Optical Coherence Tomography Angiography
for Evaluation of Reperfusion After Pterygium
Surgery
YU-CHI LIU, KAVYA DEVARAJAN, TIEN-EN TAN, MARCUS ANG, AND JODHBIR S. MEHTA

PURPOSE: To describe the use of optical coherence
tomography angiography (OCTA) to quantitatively
monitor the conjunctival graft revascularization after pte-
rygium excision and conjunctival autograft (CAG) trans-
plantation.

DESIGN: Prospective, interventional case series.

METHODS: Ten patients undergoing pterygium exci-
sion and femtosecond laser-assisted CAG transplantation
were included. OCTA was performed at 1 week, 1 and
3 months postoperatively at the CAG transplantation
site and harvested area. The vessel density at three
different depths: conjunctival epithelium or CAG epithe-
lium, conjunctival stroma or CAG stroma, and episclera,
was evaluated and quantified. The revascularization rate
was assessed and correlated with the postoperative
CAG thickness.

RESULTS: No intraoperative and postoperative compli-
cations occurred. Reperfusion of the CAGs was observed
at 1 week, and early reperfusion within the first month
accounted for more than half of graft revascularization.
The vessel regrowth density was 9.6±2.6 % and
11.1±2.8 % between 1 week and 1 month, and was
9.8±1.8 % and 11.9±1.9 % between 1 and 3 months, at
the CAG and underlying episcleral levels, respectively.
All the CAGs were well-perfused at 3 months. The vessel
regrowth density was significantly and strongly correlated
with the changes of CAG thickness in a negative relation-
ship (g [ -0.94, P [ 0.019). At the harvested site, the
vascular network of episclera was not affected, and the
conjunctival vascularization was restored at 1 month.

