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International Ophthalmology
The International Journal of Clinical
Ophthalmology and Visual Sciences

ISSN 0165-5701

Int Ophthalmol
DOI 10.1007/s10792-013-9797-4
The study of etiological and demographic
characteristics of pterygium recurrence: a
consecutive case series study from Pakistan
P.Salim Mahar & Nabeel Manzar
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ORI GI NAL ARTI CLE
The study of etiological and demographic characteristics
of pterygium recurrence: a consecutive case series study
from Pakistan
P. Salim Mahar

Nabeel Manzar
Received: 5 June 2011 / Accepted: 13 February 2013
Springer Science+Business Media Dordrecht 2013
Abstract To determine the agents of recurrence, the
demographic features, and the management and out-
comes of pterygium cases treated at Aga Khan Univer-
sity Hospital (AKUH), Karachi. This hospital-based
descriptive study included 147 patients with pterygium
(147 eyes) from both sexes, who presented at the
Ophthalmology Department at AKUH between January
1, 2002 and December 31, 2010. Data regarding their
demographic prole and other factors were collected in a
well-structured proforma. Data were analyzed using
frequencies, proportions, group means, standard devia-
tions, and Pearsons chi squared test. The male to female
ratio in our study was 2:1, with factors such as younger
age (\50 years) at presentation(P = 0.04, Pearsons chi
squared test) and the presence of secondary pterygium
(P = 0.050) correlated signicantly with the recurrence
of pterygium. There was a denite trend of decreased
recurrence seen with lower grade of pterygium
(P = 0.06). The recurrence rate in our study was
8.8 %. These results suggest that a younger age coupled
with a higher grade of pterygium as well as a history of
multiple recurrences leads to increased susceptibility of
recurrence after surgical excision. Early diagnosis and
appropriate management will lead to a better prognosis.
Keywords Pterygium Recurrence Pterygium
grade Etiologic factors Age
Introduction
Pterygium is one of the most common conjunctival
surface degenerative disorders [13]. This brovas-
cular expansion of bulbar conjunctiva over the limbus
leads to chronic irritation, impaired cosmesis, irregu-
lar astigmatism and decreased vision secondary to the
development of pupillary axis blockage by the
increased growth [2]. A number of different surgical
approaches have been proposed for the treatment of
pterygium. The most common method has been the
bare scleral excision technique, rst described by
DOmbrain [4]. However, the major limitation to
simple excision is the high rate of postoperative
recurrence [5]. Therefore adjunctive therapies have
been advocated along with excision to varying levels
of success during the last three decades. A relatively
new method being used, but relatively less in devel-
oping countries, is the conjunctival autograft method.
The recurrence rates are comparable between the two
techniques (239 %) [6, 7]. However, the widely used
method to date is the use of topical mitomycin
C(MMC) as an adjunct therapy to the bare sclera
P. S. Mahar
Section of Ophthalmology, Department of Surgery,
Aga Khan University Hospital, Stadium Road,
Karachi 74800, Pakistan
e-mail: salim.mahar@aku.edu
N. Manzar (&)
Dow University of Health Sciences, Karachi, Pakistan
e-mail: nmanzar2003@hotmail.com
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Int Ophthalmol
DOI 10.1007/s10792-013-9797-4
Author's personal copy
technique to prevent pterygium recurrence. It was rst
introduced by Kunitomo and Mori [8] of Japan and its
subsequent usage in the USA by Singh et al. [9] led to
its widespread use in Asia.
Since its inception, MMChas been used successfully
for treating various ocular disorders ranging from
pterygium to glaucoma [10, 11]. MMC was rst
developed in 1955 from Streptomyces caespitosus by
Hata et al. [12]. Since then much data and research
about pterygiumtreatment with MMCis available from
developed countries; however, there is a paucity of data
with regards to the etiology and demographics of
pterygium recurrence from developing countries such
as Pakistan because there is neither a national database
nor anyrelevant authoritythat follows recurrence cases.
A number of research studies have been carried out to
document the appropriate dosage and efcacy of MMC
in treating pterygium and preventing its recurrence.
However, relatively fewstudies have evaluated the role
of other factors such as age, gender, MMC exposure
time, as well as the size and extent of pterygium
encroaching on the cornea [1315], especially in the
context of the local population of Asia where there is
high prevalence of pterygium. The magnitude of the
problem, as well as signicant ocular morbidity and the
cost of the recurrent treatment expenditure incurred by
the state, motivated us to carry out our research. Factors
such as age, gender, type of pterygium, presenting
grade of pterygium, treatment, and outcome in terms of
recurrence of pterygium were taken into consideration.
