ORIGINAL ARTICLE

Outcome of Recurrent Pterygium with Intraoperative 0.02%

Mitomycin C and Free Flap Limbal Conjunctival Autograft
Ashok Kumar Narsani1, Partab Rai Nagdev2 and Maria Nazish Memon1

ABSTRACT
Objective: To determine the re-recurrence and the postoperative complications in recurrent pterygium cases treated by
intraoperative 0.02% Mitomycin C (MMC) and conjunctival autograft (CAG).
Study Design: Quasi-experimental.
Place and Duration of Study: Department of Ophthalmology, Liaquat University of Medical and Health Sciences,
Jamshoro, Hyderabad and Chandka Medical College Hospital, Larkana, from January to December 2010.
Methodology: Cases with recurrent pterygium were included in this study. Cases with history of first time pterygium and
pterygium with conjunctival scaring, dry eye, glaucoma and vitreoretinal disease were excluded. After topical and subconjunctival anaesthesia, pterygium was excised in single piece. Intraoperative 0.02% MMC was applied on bare sclera
for 2 minutes. CAG was excised from supero-temporal conjunctiva, and implanted on bare sclera. All cases were followedup for 6 months. Re-recurrence was defined as postoperative fibrovascular re-growth of 1.0 mm or more crossing the
corneo-scleral limbus. Data was analysed as descriptive statistics.
Results: A total of 65 eyes of 65 cases were studied having mean age of 43.26 12.81 years. Among those, 41 (63.1%)
were males and 48 (73.8%) belonged to rural area. The size of pterygium on cornea was 2-3 mm in 44 (67.7%) cases and
4-5 mm in 21 (32.3%) cases. Re-recurrence of pterygium was seen in 3 (4.6%) cases. Postoperative complications
included conjunctival granuloma in 2 (3.1%) cases, graft necrosis in 2 (3.1%) cases, graft oedema in 3 (4.6%) cases and
graft displacement in 3 (4.6%) cases.
Conclusion: The intraoperative application of 0.02% MMC with CAG markedly reduces the risk of re-recurrence of
pterygium and postoperative complications.
Key words:

Excision. Recurrent pterygium. 0.02% Mitomycin C (MMC). Conjunctival autograft (CAG).

INTRODUCTION
Pterygium is a fibro vascular wing shaped encroachment
of conjunctiva on the cornea.1 Mostly, it occurs nasally,
but can occur temporally, or on both sides of the eye
globe. Although the pathogenesis is not clear but ultraviolet light, hot, dry, windy, dusty, smoky environments
and hereditary are considered as risk factors.2-4 The
main histopathological change in primary pterygium is
an elastotic degeneration of conjunctival collagen
fibers.5 The chief complaints are foreign body
sensations in eye, decreased vision, fleshy growth over
the pupil and cosmetic blemish. Anti-inflammatory
agents and lubricants play an important role in
minimizing the patient's discomfort, but do not cure the
disease.
Surgical excision of pterygium with bare sclera
technique is widely practised, because it is a safe and
1

Department of Ophthalmology, Liaquat University of Medical

and Health Sciences, Jamshoro, Hyderabad.
Department of Ophthalmology, Chandka Medical College
Hospital, SMBBM University, Larkana.
Correspondence: Dr. Partab Rai Nagdev, Bungalow 13,
Doctor Colony, VIP Road, Larkana.
E-mail: dr_partab_rai@yahoo.com
Received July 15, 2011; accepted January 08, 2013.

