0365-6691/$ - see front matter 2010 Sociedad Espaola de Oftalmologa. Published by Elsevier Espaa, S.L. All rights reserved.

Editorial
La retina como marcador biolgico de dao neuronal
Artculos originales
Comparacin de tres instrumentos de tomografa de
coherencia ptica, un time-domain y dos Fourier-
domain, en la estimacin del grosor de la capa de
fibras nerviosas de la retina
Idoneidad de tratamiento en sospechosos de glauco-
ma. Estudio de concordancia con el grupo de estu-
dio RAND
Atrofia de la capa de fibras nerviosas de la retina en
pacientes con esclerosis mltiple. Estudio prospec-
tivo con dos aos de seguimiento
Comunicaciones cortas
Hipercorreccin secundaria a transposicin muscular
aumentada
Crtica de libros, medios audiovisuales y pginas
web oftalmolgicos
Clinical Neuro-Ophthalmology: The Essentials
Seccin histrica
Del mal de la rosa y la queratoconjuntivitis pelagrosa
Seccin iconogrfica
El estrabismo de Rembrandt
Sociedades y Reuniones Cientficas
Ofertas de trabajo
Vol. 85 Mayo 2010 Nm. 5
Contenido
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DE OFTALMOLOGA
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ARCH SOC ESP OFTALMOL. 2011;86(2):5457
Original article
Evaluation of topical vasoconstrictors in pterygium surgery
and their role in reducing intraoperative bleeding
E. Villegas Becerril,
a,b,
* L. Prula de Torres,
c
M. Bergillos Arillo,
b,d
C. Villegas del Cuvillo
e
a
Clnica de Oftalmologa MASER, Crdoba, Spain
b
Empresa Pblica de Hospitales del Alto Guadalquivir. Hospital de Alta Resolucin de Puente Genil, Servicio de Oftalmologa,
Crdoba, Spain
c
Unidad Docente de Medicina de Familia y Comunitaria, Distrito Sanitario de Crdoba, Crdoba, Spain
d
Clnica de Oftalmologa OFTALMOCOR, Crdoba, Spain
e
Clnica de Oftalmologa, Crdoba, Spain
ARTI CLE I NFORMATI ON
Article history:
Received on July 20, 2010
Accepted on Oct. 26, 2010
Keywords:
Pterygium
Vasoconstrictors
Bleeding
Complications
Phenylephrine
*Corresponding author.
E-mail: drvill@terra.es (E. Villegas Becerril).
A B S T R A C T
Objective: To reduce vascularisation before surgery through the application of topical
vasoconstrictors, decreases the rate of intraoperative bleeding, improves the dynamics of
the surgery and reduces the difficulty in surgical performance.
Methods: Only patients with primary pterygium were included in the study. A prospective
randomized clinical trial was designed to compare intraoperative bleeding, need for
cauterization and surgical time a group that was administered phenylephrine. preoperatively
and one which did not receive it. The sample was divided into two groups: 1st (n=27)
received topical phenylephrine (F) 0.1ml (10%), twice in 5minutes before surgery. 2nd (n=30)
did not receive phenylephrine (NoF). The technique was similar in both groups using
conjunctival autograft suturing. In both groups, the subconjunctival aneasthesia was
performed with 0.5% bupivacaine hydrochloride with epinephrine 1:200,000.
Results: A total of 57 patients were included in the study. The mean operation time for
group F was 15.57minutes (SD: 1.8min) and the NoF group 16.51min (SD to 1.82min, P=.057).
In the group F, it was necessary to use diathermy in 2 patients (7.4%) and in the NoF group
cauterisation was used in 14 patients (46.7%, Chi-Square=10.848, P=.001. There is a relative
risk 6.3 (95% CI 1.57 - 25.27) times greater than having to cauterise without phenylephrine
when used phenylephrine.
Conclusions: The use of topical vasconstrictors prior to pterygium surgery reduces the rate
of bleeding and the time of surgery.
2010 Sociedad Espaola de Oftalmologa. Published by Elsevier Espaa, S.L.
All rights reserved.
Document downloaded from http://www.elsevier.es, day 14/06/2013. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
ARCH SOC ESP OFTALMOL. 2011;86(2):5457 55
Introduction
Recent etiological theories affirm that pterygium is not only
a degenerative disease but also a proliferative inflammation.
