Has the Sun Protection Campaign in Australia Reduced the Need for Pterygium Surgery Nationally?

BACKGROUND: The Slip! Slop! Slap! Sunsmart safety campaign was an Australian initiative implemented in the 1980s. To assess this campaign's effect on pterygium, we examined the rate of pterygium surgery across Australia and described the prevalence and associations of pterygium in Perth, Australia's sunniest capital city. METHODS: The rate of pterygium surgery was examined using Australian Medicare data. A cross-sectional analysis of the Generation 1 (Gen1) cohort of the Raine Study was performed to investigate the prevalence of pterygium in Perth. We investigated the association between pterygium and conjunctival ultraviolet autofluorescence (CUVAF) area, an objective biomarker of sun exposure, and demographics and health variables derived from a detailed questionnaire. RESULTS: Between 1994 and 2017, the rate of Medicare funded pterygium surgery in Western Australia fell 11%, well below the national average decline of 47%. Of the 1049 Gen1 Raine Study participants, 994 (571 females; mean age 56.7 years, range = 40.9-81.7) were included in the analysis. The lifetime prevalence of pterygium was 8.4% (n = 83). A higher prevalence of pterygium was associated with outdoor occupation (p-trend = 0.007), male sex (p-trend 0.01) and increasing CUVAF area (p-value <0.001). CONCLUSIONS: The effect of Australia's Slip! Slop! Slap! Sunsmart safety campaign on pterygium been mixed. Since 1994, the rate of private pterygium surgery has declined significantly in all Australian states except Western Australia. Perth, Western Australia, has the highest pterygium prevalence of any mainland-Australian cohort. Higher CUVAF area, male sex, and outdoor occupation were associated with an increased risk of pterygium.

Role of oxidative stress and vascular endothelial growth factor expression in pterygium pathogenesis and prevention of pterygium recurrence after surgical excision.

PURPOSE: To assess the roles of oxidative stress and vascular endothelial growth factor (VEGF) in pterygium pathogenesis and prevention of pterygium recurrence after surgical excision. METHODS: Surgically removed pterygium tissue from 35 pterygium patients and normal conjunctival samples from 15 patients matched for age and sex (used as controls) constituted the study samples. The conjunctival samples were preserved at - 80 °C until analysis. Catalase (CAT), superoxide dismutase (SOD), glutathione peroxidase (GSH) and total antioxidant (TAO) enzymatic activity and the levels of nitric oxide (NO), malondialdehyde (MDA) and VEGF were studied in both groups. To evaluate the recurrence rate after surgical excision, the pterygium patients were further subdivided into three groups according to the adjuvant therapy used to prevent recurrence. Group 1 consisted of 10 patients who were treated with 0.2 mg mitomycin-c (MMC) for 2 min. Group 2 consisted of 12 patients treated with subconjunctival bevacizumab injection after surgical removal of the pterygium. Group 3 consisted of 13 patients who underwent combined treatment with 0.2 mg of MMC for 2 min and subconjunctival bevacizumab injection. The follow-up of patients in the three groups ranged from 7 to 15 months. RESULTS: The activities of CAT, SOD, GSH and TAO were significantly lower in pterygium samples than in normal conjunctival samples (p < 0.0001 each). The levels of MDA (p = 0.046), NO (p < 0.0001) and VEGF (p < 0.0001) were significantly higher in pterygium patients than in controls. The lowest recurrence rate after surgical excision was that of the third group. CONCLUSIONS: Oxidative stress and VEGF could play a role in the pathogenesis of pterygium as indicated by decreased antioxidant enzymatic activity and increased levels of VEGF in the pterygium tissue and the role of MMC and anti-VEGF therapy in decreasing the recurrence rate after surgical excision.

Topical cyclosporine A 0. 05% before and after surgery to prevent pterygium recurrence / Ciclosporina A 0, 05% antes e após a cirurgia do pterígio para a prevenção da recorrência

