EXTERNAL DISEASES SESSION - All India Ophthalmological Society

EXTERNAL DISEASES SESSION215EXTERNAL DISEASES SESSIONChairman: Prof. Vinita Singh, Co-Chairman: Dr. Arun Kumar JainConvenor: Dr. Chalini Madhivanan, Moderator: Dr. Yathish ShivannaAUTHORS’S PROFILE:DR. RAJENDRA KUMAR BISEN: M.B.B.S., N.S.C.B. Medical College, Jabalpur; D.O.M.S.,GMC, RIO, Bhopal; D.N.B. (Resident), Rotary Eye Institute Navsari, Gujrat.Comparison of Cut and Paste (No Suture) with Cut and SutureTechnique of Pterygium SurgeryDr. Rajendra Kumar Bisen, Dr. Rupam Janak Desai, Dr. Falguni Mehta, Dr. O.P. Billore,Dr. Jigisha Kiran Randeri, Dr. Pravin Jain, Dr. Kapil Khurana(Presenting Author: Dr. Rupam Janak Desai)Pterygium surgery has been performed in theperiod before 1000BC by the Indian physicianSushruta. In early days, surgical management ofpterygium included bare sclera technique butwas associated with high recurrence rate. Toavoid this, adjunctive treatment such as βradiation, thiotepa, mitomycin C, 5-fluorouracilis used. Newer techniques include conjunctivalauto grafting with or without limbal stem celltransplantation, amniotic membrane grafting.Of all these newer methods, conjuctivalautografting is most commonly performed and isassociated with low rates of recurrence. Theautograft is attached to bare sclera with the helpof 7-0/8-0 vicryl suture; this is associated withincreased surgical time, more post operativepain, discomfort, and watering, prolongedhealing time. In recent times, the universal trendtoward simpler, quicker and more comfortablesurgical procedures have fostered thedevelopment of suture less techniques and hence,use of tissue adhesives for attaching conjunctivalautograft. This technique reduces the surgicaltime, causes significantly less post operative pain,irritation, watering, induces less inflammation,reduces healing time and recurrence. Fibrin glueis the most recent among all adhesives and isgaining acceptance world over for use intreatment of various ocular conditions.Materials and MethodsA prospective, randomised, hospital based,comparative study was done, to evaluate theeffectiveness and safety of fibrin glue ascompared to Vicryl sutures for attachingconjunctival autograft after pterygium excision,in 47 eyes of 46 patients diagnosed to haveprimary pterygium. Conjunctival autograft withfibrin glue was performed in 22 eyes in 21patients and conjunctival autograft with Vicrylsuture was performed in 25 eyes in 25 patientswho were evaluated in detail and compared forefficacy and safety. The results of variousobservations were documented and charted.Documentation of pterygium location, primaryor recurrent status, Pterygium Grading (T1-3),Slit-lamp photography, pre- and post-surgery,Pre-operative measurement of pterygium extentover the cornea and width at limbus alsomeasured.Grade Extent (mm) on to corneaGrade 1- 0-2 mm from limbusGrade 2 - 2-4 mm from limbusGrade 3- more than 4 mm from limbusFibrin sealant kit; Fibrin glue (Releseal) is a fibrinsealant that imitates the final stage of coagulationprocess. This glue has two components. Oneconsists of fibrinogen (human) mixed with factorXIII (human) and aprotinin (bovine). The other

216 AIOC 2009 PROCEEDINGScomponent is a thrombin (human) and calciumchloride. Fibrinogen is converted into fibrin on atissue surface by the action of thrombin. Fibrin isthen cross linked by factor XIII to create a firm,mechanically stable fibrin network. All thecomponents are prepared from banked and wellcontrolled human blood. Equal amounts of thecomponents are mixed together in prefilleddouble syringe applicator and applied to desiredplace.• The conjunctival autograft was harvestedfrom the superotemporal quadrant in allcases.