Comparison Of Surgical Outcomes Of Primary Pterygium Surgery And Diffuse Keratoconjunctival Proliferation- A 5 Year Study.

To compare the outcomes of surgical excision with autoconjunctival transplant of Pterygium and Diffuse Keratoconjunctival Proliferation (DKP), a rare known variant of pterygium. DKP is aggressive with widespread limbal and corneal involvement often leading to limbal stem cell deficiency. DKP is histologically distinct from pterygia showing subepithelial collagenous degeneration with absence of elastotic material compared to pterygium which is primarily an elastotic degeneration of the sub conjunctival tissue. Surgical management of Pterygium and DKP are similar involving excision of lesion with conjunctival autograft or amniotic membrane transplantation with or without adjunctive use of mitomycin-C (MMC) and or 5 Fluorouracil (5-FU).

This retrospective study covering a period of 5 years included patients treated in the Ophthalmology department of Nottingham University Hospitals NHS Trust. Surgeries were performed by two surgeons HSD and DGS and their team. The study was performed as a Healthcare improvement audit. Confidentiality of the patient data was maintained.

A total of 60 patients, 32 females and 28 males with included in this study. Patients were grouped in two categories, Pterygium (51 cases) and DKP (9 cases). 59 patients in both groups underwent pterygium/DKP excision with conjunctival autograft affixed with fibrin glue. 29 cases had MMC application to the sclera, two cases had intrastromal Avastin injection and 2 cases AMT. Patients had three follow-up appointments on average of 1 week, 1 month and 3 months from surgery when patient were discharged if the condition had resolved. Demographic and ophthalmic data were analysed with descriptive statistics including percentage frequency distribution.

The patients’ age range was between 32-83 years. Majority of the patients had achieved complete resolution and were discharged after the final visit. Of the 4 eyes with recurrence 3 eyes were treated with 3 x weekly subconjunctival injection of 5-FU. One early recurrence responded to topical steroids. 2 cases had Dellen and 10 cases had epithelial defects in the conjunctival autograft epithelium, of which four cases had MMC application during surgery. In all these cases the conjunctival graft healed and were healthy on discharge.  

This study demonstrates that pterygium/DKP excision with conjunctival autograft affixed with fibrin glue is an effective procedure leading to resolution of condition in a high percentage of cases. Those who had a recurrence responded effectively to postoperative sub conjunctival 5FU treatment thus avoiding any repeat surgeries. Severe DKP cases required longer follow up to monitor for recurrences and had visual involvement at the time of presentation which didn’t improve significantly following surgery. We have also noted that that using fibrin glue rather than sutures for attachment of conjunctival autograft was cost effective, reduced surgical times and improved patient comfort.