Presenter: Dr. Pavitra K. Patel, Co-authors: Dr. Sachin Daigavane,Dr. Mala Kamble, Department of Ophthalmology, Jawarharlal Nehru Medical College & Acharya Vinoba Bhave Rural Hospital, Sawangi, Wardha.

1. COMPARATIVE STUDY OF
PTERYGIUM EXCISION WITH
CONJUNCTIVAL AUTOGRAFT,WET
AMNIOTIC MEMBRANE GRAFT &
TOPICAL MITOMYCIN C
 Presenter: Dr. Pavitra K. Patel
Co-authors: Dr. Sachin Daigavane,Dr. Mala Kamble
 Department of Ophthalmology, Jawarharlal Nehru
Medical College & Acharya Vinoba Bhave Rural
Hospital, Sawangi, Wardha.

2.  Pterygium was recognized 3000 years ago, it was
described by Susrutha way back in 100 B. C. in India.
 It was also noted by great physicians of ancient times like
Hippocrates, Galen, Celsus etc.
 A Pterygium is a wing shaped growth of fibro vascular
conjunctiva on to the cornea, its incidence varies across
geographical locations.
 Several hypotheses have been ascribed to its aetiology1.
1.Hiwt, L. Distribution, risk factors and epidemiology. In Taylor H. R. (ed) Pterygium,
Vol. 2, Kugler Publications: The Hague, Netherlands, 2000, pp. 15-28.

3.  Currently, it is believed that Pterygium is a growth
disorder characterized by conjunctivalisation of the
cornea due to localized ultraviolet induced damage to the
limbal stem cells2.
 Aggressive pterygial fibroblasts are also responsible for
corneal invasiveness3.
 The indications for surgery include reduced vision due to
encroachment of the visual axis and irregular
astigmatism4, chronic irritation and recurrent
inflammation, restriction of ocular motility and cosmesis.
2.Dushku, N., Reid, T. W. Immunohistochemical evidence that human pterygia originate from an
invasion of vimentin expressing altered limbal epithelial basal cells. Curr. Eye Res. 1994, 13: 473-
481.
3.Li, D. Q., Lee, S. B., Gurja – Smith Z., Liu, Y., Solomon, A., Meller, D. et al., over expression
of collagenase (mm P-1) and stromelysin (mm P-3) by Pterygium head fibroblasts. Arch.
Ophthalmol., 2001: 119: 71-80.
4.Oldenburg, J. B., Barbus, J., McDonnell, J. M., McDonnell, P. J. Conjunctival pterygra. Cornea
2000: 9(3): 200-204.

4.  Numerous surgical techniques including bare sclera
excision with or without the use of adjuncts like beta
irradiation, thio tepa eye drops, intraoperative or post
operative mitomycin-C (MMC) or anti neoplastic agents,
amniotic membrane transplantation(AMG), conjunctival
autograft (CAG) with or without limbal stem cells have
been described.5
 Despite these innovative procedures, recurrence
continues to be a complication. Reported rates of
recurrence range from 2% for excision with CAG to 89%
for bare sclera excision.
5.Hirst, L. W. The treatment of Pterygium. Surv. Ophthalmology 2003; 45: 145-180.

5.  Differences in study methodology, patient characteristics,
nature of pterygium, geographic area, definition of
recurrence, duration of follow up and loss to follow up
are some of the factors responsible for widely varying
rates of recurrence6.
 Pterygium has a moderate to high prevalence 30 degree
above and below the equator1.
 Pterygium surgery is fairly common in our country,
which is located within the tropics.
6.Rao, S. K., Lekha, T., Mukesh, B. N., Sitalakshmi, G., Padmanabhan, P. Conjunctival limbal autografts
for primary and recurrent pterygia: technique and results. Indian J. Opthalmology, 1998; 46: 203-209.

6. NEED FOR STUDY
 Wardha city and its
surrounding places have dry,
windy, dusty and hot climate.
 The main occupation of people
in this place is agriculture,
labours etc., which is outdoor
occupation.
 They are exposed to such dry
and dusty climate which
increase the occurrence of
pterygium.

7.  Pterygium causes visual disturbances as it encroaches the
pupillary area. But intelligent patient may find difficulty
in early stages due to refractive and cosmetic problems.
 It is effectively treated by surgery, but the recurrence rate
is very high.
 The need for conducting the present study is to compare
recurrence rate, refractive indices & surgical outcome
between wet AMG, conjunctival autograft and topical
mitomycin C.

8. To compare
the recurrence
rate between
wet AMG,
conjunctival
autograft and
topical
mitomycin C.
To compare
the refractive
indices
between wet
AMG,
conjunctival
autograft and
topical
mitomycin C.
To compare
the surgical
outcome
between
different
techniques of
pterygium
excision.

