Results : MMP-9 grades was 2.39 1.12 in the group with LPS 50% and was 1.56 1.12 in the group with LPS <50% (P = 0.016). Concept of sealing of the gap. Recurrence was graded as G1 (normal), G2 (fine episcleral vessels), G3 (conjunctival recurrence), or G4 (corneal recurrence) as described.4 Diplopia was graded as 0 (none), D1 (diplopia 20 to 40 from the primary gaze), D2 (diplopia <20 from but not at the primary gaze), or D3 (diplopia at the primary gaze) as described.13 The caruncle morphological characteristics were graded as C1 (normal elevated dome shape, Figure 4A), C2 (normal elevated dome shape), but the semilunar fold was displaced toward the limbus, Figure 4B), or C3 (flattened, Figure 4C). doi:10.1136/bmjopen-2013-003787. GaoY-Y, Di PascualeMA, LiW, Malays J Med Sci. Ma K, Xu L, Jie Y, Jonas JB. You have successfully subscribed to this discussion. At that time, use of ofloxacin was discontinued if epithelization was completed, whereas topical corticosteroid was tapered from 4 times a day for the next 4 weeks. system (DLS) to perform pterygium grading, and further predict the surgical prognosis, in combination with other clinical information. Second, we sealed the gap in all eyes. Ophthalmology. Histologically, the subepithelial tissue shows senile elastosis (basophilic degeneration) of the substantia propria with abnormal collagen fibers. Patients One hundred and forty one patients (258 eyes) were surveyed in this retrospective, Tobramycin and dexamethasone ointment (Alcon Laboratories Inc) was applied in the eye. Eyelids of the right eye were within normal limits. Methods of covering the medial rectus muscle. 2023 American Medical Association. 3 Monga S et al. TanDTH, CheeS-P, DearKBG, LimASM. KheirkhahA, BlancoG, CasasV, TsengSC. The underlying stroma shows fibrocollagenous tissue, with areas of hyalinization and superficial congested vessels. Typically, the growth progresses gradually and horizontally toward the limbus, cornea, and visual axis. Recurrent pterygium. ConclusionsCaruncle morphological characteristics and residual conjunctiva measurement help grade the severity of recurrent pterygium, guide surgical techniques, and predict outcomes. (Reproduced from Garcia-Medina JJ et al. Shiratori CA, Barros JC, Loureno Rde M, Padovani CR, Cordeiro R, Schellini SA. The prevalence of and risk factors for pterygium in an urban Malay population: the Singapore Malay Eye Study (SiMES). Parameters of width, length, and area measured in order to As a group, our surgical techniques reduced the recurrence rate to 3.1%, which was more favorable than the 20% to 73.7% reported using AM transplantation11,32 and the 7.3% to 42.8% reported using CA.911 Recurrent pterygia in our cases was more severe than that reported previously, including 2 studies reporting zero recurrence (Table 3). Pannus. By continuing to use our site, or clicking "Continue," you are agreeing to our, Table 2. PDF | Background: The aim of this study was to evaluate the efficacy of a deep learning system in pterygium grading and recurrence | Find, read and cite all the research you need on ResearchGate WebPterygium excision: Pterygium body is excised carefully with conjunctival scissors and the head of pterygium can be removed from cornea by using a 15 degree Bard Parker blade. 2013;3(11):e003787. Postoperative subconjunctival corticosteroid injection to prevent pterygium recurrence. This approach affixes the graft into place with the patients own blood, eliminating the concern of disease transmission. An incision separated the head from the peripheral corneal, limbal, and perilimbal bulbar sclera (Figure 2A), followed by dissection on the bare sclera plane to the superior and the inferior bulbar areas before separating the cicatrix from the rectus muscle surface (Figure 2B). See Image Library for figure. Pterygium Grading Studies in Asia have shown that higher prevalence is significantly associated with a rural versus an urban population. Cost of Surfers Eye (Pterygium) Surgery | NVISION Eye Centers We speculate that failure of sealing such a gap explains highly variable recurrence rates by different surgical