Novelsuturelesstechniqueforpterygiumandcysts 窑ClinicalResearch窑 Novel sutureless transplantation for primary pterygiumassociatedwithcysts

Foundationitems: SupportedbyGrantsfromTheNationalHigh ·KEYWORDS:sutureless;;cyst;AMT;CAT TechnologyResearchofChina(No.2006AA02A131);National DOI:10.3980/j.issn.2222-3959.2011.03.14 NaturalScienceFoundationofChina (No.30572001andNo. 30700926);HealthDepartmentFoundationofJiangxiProvince(No. 20091069);TechnologyFoundationofNanchangUniversity,China ShaoY,ZhouX,YuY,PeiCG,ZhouQ,LiJ,YangL,DongWJ,Yi (38) JL.Novelsuturelesstransplantationforprimarypterygiumassociated 1DepartmentofOphthalmology,theFirstAffiliatedHospitalof withcysts. 2011;4(3):280-283 NanchangUniversity,Nanchang330006,JiangxiProvince,China 2DepartmentofScienceeducation,theFirstAffiliatedHospitalof INTRODUCTION NanchangUniversity,Nanchang330006,JiangxiProvince,China pterygiumisafleshy,triangular-shapedgrowthof 3DepartmentofEndocrinology,theThirdHospitalofNanchang,the A bulbarconjunctivalepitheliumandhypertrophied AffiliatedNanchangHospitalofSouthernMedicalUniversity, subconjunctivalconnectivetissueinthemedialandlateral Nanchang330009,JiangxiProvince,China palpebralfissureencroachingontothecornea.Pterygium 4LaboratoryofNeurobiology,UniversityofCalifornia·Irvine,Irvine, occursin0.3%-29%.Surgicalinterventionisregardedasthe California92697,USA first-linetreatmentandtherecurrencerateforsurgeryare Correspondenceto: YiShao.DepartmentofOphthalmology,the FirstAffiliatedHospitalofNanchangUniversity,Nanchang between24%and89%.Untilnow,corneal/conjunctival 330006,JiangxiProvince,[email protected] cystsarenotuncommonandmayoccurspontaneouslyor Received:2011-03-29Accepted:2011-04-27 followingsub-tenon'sinjectionofanestheticagents [1], penetratingtrauma[2],cicatricialocularinflammations[3],vernal Abstract [4],strabismussurgery [5],vitreoretinal surgery [6,7],scleraltunnelphacoemulsification [8],Stevens- · AIM:Toevaluatetheefficacyandsafetyofanovel Johnsonsyndrome [9] andsebaceousglandduct[10].Suturingis suturelessAMT(amnioticmembranetransplantation)orCAT (conjunctivolimbalautografttransplantation)usingfibringlue atimeconsumingtaskandsutureinducedirritationand forreconstructingcorneoconjunctivalsurfacesforprimary rednessare frequent problems.Postoperative wound pterygiumassociatedwithcysts. infectionandcornealgraftrejectionareexamplesofpossible suturerelatedcomplications.Anidealsutureisonewhichis ·METHODS:Aprospectivedescriptivestudywasmadeof easytohandle,non-allergenic,affordableanddoesnot theperiod1January2006-1May2009.Ninepatientswith primarypterygiumassociatedwithcystsunderwent promoteinfection.Fibringlueisabiologicaltissueadhesive pterygiumandcystexcisionfollowedbysuturelessAMTor whichimitatesthefinalstagesofthecoagulationcascade CATusingfibringlue. whenasolutionofhumanfibrinogenisactivatedby ·RESULTS:Duringameanfollow-upof8.00± 0.67months, thrombin(thetwocomponentsoffibringlue)andisa alleyesmaintainedasmoothandstablecornealepithelial blood-derivedproductthatisabsorbable,relativelyeasyto