’ V Mark Twain, A Connecticut Yankee in King Arthur’s Court
210
www.apjo.org
* 2013 Asia Pacific Academy of Ophthalmology
Copyright © 2013 Asia Pacific Academy of Ophthalmology. Unauthorized reproduction of this article is prohibited.
The Use of Conjunctival Rotational Autograft in the Management of Pterygium Alvin L. Young, MMedSc(Hons), FRCS(Irel)
P
terygium is a condition commonly found within the ‘‘pterygium belt’’ between the latitudes 30 degrees north and south of the equator.1 The major risk for its development is believed to be related to environmental UV radiation.2 Many surgical treatment modalities have been tried, but the main concern after any surgery is recurrence, which can be as high as greater than 80% for primary excision alone.3 The goals of pterygium surgery should address the following issues including the restoration of a smooth ocular surface, complete removal of reactive fibrovascular tissue and active pterygium cells, and restoration of a normal limbal barrier. Clinically used surgical adjuvants include antimetabolites such as mitomycin C (MMC),4 limbal conjunctival autograft,5 amniotic membrane transplantation,6 conjunctival autografts,7 and more recently even antiangiogenic agents.8 In everyday clinical practice, prevention of recurrence postYpterygium excision is usually managed by either some form of conjunctival autografts (different variations), or some form of antimetabolites (with different modes of application and frequencies), of which MMC is probably the most commonly used or combining the two together. Surgeons may tend to favor conjunctival autograft because of the lack of potential melting risks associated with MMC, the smoother appearance of the postoperative bed, and the generally lower recurrence rates reported.9 However, in patients with glaucoma and/or multiple recurrences with extensive areas of scarred conjunctiva, harvesting a healthy and large conjunctival autograft may simply not be feasible, and further disturbing the already delicate ocular surface is surely undesirable. One variant of the conjunctival autograft is the conjunctival rotational autograft.10 Conjunctival rotational autograft confers the benefits of conventional conjunctival autograft, namely, the reconstitution of the tissue barrier and reconstruction of the limbal barrier yet without the need to disturb the rest of the remaining ocular surface. In this issue, Sune and Sune are reporting their noncomparative case series of conjunctival rotational autograft outcome in 47 Indian patients, followed up for roughly 9 months. Contrary to earlier studies in predominately Chinese eyes, they have described lower postoperative injection and pigmentation rates.10,11 It is uncertain if these differences in observation are more related to racial factors or to the degree of meticulous dissection or otherwise. Even though the earlier studies in predominately Chinese eyes indeed had higher injection (and pigmentation) rates, the actual pterygium recurrence rates were still quite comparable to the very impressive 1.8% reported in the current series (defined as 91.5 mm across the limbus).10,11 The authors have also correctly reemphasizing the fact that harvesting a satisfactory conjunctival rotational autograft is technically more demanding, and it is not always easy to obtain a reasonable graft from the pterygium. One should try his/her best to aim for as large a graft as possible (targeting for oversize) to cover the postexcision bare sclera; otherwise, resultant graft shrinkage and retraction may be inevitable. Because conjunctival rotational autograft is harvested from an unhealthy source of previously ‘‘diseased’’ origin, as one of the reasons for persistent postoperative injection, it would be worthwhile to conduct longer-term studies to examine if the low recurrence rates achieved with conjunctival rotational autograft are sustainable over time. The value of modification to any techniques needs to be subjected to stringent scientific scrutiny. Ultimately, the patients’ long-term safety, visual outcome, and recurrence rates are of prime importance for any pterygium excision. In the meantime, the surgeon and the patient must make an informed choice in an individual tailored approach, based on the current known advantages and limits of each of the adjuvant modalities.
Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital & Alice Ho Miu Ling Nethersole Hospital, Hong Kong SAR. Received for publication May 7, 2013; accepted July 21, 2013. The author has no funding or conflicts of interest to declare. Reprints: Alvin L. Young, MMedSc(Hons), FRCS(Irel), Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong. E-mail: [email protected]. Copyright * 2013 by Asia Pacific Academy of Ophthalmology ISSN: 2162-0989 DOI: 10.1097/APO.0b013e31829d3ddb
Asia-Pacific Journal of Ophthalmology
&
Volume 2, Number 4, July/August 2013
www.apjo.org
Copyright © 2013 Asia Pacific Academy of Ophthalmology. Unauthorized reproduction of this article is prohibited.
209
Asia-Pacific Journal of Ophthalmology
Editorial
REFERENCES 1. Cameron ME. Pterygium Throughout the World. Springfield, IL: Charles C Thomas; 1965. 2. Moran DJ, Hollows FC. Pterygium and ultraviolet radiation: a positive correlation. Br J Ophthalmol. 1984;68:343Y346. 3. Jaros PA, DeLuise VP. Pingueculae and pterygia. Surv Ophthalmol. 1988;33:41Y49. 4. Lam DS, Wong AK, Fan DS, et al. Intraoperative mitomycin C to prevent recurrence of pterygium after excision: a 30-month follow-up study. Ophthalmology. 1998;105:901Y904. 5. Young AL, Leung GY, Wong AK, et al. A randomised trial comparing 0.02% mitomycin C and limbal conjunctival autograft after excision of primary pterygium. Br J Ophthalmol. 2004;88:995Y997. 6. Ma DH, See LC, Liau SB, et al. Amniotic membrane graft for primary pterygium: comparison with conjunctival autograft and topical mitomycin C treatment. Br J Ophthalmol. 2000;84:973Y978.
&
Volume 2, Number 4, July/August 2013
7. Tan DT, Chee SP, Dear KB, et al. Effect of pterygium morphology on pterygium recurrence in a controlled trial comparing conjunctival autografting with bare sclera excision. Arch Ophthalmol. 1997;115:1235Y1240. 8. Galor A, Yoo SH, Piccoli FV, et al. Phase I study of subconjunctival ranibizumab in patients with primary pterygium undergoing pterygium surgery [published online ahead of print April 24, 2010]. Am J Ophthalmol. 2010;149:926Y931. 9. Hirst LW. Prospective study of primary pterygium surgery using pterygium extended removal followed by extended conjunctival transplantation. Ophthalmology. 2008;115:1663Y1672. 10. Jap A, Chan C, Lim L, et al. Conjunctival rotation autograft for pterygium. An alternative to conjunctival autografting. Ophthalmology 1999;106:67Y71. 11. Young AL, Tam PM, Leung GY, et al. Prospective study on the safety and efficacy of combined conjunctival rotational autograft with intraoperative 0.02% mitomycin C in primary pterygium excision. Cornea. 2009;28:166Y169.
‘‘You can’t depend on your eyes when your imagination is out of focus.’’ V Mark Twain, A Connecticut Yankee in King Arthur’s Court
210
www.apjo.org
* 2013 Asia Pacific Academy of Ophthalmology
Copyright © 2013 Asia Pacific Academy of Ophthalmology. Unauthorized reproduction of this article is prohibited.
