CLINICAL SCIENCE
Comparison of Pterygium Recurrence Rates Among
Different Races and Ethnicities After Primary Pterygium
Excision by Surgeons in Training
Giovanni Campagna, BS,* Matthew Adams, MD, MBA,† Li Wang, MD, PhD,†
Sumitra Khandelwal, MD,† and Zaina Al-Mohtaseb, MD†
Purpose: To evaluate the impact of race and ethnicity, surgical
technique, and level of surgeon training on recurrence rates after
primary pterygium excision.
Methods: A retrospective review of patients who underwent primary
pterygium excision at our academic institution was performed. The
surgical technique—conjunctival autografting (CAG) or amniotic
membrane grafting (AMG)—was chosen at the attending surgeon’s
discretion, and all surgeries were performed by surgeons in training. The
primary outcome measure was pterygium recurrence, defined as
regrowth of fibrovascular tissue onto a clear cornea in the region of
previous pterygium removal.
Results: There was a significant difference in age at presentation
between white (64.3 6 11.4), Hispanic (50.0 6 13.5), black (64.8 6
14.5), and Asian (59.3 6 9.2) patients (P , 0.001). Average time to
recurrence was 4.4 6 3.0 months and was similar between races (P =
0.98). There was a significant difference in recurrence rates between the
white (13%), Hispanic (28%), black (33%), and Asian (0%) patients (P =
0.049). Over 12 months, a significant difference in cumulative proportion
with recurrence after AMG versus CAG was observed in Hispanic (75%
vs. 30%; P = 0.002) and black (100% vs. 42%; P = 0.001) patients. Sex,
method of graft fixation (glue, suture, or both), and level of surgeon
training showed no difference in pterygium recurrence (P . 0.05).
Conclusions: Hispanic and black patients are more likely to
experience pterygium recurrence after AMG than CAG. White
patients are less likely than Hispanic or black patients to experience
recurrence regardless of the surgical technique. To reduce the
likelihood of recurrence, surgeons may consider race and ethnicity
when selecting their operative technique.
Key Words: pterygium, recurrence, race, conjunctival autograft,
amniotic membrane graft
(Cornea 2017;0:1–6)
Received for publication July 20, 2017; revision received September 19,
2017; accepted October 3, 2017.
From the *School of Medicine, Baylor College of Medicine, Houston, TX; and
†Department of Ophthalmology, Cullen Eye Institute, Baylor College of
Medicine, Houston, TX.
The authors have no funding or conflicts of interest to disclose.
Reprints: Zaina Al-Mohtaseb, MD, Department of Ophthalmology, Cullen Eye
Institute, Baylor College of Medicine, 6565 Fannin, NC205, Houston, TX
77030, USA (e-mail: zaina@bcm.edu).
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Cornea  Volume 0, Number 0, Month 2017
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T he pathogenesis of pterygium involves genetic factors,
immunological mechanisms, and proinflammatory cyto-
kines, many of which are significantly driven by ultraviolet
(UV) light.1–5 In particular, UV-mediated limbal damage is
often implicated, and populations with greater exposure to
UV light show higher prevalence of pterygia.4 For exam-
ple, the prevalence of pterygia is 23.7% in Hispanic males
in Arizona6 and 29% in Samoan islanders7 but only 3% in
Canadians from British Columbia.8 The prevalence of
pterygia also differs among races and ethnicities living
within the same geographic location.9,10 These findings
suggest an inherent significance in the relationship between
pterygia and race.