surfacewithoutrecurrenterosionorpersistentepithelial use,andcanbekeptatroomtemperatureorinarefrigerator. defect.Thelimbaldonorsiteshowedthepresenceofmild Itcanbepreparedatabloodtransfusioncenterorfrom depressionswithouttheformationofpseudopterygium.All patientsownbloodorobtainedasacommerciallyavailable eyeshavegoodtearsecretionfunction,tearfilmstabilityand preparation.Whenitisderivedfromindividualvolunteer ocularmotility. donations,itmayhavealowconcentrationoffibrinogen. ·CONCLUSION:Suturelesstransplantationusingfibringlue Fibringlueformsasmoothsealalongtheentirelengthofthe issafeandeffectiveforrestoringastablecorneoconjunctival woundedgeandtherebyprovidesgreaterpostoperative epitheliuminprimarypterygiumassociatedwithcysts. comforttothepatientwithfewercomplications.Untilnow, 280 陨灶贼允韵责澡贼澡葬造皂燥造熏灾燥造援 4熏晕燥援 3熏 Jun.18, 圆园11 www.IJO.cn 栽藻造押8629原愿圆圆源缘员苑圆 8629-83085628 耘皂葬蚤造押陨允韵援圆园园园岳员远猿援糟燥皂 fibringlueisbeingusedforlidsurgery,conjunctivalclosure possibletoavoidinjuringtheunderlyingcornealstroma. followingpterygiumandstrabismus surgery,lamellar Then,superficialkeratectomywasperformedbyblunt cornealgrafting,fornicealreconstructionsurgery,amniotic dissectionoffibrovasculartissue fromtheunderlying membranetransplantation,closureofcornealperforations cornealstromawithoutdamagingthesurroundinghealthy anddescematocelesmanagementofconjunctivalwound limbaltissuesandthemedialrectusmuscle.Afterappling leaksaftertrabeculectomy,adnexalsurgeryandasa fibringlue(mixtureoffibrinogenandthrombin,Baxter,Inc, hemostattominimisebleeding.Inthisstudy,ninepatients Irvine,CA,USA)ondrydenudedwoundsurface,theAMor whohadrapidlydevelopedacystsoverhispterygiumwere ATwasflippedonthecorneal,limbalorconjunctivaledges. described.Becauseofthisparticularassociation,thecysts Aftersurgery,patientsweretreatedwithtopical10g/L alsoinvolvedthecorneaandcausedsignificantastigmatism. prednisoloneacetatefourtimesadayand3g/Lofloxacin Therearethreepatternsofpterygiumwithcystsinourstudy. threetimesaday.Thepatientswerefollowedforatleastsix Tothebestofourknowledge,therehavebeennoreports monthsaftersurgery.Inordertoassessthesafetyofthis about primary pterygium with cyststreatment using procedure,eachpreoperativeorpostoperativevisitincluded suturelessmethods.Therefore,weprospectivelyreviewed completeophthalmicevaluationwithclinical and ourresultsofamnioticmembrane(AM)orconjunctivolimbal photographicdocumentationofcornealre-epithelialization, autograft (CA)transplantationusingfibringlueinpatients stromalvascularizationandcloudiness,dissolutionofAMor withprimarypterygiumassociatedwithcysts. CA,andpotentialcomplications.Successfuloutcomewas MATERIALSANDMETHODS definedbasedontherecoveryofastablecornealepithelium, Materials Thepatientsenrolledinthestudywere thelackoflatefluoresceinstaining,andadecreaseof consecutivelyreferred for examinationat Zhongshan corneal stromalneovascularizationand cloudiness. OphthalmicCenterfrom1January2006through1May Recurrencewasdefinedasanygrowthoffibrovascular 