approaches. Pterygium & Pinguecula Surgery Recovery Timeline The procedure is done in 3 logical segments: pterygium and extensive Tenon removal, retrieval of a very large and very thin graft, and finally the reconstruction of the pterygium site, including a new semilunar fold to obtain the optimal cosmetic result. Further growth may cause visual symptoms due to induced astigmatism or direct encroachment onto the visual axis. Such fibrovascular growth is more extensive in recurrent pterygia, leading to symblepharon and motility restriction.2 It remains unclear whether grading of fibrovascular tissue can also be used to assess the severity of recurrent pterygia and foretell the surgical outcome. The science of pterygia. Kaufman S C, Jacobs D S, Lee WB, Deng SX, Rosenblatt MI, Shtein RM. The histology is very similar to pterygium, and pingueculae often precede the development of pterygium. During mean (SD) follow-up of 27.5(20.5) months, 30 of 32 eyes (94%) achieved total success without recurrence and diplopia and normal caruncle in 17 of 21 eyes (81%) with abnormal caruncle before surgery. That was why RS was used to seal the gap and found to be effective in restoring a normal caruncle because of the natural tendency of the Tenon capsule to retract posteriorly (Figure 1C and F). 64 blade and/or a dental burr. In pterygium grading, sensitivity, specificity, F1 score, and accuracy were 80% to 91.67%, 91.67% to 100%, 81.82% to 94.34%, and 86.67% to 91.67%, respectively. Pterygium Ultraviolet exposure (single most significant risk factor), Wedge-shaped, translucent membrane with apex extending onto cornea (, White to pink in color, depending on vascularity, Vascular straightening in the direction of the advancing head of the pterygium, Stocker line: iron line on cornea at leading edge of pterygium (, Degenerative changes such as cystic changes, Diagnosis is made clinically based on slit-lamp examination and typical appearance of the lesion (. In our experience, recurrence is more aggressive and occurs earlierat 4 to 6 monthsin children than in adults. Cornea. Multi-Step Pterygium Grading System Could Dictate Treatment In recent decades, studies regarding molecular mechanisms and management of A meta-analysis of pooled data from 20 studies, encompassing more than 900,000 cases in 12 countries, found an overall prevalence of 10.2%, with a slightly higher rate among men than women.2. The body/tail is the mobile area of the bulbar conjunctiva, which can be easily dissected from the underlying tissue.1. By Susan Dsouza, MBBS, DOMS, and M. Gurudutt Kamath, MBBS, DOMS, MS, Instruction Courses and Skills Transfer Labs, Program Participant and Faculty Guidelines, LEO Continuing Education Recognition Award, What Practices Are Saying About the Registry, Provider Enrollment, Chain and Ownership System (PECOS), Subspecialty/Specialized Interest Society Directory, Subspecialty/Specialized Interest Society Meetings, Minority Ophthalmology Mentoring Campaign, Global Programs and Resources for National Societies, Dr. Richard Mills' Opinions, 2002 to 2016, www.ncbi.nlm.nih.gov/pmc/articles/PMC3561894/, International Society of Refractive Surgery, Astigmatism leading to visual impairment, a faculty advisor to review your manuscript and add his/her pearls from clinical experience. The caruncle grading was significantly correlated with severity of diplopia (P=.001), RC length (P=.01), and RH ratio (P=.01) (Table 2). ChengHC, TsengSH, KaoPL, ChenFK. Relevant financial disclosures: None. 2010;50(3):4761. The grading proposed by Tan et al1 is clinically useful for primary pterygia but was not suitable for recurrent pterygia because episcleral vessels were not visible in most of the 32 eyes (Figure 4). As the disease progresses, the lesion increases in size and becomes more apparent to the naked eye and may become cosmetically unpleasant for the patient. One eye (patient 23) developed G4 recurrence and D1 diplopia 5 months after surgery and was lost to follow-up. One week after surgery, there is mild conjunctival hyperemia and chemosis with complete resection of the pterygium (Figure 11). Among them, 1 