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Year : 2005  |  Volume : 53  |  Issue : 1  |  Page : 53-55

Split-Conjunctival Grafts for Double - head Pterygium

Cornea, and Refractive Surgery Service, Shri Ganapati Netralaya, Jalna, India

Date of Submission17-May-2004
Date of Acceptance22-Nov-2004

Correspondence Address:
Sejal Maheshwari
Shri Ganapati Netralaya, Devalgaonmantha Road Jalna - 431203
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0301-4738.15286

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PURPOSE: To describe the technique of split-conjunctival grafts (SCG) for double-head pterygia and to evaluate its postoperative outcome. METHOD: A retrospective analysis of seven eyes with primary double-head pterygium was done. All eyes received pterygium excision with split-conjunctival grafts harvested from the superior quadrant. All patients were followed up for recurrence of the lesion and incidence of complications. RESULTS: No recurrence was noted with a mean follow-up of 17.7 ± 6 months. CONCLUSION: Split-conjunctival graft is a useful procedure for double-head pterygium.

Keywords: Double-head pterygium, conjunctival graft

How to cite this article:
Maheshwari S. Split-Conjunctival Grafts for Double - head Pterygium. Indian J Ophthalmol 2005;53:53-5

How to cite this URL:
Maheshwari S. Split-Conjunctival Grafts for Double - head Pterygium. Indian J Ophthalmol [serial online] 2005 [cited 2022 Dec 8];53:53-5. Available from: https://www.ijo.in/text.asp?2005/53/1/53/15286

Pterygium is commonly seen in India, which is a part of the "pterygium belt".[1] Conjunctival autografts are reportedly safe and effective in treating pterygium.[2]-[5] Double-head pterygia are frequently encountered in our region (19o.2′ N to the equator). The excision of double-head pterygium leaves large conjunctival defects. I describe a technique and the clinical outcome of split-conjunctival grafts to deal with these defects.

  Materials and Methods Top

Case records of seven eyes of 7 patients who underwent pterygium excision with split-conjunctival grafts from March 2001-August 2002 were analysed retrospectively. All surgeries were performed by one surgeon (SM). Patient data collected included age at surgery, gender, past ocular, medical and surgical history, indication for surgery, surgical technique and complications. Depending on the extent of corneal involvement the pterygium was graded as follows: Grade I-crossing the limbus, Grade II-midway between the limbus and pupil, and Grade III-crossing the pupillary margin.

Surgical Procedure

A standard surgical technique similar to that described by Rao et al4 was followed with a few modifications. Under peribulbar anesthesia, after painting and draping, a wire speculum was used to separate the lids. A superior rectus bridle suture was inserted using 4.0 silk. A small conjunctival incision was made just inside the head of the pterygium, avoiding the altered conjunctiva on the head of the pterygium [Figure - 1]. The conjunctiva was progressively dissected from the body towards canthus, superior and inferior fornix. The corneal epithelium 2 mm ahead of the head of the pterygium was scraped off with a hockey-stick knife. The hockey-stick knife was used to elevate the epithelium adjacent to the head of the pterygium. The pterygium head was then avulsed using a combination of blunt dissection and traction. The body of the pterygium was then excised. The corneal and limbal area was scraped clean of residual tissue with the hockey-stick knife. Haemostasis of the scleral bed was achieved using wet field cautery. A similar procedure was used for the temporal pterygium. In all cases, care was taken not to excise the inferior limbal area, and the interconnecting inferior conjunctiva.

The size of the conjunctival graft required to resurface the exposed scleral surface was measured in three directions - extent across the limbus, maximum circumferential extent and the distance from the limbus on both nasal and temporal sides. The bridle suture was used to rotate the globe downwards exposing the superior conjunctiva. The measured dimensions were marked with wet-field cautery, dimensions of the nasal side were marked towards the limbus and the dimensions of the temporal side were marked above that [Figure - 2]. Balanced salt solution was injected beneath the conjunctiva with a 30G needle which helped in good conjunctival dissection. The conjunctival graft was excised starting from the forniceal end; once the limbus was reached the graft was flipped over the cornea and Tenon′s attachments were dissected. The graft was then split at the dimensions marked for the temporal bed; the limbal side was left attached. The graft was then placed on the temporal side and secured with 8.0 vicryl suture with four episcleral bites to maintain position and the edges sutured with continuous sutures. The limbal side of the graft was then cut with Vannas scissors. After excision the conjunctival-limbal graft was slid onto the cornea, moved onto its scleral bed on the nasal side and sutured. Before suturing it was ensured that the epithelial side of the graft was facing up and the limbal orientation was maintained on the nasal side. The eye was patched. Postoperatively, topical betamethasone eye drops were used every 2 hours for the first week and then tapered over three weeks. Topical lubricant drops (0.7% methyl cellulose) were used every 3 hours for one month. Any retained suture was removed at four weeks. [Figure - 3] shows the preoperative photograph of double head pterygium and [Figure - 4] shows the postoperative photograph of the same eye one month after surgery. A recurrence was defined as fibrovascular tissue crossing the corneo-scleral limbus onto the clear cornea.