The main purpose of our study was to determine the
agents of recurrence, the demographic features, the
management and outcomes of pterygium cases treated
at Aga Khan University Hospital (AKUH), Karachi and
to examine the factors associated with it.
Methods
This hospital-based retrospective, case series study was
carried out in the Ophthalmology Department, AKUH,
Karachi, Pakistan. Patient data les were analyzed
starting from January 1, 2002 to December 31, 2010.
One hundred and forty-seven patients (147 eyes)
diagnosed with pterygium and who fullled the inclu-
sion criteria were included in the study. The study
protocol was reviewed and approved by the ethics
committee at the study center (AKUH Ethical Review
Board), and the study was carriedout inaccordance with
the declaration of Helsinki of 1975, revised in 1983.
Patients fullling the following study criteria were
enrolled in the study:
Participants of all ages and gender as determined by
the completed proforma with established diagnosis
of unilateral progressive pterygia of different grades;
Surgical excision by the same surgeon (PSM)
using bare scleral technique along with topical
MMC administration with a minimum follow-up
period of 24 months; and
Informed consent from subjects or family for
participating in the study.
Patients with the following conditions were
excluded from the study:
Any suspicious growth other than pterygia and
corneal scarring;
Undergone pterygium excision by any other tech-
nique; or
Lost-to-follow-up during the study period.
The study was carried out in two parts. First, patient
data including detailed medical history along with
complete ocular examination were collected on a well-
structured proforma. This included best-corrected
visual acuity (BCVA), bio-microscopic examination
of anterior segment with Goldman applanation to-
nometery and fundus examination with ?90 DS lens.
This was followed by extraction of data regarding
social and demographic characteristics from the
patient archives. Pterygia were classied either as
primary or secondary (recurrent) pterygium on the
basis of rst-time episode or recurrence, respectively.
Pterygia were graded depending on the extent of
corneal involvement [3] by the principal investigator
(PSM) preoperatively to minimize any bias due to
inter-rater variability.
Grade 1, between limbus and a point midway
between limbus and pupillary margin;
Grade 2, head of the pterygium reaching the
pupillary margin (nasal papillary margin in case of
nasal pterygium and temporal margin in case of
temporal pterygium), and
Grade 3, crossing the pupillary margin.
Pterygium excisions were performed on an outpa-
tient basis by the same surgeon (PSM) using the same
Int Ophthalmol
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technique [16]. After excision using the bare scleral
technique under topical anesthesia (Proparacaine;
Alcon, Belgium), a sterile sponge (5 9 5 mm) soaked
in 810 drops of 0.2 mg/ml MMC (0.02 %) (mitomy-
cin-C; Kyowa, Japan) was applied over the corneo-
sclera and the area from where pterygium was excised
for a xed duration of 3 min. The sponge was removed
and the eye was irrigated with 20 ml of normal saline
0.9 %. This was followed by topical administration of
dexamethasone 0.1 % plus tobramycin 0.3 % (Tobra-
dex; Alcon, Belgium) and hydroxypropyl methylcel-
lulose (Tear Naturale II; Alcon, Belgium) four times a
day for 4 weeks. The dosage of MMC was calculated
in accordance with the international recommendations
[1719]. Patients were regularly followed up at
intervals of 3 months after the procedure for a
minimum period of 24 months. Any adverse effect
or physical ndings were noted on each visit. Recur-
rence of pterygium was dened as an encroachment of
brovascular connective tissue across the limbus and
onto the cornea for any distance in the position of the
previous lesion.
Classication of subjects was performed according
to age, gender, as well as site, type and grading of the
pterygium. Subjects were divided into two age
groups(1) B50 years and (2) [50 years. The poten-
tial factors were also classied accordingly (Table 1).
Data were entered in SPSS version 16. The results were
evaluated using frequencies, proportions, group means,
standard deviation and Pearsons chi squared test. A
P value of B0.05 was considered signicant.
