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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 115  |  Issue : 2  |  Page : 54-58

Evaluation of the outcomes of intraoperative subconjunctival injection of triamcinolone acetonide at the surgical site after pterygium excision using bare-sclera technique and mitomycin C


Department of Ophthalmology, Faculty of Medicine, Zagazig University, Zagazig, Egypt

Date of Submission10-Jan-2022
Date of Acceptance31-Jan-2022
Date of Web Publication08-Jul-2022

Correspondence Address:
MD Mohammed A Hegab
Lecturer of Ophthalmology, Department of Ophthalmology, Faculty of Medicine, Zagazig University, Faculty of Human Medicine-Zagazig University, Koliat Altob street, Zagazig, AlSharkia, 44519
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejos.ejos_3_22

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  Abstract 

Purpose To determine the role of the intraoperative triamcinolone acetonide application after pterygium excision using bare-sclera technique and mitomycin C (MMC).
Patients and methods This prospective randomized clinical study included 80 patients (80 eyes) who had primary pterygium and was done at the Alpha Center of Ophthalmology. In total, 40 eyes were treated by excision with bare-sclera technique with MMC combined with intraoperative subconjunctival triamcinolone-acetonide injection (group I) (steroid group), and the other 40 eyes were treated by excision with bare-sclera technique with MMC alone (group II) (control group). All patients were subjected to complete ophthalmic evaluation preoperatively and were followed up for 6 months postoperatively. The postoperative conjunctival inflammation rate at 1 week was the primary outcome measure, while the rate of pterygium recurrence 6 months postoperatively and intraocular pressure (IOP) was the secondary outcome measure. No complications developed intraoperatively or postoperatively.
Results The postoperative conjunctival inflammation was significantly higher in group II (45%) than group I (12.5%) (P=0.001). The recurrence rate of pterygium 6 months postoperative in group I was 7.5%, while in group II was 17.5%, which was statistically insignificant (P=0.176). The mean IOP 6 months postoperative in group I was 14.2±1.9, and in group II was 13.6±1.7, which was statistically insignificant (P=0.172). Pyogenic granuloma developed in one (2.5%) eye in group I and two (5%) eyes in group II.
Conclusion After pterygium excision using the technique of bare sclera and MMC, the intraoperative subconjunctival injection of triamcinolone acetonide at the surgical site was found to be beneficial in reducing the incidence of postoperative conjunctival inflammation without elevation of the IOP and decreasing the recurrence rate of the pterygium.

Keywords: conjunctival inflammation and recurrence, pterygium, triamcinolone acetonide


How to cite this article:
Elsayed TG, Dessouky RA, Salamah M, Hegab MA. Evaluation of the outcomes of intraoperative subconjunctival injection of triamcinolone acetonide at the surgical site after pterygium excision using bare-sclera technique and mitomycin C. J Egypt Ophthalmol Soc 2022;115:54-8

How to cite this URL:
Elsayed TG, Dessouky RA, Salamah M, Hegab MA. Evaluation of the outcomes of intraoperative subconjunctival injection of triamcinolone acetonide at the surgical site after pterygium excision using bare-sclera technique and mitomycin C. J Egypt Ophthalmol Soc [serial online] 2022 [cited 2022 Sep 28];115:54-8. Available from: http://www.jeos.eg.net/text.asp?2022/115/2/54/350290




  Introduction Top


Pterygium is an abnormal fibrovascular conjunctival tissue invading the cornea with subsequent diminution of vision due to irregular astigmatism. Pterygium may be caused by an altered proliferation of the epithelial cells and vascularization [1]. Ultraviolet radiation [2], viral infections [3], transition from epithelial-to-mesenchymal tissue [4], inflammatory processes [5], neovascularization upregulation, and deregulation of extracellular-matrix growth factors [6] are considered different factors affecting the pterygium formation. Also, according to Anguria et al. [7], inherited predisposition may be necessary for the development of pterygium. If pterygium affects the vision or causing recurrent inflammation and ocular discomfort, it should be surgically removed. Bare-sclera excision, amniotic membrane grafting, conjunctival rotational flap, and conjunctival autograft are all surgical techniques for pterygium treatment. Recurrence is the common pterygium operation complication [8]. The factors that influence recurrence are not completely known, yet they may be related to different patient and/or surgical factors [9]. A pterygium fleshy appearance and large size are associated with high recurrence rates, in accordance to the grading system that Tan et al. [10] developed. To reduce the recurrence rates postoperatively, many adjuvant therapies have been developed, such as various antimetabolites, beta-radiations, antiangiogenic agents, and other innovative approaches. This study aims to determine the role of the intraoperative triamcinolone-acetonide administration at the surgical site following pterygium excision utilizing the bare-sclera technique and mitomycin C (MMC).


