Saudi Journal of Ophthalmology (2018) 32, 110–113

Original Article

Comparison of conjunctival autograft and conjunctival

transposition flap techniques in primary pterygium surgery
Ayse Dolar Bilge ⇑

Abstract

Purpose: To investigate and compare the efficacy of conjunctival autograft and conjunctival transpositional flap for the treatment
of primary pterygium surgery.
Design: Retrospective, interventional case series analysis.
Materials and methods: Medical records of 48 patients who underwent pterygium surgery by conjunctival autograft or conjunctival
transpositional graft for primary pterygium surgery were reviewed. The conjunctival defects after pterygium excision were repaired
in 21 eyes with conjunctival autograft and in 27 eyes with conjunctival transpositional flaps. All operations were performed under
subconjunctival anesthesia using 8.0 vicryl sutures. Two groups were compared in terms of pterygium size, surgery time,
complications and pterygium recurrence.
Results: Mean pterygium size was 2.8 mm in conjunctival transpositional flap group, and 3.4 mm in conjunctival autograft group
(p < 0.01). Mean surgery time in conjunctival transpositional flap and conjunctival autograft groups was 15.9 and 21.7 min,
respectively. The haematoma formation under the graft was observed postoperatively in one eye of conjunctival autograft group.
The only one case of recurrence was observed in both conjunctival autograft and conjunctival transpositional flap groups (3.7% and
4.7%, respectively). Mean follow up time was 11.78 months in conjunctival transpositional flap group and 14.95 months in
conjunctival autografting group (p < 0.01).
Conclusion: Both conjunctival transpositional flap and conjunctival autograft techniques have same results in terms of pterygium
recurrence and surgery complications in the treatment of primary pterygium. Surgery time in conjunctival transpositional flap tech-
nique is significantly shorter. Conjunctival transpositional flap technique may be a good alternative method for primary pterygıum
surgery.

Keywords: Pterygium, Conjunctival transpositional flap, Conjunctival autograft

Ó 2017 The Author. Production and hosting by Elsevier B.V. on behalf of Saudi Ophthalmological Society, King Saud University.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
https://doi.org/10.1016/j.sjopt.2017.11.002

Introduction for the pterygium excision are chronic ocular irritation and
decreased vision secondary to induced astigmatism or occlu-
Pterygium is an overgrowth of fibrovascular tissue derived sion of the pupillary axis.2,3 The surgical techniques that are
from the conjunctiva, over the cornea, often with a wing-like being used at the present are bare sclera,4,5 primary
appearance, typically inducing astigmatism and leading to closure,6–8 amniotic membrane grafting, sliding or rotational
the loss of vision if occludes the pupil.1 The main indications flaps,11–13 conjunctival autografting,9,10 as well as adjuvant

Received 11 February 2017; received in revised form 5 November 2017; accepted 8 November 2017; available online 15 November 2017.

Emsey Hospital, Ophthalmology Department, Istanbul, Turkey

⇑ Address: Emsey Hospital, Camlik Mahallesi, Selcuklu Caddesi, No. 22, 34912 Pendik, Istanbul, Turkey.
e-mail address: [email protected]

Peer review under responsibility Access this article online:

of Saudi Ophthalmological Society, www.saudiophthaljournal.com
King Saud University Production and hosting by Elsevier www.sciencedirect.com
Comparison of conjunctival autograft and conjunctival transposition flap techniques 111

use in a combination with these techniques. Having similar poral conjunctiva was marked and a free graft was taken to
success rates, conjunctival transpositional flap technique is close the defect. The area was not inflated with lidocaine,
not only simpler but also less time consuming when com- in our practice we think by this method it is easier to obtain
pared to conjunctival autograft technique. thinnest conjunctiva and dissecting conjunctiva from the
In this retrospective review, we compared two techniques; Tenon’s. Limbal side of the autograft was placed on limbal
conjunctival transpositional flap and conjunctival autografting area of the defect. The graft was sutured with 8.0 separated
as the safe methods in the treatment of primary pterygium. polyprolene sutures.
After the surgery all the patients were prescribed dexam-
ethasone and tobramycine eye drops 4 times a day for 4
Patients and methods weeks.