simple procedure.6 However, with time, it becomes

apparent that the recurrence rate is un-acceptably
high with this procedure, ranging from 24% to 89%.7
Several other methods are now implemented with the
aim of improving the success rate and decreasing the
recurrence rate, for example, low dose Mitomycin C
(MMC), conjunctival autograft (CAG), rotational conjunctival flap, lamellar keratoplasty, amniotic membrane
transplant, beta radiation, ablation with YAG laser and
smoothening of the cornea with the Excimer laser.8
Mitomycin C is an antineoplastic antibiotic agent isolated
from the fermentation filtrate of Streptomyces caespitosus.
It alkylates and cross links DNA and, in addition, may
generate superoxide and hydroxyl radicals in solution.
It also inhibits DNA, RNA, and protein synthesis. All
these actions affect cellular proliferation for long-time.
However, the combination of limbal CAG and local low
dose MMC seems to be the best treatment, giving both
low recurrence rate and high safety.9 This has not been
widely tested locally.
The objective of this study was to determine the rerecurrence and the postoperative complications in
recurrent pterygium cases treated by intraoperative
0.02% Mitomycin C (MMC) and conjunctival autograft
(CAG).

Journal of the College of Physicians and Surgeons Pakistan 2013, Vol. 23 (3): 199-202

199

Ashok Kumar Narsani, Partab Rai Nagdev and Maria Nazish Memon

METHODOLOGY

RESULTS

This study was conducted at the Department of

Ophthalmology, Liaquat University of Medical and
Health Sciences, Jamshoro, Hyderabad and Chandka
Medical College Hospital, Larkana, from January 2010
to December 2010. It was a quasi-experimental study
where cases presenting with history of recurrent
pterygium were included. Cases with history of first time
pterygium and pterygium with conjunctival scaring, dry
eye, glaucoma, and vitreoretinal disease were excluded.
All cases were informed about the study and a written
consent was taken from them. After admission in the
ward, the detailed history and eye examination was
recorded on a specific proforma. After topical and subconjunctival anaesthesia, pterygium was excised in
single piece. Intraoperative 0.02% MMC was applied on
bare sclera for 2 minutes. CAG was excised from
supero-temporal conjunctiva, and implanted on bare
sclera. At the end of surgery, topical combined steroidantibiotic eye ointment was used and eye pad was
applied for 24 hours. Postoperatively oral antibiotic,
(cephradine 500 mg, 3 times/day) and analgesic,
(diclofenac potassium 50 mg, 2 times/day) were used for
5 days. The topical combined steroid-antibiotic eye
drops (dexamethasone 0.1% + tobramycin 0.3%), one
drop one hourly during awaking hours and eye ointment
at night was used for first week and then tapered to
4 times/day for a further 8 weeks (Figures 1 3). Postoperatively, all the cases were followed after first 1 week,
first 2 weeks and then in every month for 6 months.

We evaluated 65 eyes of 65 cases with mean age of

43.26 12.81 years (range 21 to 72 years). Among
those, 41 (63.1%) were males and 24 (36.9%) were
females with male to female ratio of 2:1; 48 (73.8%)
cases belonged to rural area and 17 (26.2%) to urban
area. The size of pterygium on cornea was 2-3 mm in 44
(67.7%) cases and 4-5 mm in 21 (32.3%) cases
(Table I). The re-recurrence of pterygium was seen in 3
(4.6%) cases. The postoperative complications noticed
were conjunctival granuloma in 2 (3.1%) cases, graft
necrosis in 2 (3.1%) cases, graft displacement in
3 (4.6%) cases, and graft oedema in 3 (4.6%) cases.

Re-recurrence was defined as postoperative fibrovascular re-growth of 1.0 mm size or more crossing the
corneo-scleral limbus. Any complications in the graft
were noted.
Frequencies and percentages were determined for
gender, area of origin of population, size of pterygium,
follow-up and postoperative complications. Chi-square
test was used for comparision of re-recurrence.
A p-value of 0.05 was considered statistically
significant. Statistical Package for Social Sciences
(SPSS) version 10 was used for statistical analysis of
the data.

Figure 1: Photograph showing measurement of

size of pterygium.