ABSTRACT Purpose: We evaluated the role of the conjunctival flap rotation technique using 5-fluorouracil and adjuvant therapy with topical cyclosporine A at 0.05% during short pre- and postoperative periods for the prevention of primary pterygium recurrence. Methods: In this prospective study, 76 patients with primary pterygium (76 eyes) were categorized into two groups: the control group with 31 patients who did not receive cyclosporine treatment, and the cyclosporine group with 45 patients who received topical cyclosporine A (0.05%) twice a day, for 10 days before and 10 days after the pterygium excision operations. Patients were examined for disease recurrence, side effects, and complications at 10 and 21 days, and at 2 and 6 months after the operation. Data on demography, systemic diseases, and ophthalmologic histories were obtained from all patients, and these data were analyzed using descriptive statistics involving the absolute and relative percentages of frequency distribution. Goodman test was used for contrasts among multinomial populations to study the association between cyclosporine A and recurrence. Results: Most patients were between 30 and 60 years of age, and 67.1% were women. We confirmed a higher recurrence in patients with occupational sunlight exposure. The cyclosporine A used topically 10 days before and 10 days after the pterygium removal did not significantly reduce the recurrence of the pterygium. Conclusion: Topical 0.05% cyclosporine A when used for 10 days before and 10 days after the pterygium removal does not prevent or reduce the recurrence of primary pterygium.

RESUMO Objetivo: Avaliamos os resultados da técnica de rotação de retalho conjuntival com uso de 5-fluorouracil e terapia adjuvante com ciclosporina A tópica a 0,05%, usada no pré e pós-operatório por curto período, quanto à prevenção da recidiva do pterígio primário Métodos: Estudo prospectivo, com 76 pacientes portadores de pterígio primário (76 olhos), divididos em dois grupos: controle com 31 pacientes que não receberam tratamento com ciclosporina e grupo ciclosporina com 45 pacientes que receberam ciclosporina tópica A (0,05%) duas vezes ao dia, por 10 dias antes e 10 dias após a cirurgia de excisão do pterígio. Os pacientes foram avaliados quanto à recorrência, efeitos colaterais e complicações com 10, 21 dias, 2 e 6 meses de pós-operatório. Dados demográficos, doenças sistêmicas e histórico oftalmológico foram coletados de todos os pacientes e esses dados foram analisados por meio de estatística descritiva envolvendo o percentual absoluto e relativo de distribuição de frequência. O teste de Goodman para contrastes entre populações multinomiais foi utilizado para o estudo da associação entre a ciclosporina A e a recorrência Resultados: A maioria dos pacientes tinha entre 30 e 60 anos e 67,1% eram mulheres. Confirmamos uma maior recorrência em pacientes com exposição ocupacional ao sol. A ciclosporina A tópica utilizada 10 dias antes e 10 dias após a remoção do pterígio não reduziu significativamente a sua recorrência Conclusão: A ciclosporina A tópica a 0,05% quando utilizada por 10 dias no pré e 10 dias no pós-operatório, não previne ou reduz a recidiva do pterígio primário significativamente.

Topical cyclosporine A 0.05% before and after surgery to prevent pterygium recurrence.

PURPOSE: We evaluated the role of the conjunctival flap rotation technique using 5-fluorouracil and adjuvant therapy with topical cyclosporine A at 0.05% during short pre- and postoperative periods for the prevention of primary pterygium recurrence. METHODS: In this prospective study, 76 patients with primary pterygium (76 eyes) were categorized into two groups: the control group with 31 patients who did not receive cyclosporine treatment, and the cyclosporine group with 45 patients who received topical cyclosporine A (0.05%) twice a day, for 10 days before and 10 days after the pterygium excision operations. Patients were examined for disease recurrence, side effects, and complications at 10 and 21 days, and at 2 and 6 months after the operation. Data on demography, systemic diseases, and ophthalmologic histories were obtained from all patients, and these data were analyzed using descriptive statistics involving the absolute and relative percentages of frequency distribution. Goodman test was used for contrasts among multinomial populations to study the association between cyclosporine A and recurrence. RESULTS: Most patients were between 30 and 60 years of age, and 67.1% were women. We confirmed a higher recurrence in patients with occupational sunlight exposure. The cyclosporine A used topically 10 days before and 10 days after the pterygium removal did not significantly reduce the recurrence of the pterygium. CONCLUSION: Topical 0.05% cyclosporine A when used for 10 days before and 10 days after the pterygium removal does not prevent or reduce the recurrence of primary pterygium.

Bromfenac Inhibits TGF-ß1-Induced Fibrotic Effects in Human Pterygium and Conjunctival Fibroblasts.