• The autograft was secured in place over thesite of the excised pterygium using acommercially available fibrin glue• Surgical time was noted from first cut ofconjunctiva to removal of lid speculum.Surgical steps of pterygium excision withconjunctival autograft using Vicryl sutures: Allthe surgical steps were same except, instead ofusing fibrin glue, conjunctival auto graft wasattached to bare sclera with the help of 7-0 Vicrylsuture.Patients were examined on1st postoperative day,at 1 week, at 1 month, at 3 months, and at 6months for follow-up examination, for positionof the graft, graft host junction for any gaping ordetachment, graft edema, Inflammation andRecurrence, pain, foreign body sensation wereassessed and then graded by scale 0 to 3 byquestionnaires:Absent No symptomMild Patient had tolerable symptom andpresent occasionally.Moderate Tolerable symptom present throughout the day or Intolerable symptompresent occasionally.Severe Intolerable symptom present throughout the day.Graft success was defined as an intact graft by thefourth week after surgery.Graft failure was defined as detachment of graftby the fourth week after surgery.Recurrence was defined as proliferatingconjunctival tissue extending across the limbusmore than 1 mm onto the cornea within thesurgical field.For statistical analysis, student paired ‘t’ test forunequal variance was used.Results and DisscussionOut of 47 patients 22 were female and 25 weremale. Higher prevalence rate was observedbetween the age group of 31 to 50 years. Themean age was 43.40±11.91 and 48.53±13.1 yearsin fibrin and Vicryl group respectively.Table-1: Surgical timeFIBRIN GLUE VICRYLNO % NO %< 20 MIN 11 50.00 - -21-30 MIN 11 50.00 - -31-40 MIN - - 18 72.0041-50 MIN - - 07 28.00The mean surgical time in fibrin glue group was22.72 ± 3.69 minutes while, 41.0 ± 3.53 minutesin Vicryl group. The difference is statisticallysignificant (p

EXTERNAL DISEASES SESSION217fibrin glue group. In 13.63% (3) patient anchoringsutures were taken on immediate postoperativeday. In Vicryl group all the patients had wellplaced graft on immediate post-operative day.Jaspreet Sukhija et al 2 observed 8.33% (1) patientout of 12 in the fibrin glue group with dislocationof the graft which then had to be sutured.Koranyi et al 1 reported transplant loss as 1%patient 0ut of 362 from fibrin glue group, 2% outof 156 from Vicryl suture group. In a study byUma Sridhar et al 4 , all except 4% (1) autograftwere taken up well. 4% (1) autograft was lost onthe first post operative day.The mean preoperative astigmatism in fibrin gluegroup was 2.023 ± 1.409D which reduced postoperatively to 0.640 ± 0.51 D ( p value

218 AIOC 2009 PROCEEDINGScauses damage to the inter-palpebral ocularsurface and is associated with symptoms ofocular discomfort". Dry eye is the most frequentdisorder in ophthalmology practice. Theprevalence of dry eyes varies from 10.8% to57.1%, thereby showing wide disparity. Much ofthis disparity stems from the fact that there is nostandardisation of the types of patients selectedfor the study, dry eye questionnaires, objectivetests and dry eye diagnostic criteria. Various riskfactors for dry eye alluded to in literature includeair pollution, cigarette smoking, low humidity,high temperature, sunlight exposure and drugs.To study the prevalence of dry eye in a computerjob based population and to evaluate the variousrisk factors attributable to dry eye.Materials and MethodsIn this cross-sectional study, 350 patients above20 years of age presenting with variousophthalmic problems to a tertiary eye care centrewere screened for dry eye. The patients wereselected randomly. The patients were allcomputer job based and on an average usedcomputers for a minimum period of 4 to 6 hoursper day. They were informed about the nature ofthe study. Patients suffering from acute ocularinfections with extensive corneal or conjunctivalpathology, contact lens users and those who hadundergone extraocular or intraocular surgerywithin six months of the screening wereexcluded. 