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Original Article

Treatment of primary pterygium: Role of limbal stem cells

and conjunctival autograft transplantation
Mohamed A. E. Soliman Mahdy1,2, Jagdish Bhatia2
1
Al-Hussein University Hospital, Al-Azhar University, Cairo-Egypt and 2Department of Ophthalmology, Rustaq Hospital, Rustaq,
Sultanate of Oman

Purpose: The limbus and its stem cells are very Results: Recurrence of pterygium occurred in two
important in the pathogenesis of pterygium. In this eyes (2/42; 4.75%). No significant complications were
study, the efficacy of limbal stem cells and conjunctival noted. Apart from re-operation in the two recurrent
autograft transplantation for the treatment of primary cases, no further surgical interventions were needed in
pterygium will be assessed. any case.

Design: Prospective noncomparative cohort study. Conclusions: Limbal stem cells and conjunctival
autograft transplantation is a safe and effective technique
Materials and Methods: Forty-two eyes of 42 patients for the treatment of different grades of pterygium. It is
with grade I-III primary pterygium were included in very useful in preventing pterygium recurrence, which
the study. Pterygium excision was performed followed is a major problem in pterygium surgery.
by superotemporal limbal stem cells and conjunctival
autograft transplantation in all cases. Recurrence of Keywords: Pterygium, autograft, excision, stem cells
pterygium and complications within a mean follow-up
period of 18.26 months (1028 months) was studied. Oman Journal of Ophthalmology, 2009; 2(1):23-26

Pterygium is a fibrovascular overgrowth of bulbar Heparin-binding epidermal growth factor (HB-EGF), a

conjunctiva across the limbus onto the cornea. It is seen potent growth factor capable of stimulating altered cell
more frequently in certain populations, and its incidence growth and anchorage independence, has been implicated
varies greatly in different geographical zones. Pterygium in the pathogenesis of pterygia.[5]
is thought to be caused by increased exposure to light,
dust, dryness, heat, and wind. Pterygium was seen twice Surgical treatment of pterygium is directed towards
as frequent among persons who worked outdoors but excision, prevention of recurrence, and restoration of
was only one fifth as likely among those who always used ocular surface integrity. A myriad of techniques, some
sunglasses outdoors.[1] In the Barbados eye studies, the combined with others, have been described for achieving
incidence of pterygium was high in black population, for an these goals. The main complication of these procedures has
average of 1.3% per year. Working outdoors increased the been the recurrence rate, which has been estimated as high
risk 1.5-fold, whereas having a darker skin complexion and as 30%70%.[6] Surgical techniques for pterygium include
using eyewear for either reading or distance substantially bare sclera excision, excision with simple conjunctival
decreased the risk of developing pterygium.[2] Ultraviolet closure, excision with administration of antimetabolite
(UV) light is one of the major factors implicated in the adjuvants such as mitomycin C (MMC),[7] excision
pathogenesis of pterygium, although the mechanism by with conjunctival autograft[8,9] and excision followed by
which UV light induces this disease remains elusive.[3,4] amniotic membrane transplantation.[10] Treatments such as

*The Study was presented during the XXVI ESCRS meeting in Berlin, Germany, September-2008
Copyright: 2009 Soliman Mahdy MAE. This is an open-access article distributed under the terms of the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Correspondence:
Mohamed A. E. Soliman Mahdy, The Ophthalmic Department, Rustaq Hospital, Post Box: 2, Postal code: 329 Rustaq, Sultanate of Oman
E-mail: mmahdy67@gmail.com, DOI: 10.4103/0974-620X.48418.

23 Oman Journal of Ophthalmology, Vol. 2, No. 1, 2009

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Mahdy and Bhatia: Limbal stem cell transplant in the treatment of primary pterygium

radiation therapy, the use of antimetabolites agents have All the operations were performed using peribulbar anesthesia
succeeded in diminishing the number of recurrences from with 2% lidocaine and 0.5% bupivacaine. To improve
between 5% and 12%.[2-4] However, serious complications exposure, 6/0 silk or 8/0 Vicryl traction sutures were placed
are associated with these methods of treatment, such as in the episcleral-limbal area at 12 oclock position. The
secondary glaucoma, cataracts, uveitis, corneal perforation, pterygium was removed starting with superior conjunctival
and scleral necrosis, resulting in perforation and secondary incision. The conjunctiva was then dissected to free the body
endophthalmitis.[11,12] of pterygium. Superficial keratectomy was done to clean the
cornea at the area covered by the head of pterygium using a
In 1985, Kenyon and collaborators introduced conjunctival Beaver blade. Minimal cautery was used to control bleeding
autograft as a technique for the treatment of recurrent or and the area of bare sclera was measured. A superotemporal
advanced pterygium.[8] Although this surgical technique limbal conjunctival autograft incorporating a small portion
is more time-consuming, it has reduced the number of limbal stem cells, and measuring approximately 0.51
of recurrences with the same efficacy as the previously mm larger than the recipient bed, was harvested from the
described treatments without the risk of potentially serious same eye. The graft was dissected towards the cornea with a
complications. Survival curve analysis showed that there number 15 scalpel blade to include 0.5 mm of the superficial
was a 50% chance that there would be a recurrence of limbus. Dissection of the conjunctival autograft was
pterygium within the first 120 days, and a 97% chance of commenced superotemporally from the fornix to the limbus.
recurrence within 12 months of its removal.[13] Recently, Care was taken to include minimal or no Tenons capsule.
the importance of limbal stem cells in the pathogenesis of The graft was transferred to the recipient bed and secured
pterygia has been reported,[14] and authors have suggested with 10/0 or 8/0 Vicryl sutures. The graft was oriented so that
that a healthy limbus acts as a barrier to conjunctival harvested limbal stem cells were positioned adjacent to the
overgrowth.[15] Conceptually, one could possibly reduce cornea. The host area was left with Tenons capsule exposed.
the pterygium recurrence by including healthy limbus in Postoperatively, the patients were treated with a tapering
the conjunctival autograft. Besides, moving a limited area dose of topical dexamethasone and antibiotic drops (four
of limbus stem cells may not be detrimental to the ocular times daily for 2 weeks, three times daily for 2 weeks, and
surface. two times daily for 2 weeks). The follow-up period ranged
from 10 to 28 months.
Materials and Methods
Results
The study was approved by the Hospital Scientific
Committee and written informed consent was taken from The demographic patients characteristics, preoperative and
all patients included in the study. The participants were postoperative data of cases are shown in Table 1. During
patients attending Rustaq General Hospital. Forty-two the follow-up period recurrence of pterygium beyond the
eyes of 42 patients with grade IIII primary pterygium limbal edge was noted in two eyes (4.75%). The sites from
(3 patients with pterygium grade-I, 25 patients grade-II which the grafts were harvested, epithelialized completely
and 14 patients grade-III) were included in the study. The without any significant scarring. No dehiscence, epithelial
pterygium was graded depending on the extent of corneal inclusion cysts or Tenons granulomas were observed. No
involvement as described in a previous study.[16] Table symblepharon or ocular motility disturbances were reported
1 shows the patients demographic characteristics. All in any case. The mean visual acuity improved from 0.32 to
patients underwent pterygium excision with conjunctival 0.63 (decimal notation). Figures 1 and 2 show a case before
autograft from the same eye. operation and 3 months after surgery.

