Sameh Saad Mandour, Hatem M. Marey, Hassan Gamal El Din Farahat, and Hala Mosa Mohamed
Abstract
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.
1
2 MANDOUR ET AL.
All patients of the study had a primary nasal pterygium Table 1. Descriptive Data for Group A and B
encroached on the surface of the cornea with no other ocular
pathology. A comprehensive ophthalmic examination, in- Variable Group A Group B P-value
cluding best-corrected visual acuity testing, slit-lamp ex- Age (years) mean 53.31 11.39 55 10 0.475a
amination, Goldmann applanation tonometry, fundus standard deviation
examination, and examination of ocular motility, was car- Sex 0.925b
ried out for all patients. Consents were taken from all pa- Male 18 24
tients and research was approved by the institutional review Female 17 24
board. All measures were in accordance with the tenets of Extension (mm) mean 3.37 0.74 3.04 10.8 0.123a
the Declaration of Helsinki. standard deviation
Width (mm) mean 4.01 1.12 4.46 1.44 0.128a
standard deviation
Surgical technique Follow-up (months) 30.66 4.48 29.5 4.3 0.237a
Preparation of MMC. Mutamycin (Bristol-Myers- mean standard
Squibb) vial containing 5 mg powder of mitomycin was deviation
reconstituted with 33 mL balanced salt solution to get a a
t-Test.
concentration of 0.15 mg/mL for injection. b
Chi-square test.
The postoperative care and follow-up. Topical com- Table 2. Postoperative Results
and Complications of Group A and B
bined antibioticsteroid eye drops (4 times daily) and ointment
(at bed time) were applied until all signs of inflammation Group A Group B
disappeared for an average of 4 weeks. An eye pad was applied Variable (%) (%) P-value
till complete reepithelialization. Sutures were removed after
healing of the wound or if they became loose. Recurrence 2 (5.7) 2 (4.2) 1.0a
In both groups, patients were examined 1 day postop- Subconjunctival hemorrhage 4 (11.4) 6 (12.5) 1.0a
erative and then after 1 week for evaluation of the healing Conjunctival vascularization 2 (5.7) 2 (4.2) 1.0a
Visual acuity 15 (42.9) 18 (37.5) 0.791b
process and detection of early postoperative complications. improvement 13 lines
Patients were reexamined at 1, 3, 6, 9, and 12 month
a
postoperatively and then every 6 months in the following Fishers exact test.
b
years. During each visit, a complete ophthalmic examina- Chi-square test.
PREVENTION OF PTERYGIUM RECURRENCE 3
showed a recurrence in group B, with a time interval from to lose any patient in our communities. In group A, in the
surgery to recurrence being 5 months in 1 case and 6 current study, we injected MMC in the subpterygial space
months in the other one. There was no statistically sig- 5 min before the bare sclera excision of the primary pter-
nificant difference between the 2 groups regarding the re- ygium and the results were comparable to the 2-stage sur-
currence rate (P = 1.0). gery in our previous work. To our current knowledge, there
Regarding the postoperative complications in group A, is no previous work discussing the role of intraoperative
there was subconjunctival hemorrhage in 4 cases (11.4%). subpterygial MMC injection in recurrence prevention.
There were no patients with delayed epithelial healing, We injected the same concentration and volume of MMC
dellen, or scleral melting. In group B, there was sub- in both groups. Therefore, the only difference between both
conjunctival hemorrhage in 6 cases (12.5%). Conjunctival groups was in the timing of pterygium excision after MMC
vascularization was reported in 2 cases (5.7%) in group A injection, with no statistically significant difference between
and in 2 cases (4.2%) in group B. However, it was away both groups regarding the recurrence rate, which is the main
from the limbus and was not considered as a recurrence. No goal in this work.