407 patients were initially chosen, 31were excluded and 26 refused to participate inthe study. Informed consent was obtained fromsubjects recruited for the study . A singleophthalmologist , after eliciting a completegeneral (including history of systemic disease,especially pertaining to dry eye) and ophthalmichistory performed ocular and systemicexamination and subsequently administered thedry eye questionnaire. Ocular examinationincluded review of lid surface abnormalities andMeibomian gland evaluation. Anotherophthalmologist performed the objective dry eyetests thereafter. The second observer was maskedto dry eye information from the questionnaire.The pre-designed dry eye questionnaire wasbased on models suggested by Hikichi, Toda,Roche and their colleagues and consisted ofyes/no responses to 15 symptoms, namely:ocular fatigue, non-sticky eye discharge, foreignbody sensation, heavy sensation, dry sensation,discomfort, ocular pain, watering, temporaryblurred vision (improved on blinking), itching,photophobia, redness , irritation, burning andstinging sensation. A response was defined aspositive when the subject reported a symptom tooccur sometimes, often or all the time and asnegative when reported to occur rarely or never.After ascertaining the responses to each of thequestions, the symptom score was calculated.Exposure to sunlight/high temperatures,excessive winds, air pollution, smoking anddrugs was inquired for. Objective tests (underroom temperature conditions) comprised (inTable-1: Prevalence of dry eye according toage and sexNo. of Dry eye Prevalencesubjects subjects %Age in years21-30 122 5 4.131-40 60 12 2041-50 36 7 19.44>50 132 46 34.85SexMales 181 25 14Females 169 45 27Table-2: Strength of association of environmentalfactors and drugs with dry eyeExposure Non Expo- Expo- group Oddsfactors sed sed ratiogroupTotal Dry Total Drysubj- eyed subj- eyedects ectsExcessive wind 285 45 65 19 >2Sunlight/ high temp 280 45 70 19

EXTERNAL DISEASES SESSION219order, each at 10-minute intervals to minimizereflex tearing and ocular surface changessecondary to testing) Lissamine Green staining,Schirmer's test and tear film breakup time(TBUT). Precut strips for these tests wereobtained from a common source to ensureuniformity. Presence of strands/filaments wasalso looked for before and after the tests. In thosealready using tear substitutes, dry eye tests wereperformed after overnight discontinuation ofmedication. A symptom score of more than 3,Lissamine green staining score 3 (as per astaining score key proposed by Norn), Schirmer'stest value < 5 mm in 5 minutes on Whatman'sfilter paper No. 41, TBUT value

220 AIOC 2009 PROCEEDINGStransplantation from the epithelium covering thePterygium. The procedure is more demandingcompared to conventional procedure.Limbal stem cell grafting with conjunctiva actingas a carrier tissue was done in patients withrecurrent pterygia. Here the conjunctival autograft was raised and at the limbal end, dissectionwas carried forward to include the peripheralcorneal tissue for about 0.5 mm at a depth of 0.1mm to 0.15 mm. Preserved human amnioticmembrane transplantation was done in a fewcases.Results84.9% (1145 eyes) received conventionalconjunctival auto graft 3.7% (50 eyes) hadepithelial sheet transplantation. All patients withrecurrent pterygium (10.9%:- 147 eyes) hadLimbal stem cell with conjunctiva acting as acarrier tissue. 6 eyes (0.4%) had amnioticmembrane transplantation. A standard postoperativeregimen was followedRecurrences were seen in 12 eyes(0.89%) of which11 had primary Pterygium and one recurrent.The recurrence was noted between 4 months and12 months post surgery.Graft edema was the commonest finding notedin 59 eyes in the first week of the surgery.SCH under the graft was seen in 37 eyes. Boththese findings had no implication on the outcomeof the procedure. Graft sloughing was seen in 5cases. Loss of graft in 3 eyes.Graft granuloma at the host- graft junction wasnoticed in two cases which needed excision.Donor site complications were not seen in any ofthe cases.When we analyzed the reasons for recurrence 5cases had graft sloughing and 3 cases had graftloss due to premature removal of sutures, andone case had amniotic membrane transplantationand the exact reason for recurrence was notknown.DiscussionPterygium surgery should ideally have low or norecurrence with minimal complications and becosmetically acceptable. Conventionalconjunctival autografting is considered as a goldstandard in the management of primarypterygium, limbal stem cell grafting is safe andeffective in recurrent pterygium. Conjunctivalepithelial sheet transplantation is an effectivealternative for