1

Surgical extirpation is the treatment of choice. The literature
suggests that simple excision leaving the sclera free is the
only technique with high recurrence rates of between 30%
and 70%.
2
Autogenous conjunctival graft seems to be the
best surgical method as it exhibits a low recurrence rate in
addition to less secondary effects.
3
It has recently been demonstrated that the Hispanic race
is a risk factor for increased pterygium recurrence rates,
even if the technique is utilized after the primary excision
and conjunctival autograft (CAG).
4
The contribution of UV
radiation to the pathogenesis of pterygium has been supported
by epidemiologic data on ocular solar exposure
5
. In addition,
immunohistochemical studies demonstrate the mutations of
protein p53 due to the damages caused by UV radiation. This
damage induces the production of cytokines, growth factors
and metaloproteinases of the metrics responsible for the
growth of pterygium.
6,7
Existing references demonstrate the difficulties due to
intra-op hemorrhage, occasionally requiring the use of
monopolar coagulation or suspending the intervention due to
excessive bleeding. This gives rise to numerous interruptions
and increased surgery times.
8-11
Our hypotheses is that the reduction of previous and
intra-op vascularization through the prior application of
vasoconstrictors before surgery diminishes the rate of
intraoperative bleeding, improves the surgery dynamics and
reduces the difficulty of the surgical procedure.
Subjects, material and methods
A prospective randomized clinical trial was designed
to compare intraoperative bleeding and cauterization
requirements and surgery times between a group which was
administered phenylephrine before the operation and a group
which was not. An informed consent was requested from each
patient and the study was carried out between September
2009 and February 2010.
Selection of patients and methods
We selected a group of patients (n=57) with an inclusion
criteria of pterygium diagnostic. Only the patients with
primary pterygium were included in the study. The patients
who underwent previous filtration surgery, corneal transplant
or had a history of ocular trauma and exposure to chemical
products were excluded from the study group. The sample
was divided into groups: the first group (n=27) received
topical phenylephrine 0.1ml (10%) on 2 occasions 5 min. prior
to the surgery. The second group (n=30) was not administered
phenylephrine or any other topical vasoconstrictor. The
administration of phenylephrine to each patient was masked
Palabras clave:
Pterigin
Vasoconstrictores
Sangrado
Complicacin
Felilefrina
Evaluacin de vasoconstrictores tpicos en la ciruga del pterigin y su papel
en la disminucin del sangrado intraoperatorio
R E S U M E N
Objetivo: Reducir la vascularizacin previa a la ciruga mediante la aplicacin de vasocon-
strictores tpicos disminuye la tasa de sangrado intraoperatorio, mejora la dinmica de la
ciruga y reduce la dificultad de la actuacin quirrgica
Mtodos: Slo los pacientes con pterigin primario se incluyeron en el estudio. Un ensayo
clnico aleatorizado prospectivo fue diseado para comparar el sangrado intraoperatorio,
necesidad de cauterizacin y tiempo de ciruga entre los grupos a los que se les administr
o no fenilefrina preoperatoriamente. La muestra se dividi en dos grupos: 1 (n = 27) recibi-
eron fenilefrina tpica (F) 0,1ml (10%) por dos veces 5 minutos antes de la ciruga; 2 (n = 30)
no se administr fenilefrina (NoF). La tcnica fue similar en ambos grupos, mediante autoin-
jerto conjuntival y sutura. En ambos, la anestesia subconjuntival se realiza con 0,5% de
clorhidrato de bupivacana con epinefrina 1:200.000.
Resultados: Un total de 57 pacientes se incluyeron en el estudio. La media del tiempo quirr-
gico para el grupo F fue de 15,57 minutos (SD: 1,8 min) y para el grupo de NoF de 16,51 min
(SD; 1,82 min; p = 0,057). En el grupo F, fue necesario usar la diatermia en 2 pacientes (7,4%),
en el NoF se us la cauterizacin en 14 pacientes (46,7%; Chi-cuadrado = 10,848; p = 0,001.
Existe un riesgo relativo 6,3 (IC 95%: 1,57 a 25,27) veces mayor de tener que cauterizar sin
fenilefrina que cuando se usa fenilefrina.
