Middle East Afr J Ophthalmol. 2009 OctDec; 16(4): 260–262.
Efficacy of Limbalconjunctival Autograft Surgery with Stem Cells in Pterygium
Walid M Abdalla
Department of Ophthalmology, Magrabi Eye and Ear Center, Muscat, Sultanate of Oman
Corresponding Author: Dr. Walid M. Abdalla, 106, Rumaila Bldg. Al Nahda St., P.O.Box: 513, Postal code 112, Muscat, Sultanate of Oman. E
Copyright © Middle East African Journal of Ophthalmology
This is an openaccess article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.
To determine the efficacy of limbalconjunctival autograft surgery with stem cells in the management of
primary and recurrent pterygium and determine the best corrected visual acuity after surgery.
Materials and Methods
Surgical excision of pterygium and limbalconjunctival transplantation with stem cells was of 40 eyes (of 31
patients) with pterygium. Thirty one cases were primary and nine cases were recurrent pterygia. Graft
margins were secured to the recipient site while stem cells aspect was sutured to the limbus.
After one year of followup, 37 of 40 (92.5%) eyes were free of recurrence. One of the three recurrent cases
was aggressive (recurrence occurred two months after surgery) and the other two showed 2 mm corneal
extension at 12 months followup. In 24 patients, out of 40 (60%), best corrected visual acuity improved
more than two lines.
Limbalconjunctival autograft surgery, including stem cells, appears to be an effective surgical technique in
preventing pterygium recurrence and it can also help in improving the best corrected visual acuity.
Keywords: Conjunctival Graft, Pterygium, Stem Cells
Pterygium is a common external eye disease, seen more frequently in tropical and subtropical areas where
exposure to ultraviolet sunlight is high. The main histopathological change in primary pterygium is
elastodysplasia and elastodystrophy of subepithelial connective tissue. 1 Indications for surgical excision
include impending or manifest visual loss due to involvement of the central cornea, irregular astigmatism,
restriction of ocular motility and atypical appearance leading to concerns of squamous neoplasia. 2 Surgical
treatment of pterygium is directed at excision, prevention of recurrence and restoration of ocular surface
The main concern of simple excision of pterygium is the high recurrence rate. To prevent recurrence,
adjunctive therapies are to be considered. These include application of antimetabolites such as mitomycin C,
radio therapy, conjunctival or limbal conjunctival autograft and amniotic membrane graft. Unacceptable
recurrence rates led to the abandonment of excision with bare sclera technique. There is widespread
acceptance of conjunctival autografting, since its introduction by Thoft in 1977 and application to pterygium
by Vastine et al . and Kenyon et al . However, no single autograft technique is completely effective in
preventing recurrence. Most reports also advocate a thin graft devoid of Tenon's fascia but one which is large
enough to completely cover the bare scleral defect.
Limbal conjuctival autograft, using stem cells, is reported to be an effective adjuvant to lower the recurrence
rate of pterygium. This study was carried out to determine the long term recurrence rate, visual acuity
improvement and astigmatic changes after excision of pterygium and conjunctival autografting using limbal
MATERIALS AND METHODS
The technique used was excision of pterygium, extending at least 2 mm beyond the limbus, followed by
superior conjunctival limbal autograft including limbal stem cells performed in 40 eyes of 31 patients
between February and October 2007 at our institution. Thirty one eyes had a diagnosis of primary pterygium
and nine were recurrent cases. Patients with other ocular surface disease or ocular pathology were excluded
from the study. None of the patients had previously undergone any ocular procedure. Informed consent was
obtained from all patients. Institutional review board and ethics committee approval was not required.The
surgical technique used was based on that described by Kenyon et al . who reported that the harvesting of the
conjunctival graft should not stop at the limbus but continued into clear cornea for about 2 mm to harvest
limbal stem cells. Local anesthesia was administered using Van Lint and peribulber injection of 50%
Marcaine (0.75%) and 50% Xylocaine (2%) without epinephrine. Westcott scissors were used to excise the
body of the pterygium 5 mm posterior to the limbus during which care was taken to identify the insertion of
the adjacent medial rectus muscle. The dissection was done down to bare sclera. And extended anteriorly to
the limbus where the head of the pterygium was separated from the corneal epithelium 2 mm anterior to the
pterygium head. The corneal defect was shaved for any residual tissue using a blade. Any bleeding points
were cauterized with wet field diathermy. The size of the conjunctival graft required to resurface the exposed
scleral surface was determined by Castroviejo calipers by taking measurements that covered the area of
defect created by excision. The measured dimensions were used to determine the exact size of the graft from
the superior temporal bulbar conjunctiva using a marking pen. A non toothed forceps was used to rotate the
globe. Stay sutures and injection of balanced salt solution to separate the conjunctival graft from the
underlying tenon's capsule were avoided. Care was taken to obtain thin conjunctiva without buttonholes, the
graft was then continually dissected until the limbus was reached using sharp blade till clear cornea was seen
2 mm from the anatomical limbus. Westcott scissors were used to separate the conjunctivo limbal graft and
the free graft was rotated and moved to the scleral bed maintaining limbus to limbus orientation. The graft
was secured with interrupted 8–0 vicryl sutures. The donor site was left to epithelialize without closure of the
defect. A bandage contact lens was applied post operatively for all patients for one week.