conventional conjunctivalautograft when the superior bulbar conjunctivais not available or not sufficient and amnioticmembrane, if available, can be used for primarypterygium.ATHORS’S PROFILE:DR. BALMUKUND AGARWAL: MBBS (‘95), Assam Medical College, Dibrugarh; MS (‘99),Guwahati Medical College. Fellow, General ophthalmology, Sankara Nethralaya, Chennai.Currently, Associate Consultant, Sri Sankardeva Nethralaya, Beltola, Guwahati-28.Comparison of Recurrence Rate Following Pterygium Surgery inTwo Different Methods—A Three Year Retrospective StudyDr. Balamukanda Agarwal, Dr. Chandana Kakati, Dr. Harsha Bhattacharya,Mr. Ranjay Chakraborty(Presenting Author: Dr. Chandana Kakati)Apterygium is a triangular fibrovascularsubepithelial ingrowth of degenerativebulbar conjunctival tissue over the limbus tocornea. Pterygium typically develops in patientsliving in hot climate and may represent aresponse to chronic dryness and ultravioletradiation.Pterygium occurs worldwide with a higherprevalence in tropics and subtropical countriesincluding India. Males are more commonlyaffected then females.Various surgical techniques have been described

EXTERNAL DISEASES SESSION221in literature in treating pterygium, whichincludes bare sclera techniques, thiopental drops,beta irradiation, intra and post operativeMitomycin, conjunctival auto graft , amnioticmembrane transplant and some combination ofabove mentioned procedure.However the most common problem in all theseprocedures is recurrence.To compare the recurrence rate of primarypterygium excision with Mitomycin C (MMC)with that of simple excision with MMC withconjunctival autograft.Materials and MethodsIt was a retrospective database study. The studyperiod was from 1st January 2003 to 31stDecember 2006, the study duration being threeyears. All the patients undergoing pterygiumsurgery by the same surgeon during that periodwere included in the study. However the patientswith autoimmune disease, collagen vasculardisease, dry eye, ocular trauma, glaucoma,associated limbal masses were excluded from thestudy.120 eyes of 120 patients were included in thestudy. There were 65 male and 55 femalepatients, male female ratio 1.2: 1.Age range was18 to 70 years.All the patients underwent total ophthalmicexamination. Preoperative data sheet includedname, age, sex, BCVA , refractive error ,type,extent and location of pterygium.A written consent was taken from all the patients.The patients were divided into two groupsrandomly. Group A (n=80) had primarypterygium excision followed by application of 0.2mg(0.02%) MMC for three minutes.Group B (n=40) had primary pterygium excisionalong with conjunctival autograft with 0.2mg(0.02%) MMC for three minutes. Conjunctivalauto graft was collected from ipsilateral inferiorlimbic area and sutured with 8-0 vicryl on to thebare sclera.Post operative medicine regime was same in bothgroups, consisting of antibiotic drops andointments and lubricants and topical steroidstwo days after operation. Patient follow up wasscheduled on first post operative day, then 1week , I month, 3 month , 6 month and 1 year,after which they were called every 3 monthly.Follow-up examination included visionassessment, refraction and slit lamp examination.Outcome was assessed on basis of any pterygiumrecurrence, time of recurrence, and anyimmediate and late post operative complication.An encroachment of 1 mm or more clear corneafrom limbus by fibrovascular proliferative tissuein the site of previous pterygium surgery wasconsidered as recurrence.ResultAll the eyes had uneventful surgery. Theminimum follow up period was 1 year in all thecases, with mean follow up period 22.5±10.5months.The recurrences were observed in both thegroups, which are shown in the table below.Recurrence Mmc Mmc+ Total P ValueGroup Conj.AutoGraftNumber ofCases 12 2 14 0.1077Percentage 15% 5% 11.7 %Out of total 120 cases undergoing pterygiumsurgery during that period 14(11.7%) cases hadrecurrence.Out of these 14 cases, 12 cases (15%) had occurredin simple excision with MMC group. The averagerecurrence period was 3.38±0.65 months .Twocases had persistent conjunctival congestion withchemosis