200

Table I: A summary of demographics, pterygim size, follow-up, postoperative complications and re-recurrence (n = 65).
Number of patients

Percentage
(Frequency)

Male

41

63.1

Female

24

Total

65

Gender
36.9
100

Area of origin
Urban

17

Rural

48

Total

65

26.2
73.8
100

Size of pterygium
2 3 mm

44

4 5 mm

21

Total

65

67.7
32.3
100

Follow-up
Present

52

80

Absent

13

20

Total

65

100

Postoperative complications
Granuloma

3.1

Graft necrosis

3.1

Graft oedema

4.6

Displacment of graft

4.6

Nill

55

84.6

Total

65

100

Recurrence
+ VE

4.6

- VE

62

95.4

Total

65

Figure 2: Application of MMC with cotton tip

applicator after excision of pterygium.

100

Figure 3: Complete attachment of free flap limbal

conjunctival autograft.

Journal of the College of Physicians and Surgeons Pakistan 2013, Vol. 23 (3): 199-202

Outcome of recurrent pterygium with intraoperative 0.02% Mitomycin C and free flap limbal conjunctival autograft

The re-recurrence of pterygium was seen in 3 (4.6%)

cases (p = 0.003). Postoperatively the common factors
found in re-recurrence of pterygium were graft necrosis
and graft displacement.

DISCUSSION
It is believed that surgical trauma and subsequent
postoperative inflammation activates sub-conjunctival
fibroblasts, vascular cells, and deposition of extra
cellular matrix proteins, which in turn contributes to the
pterygium recurrence. Various surgical techniques were
employed for the treatment of pterygium, but the main
problem encountered in each modality was an unpredictable rate and time of recurrence.10 The simplest
technique for pterygium excision by bare sclera alone
was proved unsatisfactory because of its high
recurrence rate 24 89%.7 Adjunctive treatment after
bare sclera technique with beta radiation showed the
recurrence rate to as low as 0.5 10%,11 but this can
produce serious complications such as scleral melting,
keratitis etc. Singh et al. introduced the use of low dose
MMC as an adjuvant to pterygium surgery in 1988.12
Although MMC significantly reduces the rate of
recurrence of pterygium to less than 10% but it can
produce serious complications such as scleral melting,
ectasia and necrosis, corneal limbal perforation.13 In
1985, Kenyon et al. reported limbal CAG as a promising
technique in the treatment of pterygium with recurrence
rate of 5.3%.14 After that, a number of papers on the
limbal CAG technique are published with various
success rates. However, the surgical factors such as the
surgeon's experience and the surgical technique has
profound influence on the recurrence rate.
The main disadvantage of limbal CAG is that it requires
prolonged per operative time in comparison to bare
sclera technique. Moreover, limbal CAG including limbal
stem cells generally yield better results, because it will
help to restore its barrier function. In 1989, Lewallen
reported a randomized trial of the limbal CAG technique
for pterygium excision and documented 19% recurrence
rate in grafted cases compared with 37% recurrence
rate in bare sclera technique cases.15 Riordan-Eva et al.
reported 14% recurrence rate following 3 years of limbal
CAG for pterygium.16 In 2005, Fahmi et al. reported
13.3% recurrence rate with limbal CAG.17 The
recurrence rate in this series of cases was 4.6% which is
comparable with studies by Altiparmak et al. and Segev
et al., they reported recurrence rate of 13.3% and 2%
respectively.18,19
Serious complications occurring after pterygium excision
with adjunctive treatment has been well reported.
However, no serious complications were noted in this
study, like study of Frucht-Pery and IIsar.20 A common
risk factor in toxicity with MMC is a relatively large
cumulative dose and duration of application. Therefore,

a single intraoperative low dose of 0.02% MMC and

short (2 minutes) duration of application would reduce
the postoperative complication rate. It was also noticed
that the frequency of recurrent pterygium was more in
the third to fifth decade of life, twice more common in
males than females and thrice common in those living in
rural area, than urban area. This may be due to more
ultraviolet exposed outdoor occupational and recreational activities of males than females and in rural
area than in urban area.

CONCLUSION
The intraoperative application of MMC combined with
free flap limbal CAG significantly reduces the risk of rerecurrence of pterygium and postoperative complications.

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