Eye (2008) 22, 420–424 & 2008 Nature Publishing Group All rights reserved 0950-222X/08 $30.00 www.nature.com/eye CLINICAL STUDY Transplantation of MR Fallah, MR Golabdar, J Amozadeh, MA Zare, S Moghimi and G Fakhraee conjunctival limbal autograft and amniotic membrane vs mitomycin C and amniotic membrane in treatment of recurrent pterygium Abstract major concern. Recurrence after primary excision varies from 24 to 89%.1 Recurrent Aim: To compare the efficacy and pterygium is more difficult to treat than complications of conjunctival limbal autograft primary pterygium because it is often (CLAU) and amniotic membrane accompanied by increased conjunctival transplantation (AMT) vs intraoperative inflammation and accelerated corneal mitomycin C (MMC) and AMT for treatment involvement.2 of recurrent pterygium. Surgical procedures for treatment of Methods: Forty eyes of 40 patients with pterygium (including recurrent pterygium) recurrent pterygium underwent CLAU and include excision with mitomycin C (MMC), AMT (20 eyes) or intraoperative MMC (0.02%, conjunctival autograft, limbal autograft, 3 min) and AMT (20 eyes). Three eyes (15%) amniotic membrane transplantation, and had symblepharon before surgery in each lamellar keratoplasty.3 group. Recurrence was compared in each Limbal stem cells may play an important Department of group by using v2 test. role in the pathogenesis of pterygium.2 Ophthalmology, Farabi Eye Results: No major postoperative There is a general agreement that the limbal Hospital, Eye Research complications occurred during 6–19 months of Center, Tehran University of stem cells are damaged in the region of follow-up. In CLAU/AMT group, no Medical Science, Tehran, pterygium,4 and therefore limbal autograft can Iran pterygium recurrence was observed. be recommended for pterygium treatment. Recurrence occurred in four eyes (20%) in Shimazaki et al5 treated 27 eyes with recurrent Correspondence: MMC/AMT group after 3 and 4 months pterygium or advanced pterygium with S Moghimi, (P-value ¼ 0.035, v2 test). No recurrence of conjunctival limbal autograft (CLAU) and Farabi Eye Hospital, pterygium or symblepharon was seen in six Eye Research Center, showed a recurrence of 7.4%. This result eyes with recurrent pterygium and Tehran University of Medical indicates that CLAU may be effective for Science, symblepharon (three eyes in each group). treatment of recurrent and advanced Tehran, Iran Conclusion: CLAU with AMT seems to be pterygium.5 Tel: þ 98 215 541 6134; more effective than intraoperative MMC with Amniotic membrane has antiadhesive and Fax: þ 98 215 541 6134. AMT for treatment of recurrent pterygium. E-mail: sasanimii@ anti-inflammatory properties and is felt to Eye (2008) 22, 420–424; doi:10.1038/sj.eye.6702657; yahoo.com decrease inflammation, neovascularization, and published online 8 December 2006 fibrosis, and promote epithelialization.6 Received: 7 April 2006 Recurrent pterygium is a condition in which Accepted in revised form: Keywords: conjunctival limbal autograft; partial stem cell deficiency and inflammation 1 October 2006 amniotic membrane transplantation; mitomycin coexist, and limbal autograft and amniotic Published online: C; recurrent pterygium 8 December 2006 membrane transplantation are expected to be effective. We state that our only Introduction Xi XH et al7 compared AMT and AMT/CLAU interest is academic and we have no financial interest in There are various surgical procedures for in treatment of recurrent pterygium or this publication pterygium; however, recurrence remains a pseudopterygium, and showed lower Stem cell graft in recurrent pterygium MR Fallah et al 421 recurrences in the latter group. Shimazaki et al8 also subjects before surgery. One surgeon performed demonstrated no recurrence in their patients when all operations. treated with AMT and CLAU. MMC use, intraoperatively or postoperatively, is one of Surgical procedure adjunctive treatments that can significantly reduce the rate of pterygium recurrence. Recurrence rates are Preserved human amniotic membrane was obtained reported to be 5.4–21% when MMC is used alone in from a community-based hospital affiliated with Tehran treating primary pterygium.1–10,11 Recurrence rate of University of Medical Sciences. All necessary procedures recurrent pterygium is still as high as 12.5–19.2% in using including inform consent from pregnant donors, MMC alone,12,13 and 12.5–33.3% when using AMT serological tests to rule out hepatitis B, C virus, HIV, alone.13,14 It is therefore expected that there is no single human T-cell lymphotropic virus, processing and and simple method achieving satisfactory results for storage, were performed by the tissue culture unit of the complicated cases, especially in eyes with severe same hospital. Retrobulbar anaesthesia with 2% lidocaine symblepharon and motility restriction. Hence, and bupivacaine 0.25 % (2 : 1) was administered to all a combined approach may be more successful in treating patients before surgery. recurrent advanced pterygium.14,15 In CLAU group, pterygium was completely resected We conducted a study to compare