Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 28  |  Issue : 1  |  Page : 18-20

Pterygium Surgeries at a Tertiary Hospital, Southwest Nigeria: A Four-Year Review


Department of Ophthalmology, College of Medicine, University of Ibadan and University College Hospital, Ibadan, Nigeria

Date of Submission23-Jan-2020
Date of Decision21-Apr-2020
Date of Acceptance28-May-2020
Date of Web Publication07-Sep-2020

Correspondence Address:
Tarela F Sarimiye
Department of Ophthalmology, University College Hospital, Ibadan
Nigeria
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njo.njo_6_20

Rights and Permissions
  Abstract 


Background: Over the years several pterygium surgical techniques have been developed with the aim of having the least possible recurrence rate. This has been from bare sclera excision which had an unacceptable recurrence rate to the current use of conjunctiva autograft with or without various adjuncts. This study was to review the current practice in a typical multi-specialist ophthalmic department. Method: The ophthalmic theatre operating register was retrospectively reviewed to obtain information on all patients who had pterygium excision at the University College Hospital, Ibadan, over a 4-year period from January 1, 2014, to December 31, 2017. Results: A total of 324 pterygium surgeries were performed and final analysis was on 249 (76.9%) surgeries which met the inclusion criteria, male to female ratio of 0.96:1. The commonest surgical technique was excision + 5-Flourouracil (5FU) + conjunctival autograft accounting for 187(75.1%) eyes. In total, postoperative recurrence was recorded in 40 (16.1%) eyes. The subgroup of excision + 5FU + autograft had the least recurrence rate of 18 (9.6%) eyes. Conclusion: A significant majority of the excision was with conjunctiva autograft with an acceptable low recurrence rate compared with most studies.

Keywords: Autograft, excision, pterygium, recurrence


How to cite this article:
Onnebune E, Sarimiye TF, Bekibele C, Ashaye A. Pterygium Surgeries at a Tertiary Hospital, Southwest Nigeria: A Four-Year Review. Niger J Ophthalmol 2020;28:18-20

How to cite this URL:
Onnebune E, Sarimiye TF, Bekibele C, Ashaye A. Pterygium Surgeries at a Tertiary Hospital, Southwest Nigeria: A Four-Year Review. Niger J Ophthalmol [serial online] 2020 [cited 2022 Aug 8];28:18-20. Available from: http://www.nigerianjournalofophthalmology.com/text.asp?2020/28/1/18/294384




  Introduction Top


A pterygium is a wing-shaped growth of conjunctiva and fibrovascular tissue on the superficial cornea.[1] It is common in the tropics with a prevalence of 0.3% to 29% and despite propounded theories the etiology is not fully known.[2],[3] One such propounded theory is exposure to ultraviolet radiation which is more in the tropics.[2],[4] Pterygium may cause ocular surface irritation, cosmetic concerns or visual impairment. The mainstay of treatment is surgery. Post-operative recurrence is the most common complication of pterygium surgeries and its absence is a major marker for successful treatment.[5],[6],[7]

There are several surgical techniques for pterygia excision and the most appropriate should be the one with least recurrent rate, least complications, short surgical time and good cosmesis. In a meta-analysis of 24 RCTs that studied 1815 eyes of 1668 patients, 14 different interventions were included. The rank from the best to worse treatment to prevent recurrence is: conjunctival autograft + ciclosporin 0.05% eye drops, bare sclera + intraoperative Mitomycin C (MMC) <0.02%, bare sclera + beta therapy (2500 cGy single dose), conjunctival autograft + beta therapy (1000 cGy single dose), bare sclera + MMC 0.02% eye drops, conjunctival autograft, bare sclera + intraoperative MMC >0.02%, bare sclera + ciclosporin 0.05% eye drops, bare sclera + intraoperative 5-fluorouracil 5%, amniotic membrane transplantation, bare sclera + intraoperative MMC 0.02%, conjunctival autograft + bevacizumab 0.05% eye drops, bare sclera + bevacizumab 0.05% eye drops and bare sclera alone.[8]

Different clinical trials have studied techniques such as bare sclera technique modified by partial thickness sclerectomy, 5FU adjuvant, conjunctival autograft, Beta irradiation, Bevacizumab adjuvant, Mitomycin-C adjuvant.[5],[9],[10],[11],[12],[13] In our hospital, pterygium surgeries have evolved over the decades from the initial bare sclera technique.

As knowledge evolves and more sophisticated equipment like Optical Coherence Tomography (OCT) becomes available for post-operative management, the searchlight remains on for the ‘ideal’ pterygium surgery with no recurrence, good cosmetic outcome and negligible complication rates.