Purpose: Nonsteroidal anti-inflammatory drugs (NSAIDs) have shown antifibrotic effects on several diseases. The aims of the present in vitro study were to investigate the antifibrotic effects of bromfenac (a kind of NSAID) on primary human pterygium fibroblasts (HPFs) and primary human conjunctival fibroblasts (HConFs), as well as to explore the possible mechanisms of these effects. Methods: The cells used in this study were primary HPFs and HConFs, and profibrotic activation was induced by transforming growth factor-beta1 (TGF-ß1). Western blot, quantitative real-time PCR, and immunofluorescence (IF) assays were used to detect the effects of TGF-ß1 and bromfenac on the synthesis of fibronectin (FN), type III collagen (COL3), and alpha-smooth muscle actin (α-SMA) in HPFs and HConFs; the changes of signaling pathways were detected by Western blot; cell migration ability was detected by wound healing assay; cell proliferation ability was detected by CCK-8 assay; and pharmaceutical inhibitions of the downstream signaling pathways of TGF-ß1 were used to assess their possible associations with the effects of bromfenac. Results: Bromfenac suppressed the TGF-ß1-induced protein expression of FN (0.59 ± 0.07 folds, P = 0.008), COL3 (0.48 ± 0.08 folds, P = 0.001), and α-SMA (0.61 ± 0.03 folds, P = 0.008) in HPFs. Bromfenac also attenuated TGF-ß1-induced cell migration (0.30 ± 0.07 folds, P < 0.001), cell proliferation (0.64 ± 0.03 folds, P = 0.002) and the expression levels of p-AKT (0.66 ± 0.08 folds, P = 0.032), p-ERK1/2 (0.69 ± 0.11 folds, P = 0.003), and p-GSK-3ß-S9 (0.65 ± 0.10 folds, P = 0.002) in HPFs. PI3K/AKT inhibitor (wortmannin) and MEK/ERK inhibitor (U0126) reduced the TGF-ß1-induced synthesis of FN, COL3, and α-SMA in HPFs. All the results were similar in HConFs. Conclusions: Bromfenac protects against TGF-ß1-induced synthesis of FN, α-SMA, and COL3 in HPFs and HConFs at least in part by inactivating the AKT and ERK pathways.

Bayesian multivariate meta-analysis of multiple factors.

In medical sciences, a disease condition is typically associated with multiple risk and protective factors. Although many studies report results of multiple factors, nearly all meta-analyses separately synthesize the association between each factor and the disease condition of interest. The collected studies usually report different subsets of factors, and the results from separate analyses on multiple factors may not be comparable because each analysis may use different subpopulation. This may impact on selecting most important factors to design a multifactor intervention program. This article proposes a new concept, multivariate meta-analysis of multiple factors (MVMA-MF), to synthesize all available factors simultaneously. By borrowing information across factors, MVMA-MF can improve statistical efficiency and reduce biases compared with separate analyses when factors were missing not at random. As within-study correlations between factors are commonly unavailable from published articles, we use a Bayesian hybrid model to perform MVMA-MF, which effectively accounts for both within- and between-study correlations. The performance of MVMA-MF and the conventional methods are compared using simulations and an application to a pterygium dataset consisting of 29 studies on 8 risk factors.

Amniotic Membrane Grafts to Reduce Pterygium Recurrence.

PURPOSE: To demonstrate the long-term outcome of pterygium surgery with adjunctive amniotic membrane transplantation (AMT) and intraoperative mitomycin C (MMC) in a large case series. METHODS: Medical records were retrieved for this noncomparative retrospective study of all patients who had pterygium excision with adjunctive AMT and intraoperative MMC, from October 2010 to June 2016 with at least 6 months of follow-up. RESULTS: There were a total of 556 eyes of 535 patients (291 males and 244 females) with average age of 51.9 ± 13 years who had pterygium excision (527 primary and 29 recurrent). For an average follow-up period of 17.3 ± 0.8 months (range 6-74 months), corneal recurrence occurred in 20 eyes (3.6%) and conjunctival recurrence in 12 (2.2%) in a total of 32 eyes (5.8%). Eleven eyes (2%) underwent reoperation. Other complications included granuloma (0.5%), diplopia (1.1%), and steroid-induced ocular hypertension (4.3%). CONCLUSIONS: Adjunctive use of AMT and short exposure of MMC can reduce recurrence after pterygium surgery. The procedure is less tedious and less time consuming, resulting in early recovery while saving the conjunctiva for future surgeries.

Low recurrence rate of anchored conjunctival rotation flap technique in pterygium surgery.

