A New Approach: Determination of the Safe Surgical Margin in Pterygium Surgery

Abstract

Purpose In this retrospective study, we aimed to determine the safe surgical limit for excision of pterygium tissue. Therefore, we aimed to prevent excessive or incomplete normal conjunctival tissue excision during surgery in the coming years.

Methods Autografted pterygium surgery was performed between January 2015 and April 2016, and the excised pterygium tissue was examined histopathologically. The files of 44 patients, who had not previously undergone any ocular surgery, who did not have an inflammatory disease and who continued to be checked for at least 1 year, were retrospectively examined. The distance (P-DSEM) from the excised pterygium tissue to the surgical excision margin was measured by a pathologist. Postoperative recurrence rates were evaluated according to this value. In this way, the clean surgical margin was determined.

Results The mean age of the participants was 44.77 ± 12.70, and the mean follow-up time was 55.61 ± 16.38 months. Recurrence developed in 5 out of 44 patients (11.4%). The average recurrence duration was 51 ± 13.87 days. Distance to the average surgical margin was 3.88 ± 0.91 mm. The surgical distances of 5 patients with recurrence were 2, 2.5, 2, 3, and 3 mm, respectively. It was determined that recurrence was less as the distance (P-DSEM) from the tissue to the surgical excision margin increased (p = 0.001).

Conclusions We found that the recurrence rate in pterygium surgery was linked to the clean surgical margin. When planning pterygium surgery, we believe that determining the amount of tissue to be excised before surgery will reduce recurrence rates.

Zusammenfassung

Zweck In dieser retrospektiven Studie wollten wir die sichere chirurgische Grenze für die Exzision von Pterygiumgewebe feststellen. Wir wollten die übermäßige oder unvollständige Entfernung von normalem Bindehautgewebe während der Operation in Zukunft verhindern.

Methoden Autotransplantierte Pterygiumoperationen wurden zwischen Januar 2015 und April 2016 durchgeführt und das herausgeschnittene Pterygiumgewebe histopathologisch untersucht. Die Akten von 44 Patienten, die zuvor keiner Augenoperation unterzogen wurden, die keine entzündliche Erkrankung hatten und die mindestens 1 Jahr nachbeobachtet wurden, wurden rückwirkend untersucht. Der Abstand (P-DSEM) vom herausgeschnittenen Pterygiumgewebe bis zum chirurgischen Exzisionsrand wurde von einem Pathologen gemessen. Postoperative Rezidivraten wurden entsprechend zu diesem Wert ausgewertet. Auf diese Weise wurde der saubere Operationsrand bestimmt.

Ergebnisse Das Durchschnittsalter der Teilnehmer betrug 44,77 ± 12,70 Jahre und die mittlere Nachbeobachtungszeit betrug 55,61 ± 16,38 Monate. 5 von 44 Patienten (11,4%) entwickelten ein Rezidiv. Die durchschnittliche Rezidivdauer betrug 51 ± 13,87 Tage. Der durchschnittliche chirurgische Exzisionsrand betrug 3,88 ± 0,91 mm. Der Exzisionsrand bei 5 Patienten mit Rezidiv betrug 2, 2,5, 2, 3 und 3 mm. Es wurde festgestellt, dass Rezidive seltener auftraten, wenn der Abstand (P-DSEM) vom Gewebe zum Exzisionsrand größer war (p = 0,001).

Schlussfolgerungen Wir fanden heraus, dass die Rezidivrate bei Pterygiumoperation mit dem sauberen Operationsrand verbunden war. Wir glauben, dass bei der Planung von Pterygium-Operationen, die Bestimmung der Menge an Gewebe, die vor der Operation entfernt werden muss, Rezidive reduzieren wird.

Conclusions

Already known

• The most common complication in pterygium surgery is recurrence. Primary excision and autograft are the most commonly used surgical techniques to reduce recurrence. The amount of conjunctival excision to be made is still not standardized.

Newly described

• In this study, for the first time in pterygium surgery, what should be the safe surgical margin was examined. We found that there was less recurrence in surgery in which we excised wide and placed a wide autograft and we showed this histopathologically. As the histopathologically clear surgical margin widened, the recurrence rate was lower. In future prospective studies, it should be histopathologically standardized how many mm of normal conjunctival tissue should be removed together with the pterygium tissue. Thus, a safe surgical margin will be created with intraoperative frozen sections.

Key words

pterygium surgical distance - pterygium surgery - relapsed pterygium - pterygium - cornea

Schlüsselwörter

Bindehaut - Kornea - plastische Chirurgie - sicherer chirurgischer Rand - Pterygium