9. MATERIALS & METHODS
1) STUDY DESIGN:
This study is conducted in the department of Ophthalmology,J.N.
Medical College,Sawangi,Wardha. It is a Randomized,prospective,
clinical,interventional study.
2) SOURCE OF DATA:
A) Outpatients attending the Dept. of Ophthalmology, JNMC
B) Inpatients attending the Dept. of Ophthalmology, JNMC
C) In-patients of other departments of JNMC referred to
Department of Ophthalmology.
3) SAMPLE SIZE: 75 patients

10. INCLUSION CRITERIA
1.All subjects with Primary
pterygium
2. Age group -21yrs to 60 yrs
EXCLUSION CRITERIA
1. All subjects with recurrent
/ secondary pterygium
2. Media opacities
3. Posterior segment
disorders
4. Subjects with
pseudopterygium

11.  Notification of history:
History regarding age, sex, occupation, address, duration of
complaints, H/O past surgery etc., were noted.
 Ocular Examination:
Detailed ocular examination of anterior and posterior
segment was done.

12.  Vision & Refraction:
o The best corrected visual acuity both preoperative and
post operative to detect any defect in vision or change in
astigmatism was recorded.
o Slit lamp examination was eventually done for evidence
of progression or any associated pathology.
o Patients were randomly selected for different surgical
techniques – Bare sclera Excision with application of
Topical Mitomycin C, Conjunctival Autograft and Wet
Amniotic Membrane Graft.
o An informed consent was taken.

13. 1.BARE SCLERA EXCISION WITH
TOPICAL MITOMYCIN C:
 Under local anaesthesia the
pterygium head was peeled
from the cornea by grasping in
fine toothed forceps near the
apex and put on tension by
drawing it away from the
cornea.
 Then,0.2mg/ml of mitomycin C
was put on a cotton bud and the
bud was kept on the bare sclera
for one minute and thorough
eye wash was given for 5
minutes.

14. 2.CONJUNCTIVAL AUTOGRAFT:
 The pterygium was resected first as in Bare Sclera
Technique.
 The size of conjunctival graft required to resurface the
exposed scleral surface was determined using vernier
calipers.This enabled the harvested graft to fit precisely
in the bed.
 Using a tooth forceps and Vannas scissors the graft was
excised starting at the forniceal end.

15.  Care was taken to obtain a graft as
thin as possible without button
holing.
 Once limbus is reached the graft was
flipped over onto the cornea and
tenon’s attachment at the limbus was
meticulously dissected.
 The flap was then excised using
Vannas Scissors, taking care to
include the limbal tissue.
 After excision, the Conjunctival
Limbal Autograft was slid onto the
cornea.

16.  Without lifting the tissue off the cornea, it was
rotated and moved onto its scleral bed with fine
non-toothed forceps.
 A limbus- limbus orientation was maintained.
 This helped to avoid inadvertent scrolling of the
graft.
 The graft was smoothened out in its bed.
 The scleral bed was viewed through the transparent
conjunctiva.
 Then the stabilisation of the graft was tested after
15-20 mins.

17. 3) WET AMNIOTIC
MEMBRANE GRAFT:
 The pterygium was resected
first as in Bare Sclera
Technique.
 Then, the amniotic membrane
was gently separated from the
nitrocellulose paper with blunt
forceps.
 The membrane was placed on
the cornea to cover the defect
and excess of amniotic
membrane was trimmed.

18.  All the patients were seen on 1st post operative day and
examined after 1 week, 4 weeks, & 6 months.
 During the review the patients were screened for any
possible complications & recurrence of pterygium.
 Vision and refraction were also done during follow up
period to determine any diminuition of vision or change
in astigmatism. Patients with recurrence were taken for
excision of pterygium by a technique which was selected
after studying the type of growth and method suitable for
it.

20. Age wise distribution
Maximum number of cases of Nasal Pterygium were in 41-50yrs (45.33%) of age followed by 51-60yrs
(25.33%) of age group. The highest incidence is in fourth decade. In a study conducted by Dr.
Meenakshi et al., (Channi AIOC, 2005) showed that 87.5% were above the age of 40 years.
Another study conducted by Dr. Rao, S. K. et al., IJO 1998 showed that 56.98% were above the age of
40 years.
Table no: 1
Age group (years) No. of patients Percentage(%)
21-30 yrs 7 9.33
31-40 yrs 15 20.00
41-50 yrs 34 45.33
51-60 yrs 19 25.33
Total 75 100.00
Mean±SD 47.92±10.83 (21-60 yrs)
21-30
yrs
9%
31-40
yrs
20%
41-50
yrs
46%
51-60
yrs
25%

21. Gender No. of patients Percentage(%)
Male 46 61.33
Female 29 38.67
Total 75 100
Male:Female Ratio 2:1
Gender wise distribution
Male, 61.33%
Female,
38.67%
Prevalence of Nasal Pterygium was more in males (61.33%) as compared to females
(38.67%). M:F= 2: 1. This is attributed to the fact that males are exposed to dust and
environmental irritants more than women. These results correlate with observations of J. H.
Hillger’s 19607, Rao Srinivas, Kijo 1998, Fernandes, M., Sangwan, V. S., 20058 and Dr.
Jaspreet Sukhija, Dr. Arun K. Jain, 2007
7. KjHilgers, J. H. Pterygium on the island of Aruba. Amsterdam Klein Offset Drukkerjj Poortpers N. V., 1959.
8. Fernandes, M., Sangevan, V. S., Bansal, A. K., Gangopadhyay, N., Sridhar, M. S., Garg, P., Aasuri, M. K., Nutheti,
R., Rao, G. N. LVPEI, India; Outcome of Pterygium surgery bt 1988-2001; Eye 2005; 19(11): 1182-90.
Table no: 2