BACKGROUND: To report the recurrence rate for an anchored conjunctival rotation flap technique in primary pterygium surgery. METHODS: Primary pterygium surgeries performed using anchored conjunctival rotation flap techniques (110 eyes in 110 patients) with a minimum follow-up of 12 months were reviewed. In this technique, a conjunctival flap is rotated to cover the bare sclera and suture-fixated with either 8-0 polyglactin (41 eyes) or 10-0 nylon (69 eyes). The recurrence rate was determined, and the two suture materials utilized were compared. RESULTS: The recurrence rate was 2.71% (3 cases in 110 eyes) when an anchored conjunctival rotation flap technique was used and patients were monitored for 26.40 ± 17.09 months. Interestingly, the recurrences were only observed in polyglactin-sutured eyes. No recurrence was detected in nylon-sutured eyes. No other complications were observed in either group. CONCLUSIONS: The anchored conjunctival rotation flap technique for pterygium surgery has a relatively low recurrence rate. Nylon suture-fixation of the flap was found to be superior to polyglactin suture-fixation in preventing recurrence.

Fibrin glue versus sutures for conjunctival autografting in primary pterygium surgery.

BACKGROUND: Pterygium, a growth of the conjunctiva over the cornea, is a progressive disease leading in advanced stages to visual impairment, restriction of ocular motility, chronic inflammation and cosmetic concerns. Surgical removal is the treatment of choice, but recurrence can be a problem. Currently the best surgical option in terms of recurrence is conjunctival autograft. To date the most common surgical methods of attaching conjunctival autografts to the sclera are through suturing or fibrin glue. Each method presents its own advantages and disadvantages. Sutures require considerable skill from the surgeon and can be associated with a prolonged operation time, postoperative discomfort and suture-related complications, whereas fibrin glue may give a decreased operation time, improve postoperative comfort and avoid suture-related problems. OBJECTIVES: To assess the effectiveness of fibrin glue compared to sutures in conjunctival autografting for the surgical treatment of pterygium. SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 9), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to October 2016), Embase (January 1980 to October 2016), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov), and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 14 October 2016. SELECTION CRITERIA: We included randomised controlled trials (RCTs) in any setting where fibrin glue was compared with sutures to treat people with pterygium. DATA COLLECTION AND ANALYSIS: Two review authors independently screened the search results, assessed trial quality, and extracted data using standard methodological procedures expected by Cochrane. Our primary outcome was recurrence of pterygium defined as any re-growth of tissue from the area of excision across the limbus onto the cornea. The secondary outcomes were surgical time and complication rate. We graded the certainty of the evidence using GRADE. MAIN RESULTS: We included 14 RCTs conducted in Brazil, China, Egypt, India, Malaysia, New Zealand, Philippines, Saudi Arabia, Sweden and Turkey. The trials were published between 2004 and 2016, and were assessed as a mixture of unclear and low risk of bias with three studies at high risk of attrition bias. Only adults were enrolled in these studies.Using fibrin glue for the conjunctival autograft may result in less recurrence of pterygium compared with using sutures (risk ratio (RR) 0.47, 95% CI 0.27 to 0.82, 762 eyes, 12 RCTs; low-certainty evidence). If pterygium recurs after approximately 10 in every 100 surgeries with sutures, then using fibrin glue may result in approximately 5 fewer cases of recurrence in every 100 surgeries (95% CI 2 fewer to 7 fewer cases). Using fibrin glue may lead to more complications compared with sutures (RR 1.92; 95% CI 1.22 to 3.02, 11 RCTs, 673 eyes, low-certainty evidence). The most common complications reported were: graft dehiscence, graft retraction and granuloma. On average using fibrin glue may mean that surgery is quicker compared with suturing (mean difference (MD) -17.01 minutes 95% CI -20.56 to -13.46), 9 RCTs, 614 eyes, low-certainty evidence). AUTHORS' CONCLUSIONS: The meta-analyses, conducted on people with pterygium in a hospital or outpatient setting, show fibrin glue may result in less recurrence and may take less time than sutures for fixing the conjunctival graft in place during pterygium surgery. There was low-certainty evidence to suggest a higher proportion of complications in the fibrin glue group.

APR-246/PRIMA-1Met Inhibits and Reverses Squamous Metaplasia in Human Conjunctival Epithelium.