Conclusiones: El uso de vasconstrictores tpicos previos a la ciruga de pterigin disminuye la
tasa de sangrado y reduce el tiempo de ciruga.
2010 Sociedad Espaola de Oftalmologa. Publicado por Elsevier Espaa, S.L.
Todos los derechos reservados.
Document downloaded from http://www.elsevier.es, day 14/06/2013. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
56 ARCH SOC ESP OFTALMOL. 2011;86(2):5457
for the only surgeon who carried out all the surgeries in
order to avoid a bias, and in addition it was randomized.
The surgical technique was similar in both groups, with
conjunctival autograft and stitch described by Harvey et al
(2005)
11
. According to the description of this author, the need
to utilize diathermia was established for intra-op bleeding.
In both groups, subconjunctival anesthesia was performed
with a combination of anesthesia and vasoconstrictor: 0.5%
bupivacaine chlorhydrate with epinephrine in 1:200.000.
Evaluation and follow-up
After the operation, the subjects of both groups were treated
with tobramycine and dexamethasone eyedrops four times a
day, with a gradually diminishing prescription through a four-
week period. All the subjects were assessed 24 hours after the
surgery and one week, one month and 3 months after the
intervention. In each postop visit a slit lamp biomicroscopy
and applanation tonometry was performed.
Statistical analysis
A descriptive statistical analysis was performed, followed
by an analysis of the comparability of both groups according
to age and sex. To verify the existence of differences between
both groups the adjustment of the quantitative variables
to normal distribution was previously verified through
the Shapiro-Wilk or Kolmogorov-Smirnov tests. As these
variables followed a normal distribution, the T for Student
test for independent samples was applied. For comparing
qualitative variables the Chi Square test was utilized,
assuming a value of p<0.05 (bilateral tests). The statistical
calculations were made with the SPSS application, version
17.0 (SPSS Inc, Chicago).
Results
In all, 57 patients were studied, of whom 47 (82.5%) were
male and 10 female (17.5%), without appreciating differences
between both groups (p=0.85). The group which was
administered preop phenylephrine (F) had a mean age of 50.59
years (SD: 12.11) and the group which was not administered
preop phenylephrine (NoF) had a mean age of 54.03 years
(SD:12.31; p=0.29). Of all the eyes, 32 were right eyes and 25
left eyes (table 1).
The mean surgical time for group F was of 15.57 minutes
(SD: 1.8min) and for the NoF group of 16.51min (SD; 1.82min;
p=0.057). In group F it was necessary to apply diathermia in
2 patients (7.4%) and in group NoF cauterization had to be
applied in 14 patients (46.7%; Chi-square =10.848; p=0.001.
Therefore, there is a relative risk of 6.3 (CI 95%: 1.57 to 25.27)
times greater having to cauterize without phenylephrine than
with phenylephrine. Two patients (7.4%) of group F exhibited
pterygium relapse against 20.0% (n=6) of the NoF group, when
preop phenylephrine was not applied (p=0.172) (table 1).
Discussion
Many attempts have been made to optimize pterygium
surgery. At presenct a large variety of techniques are utilized,
ranging from the free sclera procedure without utilizing
microscope up to the amniotic membrane transplant and
conjunctival autograft or lamellar keratoplasty.
12
However, all of the above methods report complications,
ranging from scleromalatia to some involving loss of
eyesight.
13-15
Depending on the techniques applied, we found
in the references that the main intra-op complication was
bleeding.
8-10,16
This can cause various complications during
operations such as increasing the difficulty of removing the
graft, requiring the use of diathermia for coagulating the
bleeding focus or causing graft dehiscence due to accumulation
of blood.
In our study it has been demonstrated that reducing preop
vascularization with topical vasoconstrictors significantly
reduces the rate of intraoperative coagulation with diathermia
due to bleeding. This achieves greater surgical control and
less interruptions in the chosen technique.
In addition, although the differences as regards surgery
time are not significant, the mean surgical time for group
F is nearly one minute less (15.57 minutes) than for group
NoF (16.51 minutes). It can be seen that the p value is
nearly significant, as it is close to 0.057. In our criteria, this
suggests that future clinical trials with a larger sample would
consistently evidence that the use of topical vasoconstrictor
agents prior to surgery could not only diminish the rate of
intraoperative bleeding but also significantly improve surgery
times.