Results
Atotal of 147 patients (147 eyes) based on our inclusion
criteria were enrolled in the study and were followed for
a minimum of 24 months (mean 38.6 months; range
2460 months). Twenty-six patients (in addition to the
147 patients) who were lost-to-follow-up during the
study period were excluded from the study; these cases
were similar to the study participants in terms of age,
gender and size of pterygium but their inclusion could
have biased the results so they were excluded. Ninety-
nine males and 48 females (male to female ratio 2:1)
aged between 16 and 90 years (mean SD
46.4 1.23 years) were included in the study. Primary
pterygium was present in 120 patients while secondary
pterygium was diagnosed in 27 patients. One hundred
and two eyes (69.4 %) were affected by grade 1
pterygium, 24 eyes (16.3 %) had grade 2, and 21 eyes
(14.3 %) had grade 3. In 129 eyes (87.7 %), pterygium
was located on the nasal side, in 16 eyes (10.9 %) it was
located on the temporal side, and two eyes (1.4 %) were
affected on both sides. Out of 147 eyes with pterygium,
66 were affected on the right eye and 81 on the left eye.
Baseline characteristics of patients are shown inTable 1.
The recurrence of pterygium was seen in 13 patients
(8.8 %) after a meantime of 6.77 months (SD9.38). Out
of 13 recurrences, 12 were in the \50 years age group
(P = 0.04, Pearsons chi squared test). Similarly, there
was a higher tendency of recurrence in males (10.1 %)
as compared to females (6.2 %) although this was not
signicant (P = 0.547). Most of the recurrences were
seen on the nasal side (9.3 %) while 6.3 % of pterygia
recurred on both sides (P = 1.00) Table 2.
In the group with recurrent pterygia, the recurrence
rate was greater (18.5 %) than in the group with primary
pterygium (6.7 %) (P = 0.050) with a mean (SD) time
of 3.20 (2.38) months as compared to 9.00 (11.54)
months. Adenite trend of recurrence was also noted on
Table 1 Potential risk factors in pterygium recurrence
Variable Recurrence N (%) P value
a
Yes No
Age (years)
Mean SD 46.4 1.23 0.04
\50 12 (13.5) 77 (86.5)
[50 1 (1.7) 57 (98.3)
Gender
Male 10 (10.1) 89 (89.9) 0.54
Female 3 (6.2) 45 (93.8)
Type of pterygium
Primary 8 (6.7) 112 (93.3) 0.05
Recurrent 5 (18.5) 22 (81.5)
Grading of pterygium
1 6 (5.9) 96 (94.1) 0.06
2 5 (20.8) 19 (79.2)
3 2 (9.5) 19 (90.5)
Pterygium location
Nasal 12 (9.3) 117 (90.7) 1.00
Central 1 (6.2) 15 (93.8)
Temporal 0 (00) 2 (100)
N number of subjects, SD standard deviation
a
Pearsons chi squared test
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further stratication of the subjects on the basis of
corneal involvement, with a higher rate of recurrence
seen in subjects with higher grades of corneal involve-
ment (P = 0.067). Similarly, when subjects with
primary pterygia were graded, there was a highly
signicant recurrence seen with higher grades of ptery-
gium (P = 0.008); however, the same was not seen in
participants with secondary pterygia (P = 0.334). The
role of pterygium grading in recurrence of pterygia is
shown in Table 3.
Corneal nebular opacity was a frequent nding,
being seen in seven patients (4.76 %) postoperatively
with only one patient developing a conjunctival cyst at
the site of excision.
Discussion
Pterygium remains an important health care issue in
patients globally [1] but especially in tropical and
Asian countries like Pakistan due to its hot and dusty
weather with high sun exposure. Bare surgical
removal of pterygium results in its high recurrence.
This is the reason that various adjunctive therapies
such as intraoperative topical application of MMC and
conjunctival autograft have been advocated to
increase the success rate of surgical outcome. The
present study was motivated by the invariably high
recurrence of pterygium not only in Pakistan but
worldwide [5, 20].
The recurrence rate of pterygium in the present
study was 8.8 %. In a recent clinical trial carried out in
the Pakistani population, Rahman et al. [21] estimated
a recurrence rate of 10 %. In another prospective
study, Cheng et al. [22] observed a recurrence rate of
7.9 % in subjects with primary pterygia and a
recurrence rate of 19.2 % in subjects with recurrent
pterygia. In a study carried out by Narsani et al. [23], a
recurrence rate of 6.97 %was seen in primary pterygia
patients who underwent conjunctival autograft as
compared to 16.13 % in patients treated by intraop-
erative MMC. In contrast, Frucht-pery et al. [24]
reported a recurrence rate of 6.6 % with intraoperative
MMC as compared to 13.3 % in the conjunctival
autograft group. In another study carried out by the
author (PSM), a recurrence rate of 25.9 % was seen in
the conjunctival autograft group as compared to 9.4 %
in the topical MMC group. Hence, the authors
preference for MMC-based treatment for patients is
based on his own experience [25].
