182 Vol. 31, No. 4, Oct – Dec, 2015 Pakistan Journal of Ophthalmology Original Article Comparison of Pterygium Resection with Conjunctival Auto Graft Versus Amniotic Membrane Graft Adnan Alam, Mubashir Rehman, Bilal Khan, Khurshid Alam, Adnan Ahmad Pak J Ophthalmol 2015, Vol. 31 No. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . See end of article for authors affiliations …..……………………….. Correspondence to: Adnan Alam Trainee Medical Officer, department of Ophthalmology, Lady Reading Hospital Peshawar …..……………………….. Purpose: To compare the effectiveness of pterygium resection with conjunctival auto graft versus amniotic membrane graft in terms of recurrence rate. Material and Methods: All patients were selected from eye OPD Lady Reading Hospital, Peshawar. Complete slit lamp examination was performed for pterygium. Patients were divided into two groupsi. e Group A who underwent pterygium excision with conjunctival autograft and Group B who underwent pterygium excision with amniotic membrane graft. Follow up was on 3 rd month postoperatively at which patient was examined on slit lamp for recurrence of pterygium. Results: The recurrence rate in conjunctival autograft was 10% while the recurrence rate in amniotic membrane graft was 18%. Conjunctival autograft was effective in 90% patients and was not effective in 10% patients, whereas amniotic membrane graft was effective in 82% patients and was not effective in 18% patients. Conclusion: Our study concludes that performing pterygium surgery with amniotic membrane graft compared to conjunctival autograft had a higher recurrence rate. Key words: Primary pterygium, Conjunctiva autograft, Amniotic membrane graft. terygium is an abnormal fibrovascular conjunctival tissue which encroaches the cornea.1 It is triangular in shape and is more frequently located nasally then temporally.2 Ocular irritation, hyperemia and vision loss are the most common clinical symptoms of pterygium.3 Early complaints e.g. foreign body sensation and inflammation are treated conservatively with artificial tears and anti-inflammatory drops to give symptomatic relief.4 However surgical excision remains the main treatment for pterygium causing visual impairment, cosmetic deformity, restriction of ocular motility or marked irritation or discomfort unrelieved by medical management.5 Recurrence is the most common postoperative complication after pterygium excision.5 In the past pterygium was treated surgically with bare scleral technique.2 However this technique had a very high recurrence rate of about 24 – 89%.2 Various techniques have been applied in the recent years to reduce the recurrence rate which include pterygium resection combined with conjunctival auto-graft, conjunctival resection with ammotic membrane graft and conjunctival resection with stem cell transplantation.6 Surgical excision with conjunctival auto graft is not only safe and effective but it also reduces the recurrence rate.7 Amniotic membrane transplantation after surgical excision of pterygium also appeared to be safe and effective with reduced rate of recurrence.8 Purpose of our study is to compare the efficacy of pterygium resection combined with cojunctival auto P COMPARISON OF PTERYGIUM RESECTION WITH CONJUNCTIVAL AUTO GRAFT VERSUS AMNIOTIC MEMBRANE GRAFT Pakistan Journal of Ophthalmology Vol. 31, No. 4, Oct – Dec, 2015 183 graft versus pterygium resection combined with amniotic membrane graft in our population. Pterygium is a very common ocular disease presenting to eye department. Main treatment modality in our set up is surgical excision but majority of these patients presents again with complaints of recurrence which is the most common post-operative complication. It not only disturbs daily life of patient but also put economic restrain on them. Also these patients put extra burden on OPD and OT. So in this study we wanted to find out the surgical procedure which reduces the recurrence rate to reduce burden on both patients and hospital. MATERIAL AND METHODS All patients were selected from eye OPD, Lady Reading Hospital, Peshawar. Patients between the age of 20 to 50 years both males and females, with primary pterygium of size between 2 to 4 millimeter presenting within 6 months of onset were included in the study. (In our set up pterigium between 2 mm to 4 mm usually presents within 6 months of onset, long duration pterigium were excluded to avoid pterium larger in size than 4 mm) Patients