eye received mitomycin C and 5 eyes had additional AS. Please look into Pipeline and other configurations. For 47.1(21.1) months, no recurrence was noted, 7 of 8 eyes with diplopia gained full motility, and 3 of 4 eyes with preoperative abnormal caruncles restored a C1 appearance (Figure 5A-D). A 9-0 nylon running suture (RS) is used to seal the gap in the RS group (G). Web*GRADE: Grading of Recommendations Assessment, Development and Evaluation (www.gradeworkinggroup.org) Sources of evidence. Although the pathophysiology is not clearly understood, ultraviolet (UV) light is identified as the most important risk factor. Pearls articles typically offer step-by-step summaries of etiology, diagnosis, treatment, and follow-up. ResultsCaruncle grading strongly correlated with residual conjunctiva (P=.01), severity of diplopia (P=.001), and overall success rate (P=.05). In the FG/AS group, the gap was sealed by FG (Tisseel; Baxter) before AS (Figure 2F). In the running suture (RS) group (from 2009 to 2010), the gap was sealed with a 9-0 nylon RS. Pterygium in Indonesia: prevalence, severity and risk factors.Br J Ophthalmol. 90 Based on the external Proposal and validation of a new grading system for pterygium Persistent conjunctival inflammation at the 1-month visit was graded as 0 (none), I (mild), II (moderate), or III (severe) as reported.21 The RC was measured in millimeters from the recurrent pterygial head to the clinically evident caruncle (Figure 4D and E) by displaying the external photograph of the extreme gaze in Microsoft Office Powerpoint 2003 (Microsoft Corp) (height, 3.75 in; width, 5 in; and magnification, 67%) and using E-ruler 1.1 (http://www.mycnknow.com). After that, several strategies have been advocated to curtail recurrence. Additional Contributions: Huang-Chi Chen, MD, from the Department of Ophthalmology, the Chang Gung Memorial Hospital, and the Chang Gung University, Taiwan, assisted with the statistical analysis. Epidemiology of pterygium in Victoria, Australia. New York: Lippincott, Williams and Wilkins; 2008. Advantages include quicker epithelialization, minimal scarring and a resultant smooth corneal surface.1, Adjunctive therapies. These results suggest that postoperative persistent inflammation was more prevalent in recurrent pterygia and that subconjunctival triamcinolone is an effective postoperative adjunctive measure to combat recurrence. There is a host of theories attempting to explain the pathogenesis of a pterygium; however, the etiology has yet to be determined. From 2005 to 2008 when FG was available, the FG/AS group (13 eyes) received sealing of the gap by FG and AS without thorough removal of fibrovascular tissue. In the anchoring suture (AS) group (from 2002 to 2004), the gap was sealed with 4-0 black silk AS as reported for fornix reconstruction.23 In the fibrin glue (FG)/AS group (from 2005 to 2008), the gap was sealed with FG before AS. Persistent inflammation at 4.4(2.4) weeks was noted in the adjacent host conjunctiva or caruncle in 21 eyes (66%), among which 19 eyes (90%) received subconjunctival injections of triamcinolone acetonide, resulting in complete resolution in 16 eyes (84%). 2003;10(2):91-92. www.ncbi.nlm.nih.gov/pmc/articles/PMC3561894/. The conjunctiva normally ends at the clear part of your eye, the cornea. 2009;93(2):2158. Ophthalmology. ), Figure 5. Preoperative (A and C) and postoperative (B and D) photographs show that aesthetic appearance without G3 or G4 recurrence is achieved by amniotic membrane transplantation alone in an eye with sufficient residual conjunctiva (RC) (33.8 mm) and a high residual to horizontal (RH) ratio (0.87) (A and B, patient 3) and an eye without sufficient RC (16.2 mm) and a low RH ratio (0.45) (C and D, patient 4). WebSubmitted : June 26, 2021 Published : July 18, 2021 ISSN: 2593-8339 DOI: 10.24018/ejmed.2021.3.3.949 outcomes, despite receiving removal management. 