However, comparisons between our study and
others are likely to relate to different study popula-
tions, settings and criteria used for grading. Age was
Table 2 Baseline characteristics of patients
Characteristics of
patients
No. of patients
(N = 147)
Frequency
Sex
Male 99 67.3
Female 48 32.7
Affected eye
Right 66 44.9
Left 81 55.1
Grading of pterygium
a
Primary 120 81.6
1 85 70.8
2 21 17.5
3 14 11.7
Recurrent 27 18.4
1 17 63.0
2 3 11.1
3 7 25.9
Site of pterygium
Nasal 129 87.8
Temporal 16 10.9
Central 2 1.4
Recurrence
Yes 13 8.8
No 134 91.2
a
Grading of pterygium was performed as described in
methods
Table 3 Effect of pterygium grading system on recurrence
Grading of pterygium Recurrence N (%) P value
a
Yes No
Primary
1 2 (2.4) 83 (97.6) 0.008
2 4 (19) 17 (81)
3 2 (14.3) 12 (85.7)
Recurrent
1 4 (23.5) 13 (76.5) 0.334
2 1 (33.3) 2 (66.7)
3 00 (00) 7 (100)
N number of subjects
a
Pearsons chi squared test
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signicantly related to the recurrence of pterygium in
our study, with increasing number of cases of recur-
rence in younger age groups. Similar conclusions have
been drawn from numerous worldwide studies [22, 26,
27]. Female gender was not related to recurrence in the
target group, presumably due to the fact that women in
Pakistan are usually housewives whereas men are
commonly exposed to occupational and environmen-
tal hazards leading to a higher rate of recurrence.
Site of pterygium was also investigated for its role
in recurrence, mainly because of the fact that in most
cases, pterygia is always present on the nasal side;
however, there was no signicant association between
site and recurrence. Secondary pterygium has been
recognized as a risk factor for a higher recurrence rate
in numerous studies [21, 22, 28]. Similarly, in the
present study a highly signicant rate of recurrence of
18.5 % was observed in the secondary group as
compared to 6.7 % in the primary pterygium group. In
a recent prospective study carried out by Diaz et al.
[29], no recurrences were observed on follow-up in
group of patient with previous recurrent pterygia
treated with intraoperative MMC. Many grading
systems are currently being used for grading ptery-
gium; however, in our study we used the grading
system based on the extent of corneal involvement by
the brous pterygium. The same system of grading is
currently being used extensively in Asian countries as
well as some developed countries. There was a higher
tendency of recurrence in participants with higher
grades of corneal involvement with a recurrence rate
of 5.9 % in the grade 1 group as compared to 21 % in
the grade 2 group. Similar results have been obtained
in studies across Europe where a high rate of
recurrence has been associated with increased esh-
iness of the pterygia [30]. In the secondary pterygium
group, the same results could not be achieved due to
the small sample size, although a denite trend was
noted.
In conclusion, our study found signicant associ-
ations of recurrence with younger age as well as with
secondary pterygia. There was a trend for association
with grade, which did not reach signicance level for
the whole sample. For primary pterygia there was a
signicant increase in recurrence rate with higher
grades of pterygium. While this study fullls the
objective set by the study protocol for this project of
determining the recurrence of pterygiumby its grading
method, and to evaluate the potential role of various
other risk factors in its recurrence in patients assisted
with intraoperative topical MMC (0.02 %), there
remain certain limitations to this study due to the
small sample size in the recurrent pterygium group. A
large-scale prospective study with appropriate power
is recommended for evaluating the microstructural
changes in the eye to possibly understand the dynam-
ics of the different grading on pterygiumrecurrence. A
study to document the recurrence rates in pterygium
cases following the conjunctival autograft method
should be performed to determine the potential
differences in the factors limiting the success rate of
both methods.
Acknowledgments The authors are greatly indebted to Dr.
Tashfeen Ahmad, Associate Professor, Department of Surgery,
AKUH for his assistance in statistical analysis.
Conict of interest No conicting relationship exists for any
author.
Financial Support None.
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