PURPOSE: Squamous metaplasia is a common pathologic condition in ocular surface diseases for which there is no therapeutic medication in clinic. In this study, we investigated the effect of a small molecule, APR-246/PRIMA-1(Met), on squamous metaplasia in human conjunctival epithelium. METHODS: Human conjunctival explants were cultured for up to 12 days under airlifting conditions. Epithelial cell differentiation and proliferation were assessed by Cytokeratin 10 (K10), K14, K19, Pax6, MUC5AC, and p63 immunostaining patterns. ß-catenin and TCF-4 immunofluorescent staining and real-time PCR characterized Wnt signaling pathway involvement. Pterygium clinical samples were cultured under airlifting conditions with or without APR-246 for 4 days. p63, K10, ß-catenin, and TCF-4 expression in pterygial epithelium was determined by immunofluorescent staining and real-time PCR. RESULTS: Airlift conjunctival explants resulted in increased stratification and intrastromal epithelial invagination. Such pathology was accompanied by increases in K10, K14, and p63 expression, whereas K19 and Pax6 levels declined when compared to those in freshly isolated tissue. On the other hand, APR-246 reversed all of these declines in K10, K14, and p63 expression. Furthermore, K19 and Pax6 increased along with rises in goblet cell density. These effects of APR-246 were accompanied by near restoration of normal conjunctival epithelial histology. APR-246 also reversed squamous metaplasia in pterygial epithelium that had developed after 4 days in ex vivo culture. CONCLUSIONS: Reductions in squamous metaplasia induced by APR-246 suggest it may provide a novel therapeutic approach in different squamous metaplasia-associated ocular surface diseases.

Prevention of recurrent pterygium with topical bevacizumab 0.05% eye drops: a randomized controlled trial.

PURPOSE: We assessed the efficacy and tolerability of topical bevacizumab 0.05% when used as an adjunctive therapy after excision of primary pterygia. METHODS: This randomized double-masked study included 22 patients (22 eyes) with primary pterygia who underwent pterygium surgery with the use of the bare sclera technique. After pterygium excision, 22 patients were randomized to receive the topical bevacizumab 0.05% (12 eyes) or the placebo (10 eyes) with the use of the block of four randomization method. Topical bevacizumab and placebo were applied in the respective groups 4 times daily for 3 months. Follow-up evaluations for recurrence by slit-lamp photography were conducted once monthly. Ocular and systemic adverse events were assessed every 2 weeks during the 3 months of treatment. The slit-lamp photographs were masked and analyzed. The primary and secondary outcomes were the differences in the pterygial recurrence rates between the groups and adverse events at 3 months, respectively. Corneal recurrence was defined as recurrent fibrovascular tissue invading the cornea; conjunctival recurrence was defined as either recurrent vessels or fibrous tissue in the excised area without corneal invasion. FINDINGS: All 22 patients completed follow-up at 3 months after the start of the trial medications. After 3 months of treatment, 1 patient (8.33%) and 3 patients (30.00%) from the bevacizumab and placebo groups, respectively, had a corneal recurrence. No significant (P = 0.293) differences were found between the groups as determined by Fisher's exact test. However, conjunctival and corneal recurrences were found in 4 (33.33%) and 9 (90.00%) patients, respectively, in the bevacizumab and placebo groups, a difference that reached significance (P = 0.01). No significant adverse events developed. IMPLICATIONS: Topical bevacizumab, as an adjunctive treatment after pterygium excision, was well tolerated. The trend for recurrence was lower in the topical bevacizumab group. ClinicalTrials.gov identifier: NCT01311960.

Low Recurrence Rate of Pterygium After Excision With Conjunctival Limbal Autograft: A Retrospective Study With Long-Term Follow-Up.

PURPOSE: Pterygium excision with conjunctival limbal autograft (CLAG) has been used successfully for prevention of pterygium recurrence. However, long-term follow-up data in the literature are lacking regarding CLAG. METHODS: Retrospective chart review and standard statistical analysis were performed. The records of 289 patients who underwent 323 pterygium excision procedures with CLAG, performed by a single surgeon using the same technique between August 1989 and July 2013, were reviewed. Procedures with at least 4 months of follow-up were included in the final analysis. RESULTS: A total of 234 procedures met the inclusion criteria. After a median follow-up of 25.5 months, there were 5 recurrences (2.14%) after pterygium excision with CLAG. Recurrences were observed in 4 of 58 (6.9%) cases with recurrent pterygium and 1 of 178 (0.57%) with primary pterygium. CONCLUSIONS: This study highlights the safety and efficacy of CLAG in preventing the recurrence of primary and recurrent pterygium.

Preoperative Versus Intraoperative Subpterygial Mitomycin C Injection for Prevention of Pterygium Recurrence.