2 Noor RA. The corneal (G4) recurrence rates vary from 0% to 82.4% in all reported studies of recurrent pterygia (Table 3). Pterygium is a common ocular surface disease characterized by abnormal epithelial tissues and subconjunctival fibrovascular overgrowth onto the cornea (Figure 1A and D). In a linear regression, the extent of LPS was positively correlated with MMP-9 grades (r = 0.315, P = 0.026). with the patients under general (22 eyes) or topical (10 eyes) anesthesia. If aggressive pterygium behavior is common in a patients locale, a more aggressive surgical approach is appropriate. Sealing of the gap is important to create a strong barrier for preventing recurrence, restoring caruncle morphological characteristics, and regaining full motility in multirecurrent pterygia. Yan Ke Xue Bao.2002;18(3):1814. Our findings highlight the importance of the fibrovascular tissue emanating from the caruncle in contributing to pterygium growth and demonstrate the effectiveness of sealing the gap in combating pterygial recurrences. Comments. As a pterygium gradually encroaches toward the visual axis, it can cause astigmatism, which may be the main visual complaint.1 In addition, the lesion may become inflamed, leading to ocular surface irritation. 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Pterygium: epidemiology prevention and treatment - PMC Written informed consent regarding the surgical procedures, alternatives, risks, and benefits was obtained from each patient. First, knowing RC could influence the surgical outcome, we recessed but did not resect the recurrent tissue. Your conjunctiva is the clear membrane that covers the white part of your eye. Definitive resolution may be more difficult to achieve than it is in adults, however, because pterygium recurs more aggressively and at a reportedly higher rate of 36.1% in children.4. All operations were performed by the same surgeon (S.C.G.T.) Pterygia are relatively common in the general population and typically follow an indolent course, with changes in appearance but little effect on vision and the eye itself. LewallenS.A randomized trial of conjunctival autografting for pterygium in the tropics. Medical treatment (artificial tears and lubricants) does not decrease progression or cause regression of pterygia. Pattern of eye diseases among welders in a Nigeria community. Add to My Bookmarks. PERFECT for Pterygium - American Academy of The recurrence rate is as high as 50% within 4 months and 97% recurrence rate within 12 months without autograft or amniotic membrane transplant (Hirst LW, 2003). To get started, you need only a few things: Are you a resident? Customize your JAMA Network experience by selecting one or more topics from the list below. of femtosecond laser-assisted pterygium surgery 2010;73(4):3435. The only eye unsuccessfully treated (patient 5) had no RC after 9 prior operations, was left with D2 diplopia and C2 caruncle, and was enrolled in the RS group. Pseudopterygium. Cosmesis after Pterygium Extended Removal followed by WebOverview Pterygium, a raised fleshy growth, on your cornea. B. Gelatinous. Cornea/External Disease Add to My Bookmarks Comments Views 4 The authors of this Postoperatively, pain was missing in 27 patients (84%) but only mild on eye movement in the remaining 5 patients on the first day. Cornea 1991;10:196202. The results of 1,000 consecutive surgeries with a 0.1% recurrence rate and the complications are also presented. The caruncle grading also correlated well with the overall surgical outcome of no recurrence, full ocular motility, and C1 caruncle (P=.05). A larger AM was transplanted to cover the entire bare sclera and the rectus muscle using FG (Figure 2H) to achieve a smooth surface with an elevated caruncle (Figure 2I). Arq Bras Oftalmol. The extension Pterygium pathophysiology. Many surgical techniques have been used, though none is universally accepted because of variable recurrence rates. There may be an irritated, gritty sensation, leading to constant eye rubbing. Fibrovascular tissue sandwiched between the conjunctiva (pink) and the Tenon capsule (green) flattens the caruncle (A, solid arrow) and anteriorly displaces the semilunar fold (A, broken arrow), causing recurrent pterygium (D). WebPterygium is a degenerative disorder of the conjunctiva. Am J Ophthalmol. Terms of Use| Pterygium: a review of