pterygium recurrence rate

Sarnicola V, Vannozzi L, Motolese PA. Subconjunctival bevacizumab in the impending recurrent pterygia. Targeting platelet-derived growth factor receptor b inhibits the proliferation and motility of human pterygial fibroblasts. Single and multiple injections of subconjunctival ranibizumab for early, recurrent pterygium. MMC is a natural anti-tumor antibiotic that could generate cross-links on the DNA strands . Several small studies have been performed to evaluate the role of perioperative 5-FU with or without concomitant corticosteroids in the management of recurrent pterygium since 2001.19,64 The initial results have been promising. evaluated the differences in tear film parameters between pterygium-affected and healthy eyes. The purpose of this narrative review is to summarize the recent evidence regarding different aspects of pterygium recurrence, which can provide new insights and perspectives for better management of this common disease by ophthalmologists. 18.56 0.60 month in size of <3 mm; P= 0.06). However, the main issue in pterygium management is recurrence, which is still challenging regarding prevention and management. MMC: Mitomycin C, CAU: Conjunctival autograft. They suggested that AMT-MMC is an acceptable method for the treatment of recurrent pterygium cases, with similar outcomes and complication rates.10 Barbosa et al. Before However, pterygium surgery is concerned with high rates of postoperative recurrence. Zhang LW, Chen BH, Xi XH, Han QQ, Tang LS. 1Eye Research Center, The Five Senses Institute, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran, 2Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran, 3Department of Radiation Oncology, Indiana University, Indiana, USA, 4Alavi Eye Hospital, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran. Yamada T, Mochizuki H, Ue T, Kiuchi Y, Takahashi Y, Oinaka M. Comparative study of different -radiation doses for preventing pterygium recurrence. Garca Tirado A, Boto de Los Bueis A, Rivas Jara L. Ocular surface changes in recurrent pterygium cases post-operatively treated with 5-fluorouracil subconjunctival injections. Kampitak and colleagues have been publishing multiple studies regarding the ocular surface changes in pterygium patients pre and postoperatively. Adjuvant therapy, Amniotic membrane graft/transplant, Conjunctival autograft, Conjunctival disease, Pterygium, Pterygium management, Pterygium recurrence, Recurrent pterygium, Risk factor. between intraoperative and postoperative appli- PMID: 25320400 PMCID: PMC4196535 DOI: 10.4314/gmj.v48i1.6 Abstract Objectives: To determine the epidemiology and recurrence rate of pterygium after excision using bare sclera technique. Salman AG, Mansour DE. bare sclera and postoperative MMC ranges from . Julio G, Lluch S, Pujol P, Alonso S, Merindano D. Tear osmolarity and ocular changes in pterygium. Therefore, later authors look for an adjacent procedure/medication that could increase the success rate of using AMT for the treatment of recurrent pterygia.6,10,11,15, Due to a larger area of subconjunctival fibrosis in some cases, a larger conjunctival defect is created after the excision of recurrent pterygium. Generally, they have been small-scale studies with a short duration of follow-up (16 months) which found no difference in the parameters of ocular surface like Schirmer test before and after pterygium surgery.77 However, later tear film status has been investigated widely in eyes with pterygium, and greater abnormalities have been found in cases with recurrent pterygium. Efficacy and safety of subconjunctival bevacizumab for recurrent pterygium. Patients' demographics, primary surgeon, use of conjunctival autograft (CAU) or amniotic membrane graft (AMG), recurrence of pterygium, follow-up length, and complications were . While pterygium removal was associated with an improved Schirmer test value.77 Ozsutcu et al. Galor A, Yoo SH, Piccoli FV, Schmitt AJ, Chang V, Perez VL. Rykov SO, Usenko KO, Mogilevskyy S, Ziablitsev SV, Denisiuk LE. Trkylmaz K, Oner V, Sevim M, Kurt A, Sekeryapan B, Durmu M. Effect of pterygium surgery on tear osmolarity. Malik S, Khan MS, Basit I. In another recently published study, the clinical outcomes of surgery for recurrent pterygia using MMC, double AMT, and a large conjunctival flap were investigated.99 This retrospective case series by Monden et al. Subconjunctival and topical application are the most popular administration techniques. The rationale for using intraoperative MMC after removal of the pterygium is its inhibitory effect on DNA replication, then slowing down fibrovascular tissue regrowth. Topical bevacizumab eyedrops for limbal-conjunctival neovascularization in impending recurrent pterygium. This can also explain why anti-VEGF treatments were not as much effective as in primary pterygium or as an adjunct to surgical treatment for recurrent pterygium with fibrotic elements. Kaufman SC, Jacobs DS, Lee