with recurrent pterygium, pterygium associated with other chronic ocular surface disease, patients on long term topical steriods or topical NSAIDS, patients with previous history of any surgery on conjunctiva and patients with pterygium of size less than 2 mm and greater than 4 mm were excluded from the study. (pterigium of size 2 mm to 4 mm are more common so included in the inclusion criteria so as to make sample collection easier). Complete slit lamp examination was performed for pterygium. The purpose and benefits of the study was explained to all patients and if agreed upon a written informed consent was obtained. The amniotic membrane was only taken from those patients who have undergone cesarean section and properly screened out pre operatively. Patients were divided into two groupsi.e Group A who underwent pterygium excision with conjunctival autograft and Group B who were underwent pterygium excision with amniotic membrane graft. Follow up was on 3rd month postoperatively.(we have followed the patients every three monthly, so follow up of first visit mentioned. On postoperative visit patient was examined on slit lamp for recurrence of pterygium. Surgery was considered effective with no recurrence of pterygium and not effective with recurrence of at least 2 mm. The data was analyzed using SPSS version 16.Frequencies and percentages were calculated for categorical variables like gender, side of the eye and effectiveness. Mean and standard deviation were calculated for numerical variables like age and duration. Chi square test was used to compare the effectiveness of both groups. P value of less than or equal to 0.05 was considered significant. Effectiveness in both groups was stratified among age, side of the eye and gender to see the effect of modifiers. All the results were presented as tables and charts. Post stratification chi square test was applied. DISCUSSION Pterygium is one of the most common disorders in tropical and subtropical region including Pakistan9. The most important risk factors are exposure to sunlight, hot, windy dry weather and old age10. Short body height is also cited in literature as a risk factor for pterygiumdevelopment.11 (It has been mentioned in the literature for which reference no 11 is given) It causes irritation, redness and affects the visual acuity either by directly affecting the visual axis or by producing changes in the corneal curvature.12 Prabhasawatetal9 conducted study on a total of 120 eyes in which 106 eyes had primary and 14 eyes had recurrent pterygia and showed that at 6 month after surgery conjunctival auto grafts had a recurrence rate of 13.3%. In our study the recurrence rates in both groups were higher than those reported previously, possibly because of amount of subconjunctival tissue removal, race of our population, type of suture used and drug given after surgery. Tananuvat N et al10 in their study showed the recurrence rate of 12% in conjunctival auto graft group and 22% in amniotic membrane graft group which is in accordance to our study. Soloman A et al11 conducted study on 167 eyes, which included 148 primary and 19 recurrent pterygia. They showed that after 6 months the recurrence rate in the amniotic membrane graft group was 28.1%. With the longer follow-up, the recurrence rates were 25.0% and 12.3% for amniotic membrane graft and conjunctival graft respectively. Rahman L et al13 had shown that conjunctival auto grafts and amniotic membrane grafts differ in final appearance not only with respect to the rate of recurrence but also in the percentage of normal ADNAN ALAM, et a; 184 Vol. 31, No. 4, Oct – Dec, 2015 Pakistan Journal of Ophthalmology appearance. They suggested that covering the defect area with normal conjunctival tissue also has a higher likelihood of promoting the restoration of a normal appearance. In a study conducted by SaleemM et al14 it was shown that amniotic membrane contain a thick basement membrane and a vascular matrix. The basement membrane reinforces adhesion of basal epithelial cells, facilitates migration of epithelial cells, promotes epithelial differentiation and prevents epithelial apoptosis. All these features promote rapid epithelialisation. Narsani AK et al15 in their study showed that after pterygium excision, amniotic membrane grafts are less effective than conjunctival auto grafts in reducing recurrences. Even if there is a recurrence conjunctival auto graft should be considered as the