Int Ophthalmol (2007) 27:339343
DOI 10.1007/s10792-007-9085-2
ORIGINAL PAPER
Mitomycin C and conjunctival autograft for recurrent
pterygium
Ugur E. Altparmak Yasemin Aslan Katrcoglu
Ramazan Yagc Zuleyha Yalnz Sunay Duman
Received: 1 March 2006 / Accepted: 28 March 2007 / Published online: 8 May 2007
Springer Science+Business Media B.V. 2007
Abstract
Purpose To observe the efficiency of intraoperative
low-dose Mitomycin-C combined with conjunctival
autograft in the treatment of recurrent pterygium.
Methods Fifteen eyes with recurrent pterygium
were included in this study. The mean age of the
patients was 51.6 11.4 (9 men, 6 women). All
patients underwent excision of the pterygium tissue
and subconjunctival fibrous tissue with a no cautery
approach. 0.2 mg/ml Mitomycin-C (0.02%) was
applied for 3 min. Conjunctival autograft was
obtained from the superotemporal bulbar conjunctiva
of the same eye. Eyes were followed for a mean
period of 21.0 9.1 months.
Results Recurrence was seen in two eyes (13.3%)
during the follow-up period. The only complication
seen was graft edema (two eyes; 13.3%) which
healed after pressure patching. Graft necrosis, scleral
melting or failure of revascularization was not noted.
Conclusion Intraoperative application of 0.2 mg/ml
U. E. Altparmak (&)
Y. A. Katrcoglu

Z. Yalnz
S. Duman
Department of Ophthalmology, Ankara Training and
Research Hospital, Naci Cakir mah. 13.sok. 3/29 Dikmen,
Ankara, Turkey
e-mail: ealtiparmak@hotmail.com
R. Yagc
Medical School, Department of Ophthalmology, Fatih
University, Ankara, Turkey
e-mail: ramazanyagci@yahoo.com
Mitomycin-C combined with conjunctival autograft
reduces recurrence in recurrent pterygium cases, with
minimal complications.
Keywords Mitomycin-C
Conjunctival autograft

Recurrent pterygium
Cautery
Introduction
Pterygium is the excessive fibrovascular proliferation
of the degenerated bulbar conjunctival tissue on the
exposed ocular surface. Its incidence varies in
different geographical zones. Main causes are
increased exposure to ultraviolet light, microtrauma
and chronic inflammation from environmental factors
[14].
Recurrence is the major complication of the
surgical treatment of pterygium and is estimated as
high as 3070% [3]. Removal of recurrent pterygium
tissue is more difficult due to the abundant subcon-
junctival fibrous tissue and its tight attachment to
underlying sclera [2].
Numerous approaches have been attempted to
reduce recurrence, which can mainly be grouped as:
(a) those dealing with closure of the defect [including
primary closure, pedicle flap, transposition of the
pterygium head, conjunctival autograft (CA) with or
without limbus, buccal mucous membrane grafts,
lamellar keratoplasty, amniotic membrane transplan-
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tation (AMT), penetrating keratoplasty or scleroker-
atoplasty], and (b) those dealing with adjunctive
therapy [including beta irradiation, thiotepa or mito-
mycin C (MMC)] [5].
In this study, we present our results of 15 recurrent
pterygium cases treated with CA technique (with a no
cautery approach) combined with low-dose intraop-
erative MMC.
Patients and methods
Fifteen patients with recurrent pterygium were
enrolled in this study. All patients had excision of
the pterygium tissue and closure with bare sclera
technique in their prior treatments. Eyes with a
history of adjunctive therapy and/or closure of the
defect other than bare sclera technique during prior
treatment(s) were excluded. All patients were asked
to sign an informed consent and an IRB approval was
obtained. The same experienced surgeon (YAK)
performed all of the surgeries.
Surgical technique
After excision of the pterygium tissue using Westcott
tenotomy scissors, a thorough removal of subcon-
junctival fibrous tissue was performed, as described
by Barraquer [6]. A microsponge (Alcon1 100002)
was soaked in a 0.2 mg/ml (0.02%) solution of MMC
(Kyowa1 Onko) for 1 min and placed over the
exposed sclera. After 3 min, the sponge was removed
and the ocular tissues were irrigated with 100 ml
balanced salt solution (Isolyte S1 Eczacibasi Baxter,
Turkey).
Conjunctival autografting was performed using the
technique described by Kenyon et al. [7] with the
modification that cautery was avoided to preserve
vascularity in the recipient bed.
The graft was secured and approximated with the
recipient conjunctival edge by interrupted 70 po-
lyglactin sutures (Vicryl1; Ethicon, Edinburgh, UK).
The conjunctiva at the harvest site was approximated
using 70 polyglactin sutures.
At the end of the surgery, Tobramycin 0.3%
ointment (Tobrex1 Alcon) was applied and the eye
was patched for at least one day. Postoperatively, all
eyes were treated with ciprofloxacin 0.3% (Ciloxan1
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Int Ophthalmol (2007) 27:339343
Alcon), prednisolon-acetate 1% (Pred-Forte1 Abdi-
Ibrahim, Allergan) and tear substitute (Tears Naturale
II1 Alcon) four times a day for one week, followed
by prednisolon-acetate in tapered dosages and tear
substitute until the end of the first month after
surgery.
Patients were examined on postoperative days 1,
15 and 30 and then monthly for three months, for at
least 10 months.
True recurrence was defined as fibrovascular tissue
growth onto the cornea, as described by Prabhasawat
et al. [5]. In brief, a grade 1 result denoted the
operated eye indistinguishable from normal; grade 2,
the presence of some fine episcleral vessels in the
excised area extending up to the limbus but not
beyond, in the absence of any fibrous tissue; grade 3,
the presence of additional fibrous tissues in the
excised area without invasion into the cornea, and
grade 4, true recurrence of pterygium with fibrovas-
cular tissue invading a clear cornea [5].
Results
The mean age of the patients was 51.6 11.4 (3473;
9 men, 6 women) (Table 1). The mean number of
previous surgeries was 2.4 0.6 (24) The patients
were followed for a mean period of 21.0 9.1 (715)
months. True recurrence was observed in two
(13.3%) cases during the follow-up period (Fig. 1).
All other cases had grade 1 recurrence. The only
complication was graft edema, seen in two eyes
(13.3%), which responded well to pressure patching,
within 1216 days. There was no failure of revascu-
larization, graft failure, graft necrosis or scleral
thinning.
Discussion
Even though the surgical treatment of pterygium with
the bare sclera technique was described almost half a
century ago [8], the high recurrence rate with this
technique has necessitated the evolution of secondary
approaches.
The underlying cause of recurrence seems to be
surgical trauma and subsequent postoperative inflam-
mation, which activate subconjunctival fibroblasts
and vascular cells, causing stimulation of the depo-
Int Ophthalmol (2007) 27:339343 341