CONCLUSIONS: OCTA is a promising tool to evaluate
the vascularization or revascularization of conjunctiva,
conjunctival graft and episclera, in a quantitative and
serial manner, helping in diseases diagnosis and treatment
monitoring. The graft revascularization rate was predic-
tive of postoperative graft deswelling. (Am J
Supplemental Material available at AJO.com.
Accepted for publication Apr 1, 2019.
From the Tissue Engineering and Stem Cell Group (Y.-C.L., K.D.,
M.A., J.S.M.), Singapore Eye Research Institute, the Department of
Cornea and External Eye Disease (Y.-C.L., T.-E.T., M.A., J.S.M.),
Singapore National Eye Centre, and the Ophthalmology and Visual
Sciences Academic Clinical Program (Y.-C.L., M.A., J.S.M.), Duke–
National University of Singapore Medical School, Singapore.
Inquiries to Jodhbir S. Mehta, Singapore National Eye Centre, 11 Third
Hospital Avenue, Singapore 168751; e-mail: jodmehta@gmail.com
0002-9394 © 2019 THE AUTHOR(S). PUBLISHED
https://doi.org/10.1016/j.ajo.2019.04.003
Ophthalmol 2019;207:151–158. Ó 2019 The
Author(s). Published by Elsevier Inc. This is an open
access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).)
T
HE DELINEATION OF ANTERIOR SEGMENT VASCU-
larization is important for the evaluation of diseases,
surgical planning, and postoperative monitoring.1
Angiography has been applied for the assessment of a vari-
ety of anterior segment conditions, such as corneal neovas-
cularization,1 limbal stem cell deficiency,2 limbal–
conjunctival autograft transplantation,3 iris neovasculari-
zation,4 and ocular surface neoplasia.5 Among the
angiography techniques, optical coherence tomography
angiography (OCTA), compared to fluorescein angiog-
raphy (FA) and indocyanine green angiography (ICGA),
is a noncontact, noninvasive, rapid-acquisition imaging
system that requires no intravenous dyes that may cause
an adverse reaction.1 OCTA has been rapidly gaining
popularity in the evaluation of retinal and optic nerve dis-
eases.6 OCTA was originally designed for the retina, and
therefore examination of the anterior segment vasculature
has taken some adaption to obtain consistency and valida-
tion.6–8 One of the advantages of using OCTA is that it
provides a simultaneous assessment of the depth of the
region of interest and its associated vessels.1 The split-
spectrum amplitude-decorrelation angiography (SSADA)
system from AngioVue (Optovue Inc, Fremont, California,
USA) has been shown to improve the signal-to-noise ratio
of flow detection and be useful for visualizing ocular vascu-
lature network.1 Our group has previously used the SSADA
system for the imaging and monitoring of corneal neovas-
cularization. Oie and associates2 also reported that
OCTA was a powerful tool to objectively detect the exact
area of corneal neovascularization in patients with limbal
stem cell deficiency, and the visualization of small neovas-
cularization was clearer on OCTA than on slit-lamp
photography.
Pterygium is a common ocular surface disease character-
ized by fibrovascular growth arising from the conjunctiva
and extending onto the cornea. In pterygium surgery, surgi-
cal excision of the pterygium with conjunctival autograft
(CAG) transplantation has a low recurrence rate compared
with excision with amniotic membrane graft.9 One of the
important factors for success in this technique is the ability
BY ELSEVIER INC. 151
to dissect a thin CAG with minimal inclusion of Tenon’s
tissue, which can minimize recurrence and postoperative
tissue retraction.10 We recently described a new technique
in which a low-energy, high-frequency (0.1–10 MHz)
femtosecond laser was used to obtain accurate, ultrathin,
tenon-free CAGs, with a consistent thickness of
60 mm.11,12 We showed that this technique was
independent of surgeon experience and that the cosmetic
outcomes were good.11,12
After conjunctival autografting, reperfusion of graft ves-
sels is an important indicator of graft health.13 A FA study
on 11 patients reported that no graft perfusion was observed
by postoperative day 30,13 whereas an ICGA study on 31
patients found the presence of early reperfusion from epis-
cleral circulation, and the vascular plexus of the graft
became finer and more complex 1 and 3 months postoper-
atively.3 The disparity may come from the fact that ICG
dye stays in the vessels longer and is therefore better able
to facilitate intravascular visualization.13 However, both
FA and ICG techniques provide 2-dimensional images
only, and dye leakage may block the deep vessels from anal-
ysis, whereas OCTA allows for simultaneous assessment of
the structure of lesions and its associated vessels in a
3-dimensional methodology or at any intended depth.8 In
conjunctival autografting, a potential disadvantage of using
an ultrathin graft to reduce recurrence, as we prepared by
the femtosecond laser, is the risk of necrosis because of
the lack of vascularization and perfusion; blood flow and
oxygenation are potentially preserved to a greater extent
in thicker graft than in thinner grafts because of the pres-
ence of underlying tenons.14 In this study, we aimed to
use OCTA to monitor the development of graft revascular-
ization in patients with pterygium excision and femto-
second laser–assisted CAG transplantation. We also
described a method to quantitatively evaluate vessel
regrowth density longitudinally.
METHODS

PATIENTS AND SURGICAL TECHNIQUE: Approval for
the study was granted by the institutional review board of
SingHealth, Singapore (number 2016/2512), and the study
was conducted in accordance to the Declaration of
Helsinki. Ten eyes of 10 consecutive patients who under-
went pterygium surgery with femtosecond laser–assisted
CAG transplantation were prospectively included. The
surgery was performed using a previously described tech-
nique by a single surgeon (J.M).11,12,15 In brief, under
local anesthesia, the body of the pterygium was excised at
the level of the limbus. The head was removed from the
corneal surface with a Mini-Blade. The remaining pteryg-
ium and subconjunctival Tenon’s tissue was removed to
expose the bare sclera and the area of conjunctival defect
was measured by a caliper. The Ziemer LDV Z8 (Ziemer
152 AMERICAN JOURNAL OF OPHTHALMOLOGY
Ophthalmic System, Port, Switzerland) was programmed
to harvest an ellipsoid CAG of 7-mm 3 10-mm diameter
(55.0 mm2) and 60-mm depth using the lamellar kerato-
plasty module at the superior bulbar conjunctiva
(Figure 1, A). Immediately after the laser cutting, CAG
thickness was measured by the built-in optical coherence
tomography (OCT) scanner at the graft center and 2 mm
from the center on either side. The CAG was then posi-
tioned and glued onto the area of conjunctival defect
with fibrin glue (Artiss; Baxter Healthcare, Westlake
Village, California, USA). A bandage contact lens was
applied. The postoperative regimen consisted of topical
preservative-free dexamethasone and levofloxacin every 3
hours for 1 week, on a tapering dose over 8 weeks.