After surgery, steroids, antibiotics and artificial tear drops were used four times daily for four weeks.
Demographic, preoperative, operative and post operative details including complications were obtained from
the case notes of the patients. These patients were invited for clinical review carried out by the same surgeon.
During the review; best corrected visual acuity, refractive error, slit lamp findings were noted. Attention was
given note if there was recurrence of pterygium and other complications were also noted. Recurrence of
pterygium was defined as a fibrovascular ingrowth of 1.5 mm or more beyond the limbus with conjunctival
drag as used by Singh et al . Photographs were taken in all patients who attended the review appointments.
Of the 40 operated eyes, 28 were reviewed at a mean followup period of 13.5 months (range 1215
months). Data collected from those patients is reported in Table 1. These patients were seen on the first post
operative day, at one week, two weeks and one month postoperatively and at the time of final followup.
All patients were Omani, 22 male and* female.In all eyes, pterygium was located nasally. All the eyes were
operated by the same surgeon. Three patient required general anesthesia whereas the rest were operated on
using peribulber anesthesia. In cases where the pterygium was bilateral, each eye was analyzed separately.
Improvement in best spectacle corrected visual acuity was seen (two to six Snellen lines) in 24 patients.
Recurrence was seen in three eyes (7.5%). The first, patient, a female, in her early twenties had a previously
recurrent pterygium which developed following simple excision of the pterygium, one year prior to
enrolment. The recurrence in this patient was noted three months postsurgery. The other two patients were
men who had primary pterygia and both had a small fibro vascular band that extended 2 mm anterior to the
limbus and were first noticed one year after surgery.
Peripheral corneal scarring at the site of the pterygium occurred in four patients and dellen formation
developed in one patient. Symblepharon formation or severe conjunctival scaring was not observed at the
donor site in any of the patients [Table 2].
Simple excision of pterygium is associated with a high recurrence rate ranging from 30 to 70%, To reduce
this high recurrence rate, different methods like, beta irradiation, mitomycin C, and amniotic membrane have
However, serious complications such as secondary glaucoma, uveitis, scleromalacia and
corneal perforation are associated with these methods. Contamination of amniotic membrane is a potential
risk that cannot be overlooked despite of low recurrence rate .
Pterygium excision followed by conjunctival autograft is associated with recurrence rate of 5.3 to 39%.
After the initial report by Kenyon et al .,describing the success of conjunctival autografting following
pterygium excision, other authors have largely failed to achieve the same success rate . The wide range of
recurrence rates reported number of factors. Review of published literature suggests that the surgical
technique could probably be the single most important factor influencing recurrence. The meticulousness
with which the limbal tissue is included in the autograft, in our opinion, determines the success of the
Various studies have specifically described the inclusion of limbal tissue in the graft and have demonstrated
low recurrence rates. The importance of limbal transplantation in ensuring low recurrence rates has also
been stressed by Figueiredo et al ., but their work was carried out on a higher mean age group than the
mean age in this study.
Minimal limbal conjunctival autograft showed a recurrence rate of 9.2% during a followup period of 6–29
months.11 In our study the recurrent rate of 7.59% was comparable in a followup period of 12–15 months.
Using other procedures others have shown varying degrees of recurrence that ranged from 0–15%.
demonstrated improvement in astigmatic correction in 60% of our patients which is slightly lower than that
demonstrated by Oguz and colleagues who showed that 75% of patients had improvement in the astigmatism
after prteygium surgery. We believe that this difference could be explained by the smaller numbers in our
A major drawback for limbal conjunctival autograft transplantation is that it is technically more demanding
and timeconsuming. Hence we conducted this study on limbal conjunctival autograft as an effective
procedure in treating pterygium. The main limitation that demonstrated of this study is the small number of
patients and lost patients in followup despite multiple attempts to trace and call them for review. In
conclusion, limbalconjunctival autograft appears to be an effective conjunct technique in preventing
pterygium recurrence and can also help to improve the best corrected visual acuity of patients.
Source of Support: Nil
Conflict of Interest: None declared.
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Figures and Tables
Demographic data of patients undergoing limbalconjunctival autograft surgery with stem cells in the
treatment of pterygium
Number of eyes (patients)
Follow up periods (months)
Pterygium (Primary:Recurrent) 31:9
Complications of limbalconjunctival autograft with stem cells
Complications of limbalconjunctival autograft with stem cells Number of cases Percentage
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