WB, Deng SX, Rosenblatt MI, Shtein RM. Pterygium management is mainly surgical. CAU is the most effective surgical treatment for recurrent pterygium, and other new surgical therapies need further investigation. The mean number of primary pterygium excisions was 33 per year (range, 14-56 per year). The https:// ensures that you are connecting to the also confirmed the same finding.43 In contrast, in a prospective study of 190 patients, larger preoperative size of the pterygium was confirmed as a protective factor against recurrence following CAU or limbal conjunctival autograft (LCAU) surgeries.18 It is important to mention that published studies in this aspect differ substantially not only in methodological aspects but also in their observation period, the usage of adjuvant medication, sample size, and measuring approach.17 Anguria et al. There was no significant association of pterygium recurrence with younger age (p = 0.14). Although topical bevacizumab is found to inhibit the growth of impending recurrent pterygium, the effect is mostly temporary. Hence, studies without survival curves may underestimate true recurrence rates.6,17,38,50 Using KaplanMeier analysis, Samadi et al. Multiple weekly subconjunctival 5-FU injections are shown to be safe and effective in halting the progression of recurrent pterygium. An official website of the United States government. did not find a positive association between histology and recurrence.28 In addition, they could not find any significant difference in inflammation intensity, degree of vascularization, or fibrinoid change between the primary pterygium and the recurrent pterygium group. Four studies demonstrated a higher pterygium recurrence rate in the AMT group. . Among proposed risk factors, DED, black race, and young age are considered preoperative risk factors for recurrence.1,2,3,4,5,6,7,8 Some molecular biomarkers and genetic factors have also been considered to increase the risk of recurrence. found that 45% of primary pterygium and 50% of recurrent pterygium cases were positive for p53 expression, whereas this protein was not expressed in normal human conjunctiva.26 However, another investigation by Nuhoglu et al. Zein H, Ismail A, Abdelmongy M, Elsherif S, Hassanen A, Muhammad B, et al. They included 224 patients with advanced recurrent pterygium with a mean follow-up of 62 months. DED perpetuates ocular surface inflammation in the postoperative period, and this inflammation may increase the rate of recurrence.14,77 Proper and early diagnosis and management of DED in the perioperative period could reduce the risk of recurrence.14,34. Accessibility They showed that pterygium is associated with tear hyperosmolarity and abnormal tear film function.79 Trkylmaz et al. found abnormal tear film function and osmolarity in primary pterygium cases, which improved after pterygium excision.16 However, tear osmolarity deteriorated again when recurrence happened. 10-year incidence and associations of pterygium in adult Chinese: The Beijing Eye Study. Method: Prospective randomized clinical trial. Hirst LW. Rosen R. Amniotic membrane grafts to reduce pterygium recurrence. Conclusions: According to the current evidence from literature, recurrence rates after pterygium excision with LCAG are lower when compared with the use of bare sclera, bulbar conjunctival autograft, or intraoperative mitomycin C. It should be noted that in most comparative studies, AMT had been used in combination with intraoperative MMC. Predicting factors of recurrence are not fully understood, yet, but they probably depend on a multitude of patient-related, clinical, and/or surgical factors. Lekhanont K, Patarakittam T, Thongphiew P, Suwan-apichon O, Hanutsaha P. Randomized controlled trial of subconjunctival bevacizumab injection in impending recurrent pterygium: A pilot study. Recurrence rates following bare sclera resection range from 24% to 89%, 10-12 following bare sclera resection with mitomycin application between 0% and 38%, 3-5 11 and following pterygium resection with conjunctival graft placement between 2% and 39%. PMID: 29176451 DOI: 10.1097/ICO.0000000000001453 Abstract Purpose: To evaluate the impact of race and ethnicity, surgical technique, and level of surgeon training on recurrence rates after primary pterygium excision. Long-term outcomes of conjunctivo-limbal autograft alone and additional widening of limbal incision in recurrent pterygia. Recurrence rate with inferior conjunctival autograft transplantation compared with superior conjunctival autograft transplantation in pterygium surgery: A meta-analysis. Limbal-conjunctival vs conjunctival autograft transplant for recurrent pterygia: A prospective randomized controlled trial. Monitoring the patients closely after a single injection to repeat the injection in cases with the minimal response is recommended. This was true also for participants with recurrent pterygium.65 Considering the 3-month rate of pterygium