ANGIOGRAPHY TECHNIQUE AND IMAGE ANALYSIS: A
commercial spectral-domain OCT device (RTVue- XR
Avanti; Optovue, Inc., Fremont, California, USA) was
used for the OCTA imaging and evaluation. The OCT
uses a light beam with a central wavelength of 840 nm
and a full-width half maximum of 45 nm. The axial scan
rate is 70,000 A-scans per second. OCTA volume scans
of the anterior segment measuring 304 3 304 B-scans
were acquired in 2.9 seconds. For detection of blood flow,
the device acquires 2 consecutive B-scans at the same
position to differentiate between static tissue and particles
with high fluctuation of signal intensity. The machine uses
SSADA to improve the performance of the vessel segmen-
tation algorithm.16 For imaging, the anterior segment lens
adapter was used with the Angiovue scan protocol of the
OCTA device (6.00 3 6.00 mm; AngioRetina). The eye
tracking and autofocus functions were deactivated, and
the lens moved close to the corneal surface before manual
adjustments to the Z-motor positioning and focal length
were made to achieve precise focus on the B-scan area of
interest.16 Anterior segment scans centered at the CAG
area and the harvested area were obtained at 1 week and
1 and 3 months postoperatively by a trained operator
(K.D.). We assessed vessel density at 3 depths: the conjunc-
tival and CAG epithelium (w50 mm), the conjunctival
stroma and CAG (w70–130 mm), and the episclera
(w230–300 mm) at the CAG and harvested sites, respec-
tively. Three images at each depth at each area were
obtained for each study time point.
Elimination of the horizontal line artefacts that were
caused by involuntary eye movements was performed us-
ing band-pass filtering using ImageJ software. Additional
image processing and vessel density computations were
done using an in-house automated program written in
MATLAB R2016a 64-bit (The Mathworks, Inc., Natick,
Massachusetts, USA).8 Successive follow-up OCTA im-
ages of each scanned region were overlaid using auto-
mated image registration to match for the region of
interest (ROI) based on intensity. The speckle noise
was removed using median filtering and Gaussian
smoothing, and top-hat filtering was used to improve
NOVEMBER 2019
FIGURE 1. Pterygium excision with femtosecond laser–assisted conjunctival autograft (CAG) transplantation. (A) Intraoperative
and (B) postoperative 1-week pictures showing the CAG harvested area. (C) Picture on the area of pterygium excision and CAG
transplantation 3 months postoperatively. (D) Anterior segment optical coherence tomography pictures showing the CAG
(red marks) at 1 month and (E) 3 months postoperatively.

the signal-to-noise ratio while preserving the image fea- RESULTS

tures.16 Local phase-based filter for optimal enhancement
of segmented vessels was applied, thereafter, where an
infinite perimeter active contour model to partition the
enhanced image into a binary image (vessel pixels, 1;
background, 0) was performed.16
After binarization, the binarized image from the previous
follow-up scan was subtracted from the new consecutive
follow-up binarized image. The vessel density percentage
computed in the binary subtracted image between consec-
utive follow-ups was defined as the vessel regrowth density
percentage, as shown in the following equations:
Vessels regrowth density percentage ¼ Vessels density
percentage at follow-up (n þ1)  Vessels density percent-
age at follow-up (n), where:
Vessels density percentage ¼ ʃ V.dA./ ʃ dA. *100
V ¼ 1 for white pixels (blood vessels); V ¼ 0 for black
pixels (background); A ¼ ROI

MEASUREMENT OF CAG THICKNESS AND CONJUNC-
TIVAL THICKNESS AT HARVESTED AREA: At 1 week and
1 and 3 months postoperatively, the CAG thickness 1
and 3 mm away from the limbus and the conjunctival
thickness at the center and 2 mm on each side at the
harvested area were measured by an independent observer
(T-E.T) with the built-in caliper of the OCT device.