The role of race as a risk factor for the development
of pterygium has been widely studied,6–11 but the exact
mechanism is not clear, and there is a need for research that
controls for race and environmental exposures.12,13 Even
less understood is the relationship between race and
pterygium recurrence. This is complicated by the fact that
many studies of recurrence enroll participants either of
mixed races or from the same racial group,11,14–16 so
potential underlying differences in recurrence as a function
of race are obscured by the assumed homogeneity of the
study population. Hispanic race may play a role in
recurrence,12 and recurrence rates after conjunctival auto-
grafting (CAG) and amniotic membrane grafting (AMG) in
Hispanic patients have been reported as high as 25% and
35%, respectively.15
When recurrence occurs, there is a 50% chance that it
will happen within the first 120 days and a 97% chance that
it will happen within 12 months of excision,17 which
suggests that a 1-year follow-up time is likely required to
identify recurrence. Our primary objective was to examine
the rates of recurrence after pterygium excision within 1
year after CAG or AMG in relation to race and ethnicity at
a large southern academic institution. To our knowledge,
this is the first comparison of outcomes of different races
after primary pterygium excision through 2 different
surgical modalities.
MATERIALS AND METHODS
Participants and Study Design
In this retrospective chart review, medical records were
examined of all patients who underwent primary pterygium
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Campagna et al
excision at Ben Taub General Hospital (BTGH) and the
Michael E. DeBakey Veterans Affairs Medical Center
(MEDVAMC) from January 2009 to January 2016. Data
recorded for each patient included race, ethnicity, sex, age,
preoperative astigmatism, length of follow-up, presence of
recurrence, time to recurrence, presence of postoperative
complications, time to postoperative complications, method
of the surgical technique (CAG or AMG), method of graft
fixation (glue, suture, or both), and level of surgeon training
(PGY-3, PGY-4, or PGY-5). Patients were excluded if any of
the following conditions were met:
1. The patient underwent previous corneal transplantation
2. The patient was lost to follow-up before 1
month postoperatively
3. Mitomycin C was used
4. Patient underwent excision of recurrent pterygium.
Following exclusion criteria, a total of 234 cases were
identified. Sixteen patients were found to have primary
pterygia of both eyes and underwent separate excisions. For
these patients, only the first eye was included to reduce
covariance. Thus, 218 unique cases of primary pterygium
excision were included. Our patients self-identified as “Cau-
casian, non-Hispanic,” “Caucasian, Hispanic,” “Black or
African-American, non-Hispanic,” or “Asian.” We refer to
these groups as “white,” “Hispanic,” “black,” and “Asian,”
respectively, throughout.
All study procedures adhered to the principles outlined in
the Declaration of Helsinki for research involving human
subjects, and the research and methods were HIPAA compliant.
Institutional review board/ethics committee approval was ob-
tained from Baylor College of Medicine (BCM) and
the MEDVAMC.
Surgical Techniques
Pterygium excision was standardized as follows:
written consent was obtained before each procedure. Stan-
dard povidone–iodine 5% sterile preparation was performed
on each eye. Retrobulbar anesthesia with a 50:50 mixture of
1% lidocaine without epinephrine and 0.075% bupivacaine
was used. After insertion of a lid speculum, pterygium tissue
was measured from the limbus to the head of pterygium. The
pterygium head was removed by blunt dissection using
forceps and Westcott scissors. Subconjunctival Tenon tissue
was separated from the overlying conjunctiva and excised
superiorly and inferiorly toward the fornices, and medially
or laterally. Surrounding conjunctiva was trimmed to create
a rectangular bed of the bare sclera. A diamond tip burr was
used to polish the corneal and limbal surfaces.
Conjunctival Autograft
A conjunctival autograft matching the rectangular bare
sclera bed was harvested from superotemporal bulbar con-
junctiva with forceps and Westcott scissors. Tisseel glue was
used to affix the graft onto the bare sclera in some patients,
and interrupted stitches of 8-0, 9-0, or 10-0 nylon buried
sutures were used to secure the graft in other patients. Some
patients required both glue and suture.
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Cornea  Volume 0, Number 0, Month 2017
Amniotic Membrane Graft
The fresh frozen amniotic membrane graft
(AmnioGraft; TissueTech Inc, Doral, FL) was cut to the
same size as the conjunctival defect using Westcott
scissors. Tisseel glue was used to affix amniotic mem-
brane onto the bare sclera in some patients, and interrupted
stitches of 8-0, 9-0, or 10-0 nylon buried sutures were used
to secure amniotic membrane in other patients. Some
patients required both glue and suture.