recurrence using each technique for both primary and recurrent pterygium, the recurrence rate ranged from 0% to 16.7% in the CAU and 4.76% to 26.9% in the AMT group.65 There was a substantial reduction in the risk of recurrence for . How is pterygium diagnosed? As a library, NLM provides access to scientific literature. Triple subconjunctival bevacizumab injection for early corneal recurrent pterygium: One-year follow-up. Reda et al. Intraoperative techniques like tucking-in the amniotic membrane under the surrounding conjunctiva or pinching it together with the recipient conjunctiva have been suggested by some authors to achieve a good apposition.52,59. In a study conducted by Kim et al.,101 only patients with multi-recurrent pterygia were enrolled and all eyes underwent pterygium excision followed by application of MMC, AMT, and LCAU. New treatment options for pterygium. Razeghinejad MR, Hosseini H, Ahmadi F, Rahat F, Eghbal H. Preliminary results of subconjunctival bevacizumab in primary pterygium excision. Phase I study of subconjunctival ranibizumab in patients with primary pterygium undergoing pterygium surgery. However, in some studies, AMT was compared with CAU without using intraoperative MMC. Such advances in the treatment have not only continued to reduce the recurrence rate but also may enable us in using less invasive therapeutic options. showed a bilateral correlation between DED and pterygium recurrence.14 They found that the Schirmer test result was significantly lower in patients with recurrence compared to those without recurrence. Multimicroporous e-PTFE, preserved limbal allograft and AMT, the SLET technique, and LCAU combined with the widening of the limbal incision are among novel ways to reduce recurrence. The mean follow-up period was 73 months, and pterygium recurred in about 12% of eyes within 16.5 months.53 Mednick et al. Restrictions on sex, age, language and journal or article type were not applied. proposed the simple limbal epithelial transplantation (SLET) technique as a novel way to treat recurrent pterygia. The impact of preoperative size, fleshiness, and histology of pterygium on recurrence rate are areas of controversy.17 However, in previous studies (1990s) some researchers emphasized the importance of a healthy limbal epithelium in the prevention of recurrence.5,15,17 Some studies have confirmed a positive association between preoperative size of the pterygium and its recurrence8,38,39,40,41. There are several studies which reported a recurrence rate of 0%4.5% with fibrin glue.12,40,67,68,69,70,71 Prospective randomized controlled studies showed lower long-term recurrence rates with fibrin glue in comparison to polyglactin or nylon sutures.12,67,70 It can be due to less postoperative inflammation and an immediate adherence of the graft, which plays a crucial role in inhibiting fibroblast ingrowth, encouraging earlier graft vascularization, and reducing the recurrence.19,66,72 Romano et al. Results: The pterygium recurrence rate was 6.7% at a follow-up of 1 year. Summary of prospective studies on pterygium, covering the risk factors, different treatment options, and ways to improve the surgical outcomes and decrease the recurrence rate, *Superscript numbers are related cited reference numbers. Population-based assessment of prevalence and risk factors for pterygium in the South Indian State of Andhra Pradesh: The Andhra Pradesh Eye Disease Study Pterygium in South India-APEDS. Only primary pterygium cases with a minimum postoperative follow-up of 6 months were included. Some authors believe that subconjunctival injection of MMC before the operation helps with the exact titration of drug delivery to the activated fibroblasts and minimizes corneal epithelial toxicity.73 Khalifa et al. Incomplete control of postoperative inflammation, surgical techniques such as excessive suturing and incomplete removal of the primary pterygium, young age, surgeon experience, higher morphologic grade (fleshiness of pterygium), heavy vascularization of the primary pterygium, and black race are other risk factors for recurrence of the pterygium.9,10,11,12,13,14,15,16,17,18,19,20,21,22 In addition, the precise pathogenesis of recurrence is under debate. Fuest M, Mehta JS, Coroneo MT. Assessment of fibrin glue in pterygium surgery. MMC,58,59,60 5-uorouracil (5-FU),19,59,61 corticosteroids,61 and anti-VEGFs are the most popular agents. ASCRS Cornea Clinical Committee. showed in their case series that the vertical size of the pterygium more than 6.7 mm is a risk factor for recurrence.17 Kim et al. Anguria P, Ntuli S, Carmichael T. Young patient's age determines pterygium recurrence after surgery. Safety and efficacy of fibrin glue versus vicryl sutures in recurrent pterygium with amniotic membrane grafting. Study to correlate clinical and histopathological characteristics of pterygium in predicting its recurrence. Razeghinejad R, Banifatemi M, Hosseini H. The effect of different