which subsequently cleared upfollowing use of antibiotic steroid ointment andlubricant. No other complication was noted inthis group during the follow up period. Postoperative vision was improved in all cases.In group B where conjunctival auto graft withMMC was done, two cases (5%) had shownrecurrence. The average time period ofrecurrence was 3.29±0.89 months. In one case,mild graft displacement was seen due to a loosesuture, which subsequently healed without anydefect at the end of first week. No othercomplication was noted in any of the cases. Postoperative vision improved in all cases.DiscussionVarious methods have been described inliterature to treat pterygium. However an idealmethod of pterygium surgery is yet to beestablished.

222 AIOC 2009 PROCEEDINGSBare sclera technique with a recurrence rate of 24-89% 1 is no longer advisable. Adjuvant treatmentwith beta irradiation with a recurrence rate of 0.5-16% had been associated with significantcomplications like scleral necrosis. 1Primary excision had various recurrence ratesaccording to different authors. Rao S K et al 2found the recurrence rate to be 3.3-12%, A LYoung et al 3 15.9% and Chen et al reported therecurrence to be as high as 38%. 4 Our data of 15%is comparable to their findings.In case of simple excision with auto graft,Manning et al 5 reported a recurrence rate of22.2% while Chen et al 4 reported the recurrencerate to be 39%.In our study we found recurrence rate withconjunctival auto graft with MMC group to be5%. Wong V A et al 6 found the recurrence to be9% whereas Ugur et al 7 reported this to be 13.3%.Hence our findings are comparable with theirresults.1. JAros JA et al. –Pinguecula and pterygium, Surv.Ophthamol 1988;33:41-9.2. Meckenzie F D et al.—Recurrence rate andcomplication after beta radiation for pterygium,Ophthalmology 1999;98:1776-81.3. Rao S K et al. –conjunctival limbal autograft forprimary and recurrent pterygia; Indian J Ophthalmol1998;46;203-9.4. Chenn P P et al.—A randomized trial comparingMMC and conjunctival auto graft after excision ofReferencesWhile comparing recurrence rate of MMC groupwith that of conjunctival auto graft with MMCgroup, it was observed that first group had ahigher recurrence rate (15%) in comparison tosecond group (5%) which though statisticallyinsignificant (P=.1077), is nevertheless higher.This difference was not statistically significantbecause of a small sample size.From our study it is evident that combiningMMC with conjunctival auto graft gives a betterresult than simple MMC alone. However simpleexcision alone with MMC also yielded acceptableresults. On the other hand conjunctival auto grafthas certain limitation like need of operatingmicroscope and need for greater surgical skillwith distinct learning curve. Hence the choiceof the surgical procedure should becarefully made by assessing surgeon’s levelof expertise, the facilities available and localpractice preferences.primary pterygium; American Ophthalmol 1995;120:151-60.5. Manning C A et al. –Intra operative MMC inprimary pterygium excision—A prospectiverandomized trial; Ophthalmology 1997;104:844-8.6. Wong V A et al. -Use of MMC with conjunctivalauto graft in pterygium surgery in Asian-Canadians; Ophthalmology 1999;106:1512-5.7. Uğur E.Altıparmak et al. Mitomycin C and conjunctivalautograft for recurrent pterygium 2007;27:339-43.AUTHORS’S PROFILE:DR. SHIBU VARKEY: M.B.B.S. (’93), Government Medical College, Kottayam, Kerala; M.S.(2000), Dr. MGR Medical University, Chennai, Tamil Nadu. DNB (2001), National Board ofExaminations, New Delhi; FRCS Royal College of Physicians and Surgeons 2003. Recipient of(1) Registrar, Institute of Ophthalmology, Tiruchirapalli, 2002-05, (2) Gold Medallist for M.S.Presently, Director (Academics & Research) Vasan eyecare Group, Tiruchirapalli.Contact: 9443141424, E-mail: varkeyshibu@yahoo.comThe Cut and Paste in Eye, Pterygium Surgery Made Easy andEfficientDr. Shibu Varkey, Dr. Ashad Sivaraman, Dr. D. Ravi, Dr. Roche Arokiaraj,Dr. Sreejith Karat, Dr. Nalitha Mathuram, Dr. Srinivasan R., Dr. A. M. Arun(Presenting Author: Dr. Shibu Varkey)Pterygium is a wing shaped growth ofconjunctiva onto the cornea generally on thenasal side although temporal side can beinvolved as well. It is more frequent in areas withmore ultraviolet radiation, in hot, dry, windy,dusty, and smoky environments. Some authors