STATISTICAL ANALYSIS: The correlation between the
changes in CAG thickness and vessel regrowth density per-
centage was evaluated using a Pearson correlation test
(STATA; STATACorp, College Station, Texas, USA).
All data were expressed as mean 6 standard deviation,
and P < .05 was considered statistically significant.
TEN EYES (4 RIGHT AND 6 LEFT) OF 10 PATIENTS (5 MALES AND
5 females) with primary pterygium were included. The me-
dian age was 64 years (range 36–85 years). The median
conjunctival defect size was 44.2 mm2 (range 34.5–
54.9 mm2). The median CAG area measured after laser
cutting was 48.1 mm2 (41.0–51.1 mm2). The median graft
thickness measured immediately after laser cutting was
67.5 mm (range 58.0–85.0 mm) at the center and were
69.0 mm (range 64.0–76.0 mm) and 74.5 mm (range
61.0–75.0 mm) 2 mm from the center on each side. There
were no intraoperative complications, such as buttonholes
or incomplete laser cuts. At the harvested area, the
conjunctival epithelium healed within 2 weeks in all cases,
with no evidence of conjunctival scarring (Figure 1, B).
Throughout the follow-up period of 3 months, no postoper-
ative complications, such as graft dehiscence, graft
ischemia, or recurrence, were observed (Figure 1, C).
On anterior segment OCT images, the CAG was
securely attached to the scleral bed and the margin between
the CAG and underlying sclera was visible (Figure 1, D, E).
The CAG thickness was 276.8 6 85.6 mm, 201.0 6
71.6 mm, and 123.0 6 26.9 mm, and the conjunctival
thickness at the harvested area was 334.0 6 103.8 mm,
284.7 6 77.2 mm, and 243.7 6 47.9 mm 1 week, 1 month,
and 3 months postoperatively, respectively.
The serial OCTA images at different depths at the CAG
and harvested areas are shown in Figures 2 and 3. The
conjunctival or CAG epithelium contained no blood ves-
sels. Reperfusion of the CAG was observed at 1 week. At
1 month, vessel regrowth into the CAG was markedly
noted at all depths, although some areas of the graft margin

VOL. 207 OCTA FOR EVALUATION OF REPERFUSION IN PTERYGIUM SURGERY 153

FIGURE 2. Serial optical coherence tomography angiography scans at the conjunctival autograft (CAG) site after CAG transplan-
tation at different depths over time. Early reperfusion was seen at 1 week. At 1 month, there were some hypoperfused areas at the
margin of CAG (arrowheads). The vascular network was well-formed at the CAG and episclera at 3 months.

