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Possible correlation of plica-limbal distance with the presence of primary medial pterygium

Possible correlation of plica-limbal distance with the presence of primary medial pterygium

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iMedPub Journals
2010Vol.1No. 2:4
doi: 10:3823/411
Possible correlation o plica-limbal distance with the presence o primarymedial pterygium
Herman Christiaan Izaak Themen
, Dennis Ricardo August Mans
, Robbert Bipat
, Denise JudithDoelwijt
, Dineshpersad Jiawan
, Annemarie Thelma Bueno de Mesquita-Voigt
Department o Ophthalmology, Academic Hospital Paramaribo, Paramaribo, Suriname;
Department o Ophthalmology, Faculty o Medical Sciences, Anton de Kom University o Suriname;
Department o Pharmacology, Faculty o Medical Sciences, Anton de Kom University o Suriname;
Department o Physiology, Faculty o Medical Sciences, Anton de Kom University o Suriname
Running title
: Plica-limbal distance and pterygium
Key words
: primary medial pterygium; plica-limbal distance; inverse correlation
Correspondence to
: H. Themen, MD, Department o Ophthalmology, Academic Hospital Paramaribo, Flustraat 1, Paramaribo, Suriname. Tel: 597442222 # 585. Fax: 597 441071. E-mail: hthemen@gmail.com
Pterygium is a common surace lesion o the conjunctiva thatoten encroaches onto the cornea and is usually located me-dially at the limbus. The overgrowth o conjunctival tissue ispresumably triggered by inammation caused by chronic irri-tation. Although in general asymptomatic, it may progress toan inammatory, invasive, and prolierative lesion, particularlyater recurrent surgical excision. The result is loss o bulbar con- junctival tissue and restriction o bulbar motility [1]. For thesereasons, pterygium is among the most complex and dicult-to-manage common diseases o the conjunctiva. The exact cause o pterygium is unknown. However, long-termexposure to direct and reected sunlight - especially ultraviolet
© Under License o Creative Commons Attribution 3.0 License This article is available rom:http://www.transbiomedicine.com
B (UV-B) rays - as well as chronic eye irritation caused by wind-blown dust, sand, ice, and snow, presumably play an importantrole in its development [2]. This may account or the relativelyhigh prevalence o pterygium in areas near the equator and indiverse groups such as Australian Aboriginals, Pacic Islanders,and Eskimos [3]. No incidence rates are available, but worldwi-de prevalence rates are between 3 and 10% [3]. Reports on themale-to-emale distribution are conicting [6-11], but elderlypeople seem to be more susceptible than younger individuals[6-11], with onset most common in individuals aged between20 and 30 years [3-8].Converging lines o evidence suggest the involvement o seve-ral anatomical and mechanical changes and the generation o tractional orces in the development o pterygium. Firstly, the
Loss o elastic properties, the introduction o tractional orces, and shortening o the plica-limbal distance(the distance between the nasal limbus and the semilunar plica bottom in ull abduction) are common anatomical ab-normalities in eyes o patients with primary medial pterygium. In this study, we assessed whether, and to which degreethe latter phenomenon correlated with the presence o pterygium.
Methods and fndings
: Plica-limbal distance was measured using a slit lamp in individuals who came or routine eyeexamination, and was related to pterygium size, as well as to patients’ gender and age. Data were expressed as means(95% CI). Eighty-three males and 118 emales were enrolled in the study. There were 49 eyes rom patients with uni-lateral pterygium, 84 rom patients with bilateral pterygium, and 220 rom individuals who did not sufer rom eitheruni- or bilateral pterygium. The mean plica-limbal distance in eyes with pterygium (7.3 mm, 95% CI: 6.9 – 7.7 mm) wassignicantly shorter than that in eyes without pterygium (9.9 mm, 95% CI: 9.7 – 10.1 mm). Plica-limbal distance corre-lated inversely with pterygium size (r2 = 0.32, p < 0.0001), was not related to gender, but decreased with increasing agein both individuals with and without pterygium.