EXTERNAL DISEASES SESSION223have speculated the role of limbal stem celldeficiency in the pathogenesis. Erbium:YAG laserablation and corneal resurfacing with excimerlaser have been tried.Surgery is the treatment of choice and postoperative recurrence is the main problem.Adjunct therapies such as β radiation, thiotepa,5-FU, and mitomycin C have been used yetrecurrence rates have remained high. Therecurrence in most cases occur within 6 monthsof the surgery, Autologous conjunctival graftinghas considerably reduced the recurrence rate.Our aim was to improve patient comfort by usingglue, sutures being main cause of discomfort inconjunctival graft technique.RelisealTM (Reliance life science) is a twocomponent tissue adhesive which mimics thenatural fibrin formation. The glue does not stickto intact corneal or conjunctival epithelium. Inocular surgery tissue glue has been tried forvarious applications like sealing perforations inthe lens capsule, treating conjunctival woundsand fistulas, adapting free skin transplant in lidsurgery, repairing injured canaliculi and sealingthe wound in cataract surgery. Very few reportsof its application in pterygium surgery areavailable in the literature.Materials and MethodsThis prospective study done at Vasan eyecarehospital Tiruchirapalli included 35 eyes of 35patients who underwent surgery for primarypterygium. Patients with primary nasal pterygiawere included in the study. Cases with cystic,atrophic or inflamed pterygia were excludedfrom the study. Patients with associated ocularsurface disorders were excluded from the study.All patients underwent detailed ocularexamination before the surgery. All surgerieswere done under local anesthesia. 2ml of 2%lignocaine with 1:100,000 adrenaline was injectedunder the pterygium and the neighboringconjunctiva and the chemosis was gentlymassaged with a cotton bud. Using serratedconjunctival forceps the pterygium was graspedin the region of its body and a transverse cut wasmade on the conjunctiva and subconjunctivaltissue about 1 centimetre away from the medialcanthus. The cut was extended radially towardsthe limbus reaching the neck of the pterygiumboth above and below it. The dissection of thepterygium was done upto clear cornea and thenmechanical force with the conjunctival forcepswas used to strip the pterygium off the corneacompletely. A conjunctival graft was fashionedfrom either the upper or lower bulbarconjunctiva and was slided onto the bare areamaintaining the proper orientation of the limbalstem cells. Proper care was taken to ensure thatsubconjunctival tissue or Tenon’s was notincluded in the graft. Total hemostasis wasobtained on the scleral bed using lightelectrocautery. The scleral area and the undersurface of the conjunctival graft tissue werethoroughly dried using a cotton bud. 0.5 ml ofreconstituted Fibrin glue (Reliseal TM ) was spreadevenly onto the scleral area and the graft waspressed down onto it and held securely for 20seconds taking care to expel any trapped airbubbles. Surgical time was noted. Antibioticdrops were instilled and the eye patched. Postoperatively the patient was treated with topicalantibiotic drops, steroid drops and oral antiinflammatoryagent for 10 days. The eye was notpatched and reviewed the next day, after oneweek and then once in every 2 weeks for 1monthand monthly for 6 months. During the postoperative visits the eye was examined and theposition and adherence of the flap was noted.The amount of conjunctival congestion wasnoted and graded as limbal (I) bulbar (II) bulbarand palpebral (III). Patients’ subjective feelingslike pain and foreign body sensation were alsonoted and graded as none (0) mild (I) moderate(II) severe (III).Results35 eyes of 35 patients with primary pterygiumwere treated with pterygium excision andconjunctival graft using fibrin glue. There were25 males and 10 females in this study. The age ofthe patients ranged from 20 to 60 years with anaverage age of 40 years. 30 patients wereagricultural laborers 3 patients were officeworkers and 2 patients were housewives. All the35 eyes had nasal pterygium. Patients withinflamed pterygium, atrophic or cystic changeswere excluded. The grafts were well settled inposition and adherent to the scleral bed duringthe entire course of the follow up in 33 eyes, 2eyes had flap displacement 0.5mm from thelimbus exposing a thin sliver of sclera. No case

