Modified Limbal-Conjunctival Autograft Surgical Technique: Long-Term Results of Recurrence and Complications.

PURPOSE: The aim of this study was to report the recurrence and complication rates of a modified limbal-conjunctival autograft surgical technique for pterygium excision. METHODS: This was a retrospective, single-surgeon, single-operating environment, consecutive case series of 176 eyes in 163 patients with a biopsy-proven diagnosis of pterygium. All patients underwent excision using a 23-gauge needle to "behead" the pterygium head, followed by a limbal-conjunctival autograft including ∼50% of the palisades of Vogt. Outcomes measured included recurrence, defined as any conjunctival fibrovascular growth, and complication rates. Correlations between preoperative patient characteristics, pterygium morphology, and intraoperative factors (width of corneal extension, conjunctival defect, and graft) with postoperative recurrence were examined using logistic regression models. RESULTS: The median age was 59.5 years and 122 eyes (69.3%) had primary pterygium (type I: 17%, II: 37.5%, and III: 45.5%). Kaplan-Meier analysis demonstrated the median pterygium-free follow-up period to be 723 days (range 46-7230 days). Recurrence was observed in 3 eyes of 2 patients (1.7%). No postoperative graft-related complications were observed. Postoperative symptomatology was transient. Age demonstrated a negative correlation with recurrence (odds ratio 0.888, 95% CI, 0.789-0.998, P = 0.046). However, no other correlations with preoperative or intraoperative factors, including whether pterygium was primary or recurrent, were identified (all P > 0.05). CONCLUSIONS: This modified limbal-conjunctival autograft technique represents an effective alternative that offers a very low recurrence rate and avoids extensive dissection or antimetabolites, with minimal complications and transient postoperative symptomatology, over a long-term follow-up period. This technique is relatively simple and successful for both primary and recurrent pterygia. Future comparative studies with other surgical techniques may determine which are superior.

Handing it to pterygium: Explaining pterygium laterality.

PURPOSE: To evaluate any correlation between pterygium laterality and patient handedness. METHODS: Our study represents a retrospective observational study of a series of consecutive pterygium patients recruited from two centres. Each patient was assessed for their handedness which was compared to the laterality of their presenting pterygium. Patients that possessed bilateral disease comparisons between pterygium size and handedness were made. Correlation statistics were performed to compare patient handedness and pterygium location (right or left). For patients possessing bilateral disease only, the pre-surgical differences between lengths and areas of pterygium were calculated and compared. RESULTS: A total of 219 patients were recruited into our study. 172 patients possessed unilateral disease and in 47 patients, the disease was bilateral. A significant association was identified between handedness and pterygium laterality (p < 0.001). Patients with right-sided pterygia were more likely to be right-handed (OR 2.327) and left-sided presentations who were more likely to be left-handed (OR 5.717). For bilateral presentations, patients were found to have longer (mean increase 3.50 ± 0.47 mm) and larger (mean increase 4.38 ± 0.48 mm2) pterygia in the eye ipsilateral to their dominant hand. CONCLUSIONS: A new insight of handedness as a contributing factor to pterygium laterality is consistent with evidence relating to the asymmetrical development of cortical cataract as well as to theories underlying the geometry of ocular UV exposure. A more complete understanding of factors contributing to ocular insolation may further inform as to improved protective measures and provides further evidence for the role of peripheral light focusing in pterygium pathogenesis.

The treatment of recurrent conjunctival and corneal intraepithelial neoplasia with interferon alfa-2b and retinoic acid: ~9 years' follow-up on tumor control.