Accordingly, and in the light of the data of this study, it is
proposed to develop a new topical vasoconstrictors specific for
conjunctival vascularization as well as possible combinations
thereof for reducing intraoperative bleeding.
Conflict of interest
None of the authors have declared any conflict of interest.
Age (years) Sex Eye Need for cauterization Surgical time (minutes)
F NoF F NoF F NoF F NoF F NoF
50.59 54.03 22H/5M 25H/5M 15D/12I 17D/13I 25N/2S 16N/14S 15.57 16.51
F: group that was administered phenylephrine 10% prior to surgery; NoF: group that was not administered phenylephrine prior to surgery.
Table 1
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ARCH SOC ESP OFTALMOL. 2011;86(2):5457 57
R e f e r e n c e s
1. Dushku N, John MK, Schultz GS, Reid TW. Pterygia
pathogenesis: corneal invasion by matrix metalloproteinase
expressing altered limbal epithelial basal cells. Arch
Ophthalmol. 2001;119:695-706.
2. Youngson RM. Recurrence of pterygium after excision.
Br J Ophthalmol. 1972;56:120-5.
3. Hall RC, Logan AJ, Wells AP. Comparison of fibrin glue with
sutures for pterygium excision surgery with conjunctival
autografts. Clin Experiment Ophthalmol. 2009;37:584-9.
4. Kandavel R, Kang JJ, Memarzadeh F, Chuck RS. Comparison
of pterygium recurrence rates in Hispanic and white patients
after primary excision and conjunctival autograft. Cornea.
2010;29:141-5.
5. Chui J, Di Girolamo N, Wakefield D, Coroneo MT. The
pathogenesis of pterygium: current concepts and their
therapeutic implications. Ocul Surf. 2008;6:24-43.
6. Threlfall T, English D. Sun exposure and pterygium of the eye:
a doseresponse curve. Am J Ophthalmol. 1999;128:280-7.
7. Dushku N, Reid T. P53 expression in altered limbal basal cells
of pingueculae, pterygia, and limbal tumors. Curr Eye Res.
1997;16:1179-92.
8. Pherwani A, Vakil V, Eatamadi H, Singh R, Dua HS. Postoperative
subconjunctival 5-fluorouracil in the management of recurring
pterygium. Br J Ophthalmol. 2007;91:398-9.
9. Bahar I, Weinberger D, Gaton DD, Avisar R. Fibrin Glue versus
vicryl sutures for primary conjunctival closure in pterygium
surgery: long-term results. Current Eye Research. 2007;32:
399405.
10. Donnenfeld ED, Perry HD, Fromer S, Doshi S, Solomon R, Biser
S. Subconjunctival mitomycin C as adjunctive therapy before
pterygium excision. Ophthalmology. 2003;110:1012-6.
11. Uy HS, Reyes JM, Flores JD, Lim-Bon-Siong R. Comparison of
fibrin glue and sutures for attaching conjunctival autografts
after pterygium excision. Ophthalmology. 2005;112:667-71.
12. Simona F, Tabatabay CA, Leuenberger PM. Lamellar corneal
graft in the treatment of pterygium. A 10-year retrospective
study of the recurrence and changes of astigmatism.
J Fr Ophtalmol. 1988;11:759-63.
13. Barron A, McDonald JE, Hughes WF. Long-term complications
of beta-radiation therapy in ophthalmology. Trans Am
Ophthalmol Soc. 1970;68:113-28.
14. MacKenzie FD, Hirst LW, Kynaston B, Bain C. Recurrence rate
and complications after beta irradiation for pterygia.
Ophthalmology. 1991;98:1776-80.
15. Rubinfeld RS, Pfister RR, Stein RM, Foster CS, Martin NF,
Stoleru S, et-al. Serious complications of topical mitomycin-C
after pterygium surgery. Ophthalmology. 1992;99:1647-54.
16. Marback PM, Marback EF, Marback RL. Foreign body after
pterygium surgery simulating an epibulbar tumor. Ophthal
Plast Reconstr Surg. 2009;25:150-2.
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