PURPOSE: To evaluate postoperative outcome and recurrence rate after primary pterygium excision using preoperative versus intraoperative subpterygial Mitomycin C (MMC) injection. METHODS: Eighty-three eyes with primary pterygium were divided into 2 groups. Group A (35 eyes) was operated upon with pterygium excision 5 min after subpterygial injection of 0.1 mL 0.015% MMC in the same operative setting. Group B (48 eyes) was operated upon with pterygium excision 1 month after subpterygial injection of the same amount and concentration of MMC as in group A. Pterygium regrowth over the cornea for 1 mm or more was considered as a recurrence. RESULTS: The mean follow-up was 30.66±4.48 months in group A and 29.5±4.3 months in group B. In group A, the reported recurrence rate was 5.7%, while it was 4.2% in group B. No serious postoperative complications were reported. There was no statistically significant difference between both groups regarding the recurrence rate as well as the complication rate. CONCLUSION: Both techniques proved to be effective in reducing the recurrence rate after excision of primary nasal pterygium with minimal postoperative complications, with no need of a second surgery for patients in group A.

Preoperative tranilast as adjunctive therapy to primary pterygium surgery with a 1-year follow-up.

PURPOSE: To determine the efficacy of tranilast as an adjunctive therapy in conjunctival autograft. METHODS: Twenty-nine patients were randomly allocated to the Tranilast Group (n=15) or the Control Group (n=14). The Tranilast Group received a subconjunctival injection of 0.5% tranilast 30 days prior to surgery. Conjunctival autograft was performed in both groups using fibrin sealant and 0.02% subconjunctival mitomycin C at the end of the surgery. After the resection of the pterygium, immunohistochemistry was performed with 100 cells to identify epithelial cells positive for transforming growth factor-ß (TGF-ß). Subjective symptoms were evaluated using a 5-point scale, and the recurrence rate was assessed. RESULTS: Both groups showed improvements in their symptoms and similar clinical results. Compared with the Control Group, the Tranilast Group failed to show a decreased recurrence rate (p=0.59). However, the number of epithelial cells expressing TGF-ß was lower in the Tranilast Group (5 cells; 95% CI: 2.56-13.15; Control Group, 16 cells, 95% CI: 11.53-24.76; p=0.01). Minimal but reversible complications, including glaucoma secondary to corticosteroids and granuloma, occurred during the study. CONCLUSION: Tranilast was effective in decreasing the number of pterygium epithelial cells expressing TGF-ß.

Preoperative tranilast as adjunctive therapy to primary pterygium surgery with a 1-year follow-up / Terapia auxiliar com o tranilast pré-operatório na cirurgia do pterígio primário com um ano de seguimento

Purpose: To determine the efficacy of tranilast as an adjunctive therapy in conjunctival autograft. Methods: Twenty-nine patients were randomly allocated to the Tranilast Group (n=15) or the Control Group (n=14). The Tranilast Group received a subconjunctival injection of 0.5% tranilast 30 days prior to surgery. Conjunctival autograft was performed in both groups using fibrin sealant and 0.02% subconjunctival mitomycin C at the end of the surgery. After the resection of the pterygium, immunohistochemistry was performed with 100 cells to identify epithelial cells positive for transforming growth factor-β (TGF-β). Subjective symptoms were evaluated using a 5-point scale, and the recurrence rate was assessed. Results: Both groups showed improvements in their symptoms and similar clinical results. Compared with the Control Group, the Tranilast Group failed to show a decreased recurrence rate (p=0.59). However, the number of epithelial cells expressing TGF-β was lower in the Tranilast Group (5 cells; 95% CI: 2.56-13.15; Control Group, 16 cells, 95% CI: 11.53-24.76; p=0.01). Minimal but reversible complications, including glaucoma secondary to corticosteroids and granuloma, occurred during the study. Conclusion: Tranilast was effective in decreasing the number of pterygium epithelial cells expressing TGF-β. .