doses of subconjunctival bevacizumab on the recurrence rate of excised primary pterygium. Table 2 summarizes the studies evaluating the effect of topical, subconjunctival, or subtenon bevacizumab/ranibizumab on impending recurrent pterygium. Also, basic science studies have shown that changes in the limbal stem cells and fibroblasts have a role in pterygium formation and pathogenesis.2,9. In general, the most important question regarding the surgical management of recurrent pterygium is choosing between AMT and CAU. reported their finding on recurrent pterygium cases treated with AMT combined with 0.02% MMC for 1 min or CAU combined with the same dose of MMC.10 They found a similar recurrence rate in both groups. Therefore, there is a need for ophthalmologists to update their knowledge regarding the current ongoing concepts of nature and risk factors of recurrent pterygium as well as the current treatment options to obtain better surgical results and improve patient satisfaction. Anti-VEGF treatments have different results with regard to recurrent pterygium regression. Ten percent of patients in the CAU group and only 1.0% of patients in the LCAU group developed recurrence. It has been known that angiogenesis and vascular proliferation is a part of the pterygium pathogenesis.82 Several studies have shown that in the natural history of pterygium formation and recurrence, expression of basic fibroblast growth factor, VEGF, transforming growth factor-, and platelet-derived growth factor are increased.24,83,84 Before 2009, medical adjunctive approaches to prevent neovascularization and future recurrence of pterygium included therapy with beta radiation, MMC, 5-FU, and corticosteroids in routine practice.2,8,15 However, later, the value of anti-VEGFs was noticed by some authors, as these class of adjunct medications did not have significant ocular side effects like MMC or 5-FU.84,89 Therefore, in recent years, anti-VEGF agents such as bevacizumab and ranibizumab have been studied widely in primary and recurrent pterygium treatment as adjunctive therapy to surgical excision or as a nonsurgical treatment alone.58,85,86,87,88,89,90,91,92,93 Different routes and doses of administration have been evaluated in multiple studies. Kucukerdonmez C, Karalezli A, Akova YA, Borazan M. Amniotic membrane transplantation using fibrin glue in pterygium surgery: A comparative randomized clinical trial. As there is no definite recommendation or guideline for use of adjuvant treatments, and future studies are needed to standardize dosage, time, and ways of administration. Fakhry MA. Chen Q, Li Y, Xu F, Yan Y, Lu K, Cui L, et al. Purpose: To compare recurrence rate of primary pterygium following excision with mitomycin c verses excisionwith amniotic membrane transplant.Study Design: Quasi experimental study.Place and Duration of Study: Qazi Hussain Ahmad Medical Complex, Nowshera, from January 2019 to June2019.Material and Methods: One hundred and two patients presenting. Simple limbal epithelial transplantation for recurrent pterygium: A case series. To treat the pterygium, surgical excision is one of the commonly used methods, but the recurrence rate can be high after its surgical removal . 5-FU is a pyrimidine analog that stops the process of DNA and RNA synthesis. Knowing the risk factors of recurrence and in-time use of proper methods to decrease the recurrence rates in pre, intra, and postoperative periods could be helpful in managing pterygium cases in a better way. Fakhry et al. Olusanya BA, Ogun OA, Bekibele CO, Ashaye AO, Baiyeroju AM, Fasina O, et al. Between novel surgical techniques, various studies evaluated the use of adhesives or sutures. Ratnalingam V, Eu AL, Ng GL, Taharin R, John E. Fibrin adhesive is better than sutures in pterygium surgery. Amniotic membrane transplantation with narrow-strip conjunctival autograft vs conjunctival autograft for recurrent pterygia. The mean pterygium recurrence rate in the three study groups at 12 months after surgery was 11.3% (range, 6.4-14.7%). However, as there is no clear evidence that ranibizumab is superior to bevacizumab in this area, bevacizumab is still considered the first-line choice by many authors because of the lower cost. study, multiple weekly subconjunctival intralesional 5-FU injections, 0.10.2 ml (2.55.0 mg) started within 1 month of recurrence, have been shown to be safe and effective in halting the progression and inducing regression of recurrent pterygium.19 Another study assessed the changes in pathological parameters of the ocular surface before and after 10 intralesional injections of 5-FU in recurrent pterygium cases.49 They reported an increase in the number of epithelial cells and density of goblet cells, reduction in the squamous metaplasia, and changing in abnormal cytology to normal in these injected eyes. In half of the eyes, multi-microporous e-PTFE was inserted between the transplanted amniotic membrane and the conjunctiva