  Patients and methods Top


At Alpha Center for Ophthalmology in Zagazig, we conducted this study. This study involved 80 individuals (80 eyes) with primary pterygium from October 2019 to July 2021, and they were treated by excision with bare-sclera technique with either MMC alone or combined with intraoperative triamcinolone acetonide subconjunctival. In accordance to the recurrence-rate mean from prior studies (2.7–38% [10],[11],[12],[13],[14]) using the bare-sclera method with MMC for pterygia, the sample size was calculated. Patients presented with primary pterygium of any age and both sexes attending to the Alpha Center were included in the study, while we excluded those who had recurrent pterygium. A random number table was utilized to split the 80 patients to an equal two sets. Group I (steroid group, 40 eyes) was treated with bare sclera and MMC with 4 mg of triamcinolone-acetonide intraoperative subconjunctival injection, and group II (control group, 40 eyes) was treated with bare sclera and MMC only. The Institutional Review Board of Alpha Center approved the study protocol before we started. A comprehensive ocular examination, best-corrected visual-acuity assessment, a slit-lamp examination, and an intraocular pressure (IOP) measurement had been done to each patient. The shape of pterygium was graded in accordance to Tan et al.’s [10] description, preoperatively. Atrophic pterygium (grade T1), fleshy pterygium (grade T3) in which the pterygium body completely obscured the episcleral vessels, and grade T2 for the shapes between grades T1 and T3 that have partially obscured episcleral vessels. All patients were provided with the whole study details and they gave the consent to participate before the operation. The postoperative conjunctival inflammation rate at 1 week was the primary-outcome measure, while the rate of pterygium recurrence 6 months postoperatively and IOP was the secondary-outcome measure. Under retrobulbar anesthesia and by one surgeon at the operation room, all operations were done. The pterygium body was excised 2 mm in front of the plica semilunaris, together with all subconjunctival fibrovascular tissue for 2 mm beyond the conjunctival edges, and the pterygium apex was excised above the cornea with a scalpel 11. The cauterization of bleeding vessels was kept to a minimum, and MMC had been administered for three minutes to the bare sclera and conjunctival edges using pieces of Weck-Cel surgical sponge soaked in 0.02% MMC, followed by a 100 ml of balanced salt solution to wash the surface, and interrupted 7-0 vicryl sutures had been utilized to connect the conjunctival edges to the underlying episcleral tissue leaving a bare scleral space, then on the completion of the operation procedure, patients in group I were injected a 4 mg of triamcinolone acetonide subconjunctivally around the site of operation, while patients in group II did not receive intraoperatively any steroid injections. Then postoperatively, a same course of a topical antibiotic and topical steroids were applied for 2 weeks and 3 months, respectively, for all patients. This topical-steroid therapy contained 0.1% betamethasone, five times per day for 1 month. Followed by 0.1% fluorometholone, four times per day for 2 weeks. Then three times daily for 2 weeks. Then twice daily for 2 weeks, and finally once daily for 2 weeks. A follow-up examination postoperatively was done for conjunctival inflammation detection and IOP measurement at 1 day, 1 week, and 1 month, and another follow-up examination was done for the detection of pterygium recurrence 3 and 6 months postoperatively.


  Results Top


The results of 80 patients (80 eyes) who had primary pterygium and were treated by excision and bare-sclera technique with either MMC alone or combined with intraoperative subconjunctival injection of triamcinolone acetonide were included in this study. No statistically significant differences between groups I and II were found regarding age, sex, and preoperative pterygium grade ([Table 1]).
Table 1 General characteristics in both groups

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In both groups, no complications were detected intraoperatively. The conjunctival inflammation around the site of operation was classified as 0, I, II, and III, which represents none, mild, moderate, and severe, respectively, at 1 week postoperatively. In group I (steroid group), the inflammation was observed in five cases and was graded as I (mild) in three (7.5%) eyes, II (moderate) in one (2.5%) eye, and III (severe) in one (2.5%) eye, while in group II (control group), the inflammation was observed in 18 cases and was graded as I (mild) in 10 (25%) eyes, II (moderate) in five (12.5%) eyes, and III (severe) in three (7.5%) eyes ([Table 2]). The postoperative conjunctival inflammation was significantly higher in group II (45%) than group I (12.5%) (P=0.001) ([Figure 1]).
Table 2 Inflammation at 1-week postoperative

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Figure 1 A statistically significant difference between both groups as regards the conjunctival inflammation 1 week postoperative.