clinical features and surgical treatment. The caruncle is graded as normal, C1 (A, arrow); slightly flattened, C2 (B, arrow); and flattened, C3 (C, arrow). Fotouhi A, Hashemi H, Khabazkhoob M, Mohammad K.Prevalence and risk factors of pterygium and pinguecula: the Tehran Eye Study. WebThe patient diagnosed as pterygium grade III + symblepharon + scaring cornea of left eye + senile immature cataract of both eye. Double-head recurrent pterygia was noted in 4 eyes of 3 patients (12%), with 1 patient having pterygia in both eyes. This term describes a band of conjunctiva adhering to an area of compromised cornea at its apex as a result of chemical or thermal burns, trauma, or marginal corneal disease. Chan TC, Wong RL, Li EY, et al. One week after resection of the pterygium and placement of temporal conjunctival autograft. ( 2015 American Academy of Ophthalmology, www.aao.org. Pterygium: an update on pathophysiology, clinical features, and Tsai YY, Lin JM, Shy JD. Pterygium Grading In contrast, for eyes without sufficient RC, conjunctival autograft (CA) (C and D) or oral mucosal graft (OMG) (E and F) is used. 2011; 118:17391746. To aid others who might use different cameras, we also measured the horizontal diameter of the fellow cornea at the primary gaze in the same manner as the reference for each patient (Figure 4F) and divided it by the RC to determine the residual to horizontal (RH) ratio. Stockers line, which is iron deposition in the basal layer of corneal epithelium anterior to the cap, indicates that the pterygium is chronic. MMP-9 expression did not differ between T grades or V grades. Vitamin A serves several essential functions in the eye, and deficiency can lead to a constellation of ocular signs and symptoms that affect the conjunctiva, cornea, and retina. Frequent headaches may occur as a consequence of the astigmatism. Grade II: between the limbus and the pupil, Grade III: extending to the pupillary margin, Management of pterygium in children is generally the same as in adults. However, it is unclear from the scientific literature how effective surgical intervention is in correcting astigmatism. Representative surgical outcome in the fibrin glue/anchoring suture group. The outcome measures were resolution of recurrence and binocular diplopia and restoration of a normal caruncle. Figure 7. Pterygium vs Pinguecula In patients with irritative symptoms, preservative-free artificial tears are recommended for mild inflammation and topical steroids are recommended for moderate inflammation. GaoY-Y, Di PascualeMA, LiW, A C1 caruncle was achieved in 17 of 21 eyes (81%) that had flattened caruncles before surgery. Conjunctival autograft transplantation for advanced and recurrent pterygium. Pterygium 2009;93(10):128790. Four of these 8 eyes had previously undergone failed surgery (1 from the AS group, 2 from the FG/AS group, and 1 from the RS group), strongly suggesting the necessity of additional transplantation of CA or OMG in eyes with an RC less than 20 mm or an RH ratio less than 0.6 (95% reference value). Hence, failure of sealing such a gap may lead to recurrence. The condition is often asymptomatic, especially early in its development. MethodsA total of 32 eyes of 30 patients with pterygia were managed at the Ocular Surface Center from January 1, 2002, through December 31, 2010. There is a lack of consensus in the ophthalmological community about the optimal medical and surgical management of pterygia. The horizontal diameter of the fellow cornea at the primary gaze was defined and measured (F). SciELO - Brasil - Sealing the gap between conjunctiva and Tenons Amniotic membrane transplantation alone was successful in 23 eyes with residual conjunctiva of 27.8(10.1) mm, which was significantly longer than those in 6 cases in which amniotic membrane transplantation failed (13.1[11.4] mm, P=.007) and those in 8 cases in which amniotic membrane transplantation was successful but that required an additional conjunctival autograft or oral mucosal graft (10.9[10.4] mm, P=.001). It is often dependent on the surgical procedure. Prevalence of pterygium in Latinos: Proyecto VER.