224 AIOC 2009 PROCEEDINGSrequired any additional suturing or flaprepositioning. The conjunctival congestion wasgrade II in all patients, the level of discomfortwas grade II in 10 patients and grade I in 25patients. At 6 months follow up all eyes hadsmooth ocular surface and normal tear film.DiscussionThe major problem with pterygium surgery hasbeen recurrence therefore a number of techniqueshave been tried to avoid the bare sclera techniquewhich is related to high degree of recurrence. Thelatest include conjunctival autografting andAmniotic membrane grafting. In both thesetechniques sutures have to be used which resultsin irritation and granuloma formation in somecases and also necessitates suture removal.Autologous conjunctival transplantation avoidsthe risk of scleral necrosis associated with the useof antimetabolites. However surgical time isincreased and postoperative period is marked bysuture discomfort. The cut and paste methoddescribed here considerably reduces surgicaltime and patient discomfort, especiallypostoperative pain. In addition, postoperativepatching, and restrictions in normal life aftersurgery were not required. This method entailsexcision of a smaller amount of tissue and thussmaller grafts, which leads to faster healing andless inflammation and pain. The thin membraneof glue which covers the corneal epithelial defectmay contribute to the reduction of thepostoperative pain. The adhesion of the entiregraft to the scleral bed may contribute to theinhibition of fibroblast proliferation of the nasalTenon’s tissue towards the cornea, keepingrecurrence rate low. On the flip side however isthe issue of infection by viruses, such asparvovirus B19 (HPV B19) and by prions whichhas been reported after the use of fibrin glue inthoracic surgery, though the risks for bothdiseases are minimal in a minor surgicalprocedure like pterygium surgery.Fibrin glue can be safely and effectively used forfixing the autograft in primary pterygiumsurgeries. Usage of fibrin glue considerablyreduces the surgery time because of its fast andeasy application. Its use avoids complicationsderived from sutures and also gives earlyrecovery.AUTHORS’S PROFILE:DR. REJI KOSHY THOMAS: M.B.B.S. (’86) & M.S. (’92), St. John’s Medical College;F.I.A.C.L.E. (International) (’96). Recipient of Best Paper–Karnataka Ophthal. SocietyConference, 1991, Runner-up, Col. Rangachiari Award, AIOC Cochin. Presently, Professor, St.John’s Medical College Hospital.Contact: (080)25537700, E-mail: rejiann@dataone.inI.V. Methylprednisolone (IVMP) as an Alternative toDecomprsession Surgery in Severe Thyroid AssociatedOrbitopathy (TAO) Not Responding to Oral SteroidsDr. Reji Koshy Thomas, Dr. Urmi Sheth , Dr. Ajoy Mohan , Dr. Ganapathy B(Presenting Author: Dr. Urmi Sheth)Thyroid Associated Orbitopathy (TAO) is atype II autoimmune response of theretrobulbar tissue, characterized by inflammationand increased mucopolysaccharide and collagendeposition within the muscles, with a cellmediated response in the form of cd4 / cd8activation. It is a disfiguring and invalidatingdisease that profoundly impairs the quality of lifeof affected individuals. 5-10% of patients withGraves’ disease will develop clinically relevant,active and progressive orbital complications towarrant medical or surgical intervention.Glucocorticoids have been used for the treatmentof TAO because of their anti-inflammatory andimmunosuppressive actions. Many studies havedocumented the effectiveness of high dose oralglucocorticoids (OGC) on soft tissue changes andoptic neuropathy, however proptosis and ocularmotility have not always been as responsive,making the treatment of this disease difficult.