Objetivo: Determinar a eficácia do tranilast, como terapia auxiliar no transplante autólogo de conjuntiva. Métodos: Vinte e nove pacientes foram randomizados em dois grupos: Grupo Tratado (15) e Grupo Controle (14). Trinta dias antes da cirurgia, o Grupo Tratado recebeu uma injeção subconjuntival de tranilast a 0,5%. O transplante autólogo de conjuntiva foi realizado em ambos os grupos, usando-se a cola de fibrina e a mitomicina 0,02% subconjuntival, ao final da cirurgia. Cada paciente foi examinado por 12 meses de acompanhamento. A imuno-histoquímica foi realizada, mediante um total de 100 células, a fim de que se contassem as células epiteliais positivas, para o fator de crescimento transformador beta (TGF-β), após a cirurgia do pterígio. Os sintomas subjetivos foram avaliados usando-se uma escala de cinco pontos, e a taxa de recorrência foi avaliada. Resultados: Os 2 grupos apresentaram melhora dos sintomas e com resultados clínicos similares. Quando comparado com o Grupo Controle, o Grupo Tratado falhou em mostrar uma diminuição da taxa de recorrência (p=0,59). Entretanto o número de células epiteliais expressando o TGF-β foi menor no Grupo Tratado (5 células; 95% CI=2,56-13,15; Grupo Controle, 16 células; 95% CI: 11,53-24,76, p=0,01). Complicações mínimas, mas reversíveis, ocorreram durante o estudo, incluindo glaucoma secundário ao uso de corticoide e granuloma. Conclusão: O tranilast foi efetivo em diminuir o número células epiteliais do pterígio expressando o TGF-β. .

Reducing postoperative pterygium recurrence: comparison of free conjunctival auto-graft and conjunctival rotation flap techniques.

OBJECTIVE: To compare the recurrence of pterygium between free conjunctival auto-graft and conjunctival rotation flap following simple surgical excision of pterygium. STUDY DESIGN: Quasi-experimental study. PLACE AND DURATION OF STUDY: Shifa Foundation Community Health Clinic, Shifa College of Medicine, Islamabad, from January to November 2012. METHODOLOGY: Fifty seven cases aged above 18 years, with a pterygium corneal encroachment of ³ 2 mm which was responsible for visual disability or was cosmetically undesirable were recruited for the study and randomly assigned to conjunctival auto-graft group and conjunctival rotation flap group. Cases with a history of glaucoma or glaucoma suspect, prior pterygium surgery, pterygium with concurrent ocular surface and lid disease, conjunctival inflammation and scarring, pseudo-pterygium or collagen vascular disease were excluded. After simple pterygium excision conjunctival auto-graft group (n=26) cases received a free conjunctival flap was transplanted, while conjunctival rotation flap group (n=31) cases received a conjunctival rotation flap. All cases were followed-up for 6 months after surgery for recurrence and complications. Frequency distribution and significance of association of recurrence using Fisher's exact test and Mann-Whitney U-test was carried out using Statistical Package for Social Sciences (SPSS) version 20. RESULTS: The median (and inter-quartile range) age and surgery duration in conjunctival auto-graft group and conjunctival rotation flap group were 60 (51.50-63.00) and 57 (45.00-60.00) years, 28.50 (27.00-30.50) and 16.00 (15.00-17.00) minutes respectively. Recurrence was seen in 2 (7.96%) and 3 (9.76%) cases in auto-graft and rotation flap groups respectively. No significant difference was seen in postoperative complications between the two groups (p=0.60). CONCLUSION: The surgical time for conjunctival rotation flap procedure is less as compared to free auto-graft, while their recurrence and complications are comparable.

Subconjunctival bevacizumab in the impending recurrent pterygia.

The aim of this study is to evaluate the efficacy and safety of subconjunctival bevacizumab injection(s) in the treatment of impending recurrent pterygia. Twenty-three eyes of 23 patients who developed impending recurrence after pterygium surgery with conjunctival autografting and were treated with subconjunctival bevacizumab injection(s) (2.5 mg/0.1 mL) were included in the study. Anterior segment photographs were taken prior to and at 1 week, 1, 3 and 6 months after the injection, and at the end of the follow-up period. Image analysis was performed using an image processing and analysis software program. Recurrence rate and complications were recorded. The mean age and follow-up time of the patients were 51.2 ± 6.2 (31-60 years) and 16.8 ± 3.1 (12-22 months), respectively. The average number of injections was 2 ± 0.78 (1-3). Sixteen eyes required re-injection (two injections in nine eyes, three injections in seven eyes), due to progression of vascularization. There were significant differences between size percentage of lesions before injection and at 1 week, 1, 3 and 6 months after the injection (p < 0.05 for all). Corneal recurrence developed in only one patient and no ocular or systemic side-effects of bevacizumab were observed. Repeated injections of bevacizumab may help to prevent the high recurrence rate of residual impending pterygium, due to its adjuvant role in decreasing lesion size, especially in the first year after surgery.