first choice for pterygium excision. However amniotic membrane graft can also be considered as first choice in certain situations e.g. those with advanced and diffuse conjunctival involvement or when it is needed to preserve the bulbar conjunctiva for glaucoma surgery. In similar study Katbaab A et al16 first compared amniotic membrane graft (54) to a retrospective study using conjunctival auto graft (122) in both primary and recurrent pterygium. They noted that the recurrence rate is 10.9% using amniotic membrane graft, which is still higher than 2.6% of conjunctival graft. Nevertheless, both results of amniotic membrane grafts and conjunctival auto grafts are significantly better than the primary closer, which resulted in 45% high recurrence rate for primary pterygium which is comparable to our study. Fallah MR et al17 showed in their study that by removing larger amount of subconjunctival fibrosis tissue and injecting long acting steroids, amniotic membrane grafts achieved a recurrence rate of 3.0%, as compare to conjunctival auto grafts with a recurrence rate of 2.6%. Similarly Lateefur-rehman et al13 during follow up period, showed that recurrence of pterygia was high 41.33% in the patients with Bare sclera method as compared to recurrence 33.33% while using 5-Fluorouracil antimetbolite. Ashok Kumar Narsani et al15 showed that there was 7.69% recurrences in conjunctival auto graft as compared to 16.13% recurrences with amniotic membrane graft. RESULTS Age distribution among two groups is shown in Table 1. In group A mean age was 38 years ±3.19, where as in group B mean age was 38 years ±3.77. Gender distribution among two groups was analyzed as in group A 64(63%) patients were male and 38(37%) patients were female. Where as in group B66(65%) patients were male and 36(35%) patients were female in Table 2. Duration of pterygium between two groups was analysed as in group A 44 (43%) patients had pterygium form < 3 months while 58 (57%) patients had pterygium form > 3 months. Mean age was 3 months ± 2.16. Where as in group B 48 (47%) patients had pterygium form < 3 months while 54 (53%) patients had pterygium form > 3 months. Mean age was 4 months ± 2.99 Table 3. Laterality of pterygium among two groups was analyzed as in group A 57 (56%) patients had pterygium in left eye and 45 (44%) patients had pterygium in right eye. Where as in group B 54 (53%) patients had pterygium in left eye and 48 (47%) patients had pterygium in right eye Table 4. COMPARISON OF PTERYGIUM RESECTION WITH CONJUNCTIVAL AUTO GRAFT VERSUS AMNIOTIC MEMBRANE GRAFT Pakistan Journal of Ophthalmology Vol. 31, No. 4, Oct – Dec, 2015 185 Efficacy among two groups was analyzed as conjunctival autograft was effective in 91 (90%) patients and was not effective in 11 (10%) patients. Whereas amniotic membrane graft was effective in 83 (82%) patients and was not effective in 19 (18%) patients Table 5. Stratification of efficacy with age, gender and side of the eye is given in Table 6-8. ADNAN ALAM, et a; 186 Vol. 31, No. 4, Oct – Dec, 2015 Pakistan Journal of Ophthalmology CONCLUSION Our study concludes that performing pterygium surgery with amniotic membrane graft compare to conjunctival auto graft had a higher recurrence rate. Author’s Affiliation Dr. Adnan Alam Trainee Medical Officer Department of Ophthalmology Lady Reading Hospital, Peshawar. Dr. Mubashir Rehman Department of Ophthalmology Lady Reading Hospital, Peshawar. Dr. Bilal Khan Vitreoretina Trainee Department of Ophthalmology Lady Reading Hospital Peshawar. Dr. Khurshid Alam Trainee Medical Officer Department of Ophthalmology Hayatabad Medical Complex, Peshawar. Dr. Adnan Ahmad Junior Registrar, Department of Ophthalmology, Hayatabad Medical Complex, Peshawar. Role of Authors Dr. Adnan Alam Patient selection, data collection, results and discussion. Dr. Mubashir Rehman Patient selection, data collection, results and discussion. Dr. Bilal Khan Patient selection, data collection, results and discussion. Dr. Khurshid Alam Literature search. Dr. Adnan Ahmad Literature search. COMPARISON OF PTERYGIUM RESECTION WITH CONJUNCTIVAL AUTO GRAFT VERSUS AMNIOTIC MEMBRANE GRAFT Pakistan Journal of Ophthalmology Vol. 31, No. 4, Oct – Dec, 2015 187 REFERENCES 1. American Academy of Ophthalmology. Basic and Clinical Science Course. Section 8, External disease and cornea. San Francisco: American Academy of Ophthalmology 2004: 344. 2. 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