serious postoperative complications were reported. We think that MMC diffuses after its subpterygial in-
jection into the nearby conjunctival tissue. Therefore, after
Discussion pterygium excision, MMC persists in sufficient concentra-
tion in the peripterygial conjunctival tissue inhibiting further
MMC is an alkalizing agent and a potent fibroblast inhib- abnormal growth. However, laboratory and histopathologic
itor, which causes irreversible damage to the DNA structures examination of peripterygial conjunctival tissue after some
of the cell. It inhibits both migration of fibroblast and syn- time from surgery is needed to confirm the effect of MMC.
thesis of new collagen and therefore affects wound healing.10 Unfortunately, it is not easy to convince postoperative pa-
12
Subconjunctival MMC is known to decrease the number of tients to take a specimen from their conjunctival tissue in the
stromal fibroblast cells. There is also morphological and vicinity of the removed pterygium. This may be suitable to
structural damage to vascular endothelial cells.8 be done in experimental studies instead. Therefore, we de-
MMC used to be applied topically either intraoperatively pended solely on the clinical bases in determining the effi-
or postoperatively. Topical MMC application at the time of cacy of intraoperative subpterygial MMC injection.
surgery leads to direct contact of MMC with corneal and Moreover, a longer follow-up time is needed in group A to
conjunctival epithelium, which causes persistent corneal or confirm the long-term effect of intraoperative injection of
conjunctival defects. MMC which comes in direct contact MMC on prevention of pterygium recurrence.
with the cornea has a negative effect on corneal endothe- Although the safety of the procedure had been addressed
lium. Postoperative MMC application in the form of eye previously in animal research13 and in human study for
drops has the same adverse events. Moreover, the surgeon treatment of glaucoma,14 ocular cicatricial pemphigoid,15
has to rely on the patient to correctly self-administer a toxic and pterygium,6,16 the issue of safety of local MMC injec-
chemotherapeutic agent at home.1,12 tion is still a matter of concern. In the current study, no
Subpterygial MMC injection has an advantage of more dangerous or sight-threatening complication was found in
precise titration of the drug and its direct delivery to the site any group during the relatively short follow-up period of the
of the pathology with no contact with the corneal surface. study. However, more work is needed to confirm the long-
The drug is applied directly to the activated fibroblasts in the term safety over several years. Until then, surgeons should
subconjunctival space, where it can work directly on the be cautious regarding the dosing and the technique of MMC
cells responsible for the pterygium recurrence without application, and patients should be informed about the im-
damaging the surface epithelium stem cells, that has no role portance of follow-up to detect and treat potential compli-
in pterygium formation or recurrence. This may diminish cations early.
long-term healing difficulties associated with MMC.6 We concluded that both techniques used in the current
Preoperative subpterygial injection of low-dose MMC study proved to be effective in reducing the recurrence
was suggested by Donnenfeld et al.,6 who recorded 6% re- rate after excision of primary nasal pterygium with mini-
currence rate in their series. They injected 0.015% MMC mal complications in the short- and intermediate-term
subconjunctivally 1 month before the bare sclera pterygium postoperatively.
excision in 36 patients with a follow-up of 24 months. We
adopted this technique with the same concentration Author Disclosure Statement
(0.015%) in a previous work and proved it equally effective
as a limbal conjunctival autograft transplantation in pre- No competing financial interests exist.
vention of recurrence.9 Another study used subpterygial
MMC injection 1 month before the pterygium excision, but References
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9. Mandour, S.S., Farahat, H.G., and Mohamed, H.M. Pre-
operative subpterygial mitomycin C injection versus limbal Address correspondence to:
conjunctival autograft transplantation for prevention of Dr. Sameh Saad Mandour
pterygium recurrence. J. Ocul. Pharmacol. Ther. 27:481 Department of Ophthalmology
485, 2011. Menoufia Faculty of Medicine
10. Frucht-Pery, J., Siganos, C.S., and Ilsar, M. Intraoperative 17 El Gendi Street
application of topical mitomycin C for pterygium surgery. Meet Khaqan Road
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821, 1988. E-mail: dr_ssmandour@hotmail.com