were hypoperfused. The conjunctival and episcleral
vascular beds surrounding the CAG were not disrupted.
At 3 months, OCTA showed well-perfused grafts in all
cases (Figure 2). At the harvested site, there were small
areas devoid of vascularization or areas with disrupted ves-
sels observed at the conjunctival stromal level at 1 week.
The conjunctiva became well-perfused gradually from
1 month onward. The underlying episcleral vascular
network was not affected by the laser-harvesting technique
(Figure 3).
No vessels were present in the epithelial layer, so vessel
regrowth density was assessed for the conjunctival or CAG
stromal layer and for the episcleral layer. At the graft area,
the mean ROI was 26.5 mm2. The vessel regrowth density
was 9.6 6 2.6% (2.5 6 0.7 mm2) and 11.1 6 2.8%
(2.9 6 0.7 mm2) between 1 week and 1 month and was
9.8 6 1.8% (2.6 6 0.5 mm2) and 11.9 6 1.9%
(3.2 6 0.5 mm2) between 1 and 3 months at the CAG stroma
and underlying episcleral levels, respectively (Figure 4). Early
reperfusion within 1 month accounted for more than half of
graft revascularization, and the underlying episcleral vascular
bed played an important part. At the harvested area, the
mean ROI was 34.6 mm2. The vessel regrowth
density was 7.6 6 2.3% (2.6 6 0.8 mm2) and 2.7 6 1.2 %
(0.9 6 0.4 mm2) between 1 week and 1 month and was 8.3
6 2.7% (2.9 6 0.9 mm2) and 2.1 6 1.5% (0.7 6 0.5 mm2)
between 1 and 3 months at the conjunctival stroma and epis-
clera, respectively (Figure 4). When looking at the relation
between the thickness resolution of CAGs and reperfusion,
a significant, strong and negative correlation between the
percent of changes in CAG thickness and vessel regrowth
density was noted (g ¼ 0.94, P ¼ .019).

154 AMERICAN JOURNAL OF OPHTHALMOLOGY NOVEMBER 2019

FIGURE 3. Serial optical coherence tomography angiography scans at the harvested area at different depths over time. The conjunc-
tiva was well-vascularized at 1 month, and the underlying episcleral bed was not affected.

DISCUSSION good signal strength and repeatability in image quality.7,8,16

WE PRESENT A NEW APPLICATION OF OCTA TECHNOLOGY,
with the aid of an anterior segment lens adapter, to achieve
en face and consistent imaging of the CAG and conjunc-
tival revascularization, at different depths, after pterygium
surgery. We also describe a method to quantify the graft
reperfusion rate. The CAG was well-perfused 3 months
postoperatively, and more than half of graft revasculariza-
tion occurred within the first month postoperatively. The
vessel regrowth rate was significantly associated with the
resolution of postoperative graft edema.
In the present study, we used the AngioVue system with
SSADA algorithm to delineate the conjunctival and epis-
cleral vessels. The axial and lateral optical resolutions were
3 mm and 15 mm, respectively, and the axial imaging depth
was 3 mm.16 We have applied this technique to image and
quantify corneal neovascularization and shown that it had
Serial OCTA is noninvasive and allows simultaneous
visualization of CAG structure as well as its associated
depth of vasculature,6,17 providing a potentially superior
modality than ICGA or FA. Although there was no FA
or ICGA comparison group in this study, we have
previously shown that the scan results of OCTA had
good agreement with those of ICGA.1
Our group has previously demonstrated the use of OCTA
to evaluate the fibrovascular structure in pterygium.8 Simi-
larly, Akagi and associates18 presented the feasibility of
imaging conjunctival vasculature using swept-source
OCTA in 10 normal participants in a cross-sectional study.
However, using OCTA and incorporating quantitative
assessment for the graft reperfusion after CAG transplanta-
tion, at different depths, has not been reported, especially in
longitudinal study design as in this present study. Unlike the
previous OCTA study on normal conjunctiva,18 in which

VOL. 207 OCTA FOR EVALUATION OF REPERFUSION IN PTERYGIUM SURGERY 155

FIGURE 4. Quantification of vessel regrowth between different time periods after conjunctival autograft (CAG) harvesting and
CAG transplantation. Binarized images after image processing for vessel regrowth density computation over the (A) CAG and
(B) harvested areas. Bar charts showing the percentage of vessel regrowth density over the (C) CAG and (D) harvested areas during
different time periods.