Table 1: Demographic details of study patients, Discussion

preoperative characteristics and postoperative
results The current study included 42 patients with pterygia
Number of eyes (n) 42 surgically treated with conjunctival and limbal stem cells
Age 43.4 years + 13 years (2166 years) autograft. The results showed that after a period of follow
Sex up that varied from 10 to 28 months, 95.25% of cases were
Male 30 (71%)
Female 12 (29%) successfully treated without recurrence of pterygial growth
Grades of pterygium or significant complications. Only 4.75% of cases showed
Grade I 3 eyes (7.14%) recurrence of pterygial growth.
Grade II 25 eyes (59.52%)
Grade III 15 eyes (33.33%)
Preoperative visual acuity 0.32
Varied surgical procedures have been described for the
Postoperative visual acuity 0.63 treatment of pterygium. The high postoperative recurrence
Follow-up period 18.26 months + 5.7 months rates indicate that there is still no single definitive
(1028 months) treatment. The ideal surgical technique should be one

Oman Journal of Ophthalmology, Vol. 2, No. 1, 2009 24

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Mahdy and Bhatia: Limbal stem cell transplant in the treatment of primary pterygium

dellen, graft retraction, epithelial cysts, and Tenon

granuloma.[20] A more significant complication such as
graft necrosis may occur if the graft is not properly oriented
or placed on a completely avascular zone. None of these
complications developed in our patients.

Shimazaki et al,[21] used a more or less similar technique as

described by us to treat two groups of patients, 16 of them
with primary pterygium. After an average follow-up period
of 10.5 months, only 7.4% showed slight recurrence with
1 mm of extension beyond the limbus, and no need for
additional surgery. The average age of these study patients
Figure 1: Preoperative photograph of an eye with pterygium
was 61 years as compared to 41 years in our study population.
Only two of the patients were less than 40 years of age.
Gris et al, used a similar technique closer to the one used
in our study in 7 patients with recurrent pterygium. They
reported no recurrence or significant complications.[22] In
another study, two groups of patients with pterygium who
underwent excision were studied. One group underwent
limbal conjunctival autograft with amniotic membrane
transplant. This group showed no recurrence of pterygium.
Another group underwent MMC and amniotic membrane
transplant this group had a recurrence rate of 20%.[23]
Minimal limbal conjunctival autograft has been used with
a recurrent rate of 9.2% during a follow up period of 629
Figure 2: Postoperative photograph of the same eye 3 months after surgery months.[24]

that effectively prevents recurrences without development The recurrence rate of 4.75% reported in our study is one
of complications. Of the procedures used most often to of the lowest reported so far and may be due to the use
treat recurrent or advanced pterygium, the one that comes of a very thin conjunctival graft devoid of Tenons tissue
closest to achieving this goal is, probably, the conjunctival in addition to incorporating a part of the adjacent limbal
autograft described by Kenyon et al.[8] This procedure stem cells in the graft. If we considered the relatively
reduces recurrence with minimal complications when young age of the patients operated and the geographic
compared with the use of -radiation or MMC. However, area in which these patients are living (windy, sandy with
recurrences were not completely eliminated, especially in high and prolonged exposure to UV light, as they are
patients who live in areas with high levels of ultraviolet living and working in the Arabian Gulf region), this rate
light.[17] of recurrence is even an excellent rate. Giving the above
result, we conclude that despite the fact that limbal stem
Considering the importance of the limbus and its stem cells cells and conjunctival autograft transplantation is a time
in the pathogenesis of the pterygium, a new technique has consuming procedure, it is safe and effective technique for
been developed that includes in addition to the conjunctival the treatment of different grades of pterygium. It is very
autograft, a part of the limbal stem cells that aids in the useful in prevention of pterygium recurrence, which is a
complete anatomic and physiologic reconstruction of the major problem in pterygium surgery.
excised pterygium area. This limbal reconstruction may
theoretically reduce the recurrence rate. The complication References
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Source of Support: Nil, Conflict of Interest: None

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