  Results Top

Six (85.72%) of 7 patients were males and the average age was 51.1 ± 15.2 years (30 - 70 years). The mean follow up was 17.7 ± 6 months (12 - 27 months).

Indications for surgery were visual impairment in 2 eyes (28.5%) and poor cosmesis in 5 eyes (71.4%). Preoperative uncorrected visual acuity was 6/60 in eyes with visual impairment, which improved to 6/9 postoperatively. One eye had Grade I nasal and temporal pterygia, 2 eyes had Grade II nasal and Grade I temporal pterygia, 3 eyes had Grade I nasal and Grade II temporal pterygia, and 1 eye had Grade III nasal and Grade I temporal pterygia. Recurrence of fibrovascular tissue crossing the limbus onto the cornea was not noted in any eye. Intra or postoperative complications were not noted. None of the eyes developed fibrosis at the conjunctival donor site.

  Discussion Top

Numerous surgical procedures have been recommended for pterygium excision, including bare sclera excision,[5] bare sclera excision with adjunctive measures like mitomycin C6,[7] or radiations,[8] excision with conjunctival graft,[2]-[5] amniotic graft[9],[10] or rotational auto graft.[11] An ideal pterygium surgery should achieve three principal goals: a low recurrence rate, absence of complications, and satisfactory cosmesis.[9] Conjunctival auto grafts have shown successful results and are widely accepted in the management of pterygium.[2]-[5] However, concerns have been raised to cover large conjunctival defects created in double-head pterygium; the technique of split-conjunctival graft described here is effective in managing double-head pterygium.

In this procedure the conjunctival graft including the limbal tissue was transplanted nasally, as the nasal limbus is reported to be more exposed to the UV radiation by internal reflection from the temporal limbus.[12] However, this technique cannot be used in eyes in which the conjunctiva is already scarred from previous surgery or if the conjunctiva has to be preserved for future glaucoma-filtering surgery. In summary, split-conjunctival graft appears to be a successful and safe technique in treating double-head pterygium.

  References Top

Demartini DR, Vastine DW. Pterygium In: Abbott RL, editor. Surgical Interventions for Corneal and External Diseases. Orlando, USA: Grune and Straton; 1987. p 141.  Back to cited text no. 1
Kenyon KR, Wagoner MD, Hettinger ME. Conjunctival autograft transplantation for advanced and recurrent pterygium. Ophthalmology 1985;92:1461-70.  Back to cited text no. 2
Allan BD, Short P, Crawford GJ, Barrett GB, Constable IJ. Pterygium excision with conjunctival autografting:   Back to cited text no. 3
An effective and safe technique. Br J Ophthalmol 1993;77:698-701.  Back to cited text no. 4
Rao SK, Lekha T, Bickol MN, Sitalaksami G, Padmanabhan P. Conjunctival-limbal autografts for primary and recurrent pterygia: technique and results. Indian J Ophthalmol 1998;46:203-6.  Back to cited text no. 5
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Tan DT, Chee SP, Dear KB, Lim AS. Effect of pterygium morphology on pterygium recurrence in a controlled trial comparing conjunctival autografting with bare sclera excision. Arch Ophthalmol 1997;115:1235-40.  Back to cited text no. 6
Avisar R, Snir M, Weinberger D. Outcome of double-headed pterygium surgery. Cornea 2003;22:501-3.  Back to cited text no. 7
Lam DSC, Wong AKK, Fan DSP, Chew S, Kwok PSK, Tso MOM. Intraoperative Mitomycin C to prevent recurrence of pterygium after excision. A 30 month follow up study. Ophthalmology 1998;105:901-04.  Back to cited text no. 8
Mackenzie FD, Hirst LW, Kynaston B, Bain C. Recurrence rate and complications after radiations for pterygium. Ophthalmology 1991;98:1776-81.  Back to cited text no. 9
Solomon A, Pires RTF, Tseng SCG. Amniotic membrane transplantation after extensive removal of primary and recurrent pterygia. Ophthalmology 2001;108: 449-60.  Back to cited text no. 10
Prabhasawat P, Barton K, Burkett G, Tseng SCG. Conjunctival autografts versus amniotic membrane graft for pterygia. Ophthalmology 1997;104:974-85.  Back to cited text no. 11
Jap A, Chan C, Lim L, Tan DT. Conjunctival rotational autograft for pterygium. An alternative to conjunctival autografting. Ophthalmology 1999;106:67-71.  Back to cited text no. 12


  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]

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