  Materials and Methods Top


The ophthalmic theatre operating register was retrospectively reviewed to obtain information on all patients who had pterygium excision at the University College Hospital, Ibadan, over a 4-year period from January 1, 2014, to December 31, 2017. Clinical records of patients were also retrieved. The information obtained included patients’ demographics, preoperative visual acuity, clinical presentation, surgical management and post-operative complications. The data obtained were entered into SPSS (SPSS for Windows, version 20.0; SPSS, Chicago, IL, USA) statistical package and analyzed. Descriptive statistics were used to yield frequencies, percentages, and proportions. The demographics of patients, follow-up duration, surgery performed (bare sclera excision, conjunctival autograft, amniotic membrane graft, or concomitant use of surgical adjuvants), recurrences with respect to the type of surgery performed and other postoperative complications were analyzed. The retrieval and analysis of patient’s data followed the ethical standards of the Helsinki Declaration of 1975, as revised in 2000.

Mean follow up duration was 9 months with a median of 5 months and a range of 0–53 months. In the final analysis we excluded patients with missing post-operative notes, cataract surgery combined with pterygium excision, follow up of less than 4 months and patients whose case notes could not be retrieved.

Definitions

Pterygium can simply be divided into four stages.[14] Stage I: Incipient stage, when it is just crossing the limbus; Stage II: The pterygium is midway between the limbus and pupillary margin; Stage III: The pterygium is at the pupillary margin; Stage IV: The pterygium has crossed the visual axis and could cause blindness/low vision. Pterygium recurrence was defined as any fibrovascular re-growth across the limbus.


  Results Top


A total of 324 pterygium surgeries were performed on 290 patients in the study period. Only 1 patient had the same eye re-operated during that period. The male to female ratio was 0.95:1. The overall mean age was 51.3 ± 13.5 years, while the age range was 20–90 years. More resident doctors performed surgeries compared to consultants with a ratio of 4.28:1.

In the final analysis, 249 (76.9%) surgeries were included with a male to female ratio of 0.96:1. The mean age was 50.8 years with a range of 20-90 years. The age group with highest operation was 41–50 years, with a total of 77 patients (30.9%).

The left eye had slightly fewer surgeries compared to the right with a ratio of 0.86:1. Two hundred and twenty-two cases of pterygium (89%) occurred on the nasal aspect of the eyeball, 9 (4%) on the temporal aspect and 17(7%) were double (temporal and nasal) pterygia. The pre-operative visual acuity was ≥6/18 in 209 (84%).

Though the pterygium was not graded or measured in 76(30.5%) of the eyes, for those that were measured; surgery was performed for pterygium between 2 and 4mm from limbus in 94(37.8%) and 44(17.7%) had pterygium of >4mm.

Excision + 5Fluorouracil + Autograft was the commonest surgery performed in 187(75.1%) eyes and 45(18.1%) had no type of graft. Bare sclera technique was performed in only 4(0.02%) of the eyes. [Table 1] shows the different surgical techniques performed.
Table 1 Different surgical options

Click here to view


Post-operatively, recurrence following pterygium excision was documented in 40 (16.1%). The recurrence rate when sub-analyzed with surgical techniques and was found to be higher in patients with no autograft. Recurrence was noted in 18 (47.4%) eyes of patients who had only Excision + 5FU compared to 18 (9.6%) eyes of the patients who had Excision + 5FU + Autograft. Other notable postoperative complications include granuloma, symblepharon, ankyloblepharon, orbital cellulitis and panophthalmitis [Table 2]. The patients each with orbital cellulitis and panophthalmitis were diabetic, defaulted on medication use and follow up.
Table 2 Post-operative complications

Click here to view



  Discussion Top


There has been an evolution in the surgical techniques for pterygium excision performed in our Hospital. Bare sclera technique though easy and quick has been replaced with newer techniques such as excision + 5-FU with conjunctiva autograft (CAG) or amniotic membrane (AM) transplantation. Ashaye10 in 1991 reported a mainly bare sclera excision which now forms only 0.02% of surgeries performed during this period of analysis, more than 2 decades after. Grafts and or adjuvants made up 99.98% of our surgical procedures.

Detailed analysis was limited in this study because of very small number of eyes undergoing some specific surgical procedures, poor morphologic characterization of pterygium and poor follow up visits.

Post-operative recurrent rates for pterygium excision vary widely based on surgical techniques, morphology of pterygium and recurrence of pterygium.

Primary closure though technically easier was not performed in the study period despite the bulk of the operation performed by trainees. This can be attributed to the standard operating practice of performing pterygium excision with conjunctiva autograft in our centre.