Neomycin, polymyxin B sulfate, and dexamethasone
ointment (Maxitrol; Alcon Laboratories Inc, Fort Worth, TX)
was placed in all eyes immediately postoperatively, and
a pressure patch was applied. Patients received prednisolone
acetate 1% (Pred Forte; Allergan, Irvine, CA) 4 to 6 times
daily, tapered over 3 months. All surgeries were performed by
BCM surgeons in training under supervision of an attending
faculty ophthalmologist. Patients followed up with BCM
ophthalmology residents and attendings 1 day, 1 week, 1, 3, 6
months, and 1 year after operation. At these visits, patients
were evaluated for postoperative complications
and recurrence.
Outcome Measures
The primary objective was to determine whether and
how race and ethnicity are associated with recurrence after
primary pterygium excision and CAG or AMG. Similarly,
performance of each race relative to the other races after
excision was investigated. Secondary outcome measures
included whether and how the method of graft fixation after
CAG or AMG affected recurrence. The association between
recurrence rates and the level of resident surgeon training was
also measured. Finally, demographic factors such as age and
sex and their associations with recurrence were investigated
among the races.
Statistical Analysis
Significance was assessed with the x2 test or Fisher
exact test for categorical data and with 1-way analysis of
variance for numerical data. The Bonferroni correction
was applied for those with significance on analysis of
variance. Logistic regression was used to identify patient
factors associated with pterygium recurrence. Recurrence
over time was assessed using the Kaplan–Meier method,
and significance was determined through log-rank analysis.
P , 0.05 was considered statistically significant. All
statistics were performed using Stata/IC 15.0 statistical
software package.
RESULTS
The demographic characteristics of all patients are
detailed in Table 1. Males accounted for approximately
94% of white patients, 65% of Hispanic patients, 100% of
black patients, and 33% of Asian patients (P , 0.001). The
recurrence rate was significantly different among the 4 races
(13% white, 28% Hispanic, 33% black, and 0% Asian; P =
0.049). Mean age at recurrence, 51.9 6 13.9 years, did not
differ among races (P = 0.08).
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Cornea  Volume 0, Number 0, Month 2017 Comparison of Pterygium Recurrence Rates

The exact size of the pterygia preoperatively was not
available for all patients, but preoperative topography was
available in most cases (92.2%). Mean pterygium astigmatism
was 4.0 6 2.8 diopters (D) among whites, 4.6 6 2.5 D among
Hispanics, 3.6 6 2.6 D among blacks, and 6.2 6 5.3 D
among Asians, which was not statistically significant (P =
0.1). The average length of follow-up after excision was 7.3
6 4.7 months among whites, 5.3 6 3.9 months among
Hispanics, 5.5 6 4.4 months among blacks, and 5.5 6 5.4
months among Asians (P = 0.016). Only whites and
Hispanics differed significantly on multiple comparison
analysis (P = 0.009). There was no significant difference
among different races in the proportion of cases available for
follow-up evaluation at 6 months (P = 0.86), but a difference
was observed at 12 months (P = 0.013). Despite this
difference, the mean time to recurrence among all races was
4.4 6 3.0 months and did not differ among races (P = 0.98).
Logistic regression for recurrence as a function of
different preoperative factors stratified by race is shown in
Table 2. Regression analysis could not be performed for
Asian race because of the small sample size. Among whites,
young age at presentation was associated with recurrence
[odds ratio (OR) = 0.93, 95% confidence interval (CI) = 0.87–
0.99, P = 0.031]. The choice of AMG rather than CAG as the
surgical technique was associated with recurrence among
both Hispanics (OR = 3.41, CI, 1.48–7.88, P = 0.004) and
blacks (OR = 22, CI, 1.54–314, P = 0.023). Sex, method of
graft fixation, and level of surgeon training were not
associated with recurrence.