the border between the conjunctival and scleral tissues
could not be delineated, the visible CAG margin in the pre-
sent study provided us clear information for the depth
sectioning at the CAG level or underlying episcleral level.
Understanding the structure and vascularization of pteryg-
ium and the graft reperfusion after surgery helps to evaluate
the risks for recurrence19 and graft health.
Our results showed that the graft revascularization was
not compromised even with an ultrathin CAG. Early revas-
cularization of CAG was seen at 1 week, and the reperfu-
sion within the first month accounted for more than half
the graft revascularization. The vascular network was
well-formed by 3 months. In patients where no early graft
reperfusion or inadequate vascularization was observed,
close monitoring of the CAG may be required. Our findings
are in agreement with a recent study using qualitatively
slit-lamp photographs, in which the authors reported that
underperfusion areas were observed in the CAGs at postop-
erative weeks 4–8, and a well-formed vascular network was
noted after 8 weeks to 6 months.20 However, that study
provided no quantitative evaluation because it was under-
taken using photographs alone. OCTA may offer the
ability to detect early graft hypoperfusion or subclinical
graft hypoperfusion before graft ischemia is noted by slit-
lamp biomicroscopy. It may be particularly useful in cir-
cumstances that may be associated with a greater risk of
graft ischemia, such as ultrathin grafts or inadvertently
upside-down grafts. Early detection of graft ischemia also
allows of early intervention of graft exchange. In an
ICGA study, the authors also described that the reorgani-
zation of the CAG vessels continued for 3 months after
surgery.3 The potential clinical applications of OCTA
technique we reported are not only limited to CAG in pte-
rygium surgery but can also be extended to anterior
segment diseases involving abnormal conjunctival or epis-
cleral vessel plexus, such as conjunctival carcinoma, limbal