: Our results suggest that plica-limbal distance correlated inversely with the presence o pterygium. Thisnding may have important consequences or the identication o individuals at risk, as well as or improvement o thetreatment o this condition.
iMedPub Journals
2010Vol.1No. 2:4
doi: 10:3823/411
ormation o pterygium under the inuence o UV-B is accom-panied by the excessive production o matrix metalloproteina-ses in ocular epithelial cells [9,10]. This may promote the degra-dation o brillar collagen, which may result in loss o the elasticproperties o primary pterygium tissue and the introduction o traction in the pterygium tissue. Also, subconjunctival bro-vascular tissue o pterygia contains an appreciable number o contractile myobroblasts [11]. This has been indicated by animmunohistochemical and ultrastructural assessment o surgi-cally removed primary and recurrent pterygia and exenteratedeyes without pterygia, and may also lead to contraction, restric-ting eye motility even more. Furthermore, a study on the de-velopmental relationship between semilunar temporal ectopiaand primary nasal pterygia not only substantiated the presenceo tractional orces in pterygium, but also that these orces wereoperating at both pterygium ends [12].Notably, using a bovine eye model along with computer-assis-ted ray-tracing techniques to model limbal ocusing, the nasalpart o the conjunctiva was shown to be more exposed to lightwhen compared to the temporal part [13]. This may provide anexplanation or the location o most pterygia at the medial lim-bus, in the junction between the sclera and the cornea on thenasal side [13]. In addition, since the nasal part o the conjuncti-va is shorter than the temporal part, it can be argued that theormer may be more susceptible to traction with eye and lidmovements when compared to the latter. Together, the data mentioned above suggest that the develo-pment o pterygium is accompanied by tractional orces whichmay pull stronger at the nasal than at the temporal side. I true,the possibility exists that such orces may progressively shortenthe distance between the nasal limbus and the semilunar plicabottom – the plica-limbal distance – during pterygium orma-tion. In this study, we searched or indications or this hypothe-sis by determining distances between the nasal limbus and thesemilunar plica bottom in maximum abduction in eyes with pri-mary medial pterygium, and comparing these ndings to thosewith eyes without pterygium. The data obtained were also re-lated to pterygium size which can be taken as an indication orthe degree o pterygium progression [14]. Because the diseasemay or may not have a predilection or either gender [3-8] andmay maniest preerentially in older than in younger individuals[3-8], the data were also related to patients’ gender and age atthe time o diagnosis.
Patients and methods
Study population
 This study was carried out at the Department o Ophthalmolo-gy o the Academic Hospital Paramaribo (Paramaribo, Republico Suriname) and its auxiliary branch in Nickerie (Republic o Suriname), and at a private practice in Paramaribo, in the pe-
© Under License o Creative Commons Attribution 3.0 License This article is available rom:http://www.transbiomedicine.com
riod between January 2004 and April 2009. Individuals whowere included in the study were between 7 and 100 years o age, had presented or routine eye examination or mainly re-raction anomaly, or had been diagnosed with pterygium. Tocertiy that all pterygia studied had developed in an untroubledway and were located at the semilunar plica, only eyes with pri-mary medial pterygium were included. Eyes with either motilityrestrictions, or surgical scars or visible pathologies in the plica-limbal area, were not eligible. Eyes in which the plica-semilunartemporal or bulbar old bottom mark was not visible were alsoexcluded. All individuals included in the study had given theiroral consent ater having been inormed o its aims. The studydesign had been approved by the Ethics Committee o the Aca-demic Hospital Paramaribo.
Determination o plica-limbal distance and pterygium size
Plica-limbal distance was determined by measuring the distan-ce in mm rom the temporal or bulbar part o the semi-lunarold bottom mark to the limbus in ull abduction (Figure 1).Pterygium size was determined by measuring the distance inmm rom apex to limbus (Figure 1), as has been done in a pre-vious study [15].
Figure 1. Measurement o the plica-limbal distance in an eye in maximum abduction. A: pli-ca semilunaris, B: light reection o slit lamp, C: limbus. Subject has given oral and writtenpermission to publish photograph.