2009.Clinicaldatawereabstractedfromthemedical tissueintothecorneabyslitlampexamination.Aslit-lamp records,includingdiagnosisandpre-andpost-operative examinationwasperformedateveryvisittomonitor ocularalignment(Table1).Ninepatientswereoperatedon autograft-bed integrityanddevelopment ofpossible byonesurgeonandconsecutivelyoperatedwithAMTor complications.Thesurgicaloutcomewasdeterminedbya CATbyfibringlue,Diagnosisofprimarypterygium maskedreaderbasedonthephotographicdocumentation. associatedwithcystswasmadeclinicallybythepresenceof Moreover,the followingtestswereperformed:tear cornealpannus,corneaastigmatism,andlateslitlamp fluoresceinbreakuptime(TFBUT,seconds),Schirmer'sI examination.Theinvadeareaincludedamean2.32 0.78cm test(mm/5minutes),healingtimeandocularmotility. 依 (range,1to4mm)andameaninvadeareaof10.6% 2.8% StatisticalAnalysis Summarydatawerereportedasmean 依 依 (range,5%to30%)oftheentirecornealarea. SD.SPSS15.0statisticalsoftwarewasusedfordata Methods Thiswasaprospectiveinterventionalstudy, analysis.Inthisstudy, <0.05hasbeenconsideredas performedwithInstitutionalReviewBoardapproval.The statisticallysignificant. studywasalsoapprovedbytheethicalCommitteefor RESULTS HumanResearchofNanchangUniversity.andZhongshan Therearethreepatternslocationofcystpatientsinthis University.Informedconsentwasobtainedfromallpatients. study:nasalside,temporalsideandbothsides.Nineeyesof Amnioticmembranetissuewasobtained,processedwiththe ninepatientsunderwentsuperficialkeratectomyandcyst basement-membranesideup,andplacedonacultureplate excisionwithAMTorCATusingfibringluewithout andincubatedat37℃ inanatmosphereof5mL/LCO2 and complications.Duringameanfollow-upof8.00 0.67 依 95mL/Lairovernightbeforetheywereused.Thedonorgraft months(range,sixtoninemonths),alleyesachieved atsuperiorlimbuswasexcisedwithanadditional1.0mmof successfuloutcomesbyregainingasmoothandstable lengthandwidthrelativetothedimensionsofthegraftbed. cornealepithelialsurfacewithoutrecurrenterosionor Byuse of minimalmanipulationwithatraumatic persistentepithelialdefect,andbyshowinglessstromal conjunctivalforcepsandVannasscissors,theconjunctiva cloudinessandvascularization. withpalisadesofVogtwascarefullydissectedawayfrom Alleyesthatreceivedpterygiumandcystexcisionand theTenon'scapsule.Beforesurgery,risksandbenefitsof ocularreconstructiondidnotexperienceanyrecurrenceat surgeryandalternativetreatmentswerediscussedindetail thefinalexamination(Table2).Accompaniedbythe withthepatientsandtheirwrittenconsentsorassentswere improvementmadeonthecornealsurfacewasimproved obtained.Aftertopicalanesthesiaandvasoconstriction,the best-correctedvisualacuityinalleyes(100%)(Table1). headofthepterygiumandcystwasremovedasbluntlyas Immediatelyaftersurgery,AMorCAwascompletely 281 Novelsuturelesstechniqueforpterygiumandcysts