Publication History

Received: 15 October 2022

Accepted: 22 February 2023

Article published online:
30 June 2023

• References

• 1 Chui J, Di Girolamo N, Wakefield D. et al. The pathogenesis of pterygium: current concepts and their therapeutic implications. Ocul Surf 2008; 6: 24-43
• 2 Rezvan F, Khabazkhoob M, Hooshmand E. et al. Prevalence and risk factors of pterygium: a systematic review and meta-analysis. Surv Ophthalmol 2018; 63: 719-735
• 3 Liu C, Song Y, Wang X. et al. The Key Role of VEGF in the Cross Talk between Pterygium and Dry Eye and Its Clinical Significance. Ophthalmic Res 2020; 63: 320-331
• 4 Chui J, Coroneo MT, Tat LT. et al. Ophthalmic pterygium: a stem cell disorder with premalignant features. Am J Pathol 2011; 178: 817-827
• 5 Kim KW, Park SH, Kim JC. et al. Fibroblast biology in pterygia. Exp Eye Res 2016; 142: 32-39
• 6 Khan L, Malukani M, Saxena A. et al. Conjunctival Lesions: When Should We Perform Biopsy?. Nepal J Ophthalmol 2017; 9: 160-169
• 7 Tsai YY, Chang KC, Lin CL. et al. p 53 Expression in pterygium by immunohistochemical analysis: a series report of 127 cases and review of the literature. Cornea 2005; 24: 583-586
• 8 Kaufman SC, Jacobs DS, Lee WB. et al. Options and adjuvants in surgery for pterygium: a report by the American Academy of Ophthalmology. Ophthalmology 2013; 120: 201-208
• 9 Aydin A, Karadayi K, Aykan U. et al. [Effectiveness of topical ciclosporin A treatment after excision of primary pterygium and limbal conjunctival autograft]. J Fr Ophthalmol 2008; 31: 699-704
• 10 Clearfield E, Muthappan V, Wang X. et al. Conjunctival autograft for pterygium. Cochrane Database Syst Rev 2016; (02) CD011349
• 11 Syam PP, Eleftheriadis H, Liu CS. et al. Inferior conjunctival autograft for primary pterygia. Ophthalmology 2003; 110: 806-810
• 12 Okoye O, Oguego NC, Chuka Okosa CM. et al. Short-term results of pterygium surgery with adjunctive amniotic membrane graft. Niger J Clin Pract 2013; 16: 356-359
• 13 Clearfield E, Hawkins BS, Kuo IC. et al. Conjunctival Autograft Versus Amniotic Membrane Transplantation for Treatment of Pterygium: Findings From a Cochrane Systematic Review. Am J Ophthalmol 2017; 182: 8-17
• 14 Tsim NC, Young AL, Jhanji V. et al. Combined conjunctival rotational autograft with 0.02 % mitomycin C in primary pterygium surgery: a long-term follow-up study. Br J Ophthalmol 2015; 99: 1396-1400
• 15 Kim SH, Oh JH, Do JR. et al. A comparison of anchored conjunctival rotation flap and conjunctival autograft techniques in pterygium surgery. Cornea 2013; 32: 1578-1581
• 16 Fonseca EC, Rocha EM, Arruda GV. et al. Comparison among adjuvant treatments for primary pterygium: a network meta-analysis. Br J Ophthalmol 2018; 102: 748-756
• 17 Yulish M, Khatib A, Pikkel J. et al. Systemic Absorption of Mitomycin-C When Used in Pterygium Surgery. Cornea 2018; 37: 746-747
• 18 Lam DS, Wong AK, Fan DS. et al. Intraoperative mitomycin C to prevent recurrence of pterygium after excision: a 30-month follow-up study. Ophthalmology 1998; 105: 901-904
• 19 Jürgenliemk-Schulz IM, Hartman LJ, Roesink JM. et al. Prevention of pterygium recurrence by postoperative single-dose beta-irradiation: a prospective randomized clinical double-blind trial. Int J Radiat Oncol Biol Phys 2004; 59: 1138-1147
• 20 Elgouhary SM, Elmazar HF, Naguib MI. et al. Role of oxidative stress and vascular endothelial growth factor expression in pterygium pathogenesis and prevention of pterygium recurrence after surgical excision. Int Ophthalmol 2020; 40: 2593-2606
• 21 Viveiros MM, Kakizaki FY, Hércules LA. et al. In vitro study of cyclosporine A 0.05 % on primary and recurrent pterygium fibroblasts. Int Ophthalmol 2016; 36: 237-242
• 22 Mednick Z, Boutin T, Einan-Lifshitz A. et al. Simple limbal epithelial transplantation for recurrent pterygium: A case series. Am J Ophthalmol Case Rep 2018; 12: 5-8
• 23 Hirst LW. Prospective study of primary pterygium surgery using pterygium extended removal followed by extended conjunctival transplantation. Ophthalmology 2008; 115: 1663-1672
• 24 Hirst LW. Recurrence and complications after 1,000 surgeries using pterygium extended removal followed by extended conjunctival transplant. Ophthalmology 2012; 119: 2205-2210
• 25 Allam WA, Alagorie AR, Nasef MH. et al. Safety and efficacy of pterygium extended removal followed by extended conjunctival transplant for recurrent pterygia. Int Ophthalmol 2022; 42: 2047-2053
• 26 Cornelius CR. Recurrence Rate and Complications of Pterygium Extended Removal Followed by Extended Conjunctival Transplant. Cornea 2017; 36: 101-103
• 27 Lee JS, Ha SW, Yu S. et al. Efficacy and Safety of a Large Conjunctival Autograft for Recurrent Pterygium. Korean J Ophthalmol 2017; 31: 469-478
• 28 Wong VW, Rao SK, Lam DS. et al. Polyglactin sutures versus nylon sutures for suturing of conjunctival autograft in pterygium surgery: a randomized, controlled trial. Acta Ophthalmol Scand 2007; 85: 658-661
• 29 Dupps Jr. WJ, Jeng BH, Meisler DM. Narrow-strip conjunctival autograft for treatment of pterygium. Ophthalmology 2007; 114: 227-231
• 30 Hovanesian JA, Starr CE, Vroman DT. et al. Surgical techniques and adjuvants for the management of primary and recurrent pterygia. J Cataract Refract Surg 2017; 43: 405-419