Table 1 Patient data

Patient no. Age Sex Follow-up No. of recur. Preop. move. Postop. move. L(mm) W(mm) Recurrence Complication

1 61 F 24 2 Full Full 15 7 None None

2 48 M 14 4 Abduction 60% Full 13 8 None None
3 56 F 19 3 Full Full 12 9 None None
4 59 F 18 2 Full Full 13 7 None None
5 45 M 14 2 Full Full 16 7 None None
6 73 F 18 2 Abduction 50% Full 13 8 None Graft edema
7 45 M 14 3 Full Full 15 8 None None
8 63 M 11 3 Full Full 14 7 None None
9 50 M 10 2 Full Full 14 5 None Graft edema
10 34 M 13 2 Full Full 15 6 + None
11 48 M 14 3 Full Full 14 6 None None
12 44 M 12 2 Full Full 15 5 + None
13 42 M 12 3 Full Full 15 5 None None
14 35 F 11 2 Full Full 14 4 None None
15 63 F 13 2 Full Full 15 7 None None
No.: number; recur.: recurrence; move.: movement; preop.: preoperative; postop.: postoperative; L: length; W: width

Intraoperative use of MMC was preferred in this

Fig. 1 True recurrence (grade 4 by Prabhasawat (5))
sition of extracellular matrix [9]. Therefore, the
secondary approaches have mostly focused on the
reduction of hyperproliferation of this fibrovascular
tissue.
Among the adjunctive therapies performed, b-
irradiation [10] and thiotepa [11] have not been
popularized due to their side-effects. Mitomycin-C
has become more favorable than 5-fluourouracil due
to its stronger inhibition of fibroblast proliferation
[12] and migration [13], as an anti-proliferative
agent. Mitomycin-C can inhibit fibroblast prolifera-
tion with concentrations of 0.2 mg/ml (0.02%) and
exposures as short as 1 min [12].
study, due to the equal effectiveness of intraoperative
and postoperative topical use [14] and serious
complications seen with increasing cumulative dos-
age with postoperative topical use [15]. The selection
of the 0.2 mg/ml concentration and the 3 min
duration for this study were based on the results
from our geographical zone [14, 1618], the recurrent
nature of these cases and concurrent CA transplan-
tation. Alternatively, MMC could be applied subcon-
junctivally in the preoperative period, as described by
Donnenfeld et al. (19). However, the comparison of
preoperative subconjunctival MMC with intraopera-
tive MMC is beyond the scope of our study and
preoperative use of MMC was not preferred due to
lack of experience with the technique.
Conjunctival autograft with or without limbus [5]
has been popularized in recent years for closure of the
defect. The probable mechanisms of prevention of
recurrence can be summarized as contact inhibition
of abnormal residual tissue and restoration of limbal
barrier by transplanting healthy limbal cells (when
limbal tissue is transplanted) [20]. In the literature the
recurrence rate of CA alone for recurrent pterygium
varies from 0% [21] to 25% [22]. Though the use of
limbal autograft seems advantageous, this method is
more technically demanding and necessitates the use
of lifelong immunosupressants, if an allograft is used.