CAG transplantation

This technique reduces the risk of recurrence as transplantation of normal conjunctiva forms a barrier to the proliferation and advancement of residual abnormal tissue (both conjunctival and episcleral tissues) towards the limbus. It is worthy of note that there was no indication in the surgical documentation that the CAG surgery ensured limbal autograft, though this is the standard operating practice in our centre.In this series, the recurrence rates for excision + 5FU + CAG (9.6%) was comparable with excision + AMG alone (8.3%). Compares favorably with Bekibele et al.[11] where recurrence using conjunctival autograft was 12.1%. This study also had comparable recurrent rate with studies such as Fahez et al., Gular et al.[15],[16],[17],[18],[19] Lower recurrence rates were recorded in an American series in a retrospective study of 234 cases with total recurrence of 2.14% and rate of 6.9% versus 0.57% for recurrent versus primary pterygium surgery with CAG.[20]


  Conclusion Top


This retrospective study reported significant majority of the excision was with conjunctiva autograft with an acceptable low recurrence rate. This may not be unrelated to the outcome of previous randomized study outcomes of pterygium excision with CAG in the same centre, thus influence the choice. We recommend that pterygium excision with conjunctival autograft should be the first consideration in pterygium surgeries.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rosenthal JW. Chronology of pterygium therapy. Am J Ophthalmol 1953;36:1601-16  Back to cited text no. 1
    
2.
Moran DJ, Hollows FC. Pterygium and ultraviolet radiation: a positive correlation. Br J Ophthalmol 1984;68:343-6  Back to cited text no. 2
    
3.
Taylor HR, West S, Munoz B. The long-term effects of visible light on the eye. Arch Ophthalmol 1992;110:99-104  Back to cited text no. 3
    
4.
Cameron ME. Pterygium throughout the world. Charles C. Thomas: Springfield, Illinois, USA, 1965  Back to cited text no. 4
    
5.
Olusanya BA, Ogun OA, Bekibele CO, Ashaye AO, Baiyeroju AM, Fasina O et al. Risk factors for pterygium recurrence after surgical excision with combined conjunctival autograft (CAG) and intraoperative antimetabolite use. Afr J Med Med Sci 2014;43:35-40  Back to cited text no. 5
    
6.
Onwasigwe EN, Ezegwui IR. An overview of management of pterygium in Nigeria. Int J Ophthalmol 2008;1:367-9  Back to cited text no. 6
    
7.
Sánchez-Thorin JC, Rocha G, Yelin JB. Meta-analysis on the recurrence rates after bare sclera resection with and without mitomycin C use and conjunctival autograft placement in surgery for primary pterygium. Br J Ophthalmol 1998;82:661-5  Back to cited text no. 7
    
8.
Fonseca EC, Rocha EM, Arruda GV. Comparison among adjuvant treatments for primary pterygium: a network meta-analysis. Br J Ophthalmol 2018;748-56  Back to cited text no. 8
    
9.
Bekibele CO, Baiyeroju AM, Olusanya BA, Ashaye AO, Oluleye TS. Pterygium treatment using 5-FU as adjuvant treatment compared to conjunctiva autograft. Eye 2008;22:31-4  Back to cited text no. 9
    
10.
Ashaye A. Pterygium in Ibadan. West Afr J Med 1991;10:232-43  Back to cited text no. 10
    
11.
Ashaye AO. Modified bare sclera method for the treatment of primary pterygium: a preliminary report. West Afr J Med 2005;24:66-9  Back to cited text no. 11
    
12.
Bekibele CO, Sarimiye TF, Ogundipe A, Olaniyan S. 5-Fluorouracil vs avastin as adjunct to conjunctival autograft in the surgical treatment of pterygium. Eye 2016;30:515-21  Back to cited text no. 12
    
13.
Bekibele CO, Baiyeroju AM, Ajayi BGK. 5-fluorouracil vs. beta-irradiation in the prevention of pterygium recurrence. Int J Clin Pract 2004;58:920-3  Back to cited text no. 13
    
14.
Johnson SC, Williams PB, Sheppard JD. A comprehensive system for pterygium classification. Invest Ophthalmol Vis Sci 2004;45:2940  Back to cited text no. 14
    
15.
Al Fayez MF. Limbal versus conjunctival autograft transplantation for advanced and recurrent pterygium. Ophthalmology 2002;109:1752-5  Back to cited text no. 15
    
16.
Guler M, Sobaci G, Ilker S et al. Limbal-conjunctival autograft transplantation in cases with recurrent pterygium. Acta Ophthalmol (Copenh) 1994;72:721-6  Back to cited text no. 16
    
17.
Mutlu FM, Sobaci G, Tatar T et al. A comparative study of recurrent pterygium surgery: limbal conjunctival autograft transplantation versus mitomycin C with conjunctival flap. Ophthalmology 1999;106:817-21  Back to cited text no. 17
    
18.
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;88:995-7  Back to cited text no. 18
    
19.
Soliman Mahdy MA, Bhatia J. Treatment of primary pterygium: role of limbal stem cells and conjunctival autograft transplantation. Eur J Ophthalmol 2009;19:729-32  Back to cited text no. 19
    
20.
Masters JS, Harris DJ. Low recurrence rate of pterygium after excision with conjunctival limbal autograft: a retrospective study with long-term follow-up. Cornea 2015;34:1569-72  Back to cited text no. 20
    



 
 
    Tables

  [Table 1], [Table 2]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials and Me...
Results
Discussion
Conclusion
References
Article Tables

 Article Access Statistics
    Viewed1329    
    Printed43    
    Emailed0    
    PDF Downloaded146    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]