You are on page 1of 6

Patients &

Methods
Patients and Methods
Twenty patients with primary pterygia attending the outpatient
clinic of Menoufiya University Hospital during the period of the study
from March 2004 to April 2005 were included in this study. The selected
cases were injected with subconjunctival 0.1 ml of 0.15 mg/ml MM-C
one month before excision with bare sclera technique.

The criteria of selection:

(1)Known primary pterygium.

(2)Pterygium growth is more than 2 mm over the cornea, horizontally

from the limbus.

(3)No signs of active ocular diseases.

Pre-operative Evaluation:
History taking and complete ophthalmic examination were done for
the selected cases.

1- Ocular and general history taking:

History was taken including personal history, complaint, present


history of any ocular surface disorders or glaucoma and past history of
any previous surgical excision of the ptergyium.

2- Complete ophthalmic examination with particular attention to:

a) Measurement of uncorrected and best corrected visual acuity using


landolt's broken rings chart.

b) Estimation of refraction. (topcon autorefractometer was used).

-55-
Patients &
Methods
c) Slit-lamp biomicroscopy of the anterior segment of the eye noting the
following:

*Site of ptergyium.

*Corneal extension of ptergyium.


*Grading according to pterygium morphology (Tan et al. 1997):
This grading is based on the relative translucency of pterygium
tissue overlying the sclera, as seen at the slit lamp (Fig. 9).
Grade T1 (atrophic): A pterygium in which the episcleral vessels
underlying the body of the pterygium are clearly distinguished and
unobscured.
Grade T3 (Fleshy): A thick, fleshy pterygium in which the
episcleral vessels underlying the body of the pterygium are totally
obscured.
Grade T2 (intermediate): All other pterygia that do not fall into
these two categories i.e. episcleral vessels details are seen indistinctly or
partially obscured.

Fig (9): (A) Grade T3 pterygium (B) Grade T2 pterygium.

-56-
Patients &
Methods
d) Measurement of I.O.P

e) Fundus examination.

f) Photographic documentation before and after surgery.

Preparation of mitomycin-C for injection:

Mutamycin (Bristol-Myers-Squibb) vial contains 5 mg powder of


mitomycin. Reconstituted with 33 ml sterile water for injection to a
concentration of 0.15 mg /ml.

Technique of MM-C injection:-

Each patient was first given two drops of benoxinate hydrochloride


0.4% topical anesthetic in the involved eye.

After five minutes, the patient was injected subconjunctivally with


a 27-gauge needle on insulin syringe containing mitomycin-C (0.1 ml of
0.15 mg/ml).

The injection was done directly into the pterygium at the limbus.

A cotton tiped applicator was apllied to the site of injection upon


withdrowal of the needle to prevent reflux of the injected drug.

Thorough rinsing of the external ocular surface with saline to


remove any MM-C.

After injection, the patient received topical combined antibiotic


steroid eye drops four times daily and dexmethasone 0.1% ointment at
bed time for one week. The patient was seen 1 day, 1 week and 1 month
after the subconjunctival injection of mitomycin. A complete slit-lamp
examination was performed, including fluorescein staining of the
conjunctiva and cornea to evaluate epithelial defects. The intra ocular
pressure was measured at each visit.

-57-
Patients &
Methods
One month after mitomycin-C injection, the patient underwent bare
sclera excision of the pterygium.

Technique of bare sclera excision of the pterygium:-

Surgical excision was performed using Topcon OMS 600 operating


microscope. Povidone iodine (5%) solution was used to prepare eyelids
and periocular skin.

1. Topical benoxinate (0.4%) drops were instilled into the


conjunctival sac to anaesthetize the ocular surface.

2. Placement of rigid self retaining speculum.

3. A subconjunctival injection of mepecaine with epinephrine


1:100.000 was injected beneath the body of the pterygium with 27
gauge needle.

4. The pterygium was fixed at its neck with toothed fixation forceps.
Partial thickness vertical incision was done by the bard Parker
blade. The cut edge was lifted up, the lamellar dissection
completed by the knife and kept in one plane, while retracting the
head of the pterygium to see the base of the cleft, so, a smooth
clear surface was left.

5. On reaching the limbus, the plane of dissection was brought to the


surface to avoid injury of the limbus. The head of the pterygium
was gently grasped by conjunctival forceps to expose the
subconjunctival tissue forming the body of the pterygium. With
blunt dissection, the body was dissected from the overlying
conjunctiva and the underlying sclera by Westcott scissors.

6. Excision of pterygium leaving bare scleral area aproximately 5 mm


posterior to the limbus. Excision of pterygium did not extend to or
involve the plica semilunaris. When there was a large bare sclera,
the conjunctiva was sutured to the episclera 3 mm from the limbus.

-58-
Patients &
Methods
7. The corneal surface was then smoothed with corneal rust ring
remover (Algerbrush II) (Fig. 10).

Scraping the limbus by the scalpel to remove any remaining


tissues.

Minimal cauterization of the scleral bed was applied to control the


bleeding if needed. Antibiotic-corticosterios eye drops and short acting
cycloplegic (cyclopentolate hydrochloride 1%) eye drops were instilled.

Eye pad and bandage were applied for 48 hours.

After surgery, patients were treated with prednisolone acetate 1%


and ofloxacin 0.3% four times daily for 1 week and then with
prednisolone acetate 1 % once a day for 2 weeks.

Patients were followed up at 1 day, 1 week, 1 month, 3 months, 6


months, 9 months and 12 months.

Patients were examined at each visit to identify any complication


and pterygium recurrence.

Histopathological evaluations of 15 specimens excised from MM-


C treated cases and one specimen of non treated case (as a control) was
done.

The specimens were immediately fixed in buffered 10% formalin.


The gross specimens were then bisected and the center edge was
submitted for paraffin- embedded blocks. The blocks were cut into 4
microns sections. The sections were stained with hematoxylin-eosin.

(Fig. 10): corneal rust ring remover (Algerbrush II)

-59-
Patients &
Methods
Statistical analysis
Data of the study was of both qualitative and quantitative types.

Qualitative data was expressed as number & percent.

Quantitative data was expressed as mean ± SD tests of significant


used were:

• Chi square test. To assess the relationship between qualitative


variables.

• t. student test to measure the difference between two means.

• ANOVA "Analysis of variables" to measure the difference between


more than two means.

• LSD "Least significant difference" to state the significant relation


of ANOVA.

With a level of significance at 99%. So P. value > 0.05 was


considered non statistically significant result and that < 0.05 considered a
statistically significant result.

Using SPSS (11) statistical package of social science for win Xp.

-60-