156 AMERICAN JOURNAL OF OPHTHALMOLOGY NOVEMBER 2019

stem cell deficiency, bleb vascularity after glaucoma
surgery, and episcleritis.21
We found that the vessel regrowth density was signifi-
cantly and strongly correlated with the changes of CAG
thickness in a negative relationship, indicating that the
graft reperfusion might play a role in the resolution of tissue
swelling after surgery. Reperfusion with vessels anastomose
with vasculature in the surrounding conjunctiva and un-
derlying episclera allows reoxygenation and transport of
nutrients that could help in the resolution of tissue
edema.20,22 The average bulbar conjunctival epithelial
thickness has been reported to be between 42.4–
54.7 mm,23,24 and therefore we set 60 mm as the targeted
thickness to achieve tenon-free grafts. The depth was
also based on the results of our preclinical study showing
that cutting of 60-mm grafts was associated with less devi-
ation and variability than cutting deeper.12 The laser cut-
ting was accurate, with the achieved graft thickness
measuring 67.5–74.5 mm intraoperatively. After surgery,
the CAG thickness decreased with time. Similar thickness
resolution trend was shown by an OCT study where the au-
thors reported there was significant thickening of the CAG
at postoperative 1 week which continued to decrease up to
3 months, with the 3-month CAG thickness at 291
6 124 mm,25 which was thicker than our value. This differ-
ence might be related to the inevitable inclusion of
Tenon’s tissue during their manual dissection. The
conjunctival epithelium at the harvested area healed
completely within 2 weeks in our study, and the conjunc-
tival thickness resolved to a normal level23,24 after
1 month.
After excision of pterygium, CAG transplantation has a
lower recurrence rate compared with amniotic membrane
transplantation,9 and previous studies have shown that
there is no difference in the recurrence between CAG
and limbal autograft transplantation for patients with pri-
mary pterygium.26 The use of femtosecond laser to prepare
ultrathin and tenon-free CAGs has been reported to be safe
and reproducible,11,12 and the use of a thin conjunctival
graft is recommended because it avoids excessive graft
chemosis and minimizes scarring and therefore
recurrence.10,27 After the laser cutting, there was some
shrinkage of the CAG because of tissue contraction
resulting from the elasticity of conjunctiva, but the
ALL AUTHORS HAVE COMPLETED AND SUBMITTED THE ICMJE FORM FOR DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST.
Funding/Support: Supported by the Singapore National Research Foundation under its Translational and Clinical Research program (NMRC/TCR/1021-
SERI/2013). Financial Disclosures: The authors indicate no financial support or financial conflict of interest. All authors attest that they meet the current
ICMJE criteria for authorship.
REFERENCES
1. Ang M, Cai Y, MacPhee B, et al. Optical coherence tomog-
raphy angiography and indocyanine green angiography for
VOL. 207 OCTA FOR EVALUATION OF REPERFUSION IN PTERYGIUM SURGERY
post-cut CAG area was still larger than the conjunctival
defect area (48.1 vs 44.2 mm2). At the harvested area,
the unaffected episcleral vasculature indicated that the
underlying vascular bed was not affected by the laser tech-
nique. The re-epitheliaization and revascularization
observed within the first month also indicated that the
wound healing and vessel anastomosis were not compro-
mised by the laser harvesting. We have also previously
reported that the laser cutting resulted in no tissue thermal
damage.15 For the institutes that have already equipped
with the laser, femtosecond laser–assisted CAG prepara-
tion can be an additional application.
There are several limitations in the present study. First,
the current OCTA system is not optimized for anterior
segment imaging. Substantial efforts must be made for
the imaging processing and removal of artefacts before
vessel density computations. The presence of subconjunc-
tival fibrosis following surgery might also lead to false
hyperreflective areas, although we did not observe
subconjunctival scarring in our cases. In this scenario,
clinicians may need to refer to corresponding slit-lamp
photographs and structural OCT images before interpret-
ing OCTA images. Second, the study focused on the
CAGs prepared by a femtosecond laser as we aimed to
investigate the consequences on the vascular network
of using this laser technique (because there is no standard
of care in our institution). A comparative study on
CAGs prepared by manual dissection will be considered
in future studies. Third, this is a small pilot study report-
ing the results of 10 patients. However, our investigation
is the first longitudinal study on the OCTA application
and the first report describing the use of OCTA to assess
the revascularization rate.
In conclusion, the conjunctival and graft reperfusion af-
ter pterygium surgery could be reliably and quantitatively
assessed in a serial manner by the OCTA system, adapted
for the anterior segments. The graft revascularization rate