For measurements, subjects’ heads were held straightorwardbehind a Haag-Streit 900 slit lamp (Bern, Switzerland) with mi-nimum and maximum slit lengths o 1 and 8 mm, respectively. The margins o the slit had to be clear when reading the dis-tances. Plica-limbal distances greater than 8 mm were determi-ned by projecting one end o the 8-mm slit on the vertical linethrough the center o the temporal or bulbar plica bottom area,turning the slit perpendicular to this line, pointing perpendicu-lar at the vertical tangent o the limbus in the horizontal meri-dian, searching or a marking point - usually a blood vessel inthe conjunctiva - and rom that point on measuring urther tothe limbus in the horizontal meridian. When measuring ptery-gium size, distances less than 1 mm were estimated at 0.25,
iMedPub Journals
2010Vol.1No. 2:4
doi: 10:3823/411
0.50, or 0.75 mm. All measurements were perormed by thesame person.
Data processing
Plica-limbal distances and pterygium sizes o eyes o patientswith both unilateral and bilateral pterygium were averaged,and compared to those o the means o eyes o patients whodid not sufer rom this condition. Comparisons were madeusing Student’s t-test (95% CI). Diferences were considered sta-tistically signicant with p < 0.05.
Patient characteristics
In the period covered by the study, a total o 201 individuals(83 males and 118 emales) presented or routine eye exami-nation or mainly reraction anomaly. There were 49 eyes rompatients with unilateral pterygium, 84 eyes rom patients withbilateral pterygium, and 220 eyes rom individuals who did notsufer rom either uni- or bilateral pterygium. The median age o the individuals without pterygium was 37 years (range 7 – 100years), that o those with pterygium was 52 years (range 12 – 87years).
Plica-limbal distance o eyes with and without pterygium
 The mean plica-limbal distance in the group o patients withboth unilateral and bilateral pterygium was 7.3 mm (95% CI:6.9 – 7.7 mm), that in the group o patients without pterygium9.9 mm (95% CI: 9.7 – 10.1 mm) (Figure 2). This diference wasstatistically signicant (p < 0.0001), suggesting that the averageplica-limbal distance o eyes with pterygium was approxima-tely three-quarters o that o eyes without pterygium.
© Under License o Creative Commons Attribution 3.0 License This article is available rom:http://www.transbiomedicine.com
Relationship between pterygium size and plica-limbaldistance
 To explore to which degree plica-limbal distance was associa-ted with pterygium size, plica-limbal distances o all eyes withpterygium were plotted against their respective size. As shownin Figure 3, linear regression o this plot generated a straightline (r
= 0.32, p < 0.0001), suggesting that plica-limbal distancewas inversely related to pterygium size.
Plica-limbal distance and gender
 There were 54 women and 38 men with uni- or bilateral ptery-gium. As shown in Figure 4, the mean plica-limbal distance o eyes o males with pterygium did not difer signicantly romthat o emales sufering rom the disease (7.8, CI 7.3 – 8.4, and7.0, CI 6.5 – 7.5), respectively). The same held true or plica-lim-bal distances o eyes without pterygium (10.4, CI 10.1 – 10.7,and 9.6, CI 9.3 – 9.8, respectively).
Plica-limbal distance and age
Figure 5 depicts the relationship between plica-limbal distanceso individuals with or without pterygium, and age. Plica-limbaldistance decreased in eyes with pterygium at the same rate asin eyes with pterygium with older age (average 0.02 – 0.03 mm/year), suggesting that this phenomenon was a general age-as-sociated phenomenon. However, plica-limbal distances in eyeswith pterygium were at every age consistently shorter whencompared to eyes without pterygium with a mean diferenceo 2.5 mm.
Figure 2. Mean (CI 95%) plica-limbal distance (mm) in eyes o individuals without (pt -) and inthose o individuals with uni- or bilateral pterygium (pt +).Figure 3. Relationship between plica-limbal distance (mm) and pterygium size (mm).

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