Table 1 Characteristics of patients with primary pterygium associated with cysts No/Sex// IA PC CC Visual acuity Objective Visual SOMR Side CS(mm) Age, y (mm) (yr) (mo) Preoperative final refraction field (preoperatively) 1/M/L/77 TS 4 2 4×3×2 1/2 0.25 0.4 3.50-2.50×1800 N Yes 2/F/R/53 NS 1.5 53 3×3×2 12 1.0 1.0 0.50-1.50×1800 ND Yes 3/M/R/51 NS 2 20 3×3×2 2 0.8 1.0 1.50-1.20×1600 N No 4/M/R/44 TS 3 1 2×3×1 3 0.8 0.8 0.50-0.75×1200 N No 5/ M/R/76 NS 1 4 2×2×1 1 0.6 0.8 -1.00×1050 N No 6/M/L/74 NS 3.5 1 1.5×1.5×1 1 0.6 0.8 2.50-4.50×1700 N No 7/M/R/17 NS,TS 3 1 2×1.5×1 6 1.0 1.0 0.50-2.25×1750 ND No 8/M/L/58 TS 3 1 3×2×1 1/4 0.8 0.8 N N No 9/M/L/9 NS 3.5 2 3×3×1 1 1.0 1.0 N ND No CC: Cyst course; CS: Cyst size; IA: Invade area; lTx, lamellar keratoplasty (performed before the study); N: Normal. ND: Not done; NS: Nasal side; PC: Pterygium course; TS: Temporal side; SOMR: Severe ocular motility restriction

Table 2 Ocular surface condition of patients with primary pterygium associated with cysts No. Previous Follow-up HT TFBUT STⅠ Surgery Surgery (mo) (d) P FA (mm) 1 AMT Dry eye, 10 7 6 10 6 2 No CAT Astigmatism 9 6 8 14 11 3 No CAT Astigmatism 9 7 9 15 12 4 No CAT Astigmatism 8 6 10 16 15 5 No AMT Astigmatism 8 7 7 16 10 6 Cataract AMT Astigmatism 8 5 8 15 11 7 No CAT Astigmatism 8 5 7 13 10 8 No AMT No 6 7 9 16 12 9 No CAT No 6 7 8 15 11 FA: Final exam; HT: Healing time; P: Preoperative; SOMR: Severe ocular motility restriction; STⅠ: Schirmer TestⅠ securedontotheocularsurfaceinalleyes.Afterthefinal Moreover,aprolongedoperativetimeandtechnicalskillare follow-up,alleyeshavegoodtearsecretionfunction,tear needed.Suturescannotonlycausepostoperativepainand filmstabilityandocularmotility(Table2). discomfort [11],butalsocanbeassociatedwithsuture-related DISCUSSION complications [12].Althoughcornealcontactlensgluinghas Ourstudy,forthefirsttime,demonstratedthatsutureless notbeenwidelyusedbutithasbeenshowntoreduce AMTorCATusingfibringluecanbeusedasthenovelty neutrophilinfiltration,whichmay contributeto tissue therapymethodforpterygiumassociatedwithcysts.Most damage [13-15].Toavoidsuture-relateddisadvantagesand cystsremainsmallandasymptomaticbutoccasionallythey complications,inour study,wedevisedasutureless mayreachlargeproportionsandcausesignificantcorneal transplantationtechniquewiththeappropriateamountof astigmatism,foreignbodysensation，exposurekeratitisand fibringlue.OurstudyshowsthatthisAMTorCATisasafe visualimpairment.Inourstudy,thesizeofthecystswas andusefultechniqueforclinicaluse,providingadistinct correspondingwiththesizeoftheheadofpterygium. advantageoversuturetechnique.AMTorCATusingfibrin Mechanicalfrictionbypterygiumandbulbarconjunctival gluecanfacilitaterapidepithelializationandrestoredocular mayplaythekeyeffectonthedevelopmentofthecysts.The surfacesstabilityinnineeyeswithprimarypterygium epitheliumproliferatesandgivesrisetoacavitywithfluid associatedwithcysts.Duringthefollow-up,theunderlying andremainsofcell flakingandinflammatorycells. stromashowedlessvascularizationandscarring. Preventingpterygiumandcystrecurrenceisthemain Inthisstudy,wehavefoundthatsuturelesstransplantation concernofsurgery.Thecurrentmajormethodstoprevent