The medical records of 47 consecutive patients who

underwent primery pterygium surgery with the cojunctival Results
autograft and conjunctival transpositional flap technique
between January 2009 and January 2011 were reviewed. A total of 48 eyes of 48 patients (13 female 35 male; age
Demographic characteristics of patients, pterygium size, sur- range 22–76 years; median age 55 years) were carried out
gery time according to anesthesia form, surgery outcome, excision of primer pterygium. The total number of eyes which
complications and follow up time were recorded. This study underwent primary pterygium excision followed by conjuncti-
was conducted in accordance with the tenets of the Declara- val autografting and conjunctival transpositional graft was 21
tion of Helsinki, and all patients gave informed consent. As (6 female 15 male; median age 53 years), and 27 (7 female 20
the study is a retrospective review of the medical data, insti- male; median age 57 years), respectively. The surgical proce-
tutional review board approval was not obtained for this dure was technically succesfull in all cases. In a patient who
study. underwent conjunctival autografting had hematoma forma-
The surgical procedure was performed under local anes- tion under the graft that totally disapeared spontaneously
thesia using lidocaine-bupivacaine mixture with monitored after 2 weeks. Postoperative follow-up time ranged from 6
anesthesia care. Surgical procedures were carried out under to 22 months (mean, 11.7 months). The conjunctival, corneal
subconjunctival anesthesia with lidocaine HCl 20 mg/ml with and anterior chamber changes at days 1, weeks 1 and 4 after
epinephrine 0.0125 mg/ml. The pterygium was cut near the surgery were recorded. The results at 6 weeks and 6 months
limbus by Wescott’s scissors, the head of the pterygium were analyzed and recurrence was defined as the presence of
was detached from the surface of the cornea and subconjunc- any fibrovascular growth crossing the limbus and extending
tival fibrous tissue was completely removed. Any abnormal over the cornea. There was no statistically significant differ-
fibrous tissues were removed with no 15 blade. Minimal cau- ence in terms of age and follow up time between the two
terization was applied. For conjunctival flap technique, flap groups (p > 0.05). Recurrence rates at 6 months in conjuncti-
was made from the inferomedial conjunctiva, near the limbus val autograft group and conjunctival transpositional flap
and margin of the defect. The flap thinly dissected avoiding group was 4.76% and 3.70%, respectively. Mean operating
the Tenon’s capsule, transposed to the defect area and time in conjunctival autograft group and conjunctival trans-
sutured separately with 8.0 polyprolene sutures (Figs. 1 and positional flap group was 21.76 min and 15.96 min, respec-
2). In conjunctival autograft technique, the area of inferotem- tively (t = 7.344, p < .001).

Fig. 1. Schematic steps of the primary pterygium excision and repair with conjunctival flap technique. a–c, Pterygium excision. d and e, Transpositional
flap preparation. f, Transpositional flap saturation to defect area.
112 A.D. Bilge

Fig. 2. Preoperative (a), postoperative day 1(b) and postoperative day 15 photos of a patient operated using conjunctival transpositional flap technique.

Dıscussıon higher, such as 31.3%, 33.3% in case of recurrent pterygium.

Taking into consideration further need for filtration surgery,
In this study we evaluated conjunctival transpositional flap we prepared conjunctival grafts from inferior quadrant. Koc
and autografting technique in terms of efficacy, safety, pre- et al. demonstrated that auto grafting from inferior or supe-
venting recurrences and shorting operating time. At the rior quadrants in primary pterygium caused no significant dif-
mean follow up of 14.95 and 11.78 months respectively, the ference in terms of recurrence.22
procedures seemed to be free from severe complications Rotational conjunctival flaps have been carried out since
and with low recurrence rates and satisfactory cosmetic 1940s23 with different recurrence rates ranges. Mc Coombes
appearances. Conjunctival auto grafting is considered to be and colleagues reported 3.2% recurrence rates by using slid-
the most effective method in the treatment of pterygium ing conjunctival flap technique.24 Alpay and colleagues
for many years.16 In our study we intended to emphasize that reported their recurrence rates as 33.33% by using flap tech-
conjunctival rotational flap method also has low recurrence nique in 18 patients but it’s not clear which flap has been
rate and can save extra surgery time if compared with con- used for repairing conjunctival defect.25 In our study we used
junctival autografting. transpositional flap and we think this technique has less tor-
The complication and recurrence rates of the pterygium sion effect on tissues and has better cosmetic results in an
surgery varies in the literature. We think that beyond the cho- early and late postoperative period. In our study we used
sen technique, the skills of a surgeon play an important role transposition flap and we think this technique has less torsion
in the success, so all our procedures were performed by effect on tissues and has better cosmetic results in an early
the one high skilled surgeon. and late postoperative period.
Although recurrence rates in two study groups are similar Finally, on occasion there is a need for a peribulbar anes-
(4.76% in conjunctival autograft group, 3.70% in conjunctval thesia and traction sutures in conjunctival autografting tech-
transpositional flap group) we think more studies with a nique while it is nearly unnecessary in transpositional flap
greater number of patients should be performed to get sta- technique. Also in transpositional graft technique there is
tistically significant recurrence rates. In general, pterygium no risk of graft loss and inversion, less time consuming and
recurrences occur during the first 6 months following the the vessel structure is preserved so healing process is better
surgery.14 In our study two patients had recurrences at post- we think that this method is safe and is a good alternative for
operative 3 and 4 months. conjunctival autografting, should be kept in mind in almost all
Conjunctival autograft transplantation was first described pterygium cases except huge ones which needs large size of
in 1985 by Kenyon and his colleagues.15 Many clinical studies grafting material.
report different recurrence rates. Syam et al. reported a
recurrence rate of 3.3% in their study of 27 eyes that under- Acknowledgement
gone conjunctival autografting which is similar to our results.
Koranyi et al.,18 Fernandes et al.,19 Ma et al.20 and Al Fayez The author would like to extend thanks to medical art/
et al.21 reported 13.5%, 12.2%, 5.4%, 8.3% recurrence rates illustrator Dr.Yesßim Kutlutürk for her great help in preparing
respectively. It was reported that these rates can be much figures.
Comparison of conjunctival autograft and conjunctival transposition flap techniques 113

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