Log-rank analysis of recurrence as a function of race,
method of graft fixation, and level of surgeon training for
CAG cases and AMG cases is shown in Table 3. Log-rank
analysis showed a significant difference in recurrence
between the races among AMG cases (P = 0.003) but not
CAG cases (P = 0.44). Kaplan–Meier survival curves of
recurrence after CAG versus AMG for each race that expe-
rienced recurrence is depicted in Figure 1. Pterygium excision
after AMG showed greater recurrence than CAG among
Hispanic (P = 0.002) and black (P = 0.001) patients but not
among white patients (P = 0.12).
The most common postoperative complication was
dellen formation, which occurred in 1 white patient (1.5%),

TABLE 1. Demographics and Characteristics of Pterygium Cases

White (n = 68) Hispanic (n = 126) Black (n = 18) Asian (n = 6) Total (n = 218) P
Affected eye† 0.37
OD 37 (54%) 70 (56%) 9 (50%) 1 (17%) 117 (54%)
OS 31 (46%) 66 (44%) 9 (50%) 5 (83%) 111 (46%)
Sex† ,0.001*
Male 64 (94%) 82 (65%) 18 (100%) 2 (33%) 166 (76%)
Female 4 (6%) 44 (35%) 0 (0%) 4 (67%) 52 (24%)
Recurrences‡ 9 (13%) 35 (28%) 6 (33%) 0 (0%) 50 (23%) 0.049*

Age (yr)§ 64.3 6 11.4 50.0 6 13.5 64.8 6 14.5 59.3 6 9.2 55.9 6 14.6 ,0.001*
Age with recurrence (yr)§ 56.3 6 14.2 49.1 6 13.0 61.3 6 15.0 — 51.9 6 13.9 0.08
Time to recurrence (mo)§ 4.2 6 3.7 4.4 6 2.7 4.5 6 3.8 — 4.4 6 3.0 0.98
Cases available for follow-up†
3 mo 53 (78%) 92 (73%) 15 (83%) 2 (33%) 162 (74%) 0.08
6 mo 41 (60%) 72 (57%) 12 (67%) 3 (50%) 128 (59%) 0.86
12 mo 40 (59%) 44 (35%) 9 (50%) 2 (33%) 95 (44%) 0.013*
Surgical technique‡ 0.12
CAG 50 (74%) 79 (63%) 13 (72%) 6 (100%) 148 (69%)
AMG 18 (26%) 47 (37%) 5 (28%) 0 (0%) 70 (31%)
Method of graft fixation† 0.95
Glue 46 (68%) 81 (64%) 11 (61%) 4 (67%) 142 (65%)
Suture 11 (16%) 16 (13%) 3 (17%) 1 (17%) 31 (14%)
Glue and Suture 11 (16%) 29 (23%) 4 (22%) 1 (17%) 45 (21%)
Level of surgeon training† 0.013*
PGY-3 1 (1%) 20 (16%) 1 (6%) 0 (0%) 22 (10%)
PGY-4 24 (35%) 53 (42%) 8 (44%) 4 (67%) 89 (41%)
PGY-5 43 (64%) 53 (42%) 9 (50%) 2 (33%) 107 (49%)
Data are presented as n (%) or mean 6 SD.
*Denotes statistical significance.
†Analysis performed with the x2 test.
‡Analysis performed with the Fisher exact test.
§Analysis performed with 1-way analysis of variance; post hoc testing using the Bonferroni test of multiple comparison.