PURPOSE: To evaluate the long-term follow-up of recurrent conjunctival and corneal intraepithelial neoplasia (CCIN) treated with combination topical interferon alfa-2b and retinoic acid (I/RA). METHODS: Our study represents a retrospective observational interventional series of 82 eyes from 82 patients from a single institution, reviewed for CCIN. All were administered topical interferon alfa-2b 1 million IU/mL QID and retinoic acid 0.01% every other day. Patients had been diagnosed by biopsy. A Kaplan-Meier survival analysis, Wilcoxon signed-rank test and a multivariate logistic regression were statistical tests used to correlate recurrence with patient and tumor variables. RESULTS: 79 eyes assessed for CCIN diagnoses and treated with I/RA achieved tumor resolution. The median tumor-free follow-up was ~109.1 months with a median time to resolution being ~2.8 months. Our median treatment duration was ~11.3 months. The greatest difference in the mean total residual tumor size was identified between Months 0-1 [-7.63 mm2]. The difference in mean total residual tumor size remained significant till 36-months. A statistically significant correlation with recurrence was identified for biopsy type [OR 0.138]. 6 patients experienced papillary conjunctivitis which resolved with dosage reduction. CONCLUSIONS: Combination I/RA was effective in treating CCIN lesions with few transient side effects. The combination of retinoids and interferons may represent a viable topical therapeutic agent with an extended tumor-free follow-up and a large proportion of our study's patients achieving >10 year's tumor-free follow-up. Our treatment duration is long, but by cost-comparing surgical against medical interventions, topical I/RA may serve as a safe and effective alternative.

Conjunctival Squamous Cell Carcinoma with Corneal Stromal Invasion in Presumed Pterygia: A Case Series.

AIM: To describe 4 cases of conjunctival squamous cell carcinoma (SCC) with corneal stromal invasion. METHODS: Retrospective, clinicopathologic case series. RESULTS: All patients had prior resections of presumed pterygia. The degree of corneal involvement dictated the extent of surgical management. One eye with localized invasion was treated with lamellar keratoplasty and plaque brachytherapy. Another case with widespread invasion warranted penetrating keratoplasty and eventual enucleation. Two cases were treated medically prior to surgical intervention: one with localized invasion was treated with topical interferon and retinoic acid; another with significant inflammation was treated with doxycycline and fluorometholone. The patient who underwent keratoplasty and brachytherapy had no recurrence after 7 years of follow-up. Those initially treated medically had resections of recurrence but ultimately required enucleation. Histologically, specimens demonstrated SCC invading the deep corneal stroma, with 2 tumors of the mucoepidermoid type. CONCLUSIONS: This series demonstrates the importance of maintaining clinical suspicion of conjunctival squamous neoplasia in pterygia. We recommend that all excised pterygia be submitted for histopathologic evaluation and be carefully evaluated for dysplasia and variants of SCC associated with increased risk of intraocular invasion. Undetected ocular surface squamous neoplasia may give rise to potentially vision- and eye-threatening invasive corneal SCC.

Significance of Fuchs Flecks in Patients With Pterygium/Pinguecula: Earliest Indicator of Ultraviolet Light Damage.

PURPOSE: Fuchs flecks (FFs) have been previously identified at the leading edge of pterygia and may represent collections of epithelial stem-like cells that give rise to this condition. This study aims to evaluate the clinical significance of FFs in patients with ocular surface disorders, such as pterygium and pinguecula, by in vivo confocal microscopy (IVCM). METHODS: This study is a Single-center, retrospective, observational case series of 40 eyes from 20 patients with clinical diagnoses of pinguecula or pterygium, or both. IVCM (Rostock Cornea Module; Heidelberg Engineering, Heidelberg, Germany) was performed on patients with pinguecula or pterygium, or both. The presence of FFs on the ocular surface of patients with pterygium and pinguecula was assessed by IVCM and subsequently documented. RESULTS: FFs were present in 24 of 30 eyes (80.0%) in paired macroscopically normal nasal or limbal regions, 19 of 20 (95.0%) in pinguecula, 13 of 15 (86.7%) in primary pterygia, and 7 of 7 (100%) in recurrent pterygia. CONCLUSIONS: High rates of FFs were identified at the head of pinguecula, primary pterygium, recurrent pterygium, and macroscopically normal nasal and temporal limbus. We postulate that FFs may represent precursor lesions to UV-associated ocular surface pathology. Identification of Fuchs fleck by IVCM may permit clinicians to predict the patients who may progress to develop more advanced pathology.