Introduction
Pterygium is a fibro vascular growth of bulbar conjunctiva, growing upon cornea on either side, usually from nasal part of the limbus within the palpebral aperture. It is a common ocular surface disorder in hot tropical climate. The exposure to ultraviolet radiation is thought to be a major risk factor, as the pathogenesis is unclear. The common Pterygium related symptoms are redness, foreign body sensation, irritation, lacrimation, reduced visual acuity, cosmetic disfiguration and difficulty in contact lens fitting.
Treatment of the pterygium is vertical excision of pterygium with living bare sclera, but the recurrence of pterygium is very common which about 55.9% to 89% is. The recurrent pterygium is very difficult to manage as there is thinning of underlying cornea and extensive scaring.
Various method used to prevent the recurrence of pterygium are beta radiation mitomycine, thiotepa, 5 fluorouracil. These agents are tried intraoperatively in addition to surgical excision now the recent trend is Conjuctivial autograph which shows less recurrence. Further recurrence is reduced by intraoperative Triamcinolone and Bevacizumab (avastin). Factors responsible for recurrence of Pterygium are postoperative inflammation and fibro vascular growth angiogenesis the action of Triamcinolone is to suppress inflammation and, the role of Bevacizumabis is to suppress angiogenesis thus prevents the recurrence.
Materials of Methods
The present study design was randomized blind study. Total 150 patients of primary nasal pterygium were included in the study. The selection of patients done at EYE OPD of Eye department, Patna Medical College, Patna from MAY 16 to APRIL 17. The inclusion criteria-only primary pterygium. The Exclusion criteria-recurrent pterygium, infection, ocular surface disorder, diabetes, chronic dacrocystities. Total 150 eyes of 150 patients having primary nasal pterygium were selected for the study who met the all criteria for inclusion. The informed consent was taken for the study. The complete ocular examination such as visual acuity, slit lamp examination, fundoscopy, Applanation tonometry was done before and after surgery. On the basis of systemic random sampling all 150 eyes of 150 patients divided into three groups i.e groups A, B, and C. The first patient of study are put in group A, second in group B, and third in group C irrespective of grading and stages of pterygium.
Group A: surgical excision of pterygium with Conjuctivial autograft alone.
Group B: Conjuctivialauto graft with subconjuctival injection of Triamcinolone intraoperatively.
Group C: with Bevacizumab intraoperatively a long with conjunctival autograft.
All surgery was done by single surgeon. After taking all aseptic precaution all 150 eyes were subjected to surgery under local anesthesia of xylocaine 4% topically and xylocaine 2% local infiltration. In all 150 eyes the pterygium were dissected and peeled off from underlying cornea, 4.5mm of conjunctiva covering head and body of pterygium was excised leaving behind bare sclera. Then conjuctival auto graft was put on bare sclera and secured by suturing.
Group A: Only conjuctival autograft done
Group B: Conjuctival autograft + subconjuctival Triamcinolone 12mg given in lower fornix
Group C: Conjunctival autograft + subconjuctival Bevacizumab 2.5mg/0.1ml given subconjuctival in lower fornix.
Postoperative Care
Antibiotics drops (Moxi+Ketorolac) one drop thrice daily, steroid drops (Predforte) one drop thrice daily. Tear substitute one drop four times in a day.
All the sutures were removed after 2weeks, Postoperative follow up was done on day1, 1st week, 2nd week, 1st month and 3rd, 6th, 12th month after surgery. Recurrence is defined as- if the size of pterigyium is more than 1 .5mm across the limbus over cornea.