usingfibringluecaninhibitsub-AMorsub-CAfibrosis,and recurrenceincludeuseofMMC,conjunctivalautografting, isaneffectivesurgicalprocedurefortreatingpatientswith andamnioticmembranegrafting.AMorCAisusually pterygiumassociatedwithcystsafterexcisionsurgery.We suturedontotheocularsurfaceusing10-0nylonsuturesto introducethisnewtechniqueandhighlyrecommenditasan fix [11].Althoughthesuturingmethodmakesforasecure alternativetherapyinthe managementofpterygium attachment,itinflictstrauma totheocularsurface. associatedwithcysts.In conclusion, sutureless

282 陨灶贼允韵责澡贼澡葬造皂燥造熏灾燥造援 4熏晕燥援 3熏 Jun.18, 圆园11 www.IJO.cn 栽藻造押8629原愿圆圆源缘员苑圆 8629-83085628 耘皂葬蚤造押陨允韵援圆园园园岳员远猿援糟燥皂 transplantationusingfibringlueappearstobeasafeand intraoperative0.02%mitomycin-Cfortreatmentofprimarypterygium. effectivemethodofrestoringastablecorneoconjunctival 2007;27(5):281-285 8NarayanappaS,DayanandaS,DakshayiniM,Conjunctivalinclusioncysts epitheliumforcaseswithprimarypterygiumassociatedwith followingsmallincisioncataractsurgery.GangasagaraSB,PrabhakaranVC. cysts.Furtherstudiesarenecessarytoevaluatethelong-term 2010;58(5):423-425 recoveryofthissurgerymethodandtheeffectinalarge 9SinghG,RajaramanR,RaghavanA,PalanisamyM.Bilateralconjunctival quantityinpatientswithpterygiumassociatedwithcysts. retentioncystsintheaftermathofStevens-Johnsonsyndrome. REFERENCES 2008;56(1):70-72 1VishwanathMR,JainA.Conjunctivalinclusioncystfollowingsub-Tenon'slocal 10JakobiecFA,MehtaM,GreensteinSH,ColbyK.Thewhitecaruncle:signofa anaestheticinjection. 2005;95:825-826 keratinouscystarisingfromasebaceousglandduct. 2010;29(4):453-455 2PillingRF,KhanA,BallJL.Theutilityofanteriorsegmentopticalcoherence 11OzkurtYB,KocamsO,ComezAT,UsluB,DoganOK.Treatmentofprimary tomographyinmonitoringintraocularepithelialcystsinchildren:aminicase pterygium. 2009;86(10):1178-1181 series. 2010;94(9):1265 12KoranyiG,ArtzénD,SeregardS,KoppED.IntraoperativemitomycinC 3MemarzadehF,ChuckRS,McCulleyTJ.Fornixreconstructionwithconjunctival versusautologousconjunctivalautograftinsurgeryofprimarypterygiumwith inclusioncystmarsupializationinStevens-Johnsonsyndrome. four-yearfollow-up.ActaOphthalmol2010May28.doi:10.1111/j.1755- 2006;22:475-476 3768.2010.01936.x. 4LeeSW,LeeSC,JinKH.Conjunctivalinclusioncystsinlong-standingchronic 13PandaA,KumarS,KumarA,BansalR,BhartiyaS.Fibringluein vernalkeratoconjunctivitis. 2007;21:251-254 . 2009;57(5):371-379 5BhattPR,RamaeshK.Intrastromalcorneallimbalepithelialimplantationcyst. 14PanHW,ZhongJX,JingCX.ComparisonofFibrinGlueversusSuturefor 2007;21(1):133-135 ConjunctivalAutograftinginPterygiumSurgery:AMeta-Analysis. 6Pérez-FloresMI,Ortiz-ReyJA,Antón-BadiolaI,Lorenzo-CarreroJ. 2011Feb1 Conjunctivalinclusioncystafterstrabismussurgerybyhang-backrecession. 15NieuwendaalCP,vanderMeulenIJ,MouritsM,Lapid-GortzakR.Long-term 2006;81:653-656 follow-upofpterygiumsurgeryusingaconjunctivalautograftandTissucol. 7AkinciA,ZileliogluO.Comparisonoflimbal-conjunctivalautograftand 2011;30(1):34-36

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