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All cases with grade-II and grade-III postoperative inflammation were treated with a 4-mg triamcinolone acetonide, subconjunctival injection, and frequent topical betamethasone 0.1%. The conjunctival inflammation resolution in all cases had been occurred after injection. Postoperative outcome of the pterygium excision in both groups was followed using a grading system to detect the recurrence. The recurrence grade was I, II, III, and VI, which represents normal conjunctiva, the presence of only fine episcleral blood vessels, the presence of fibrovascular tissue but without corneal invasion (conjunctival recurrence), and true corneal recurrence with fibrovascular tissue invading the cornea [15], respectively. At the sixth month postoperatively, in group I, grade-II postoperative recurrence was observed in two (5%) eyes, and grade III was observed in one (2.5%) eye. On the other hand, in group II, grade-II postoperative recurrence was observed in four (10%) eyes, grade III was observed in two (5%) eyes, and grade IV in one (2.5%) eye. The recurrence rate observed in group I was 7.5%, while in group II was 17.5%, which was statistically insignificant (P=0.176).

At the nasal edge of the surgical area, pyogenic granuloma was developed in one (2.5%) eye in group I at 2 months after operation, and in two (5%) eyes in group II. One was detected at 1 month and the other at 2 months after operation. At 1 month postoperatively, one eye in group II developed grade-III conjunctival irritation and a significant granuloma. Despite the fact that subconjunctival triamcinolone injection resolved the conjunctival inflammation and granuloma, this case developed conjunctival recurrence 6 months after surgery ([Table 3]). In group I, an IOP increase was noticed in one eye, but it had been medically controlled. During the 6 months of follow-up, no MMC-related complications were found.
Table 3 Six-month intraocular pressure and recurrence rate in both groups

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Statistical methods

The SPSS version 25 (IBM, Armonk, New York, USA) was used to do the data management and statistical analysis. The Shapiro–Wilk test and direct data-visualization methods was used to assess the quantitative data for normality. As means and SDs, the numerical data were summarized, while as numbers and percentages, the categorical data were summarized. The independent t test was used to compare the quantitative data of the study groups, while the χ2 or Fisher’s exact test was used to compare the categorical data. All statistical tests were two-sided. P values less than 0.05 were significant.


  Discussion Top


This study had shown that the postoperative conjunctival inflammation detected 1 week was 45% in group II (control group). Application of steroid for management of postoperative conjunctival inflammation led to a low recurrence rate of pterygium following the operation. In this study, the intraoperative triamcinolone-acetonide injection effectively reduced the postoperative conjunctival inflammation and the recurrence of pterygium. Five (12.5 %) eyes in group I and 18 (45 %) eyes in group II showed conjunctival inflammation around the surgical site at 1 week postoperatively. In group I, the postoperative inflammation grades were I (mild) in three (7.5%) eyes, II (moderate) in one (2.5%) eye, and III (severe) in one (2.5%) eye. Meanwhile, in the control group, it was I in 10 (25%) eyes, II in five (12.5%) eyes, and III in three (7.5%) eyes. This conjunctival inflammation has previously been reported at rates of 15% or 31–84% with different surgical procedures such as conjunctival autograft and AMT without intraoperative steroid administration, respectively [16],[17],[18]. In this study, intraoperative triamcinolone-acetonide injection was linked to a decreased conjunctival inflammation rate at 1 week postoperatively (12.5 vs. 45%), a difference that was statistically significant (P=0.001). The triamicinlone-acetonide effects were still present as the conjunctival inflammation was assessed at 1 week postoperatively. This may account for the significant difference in conjunctival inflammation incidence among the two groups. Although the longer-acting steroids may be more effective to suppress the inflammation, it may also increase the steroid-related complication risk. At the sixth month postoperatively, in group I, grade-II postoperative recurrence was observed in two (5%) eyes, and III in one (2.5%) eye. On the other hand, in group II, grade-II postoperative recurrence was observed in four (10%) eyes, III in two (5%) eyes, and IV in one (2.5%) eye. The recurrence rate in group I was 7.5%, and 17.5% in group II, which was statistically insignificant (P=0.176). Excision of primary pterygium utilizing the method of bare sclera with the intraoperative MMC administration and without the injection of intraoperative steroid was reported to have a recurrence rate of 2.7–38%, and this is comparable to our results, in which intraoperative steroid injection reduced the recurrence rate from 17.5 to 7.5% [10],[11],[12],[13],[14]. The better results in the current research might be due to the subconjunctival fibrovascular tissue complete removal and the inflammation strict management with intraoperative or postoperative steroid injections [10],[11],[12],[13],[14].[19],[20] It was also noticed that subconjunctival steroid injections for postoperative conjunctival inflammation enhanced the surgical outcome of pterygium removal and reduced recurrence [16],[17],[18].

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Avisar R, Gaton DD, Loya N, Appel I, Weinberger D. Intraoperative mitomycin C 0.02% for pterygium: effect of duration of application on recurrence rate. Cornea 2003; 22:102–104.  Back to cited text no. 14
    
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