A Report by the American Academy of Ophthalmology Ophthalmic Technology Assessment Committee Cornea and Anterior Segment Disorders Panel: Stephen C. Kaufman, MD, PhD1; Deborah S. Jacobs MD2; W. Barry Lee, MD3; Sophie X. Deng, MD, PhD4; Mark I. Rosenblatt, MD, PhD5; Roni M. Shtein, MD6
Ophthalmology, January 2013, Vol 120, 201-208 © 2013 by the American Academy of Ophthalmology. Click here for free access to the OTA.
Objective: To assess the outcomes and safety of current surgical options and adjuvants in the treatment of primary and recurrent pterygium.
Methods: Literature searches of the PubMed and the Cochrane Library databases were last conducted in January 2011 using keywords and were restricted to randomized controlled trials reporting on surgical intervention for pterygium. The searches were limited to articles published in English and yielded 120 citations. Citation abstracts, and if necessary the full text, were reviewed to identify randomized controlled trials that reported recurrence as an outcome measure and had a mean follow-up of at least 6 months. Fifty-one studies comparing bare sclera excision, conjunctival or limbal autograft, intraoperative mitomycin C, postoperative mitomycin C, and amniotic membrane transplantation for primary and recurrent pterygia fit these inclusion criteria.
Results: Four studies demonstrated that the conjunctival or limbal autograft procedure is more efficacious than amniotic membrane placement. Use of conjunctival or limbal autografts or mitomycin C during or after pterygium excision reduced recurrence compared with bare sclera excision alone in most studies of primary or recurrent pterygium. The outcomes of conjunctival or limbal autograft were similar to outcomes for intraoperative mitomycin C in the few studies that directly compared the 2 techniques. There is evidence that increased concentration and duration of exposure to intraoperative mitomycin C is associated with increased efficacy. Of the adjuvants studied, only mitomycin C was associated with vision-threatening complications, including scleral thinning, ulceration, and delayed conjunctival epithelialization; there is some evidence of increasing complications with increased concentration and duration of exposure. There is conflicting evidence as to whether increasing age is protective against recurrence, but the morphologic features of pterygium was shown to affect the recurrence rate.
Conclusions: Evidence indicates that bare sclera excision of pterygium results in a significantly higher recurrence rate than excision accompanied by use of certain adjuvants. Conjunctival or limbal autograft was superior to amniotic membrane graft surgery in reducing the rate of pterygium recurrence. Among other adjuvants, there is evidence that mitomycin C and conjunctival or limbal autografts reduce the recurrence rate after surgical excision of a pterygium. Furthermore, the data indicate that using a combination of conjunctival or limbal autograft with mitomycin C further reduces the recurrence rate after pterygium excision compared to conjunctival or limbal autograft or mitomycin C alone. Additional studies are necessary to determine the long-term effects, optimal route of administration, and dose and duration of treatment for mitomycin C. Factors such as availability of resources, primary or recurrent status of pterygium, age of patient, and surgeon or patient preference may influence the surgeon’s choice of adjuvant because there are insufficient data to recommend a specific adjuvant as superior.
1Department of Ophthalmology, University of Minnesota, Minneapolis, Minnesota.
2Boston Foundation for Sight, Needham, Massachusetts.
3Piedmont Hospital and Eye Consultants of Atlanta, Atlanta, Georgia.
4Jules Stein Eye Institute, University of California, Los Angeles, Los Angeles, California.
5Department of Ophthalmology, Weill Cornell Medical College, New York, New York.
6Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, Michigan.