the efficacy and from the cornea and the body of the pterygium was complications of two combined approaches. One dissected and excised with Westcott scissors. Abnormal approach that has no serious complication is to replace scarring tissue on the corneal surface was polished. the damaged stem cells, but it is technically difficult and Minimal cautery was used to control bleeding. Donor may not be possible in all eyes. Another approach is to tissue consisted of corneal–limbal–conjunctival tissue inhibit the proliferation of fibrovascular tissue, which is that was harvested from supra-temporal part of the same technically easy but has rare serious complications eye or fellow eye. Autograft contained 0.5 mm clear (intraoperative MMC). To the best of our knowledge, this cornea, limbus, and 1 mm of the adjacent bulbar study was the first randomized clinical trial study that conjunctiva. The length of autograft was equal to the compared efficacy and complications of these two excised limbus at the pterygium site. A front cutting treatment approaches in the management of recurrent edged calibrated diamond knife was set to 150 mm. The pterygium. knife was used to make a circumferential corneal incision, parallel to limbus, and two radial incisions, extending from either end of circumferential incision to the limbus. An angled beveled blade (crescent knife) was Materials and methods used to dissect the 150 mm of corneal tissue and emerged This study was conducted in accordance with the beyond the limbus, under conjunctiva. Then one declaration of Helsinki Principles. Use of human millimeter of conjunctiva that was attached to the amniotic membrane for surgery and operative procedure corneal–limbal tissue, along the limbal border, was was approved by the ethics committee of Tehran excised. Then, the calibrated diamond knife was set to University of Medical Sciences. 100 mm (an allowance of 50 mm was made for the lack of This study was a prospective randomized controlled epithelium) and a bed was then fashioned at the recipient trial. From April 2004 to July 2005, 40 eyes of site. The donor tissue was sutured into the recipient site 40 patients with recurrent pterygium were randomly with two interrupted 10-0 nylon sutures at either ends of assigned to receive excision of pterygium followed by tissue.16 Bare sclera region was covered with amniotic either CLAU combined with AMT or AMT combined membrane (basement membrane was upside), and then with intraoperative MMC in Farabi Eye Hospital, sutured to adjacent normal bulbar conjunctiva with Tehran, Iran. interrupted 10-0 nylon.6 Sutures of amniotic membrane All patients with recurrent pterygium (number of and corneal limbal tissue were removed 2 and 3 weeks previous surgery Z1), size of pterygium head on the after surgery, respectively. cornea equal or greater than 2 mm and presence of In the second group (AMT with intraoperative MMC indications for pterygium surgery such as ocular 0.02%), procedure was performed as follows: after discomfort refractory to medical treatment or resection of pterygium head and excision of pterygium cosmetic purposes were included. Patients with body, a weak-cell sponge soaked with 0.02% MMC was glaucoma, vitreoretinal disorders, pseudopterygium, placed on the bare sclera for 3 min and then rinsed with connective tissue disorders, systemic vasculitis, normal saline serum for 5 min. The bare sclera was then and diabetes mellitus were excluded from the covered with amniotic membrane (basement membrane study. Informed consent was obtained from all was upside) and sutured to adjacent normal bulbar Eye Stem cell graft in recurrent pterygium MR Fallah et al 422 conjunctiva with interrupted 10-0 nylon.6 Sutures of Epithelial defect of cornea healed within 5 days in all amniotic membrane were removed 2 weeks after surgery. eyes. Four patients in the CLAU/AMT group and three Postoperative treatment consisted of topical patients in the MMC/AMT group showed significant chloramphenicol, topical betamethasone, and artificial oedema of amniotic membrane in the first few tear, 4 times daily for first four weeks. Then postoperative days that spontaneously resolved few betamethasone was changed to fluorometholone, four days later. The donor area in the CLAU/AMT group times daily, for the remaining 2 weeks. All patients were healed without complications in all patients followed up daily until corneal epithelial defect healed, (ie, pseudopterygium or pannus formation). Follow-up 1 week, 2 weeks, 1, 2, 3, 6 months, then every 3 months. ranged from 6 to 19 months. During the follow-up Minimum duration of the follow-up period was period, pterygium did not recur in any eyes in the 6 months. Recurrence was defined as any fibrovascular CLAU/AMT group, but recurred in four eyes (20%) in tissue that extended over the clear cornea (corneal the MMC/AMT group (P-value ¼ 0.035, w2 test). recurrence). In each follow-up visit, patients were Recurrences were seen 3 months postoperatively in two examined for recurrence and any potential postoperative eyes and 4 months postoperatively in two other eyes.