22. Laterality No. of patients Percentage(%)
Unilateral 49 65.33
Bilateral 26 34.67
Total 75 100.00
Distribution of study participants according to laterality
Unilateral,
65.33%
Bilateral,
34.67%
Table no: 3

23. Grade of pterygium No. of patients Percentage(%)
Grade T1(Atrophic) 17 22.67
Grade
T2(Intermediate)
22 29.33
Grade T3(Fleshy) 36 48.00
Total 75 100.00
Distribution of study participants according to slit lamp grading of pterygium
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Grade T1 Grade T2 Grade T3
22.67%
29.33%
48%
%ofpatients
Grade of Pterygium
Table no: 4

24. Grade of
pterygiu
m
No. of
patients
Pre op-
astigmati
m
Post op
astigmati
m
Pre op
Mean±SD
Post op
Mean±SD
Grade I 31 1.47±0.45 0.62±0.30*
2.36±1.24
1.42±1.43*
Grade II 33 2.42±0.58 1.40±0.78*
Grade III 11 4.68±1.65 3.73±2.252
*
Grade IV 0 - -
Grade of pterygium and astigmatism
*-Difference in pre and post test is statistically significant,p<0.001
Table no: 5
1.47
2.42
4.68
0.62
1.4
3.73
0
1
2
3
4
5
6
7
Grade I Grade II Grade III
MeanAstigmatism&SD
Grade of pterygium
Pre-op Cyl Post-Op Cyl
Grade IVGrade IV
Grade IV

25.  The amount of astigmatism varied with the grade of
ptergium.
 The present study verifies that as the size of the
pterygium increases, the amount of pterygium induced
astigmatism also increases in direct proportion.
 Successful pterygium surgery reduces the pterygium
induced refractive astigmatism and also improves vision.

26. Surgery No. of
patients
Pre-op
astigmati
m
Post-op
astigmati
m
t-value p-value
WET AMG 25 2.66±1.31 1.52±1.76 5.28 0.000
S,p<0.05
CAG 25 2.12±1.01 1.19±0.97 4.67 0.000
S,p<0.05
MIT-C 25 2.45±1.39 1.52±1.49 5.39 0.000
S,p<0.05
Pre-op and Post op Astigmatism in each surgery
2.66
2.12
2.45
1.52
1.19
1.52
0
0.5
1
1.5
2
2.5
3
3.5
4
WET-AMG CAG MIT-C
MeanAstigmatismandSD
Type of Surgery
Pre-op Cyl Post-Op Cyl
Table no: 6

27. Surgery Granuloma Inclusion cyst Displaced graft
WET AMG - - -
CAG - - 1(4%)
MIT-C 4(16%) 1(4%) -
Surgery wise complications
Recurrence Rate
Follow up
period
WET AMG CAG MIT-C
1 week - - -
1 month - - -
2 months 1(4%) - -
3 months - 1(4%) 3(12%)
6 months - - -
Recurrence Rate
Table no: 8
Table no: 7

28.  Minor post – operative complications included-
 1 case of displaced graft in CAG pts
 1 case of inclusion cyst in Mitomycin-C pts
 4 cases of granuloma in Mitomycin-C pts.

29.  The cause of granulomas were due to trauma to the
Tenon’s capsule following pterygium excision; producing
a fleshy red granuloma which was pedunculated due to
squeezing effect of lids. The large lesion was excised.
 1 case of inclusion cyst was seen and it was excised.
 In our study, the overall complication rate was 8%.

30. Gender No. of recurrence Percentage(%)
Male 5 20.0
Female 0 0.0
Total 5 20.0
Sex wise Recurrence Rate
Table no: 9
• Recurrence occurred in 5 (6.6%) eyes after 2-3 months post
operatively. Recurrence of Pterygium was more common in
patients younger than 40 age. In this study 22 patients were
younger than 40 years, of these 5 developed recurrence.
• We have noted recurrence was significantly higher in males with
primary pterygium and it was also higher in patients below 40 years
age. The lipid degeneration in the peripheral cornea in elderly
individuals may be an inhibiting factor to Pterygium progression.9
9.Wong, W. W. A hypothesis on the pathogenesis of pterygiums. Ann. Ophthalmol.,
1978; 10: 303-308.

31.  Recurrence and complications can be avoided by carefully
selecting the patients and improving the technique of
surgery.
 We have compared the surgical result of primary pterygium
removal followed by amniotic membrane graft, conjunctival
autograft, and topical mitomycin C treatment.
 We have shown that amniotic membrane graft was as
effective as the other two methods in reducing pterygium
induced astigmatism and was safe with no major
complications.
 This suggests that amniotic membrane graft may be a
preferred procedure for primary pterygium, and is especially
suited for pterygium with diffuse conjunctival involvement.