was predictive of postoperative graft deswelling. The study
also showed that the use of the femtosecond laser did not
compromise the reperfusion at the graft harvested site
and the graft revascularization, even with a thin graft.
OCTA can be a promising tool in the diagnosis and moni-
toring of conjunctival or episcleral diseases associated with
abnormal vascularization.
corneal vascularisation. Br J Ophthalmol 2016;100(11):
1557–1563.
2. Oie Y, Nishida K. Evaluation of corneal neovascularization
using optical coherence tomography angiography in patients
157
 with limbal stem cell deficiency. Cornea 2017;36(suppl 1):
S72–S75.
3. Kim YJ, Yoo SH, Chung JK. Reconstruction of the limbal
vasculature after limbal-conjunctival autograft transplanta-
tion in pterygium surgery: an angiography study. Invest
Ophthalmol Vis Sci 2014;55(12):7925–7933.
4. Roberts PK, Goldstein DA, Fawzi AA. Anterior segment op-
tical coherence tomography angiography for identification of
iris vasculature and staging of iris neovascularization: a pilot
study. Curr Eye Res 2017;42(8):1136–1142.
5. Brunner M, Steger B, Romano V, et al. Identification of
feeder vessels in ocular surface neoplasia using indocyanine
green angiography. Curr Eye Res 2018;43:163–169.
6. Ang M, Tan ACS, Cheung CMG, et al. Optical coherence
tomography angiography: a review of current and future clin-
ical applications. Graefes Arch Clin Exp Ophthalmol 2018;
256(2):237–245.
7. Ang M, Cai Y, Shahipasand S, et al. En face optical coher-
ence tomography angiography for corneal neovascularisation.
Br J Ophthalmol 2016;100(5):616–621.
8. Ang M, Sim DA, Keane PA, et al. Optical coherence tomog-
raphy angiography for anterior segment vasculature imaging.
Ophthalmology 2015;122(9):1740–1747.
9. Clearfield E, Muthappan V, Wang X, et al. Conjunctival
autograft for pterygium. Cochrane Database Syst Rev 2016;2:
CD011349.
10. Farrah JJ, Lee GA, Greenrod E, Vieira J. Outcomes of auto-
conjunctival grafting for primary pterygia when performed
by consultant compared with trainee ophthalmologists. Clin
Exp Ophthalmol 2006;34(9):857–860.
11. Fuest M, Liu YC, Coroneo MT, Mehta JS. Femtosecond laser
assisted pterygium surgery. Cornea 2017;36(7):889–892.
12. Fuest M, Liu YC, Yam GH, et al. Femtosecond laser-assisted
conjunctival autograft preparation for pterygium surgery.
Ocul Surf 2017;15(2):211–217.
13. Tayanc E, Akova Y, Yilmaz G, Aydin P. Anterior segment
indocyanine green angiography in pterygium surgery with
conjunctival autograft transplantation. Am J Ophthalmol
2003;135(1):71–75.
14. Memarzadeh K, Sheikh R, Blohmé J, Torbrand C,
Malmsjö M. Perfusion and oxygenation of random
advancement skin flaps depend more on the length and
thickness of the flap than on the width to length ratio.
Eplasty 2016;16:e12.
158 AMERICAN JOURNAL OF OPHTHALMOLOGY
15. Tey ML, Liu YC, Chan AS, Mehta JS. Excision of conjunc-
tival melanosis and conjunctival autografting by femtosecond
laser. Clin Exp Ophthalmol 2018;46(4):432–434.
16. Ang M, Devarajan K, Das S, et al. Comparison of anterior
segment optical coherence tomography angiography systems
for corneal vascularisation. Br J Ophthalmol 2018;102(7):
873–877.
17. Cai Y, Alio Del Barrio JL, Wilkins MR, Ang M. Serial optical
coherence tomography angiography for corneal vasculariza-
tion. Graefes Arch Clin Exp Ophthalmol 2017;255(1):135–139.
18. Akagi T, Uji A, Huang AS, et al. Conjunctival and intra-
scleral vasculatures assessed using anterior segment optical
coherence tomography angiography in normal eyes. Am J
Ophthalmol 2018;196:1–9.
19. Han SB, Jeon HS, Kim M, et al. Risk factors for recurrence
after pterygium surgery: an image analysis study. Cornea
2016;35(8):1097–1103.
20. Ghoz N, Elalfy M, Said D, Dua H. Healing of autologous
conjunctival grafts in pterygium surgery. Acta Ophthalmol
2018;96(8):e979–e988.
21. Ang M, Baskaran M, Werkmeister RM, et al. Anterior
segment optical coherence tomography. Prog Retin Eye Res
2018;66:132–156.
22. Chao CY, Zheng YP, Cheing GL. The association between
skin blood flow and edema on epidermal thickness in the dia-
betic foot. Diabetes Technol Ther 2012;14(7):602–609.
23. Feng Y, Simpson TL. Corneal, limbal, and conjunctival
epithelial thickness from optical coherence tomography.
Optom Vis Sci 2008;85(9):E880–E883.
24. Zhang X, Li Q, Xiang M, et al. Bulbar conjunctival thickness
measurements with optical coherence tomography in healthy
Chinese subjects. Invest Ophthalmol Vis Sci 2013;54(7):
4705–4709.
25. Kheirkhah A, Adelpour M, Nikdel M, Ghaffari R,
Ghassemi H, Hashemi H. Evaluation of conjunctival graft
thickness after pterygium surgery by anterior segment optical
coherence tomography. Curr Eye Res 2011;36(9):782–786.
26. Al Fayez MF. Limbal versus conjunctival autograft transplan-
tation for advanced and recurrent pterygium. Ophthalmology
2002;109:1752–1755.
27. Hovanesian JA, Starr CE, Vroman DT, et al. Surgical tech-
niques and adjuvants for the management of primary and
recurrent pterygia. J Cataract Refract Surg 2017;43(3):
405–419.
NOVEMBER 2019