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Campagna et al Cornea  Volume 0, Number 0, Month 2017

This was not true of our white patients, who showed no

TABLE 2. Logistic Regression of Factors Associated with
difference in recurrence over time with either surgical
Pterygium Recurrence
technique (P = 0.12). These findings suggest that it is prudent
Race OR 95% CI P to question whether and how the mechanisms of pterygium
Sex white 0.43 0.04–4.64 0.49 fibroblast inhibition by AMG after primary pterygium
Hispanic 1.41 0.60–3.29 0.43 excision differ in Hispanic and black patients from white
black — — — patients. This has great clinical significance because surgeons
Age white 0.93 0.87–0.99 0.031* may reduce the likelihood of recurrence by considering
Hispanic 0.99 0.96–1.02 0.65 patient race when selecting their surgical technique.
black 0.97 0.91–1.04 0.46 The prevailing theory of pterygium recurrence maintains
Surgical technique† white 2.65 0.62–11.3 0.19 that postoperative inflammation activates subconjunctival fibro-
Hispanic 3.41 1.48–7.88 0.004* blasts,18,19 leading to hyperproliferation, overexpression of
black 22.0 1.54–314 0.023* proinflammatory cytokines,1,3,20 and increased deposition of
Method of graft fixation white 1.57 0.65–3.76 0.32 extracellular matrix proteins,21 resulting in recurrence. To
Hispanic 1.06 0.67–1.69 0.81 counter these mechanisms, amniotic membrane suppresses
black 1.13 0.35–3.65 0.84 various signaling pathways of pterygium fibroblasts.18,22,23
Level of resident white 0.77 0.21–2.87 0.7 Although differences in activity of fibroblastic growth factors
surgeon training among racial groups after pterygium excision and AMG may
Hispanic 1.88 0.99–3.58 0.06 not be entirely clear, there are documented differences in scar
black 0.63 0.12–3.23 0.58 tissue formation in patients with darker skin.24,25 The pathogen-
*Denotes statistical significance. esis of this exuberant scar tissue is attributed to heightened
†AMG relative to CAG. sensitivity to dysregulated TGF-b and platelet-derived growth
factor,26,27 which has a strong genetic component.24,25,27,28
Because recurrent pterygia demonstrate histological fibrovascu-
5 Hispanic patients (4.0%), and 1 Asian patient (16.7%). Each lar proliferation similar to that of exuberant scar tissue,12,20 the
was treated successfully with lubrication, and none experi- pathogenesis of pterygium recurrence and scar tissue formation
enced pterygium recurrence. One white patient experienced may be similar. Racial groups that demonstrate heightened
a suture granuloma 4 weeks postoperatively, which was sensitivity to growth factor dysregulation may paradoxically
repaired surgically at 4 months, and 1 Hispanic patient show an exaggerated tissue growth response, as they do with
experienced a pyogenic granuloma 6 weeks postoperatively, exuberant scar tissue. This may explain the increased rates of
which was treated successfully with steroid eye drops. pterygium recurrence in Hispanic and black patients relative to
Neither experienced pterygium recurrence. Symblephara were white patients after AMG. CAG, however, may show lower
experienced by one white patient and 5 Hispanic patients, and recurrence rates across all races because it is autologous tissue
the time course ranged from 1 week to 7 months post- and less likely to lead to inflammation and dysregulated
operatively. All were surgically lysed. Four Hispanic patients epithelialization. There is no evidence that the contribution of
with symblephara experienced pterygium recurrence between young age to recurrence is related to the surgical technique,29
3 and 12 months after CAG. There were no associations and we found no difference in mean age of patients undergoing
between the complication rate and race after CAG (P = 0.15) either technique (P = 0.22).
or AMG (P = 0.41). Our higher rates of recurrence among AMG cases
(38.6%) relative to CAG cases (13.5%) cannot be explained
by a difference in proportion of AMG to CAG among races
DISCUSSION with higher rates of recurrence, as this was not significant (P
We observed that recurrence rates are greater in our = 0.12). Our recurrence rates overall are high but not
Hispanic and black patients than in our white and Asian inconsistent with the literature. Recurrence after primary
patients with no difference in mean time to recurrence (P = pterygium excision and CAG performed by experienced
0.98). Recurrence was more likely in Hispanic (P = 0.002) surgeons occurs in 1.9% to 5.3% of cases,16,30,31 but some
and black (P = 0.001) patients with AMG rather than CAG. studies show rates of 25%32 to 39%15 in Hispanic patients.