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Table 2 Results of recurrent pterygium treatment from other studies in the literature
Author (year published) Method
Mutlu et al. 31 (1999) MMC + conjunctival flap
Cheng et al. 27 (2001) Intraop. MMC + conjunctival graft
Segev et al. 18 (2003) Intraop. MMC + conjunctival graft
Nabawi et al. 28 (2003) Intraop. MMC + conjunctival graft
Kawasaki et al. 29 (2003) Intraop. MMC + amniotic membrane
Miyai et al. 30 (2005) Intraop. MMC + limbal autograft and AMT
Yao et al. 26 (2005) Intraop. MMC + limbal autograft and AMT
Ma et al. 32 (2005) Intraop. MMC + AMT
Ma et al. 32 (2005) AMT
Current study (2007) Intraop. MMC + conjunctival graft
MMC: mitomycin-C; intraop.: intraoperative; AMT: amniotic membrane transplantation
Therefore, CA without limbal tissue was preferred in
this study, due to limited experience with the former
technique.
For the treatment of recurrent pterygium, combi-
nation of intraoperative MMC application with CA
may have several advantages. While benefiting from
the antiproliferative and avascular effects of MMC,
complications such as scleral thinning, perforation
[23, 24] and necrotizing scleritis can potentially be
prevented by using the graft. The graft can also
enable the use of a lower concentration of MMC.
Therefore, theoretically, this technique can be more
efficient than CA or MMC alone for the treatment of
recurrent cases. On the other hand, conjunctival
autografting alone may not be sufficient to avoid
necrotizing scleritis, as seen in sporadic case reports
[25]. Avoiding cautery in such cases may be an
additional factor in preventing necrotizing scleritis,
by avoiding the avascular bed. It may also help
decrease postoperative inflammation and decrease the
recurrence rate. Avascular effects of Mitomycin-C
can be helpful to avoid cauterization. Scleral thinning
or necrotizing scleritis were not observed in similar
studies where MMC was co-administered with con-
junctival autograft or amniotic membrane transplan-
tation (Table 2). However, MMC was used at a low
concentration (0.02%) with relatively short exposure
times (maximally 5 min by Yao et al. [26]) in all
these studies [18, 2732]. Cautery was used in the
study by Ma et al. [32] but data is lacking about its
use in the other studies [18, 2731].
The results of this study is slightly more successful
than that of Segev et al. [18] (recurrence of 13.3% vs
14.2%) despite the older mean age group (51.6 vs.
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Int Ophthalmol (2007) 27:339343
Follow-up (months) Recurrence (no. of eyes)
15.5 12.5 % (40)
40.9 6.3% (35)
29.2 14.2%(7)
>18 (34)
17.3 12%(26)
21.5 (12)
22.4 14.2%(7)
27.9 12.8% (47)
28.6 12.5% (48)
21.0 13.3% (15)
46.1) and the higher number of previous surgeries
(1.28 vs. 2.4) in our patients. On the other hand, our
results are worse than the results of Cheng et al. [27]
(recurrence of 13.3% vs. 6.3%). The mean age of the
patients in this study is younger than Chengs group
(51.6 vs. 64.3) and the number of previous surgeries
is higher (2.4 vs. 1.16), which may be the causes of
this difference.
We believe that, to increase the success of surgery,
thorough excision of the subconjunctival tissue in an
area much greater than the pterygium body [6], and
closure of the donor conjunctival site to prevent
postoperative scarring of the donor area [33] are
important preventive measures. Avoidance of cauter-
ization of the recipient scleral bed may be an
addendum to increase the safety of MMC use [15, 34].
The limitations of this study are the lack of a
control group and the small number of patients. Since
this was a pilot study at this institution, the selected
group was small. Further comparative studies with
larger groups would yield additional data about the
technique described.
To summarize, although the number of subjects is
limited, combining MMC intraoperatively with con-
junctival autografting (without cauterization) seems a
safe and promising method for cases of recurrent
pterygium.
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