Bevacizumab in the treatment of pterygium: a meta-analysis.

PURPOSE: The aim of this study was to assess the efficacy and safety of bevacizumab in the treatment of pterygium and to mainly explore its effects on recurrence rate and complications. METHODS: We searched MEDLINE, EMBASE, Web of Science, and Cochrane Central Register from the inception to July 2013 for relevant randomized controlled trials that examined bevacizumab therapy for pterygium. Data concerning study design, patient characteristics, treatment, and outcomes were extracted. The methodological quality of the studies included was assessed using the Jadad score. Relative risk (RR) was calculated for recurrence rate and complications. RESULTS: A total of 474 patients with 482 eyes in 9 randomized controlled trials were analyzed. The pooled estimate showed that bevacizumab had no statistically significant effect on preventing pterygium recurrence [RR 0.90, 95% confidence interval (CI) 0.77-1.07, P = 0.23]. None of the subgroup analyses yielded significant results in favor of bevacizumab (surgery group: RR 0.77, 95% CI 0.50-1.18, P = 0.23; nonsurgery group: RR 0.98, 95% CI 0.86-1.11, P = 0.76; primary pterygium group: RR 0.82, 95% CI 0.53-1.26, P = 0.36; recurrent pterygium group: RR 0.95, 95% CI 0.82-1.09, P = 0.44). There were no statistically significant differences in the complications between the 2 groups (RR 1.00, 95% CI 0.73-1.37, P = 1.00). However, the bevacizumab group was associated with a higher risk of developing subconjunctival hemorrhage (RR 3.34, 95% CI 1.07-10.43, P = 0.04). CONCLUSIONS: Topical or subconjunctival bevacizumab was relatively safe and well tolerated, but it had no statistically significant effect on preventing pterygium recurrence. A large-scale trial with a suitable dosage and a longer follow-up would be required to rule out the possibility of any treatment benefit.

Superior versus inferior conjunctival autografts combined with fibrin glue in the management of primary pterygia.

PURPOSE: To compare the outcomes of superior versus inferior conjunctival autograft (CAU) in the prevention of recurrence after performing a pterygium surgery in patients with primary pterygia. METHODS: This was a prospective randomized study of 60 eyes of 60 patients with primary pterygium. All the eyes underwent pterygium excision and were assigned randomly to receive either superior (30 eyes) or inferior (30 eyes) CAU. All grafts were attached with fibrin glue. The patients were followed up on postoperative day 1, day 7, 1 month, 3 months, and 6 months. RESULTS: Outcome measures included rate of recurrence, mean surgical time, visual analog scale pain score, and amount of pain medication required in the first postoperative week. The mean surgical time, visual analog scale pain score, and amount of pain medication required in both groups were not statistically different. A follow-up of at least 6 months (mean 5.5 ± 1.1 months) was achieved in 49 eyes of 49 patients (24 eyes in the superior CAU group and 25 eyes in the inferior CAU group). One eye in the superior CAU group (4.2%) and 1 eye in the inferior CAU group (4.0%) developed pterygium recurrence. There was no statistically significant difference in the recurrence rates between the 2 groups. In the inferior CAU group, mild localized donor site scarring was noted in 2 patients (8.3%). CONCLUSIONS: Pterygium excision with superior or inferior CAU secured with fibrin glue is safe and effective. There was no significant difference in surgical time, pain, and recurrence rates of pterygium after excision with superior or inferior CAU.

Intra-operative use of 5-Fluorouracil in pterygium surgery: a comparative study.

PURPOSE: Evaluate the efficacy and safety of intraoperative application of 5-Fluorourail in pterygium surgery and the recurrent pterigyum postoperative. MATERIALS AND METHODS: 240 eyes of 120 patients with bilateral primary pterygium were operated. One hundred twenty eyes had 5-FLU (25 mg/ml) applied intraoperatively on a sponge for five minutes. One hundred twenty contralateral eyes served as controls. RESULTS: After a follow-up of 90 days, 7 (5.83%) recurrences of the eyes which had 5-FLU applied intraoperatively were observed. In the control eyes, 25 (25.5%) recurrences were observed. Complications such as keratitis and lid edema were common in both groups. CONCLUSION: This study suggests that antifibroproliferative therapy with intraoperative sponge 5-FLU is effective and safe. Its use may be a useful adjunct in primary pterygium surgery.