intraoperatively. Bahuva A, Rao SK. 166 . Many authors have evaluated the use of anti-VEGF drugs as an adjuvant treatment after surgical resection. An MX, Wu KL, Lin SC. This emphasizes the importance of early administration of these drugs. Comparative evaluation of lymphatic vessels in primary versus recurrent pterygium. though it carries with it an increased risk of pterygium recurrence . This means that different pathogenesis may exist between primary and recurrent pterygia.23 Therefore, the process of pterygium recurrence is accelerated by induction of pre-inflammatory cytokines, growth factors, and different molecular biomarkers like excessive levels of stromal cell-derived factor 1, angiogenin, transcription factor specificity protein 1, and collagen I, which all are considered to be associated with higher recurrence rates.8,24,25, p53 is a known important tumor suppressor protein that plays a role in regulating cellular proliferation and apoptosis. Pterygium is an abnormal growth of epithelial and fibrovascular tissue invading the cornea across the limbus and can lead to impaired vision (due to excessive dimensions or induced astigmatism) or recurrent inflammation. Changes of tear film function after pterygium operation. Ozsutcu M, Arslan B, Erdur SK, Gulkilik G, Kocabora SM, Muftuoglu O. The recurrence rate was 2 eyes in group 1 (10%) (limbal stem cell transplantation + conjunctival autograft), 6 eyes in group 2 (30%) (AMT) and 4 eyes (20%) in group 3 (MMC + AMT). Barbosa JB, De Farias CC, Hirai FE, Pereira Gomes J. We reviewed risk factors associated with the recurrence of pterygium, timing of recurrence, medical treatments to prevent from recurrence, and nonsurgical and surgical alternatives for management of recurrence. This technique included extensive tenonectomy and pterygium resection followed by the transplantation of a large CAU, which led to very low recurrence rates (0.1% for 1000 patients) in primary and recurrent cases.50 In 2015, Katircioglu et al. This was consistent with low recurrence rate, which was one case of recurrence in the 1000 surgeries (0.1%). It has been shown that increasing the duration of intraoperative bare sclera exposure to MMC reduces recurrence and improves outcomes in the expense of increasing complications.15,62 Kaufman et al. Comparison of fibrin glue with sutures for pterygium excision surgery with conjunctival autografts. Risk factors for pterygium recurrence after surgical excision with combined conjunctival autograft (CAG) and intraoperative antimetabolite use. Methods Retrospective analysis of medical records of 920 patients (989. No sign of limbal stem cell deficiency was observed during follow-up.22 A Cochrane review of 20 published studies on pterygium from eight countries worldwide found that in 6 months after surgery, CAU is associated with a lower risk of recurrence in comparison to AMT. Katircioglu et al. Using fibrin glue instead of sutures can further reduce recurrence rates and surgery time. Kim KW, Kim JC. Younger age was associated with a significantly increased recurrence rate (P=0.002). Vascular endothelial growth factor gene polymorphism and protein expression in the pathogenesis of pterygium. evaluated 51 studies and confirmed this finding in an Ophthalmic Technology Assessment paper.15 Most of the published studies have used MMC with a range of 0.01%0.04% intraoperatively. Management of recurrent pterygium with intraoperative mitomycin C and conjunctival autograft with fibrin glue. Table 1 sumerizes the prospective studies on pterygium, covering the risk factors, treatment options, and options to improve the surgical outcomes and decrease the recurrence rate. showed that augmenting CAU with Ologen implantation is effective in the management of recurrent pterygium with mild nonvision-threatening postoperative side effects comparable to that of MMC.63 It should be noted that a combination of different adjunct therapies is much better than single adjunct therapy in reducing the rate of recurrence.64. The results showed that there is no difference in the recurrence rate and cosmetic outcomes between groups. CAU is superior to amniotic membrane transplantation in the treatment for recurrent pterygia. Pterygium, from the Greek pterygos meaning "wing", is a common ocular surface lesion originating in the limbal conjunctiva within the palpebral fissure with progressive involvement of the cornea. NR: Not reported, CAU: Conjunctival autograft, AMT: Amniotic membrane transplantation, LCAU: Limbal CAU, MMC: Mitomycin C, 5-FU: 5-fluorouracil, Reports published before 2009 found an overexpression of different biomarkers like matrix metalloproteinases (MMPs) and p53 in fibroblasts from primary pterygium head and were usually based on immunohistochemical (IHC) studies.8,23 However, investigative studies in recurrent pterygium were less reported or just clinical observations were revealed.

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