For AMG, typical recurrence rates range from 10.9% to
13.8%,30–33 but rates have been as high as 35%15 and 40%34
TABLE 3. Log-Rank Analysis of Pterygium Recurrence by Race in various ethnic groups. Two randomized control trials found
and Operative Factors recurrence rates after primary pterygium excision with AMG
Amniotic to be 23%35 and 25%36 in mixed populations. Our operations
Conjunctival Membrane were performed by surgeons in training, and there is scant
Stratified by Autograft, P Graft, P literature on resident-performed pterygium excision, so
Race 0.44 0.003* comparisons are challenging, but one report comments on
Method of graft fixation 0.39 0.07 a pterygium recurrence rate after resident-performed oper-
Level of resident surgeon training 0.71 0.65 ations of about 35%, similar to our AMG cases.37 Among our
*Statistically significant. residents, the level of training was not linked with recurrence.
Therefore, the most likely explanation for our elevated rates

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Cornea  Volume 0, Number 0, Month 2017
FIGURE 1. Kaplan–Meier survival curves of recurrence after primary pterygium excision followed by a conjunctival autograft and
amniotic membrane graft in white, Hispanic, and black patients. Survival curves unavailable for Asian patients because no patient
showed recurrence and all underwent conjunctival autografting (CAG).
of recurrence is a combination of surgeon inexperience and
a majority (66% Hispanic or black) of patients who may be
genetically predisposed to high rates of recurrence, especially
with AMG.
There are several epidemiological factors that could
contribute to higher rates of recurrence in some racial groups
than others including environmental exposures, socioeconomic
status, compliance, and occupation.5,10,38 It is possible that
socioeconomic constraints could have limited certain patient
groups from attending follow-up appointments or adhering to
therapy. We found a significant difference in mean age of all
Hispanic patients relative to white and black patients (P ,
0.001) and a significant difference in proportion of males to
females among the races (P , 0.001), but we attribute this to the
typical patient population of the MEDVAMC, which comprises
mostly elderly white and black male patients. Sex was not
associated with recurrence. Mean age with recurrence was not
different among the races. Thus, we suggest that these
demographic differences did not substantially contribute to
differences in recurrence rates among races.
Limitations of this study are largely due to the
retrospective design. The operative technique was left to the
attending surgeon’s discretion and partially reflective of
training requirements for resident education, and it is unclear
whether the complexity of the case or some other measure of
pretest propensity for recurrence influenced these decisions at
the time of operation. Many studies suggest superiority of
CAG over AMG to reduce recurrence, but this is not always
the case,18,30 so proficiency with both techniques is desirable.
The majority (41/70, 59%) of AMG cases occurred during the
first 3 years of this 7-year study, which could reflect a trend
toward CAG in recent years. We also cannot know with
certainty that patients who chose to forgo follow-up did not
experience recurrence. Last, pterygium morphology was not
assessed, but pterygium opacity has shown associations with
recurrence.39 These limitations are common to retrospective
case–control studies on this topic. Prospective analyses that
control for epidemiological and other preoperative contrib-
utors to recurrence are needed to further investigate the role of
race as a predictor of pterygium recurrence after surgical
excision of primary pterygium.
To our knowledge, this study of pterygium recurrence
after 2 different surgical modalities in multiple racial groups
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Comparison of Pterygium Recurrence Rates
is the only one of its kind. Our results show a variation in
response to treatment of primary pterygia among different
races, and the utility of the information is particularly
important in the preoperative period. AMG provides advan-
tages over CAG including shorter operating times and
preservation of conjunctiva for prospective glaucoma-
filtering procedures,36 but it is associated with higher rates
of recurrence in Hispanic and black patients and may not be
the preferred technique in these groups. Regarding recur-
rence, the choice of the surgical technique may not be as
important for white patients, who showed no statistically
significant difference in recurrence for either technique and
performed as well, if not better, than other races regardless
of the conditions applied in this study.
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