Results
The relevant data obtained from the study were put on master chart and analyzed with the help of software SPSS (version 15). Since it was small sample study so student ‘ t – test ’ were used to anlysed the data the result were tabulated in form of mean +/- SD and analyzed on the basis of ‘t-test’ and role of significance was determined by using its P value, P value < 0.05 was taken as statistically significant. The mean age of the patient was 39+/-10 years ranging from 24 to 59 years. All the patients were followed up completely for 12 months. The recurrence was seen in 17 patients in Group A, 8 patients in Group B & 7 patients in Group C. All recurrences occurred within 5 to 9 months of surgery. It further observed that recurrences were more common in younger age group. All 150 patients had at least 12 months of follow up. Average age of the patients was 39.2+ /-10.4 years (range 24-56years). Pterygium with grade T1 were seen in 17 patients, grade T2 were seen in 84 patients, grade T3 were seen in 39 patients. There were 50 patients in each Group A, B& C. Table 1 shows mean age of patients in the groups. Table 2 shows pterygium grade of eyes. There were no statistically significant differences in age between the three study groups. No complication noted during the study.
Table 1
| Group | N | Mean | SD | Pair | T | P | Significance |
| A | 50 | 41.25 | 10.56 | AB | 1.17 | >0.05 | NS |
| B | 50 | 38.71 | 11.21 | BC | 0.67 | >0.05 | NS |
| C | 50 | 40.33 | 12.72 | CA | 0.39 | >0.05 | NS |
Mean age of patients in the groups
Table 2
| Group | N | T1 | % | T2 | % | T3 | % |
| A | 50 | 10 | 20.0 | 29 | 58.0 | 11 | 22.0 |
| B | 50 | 9 | 18.0 | 25 | 50.0 | 16 | 32.0 |
| C | 50 | 8 | 16.0 | 30 | 60.0 | 12 | 24.0 |
Pterygium grade of eyes
The main objective was focused on postoperative recurrence of pteygium in each group. It was 17 patients in group A, 8 patients in Group B and 7 patients in Group C. So, the recurrence rate s in Group A, B & C were 34%, 16% and 14% respectively. This difference in recurrence of pterygium were statistically significant (p<0.05) in Group A& C and were statistically insignificant (p>0.05) in Group B. The average month of recurrence of pterigiyum was 6.5 months. Younger age group showed more recurrence than the older age group. Intraocular pressure was raised in two eyes in group B (which were given Triamcinolone subconjunctivally), was controlled by topical medications. No complication was seen in the study groups through the follow up period.
Discussion
The objective of this prospective, randomized study was to evaluate the outcome and safety of triamcinolone and bevacizumab, and its recurrence.
The recurrences observed were actually less in group B(16%) and C(14%), which had received triamcinolone and bevacizumab respectively, while it was higher in group A(34%) which had undergone only conjunctival autograft.
Having known the etiopathogenesis, adjunct therapies like Conjuctival autograft application of metomycin C1, Use of cyclosporine, sub-Conjuctivial Triamcinolone and Bevacizumab along with excision of Pterygium were tried to prevent recurrences.
Thus it was seen that the recurrences were less in group B & group C i.e. auto graft7 with Triamcinolone/Bevacizumab given intraoperatively than group A i.e only conjunctival autograft. This study was undertaken to explore the role of subconjuctival injections after surgical excision of primary pterygium with conjunctival autograft. Triamcinolone acetonide is an intermediate acting medium potency steroid. It is five times more potent than hydrocortisone. Intraoperative injection of triamcinolone reduces postoperative inflammation thereby reducing the chance of recurrences. Currently the role of anti-VEGF agent such as bevacizumab as an adjunctive to pterygium excision with conjunctivaauto graft has no effect on recurrence rate as stated by Razeghinejadet al.9, 8 Various workers evaluated the role of Bevacizumab as adjunctive therapy in intraoperative pterygium surgery. It failed to produce any definite results.
But in this study the single dose of subconjuctival injection of Triamcinolone and Bevacizumab can combined with conjunctival autograft intraoperatively to prevent recurrence of pterygium. However we found no added advantage between Triamcinolone and Bevacizumab but in our setup Triamcinolone is more cost effective. However more studies with larger study groups are desired to establish the promising role of anti-VEGF in treatment of primary pterygium and its recurrence.