EXTERNAL DISEASES SESSION225The aim of this study was to evaluate the safetyand efficacy of I.V.Methylprednisolone (IVMP)as an alternative to Decompression Surgery insevere Thyroid Associated Orbitopathy (TAO)not responding to oral steroids.Materials and Methods8 patients with TAO who did not respond to oralhigh dose steroids were included in the study.All 8 patients had dry eye, motility restriction,proptosis, nocturnal exposure and resistance toretropulsion. 4 had progressive loss of visualfields with a drop in visual acuity as well. RaisedIOP was observed in 3, papilledema in 2.Decompression surgery was considered in 5 ofthese patients. Activity of TAO was defined witha CAS of >/= 3 points. CAS was the basis fortherapy and evaluation of success because of thehigh predictive value of CAS for the outcome.The classification system (activity score) rangedfrom 0 to 10 points. Patients were determined byassigning 1 point each for the presence ofspontaneous pain behind the globe, pain onattempted upgaze, redness of the conjunctiva,redness of the eyelid, chemosis, swelling of thecaruncle, eyelid swelling, increase of proptosis by2mm, decrease of eye movements in anydirection by 5mm, and decreased visual acuity(VA) of 1 line(s). A score of 6 points representsthe maximum activity score. Thickness ofextraocular muscles (maximum coronal sectionarea of the most hypertrophic rectus muscle ineach eye) of all the patients was measured withorbital CT/MRI.Dosage: 500 mg of IVMP in 100ml ofphysiological saline as a 30 min i.v. infusion 2times a day over three days followed by oralprednisolone (1mg/kg body weight tapered by10% every 2 weeks).Follow up period : 3 months from the start of theIVMP treatment.Responders: An activity score of 2 points lessthan the original CAS score.Non-responders: Patients showing no changes orimprovement.4 of these patients showed significantimprovement (responders) within 3 months ofthe IVMP and remained so over the next 2 years.A repeat pulse was administered to the 4 patientswho did not respond to the first pulse ofmethylprednisolone followed by similar doses oforal prednisolone. The response to the repeatpulse was significant with all 4 initial nonresponders also showing marked recovery bothsymptomatically and functionally.All patients were followed up for a minimumperiod of 2 years and none of the patients hadany recurrence nor did they need any additionaltherapy during that period. The activity score ofall the patients after therapy remained at 1 orbelow.ResultsWe observed a higher percentage of favorableeffects in patients treated with IVMP in terms ofeffectiveness, tolerability, side effects and qualityof life. 50% of the patients responded to a singlepulse treatment of IVMP for 3 days followed byoral prednisolone. A repeat pulse of a similarduration 3 months later provided total success inall our 8 patients.DiscussionGlucocorticoids have been used for the treatmentof TAO because of their anti-inflammatory andimmunosuppressive actions. However long termoral glucocorticoids are associated with numberof side effects. Previous studies have shown ahigh effectiveness of IVMP therapy oninflammatory signs and optic nerve involvement.Kahaly et al (1) studied 70 patients with Gravesophthalmopathy and randomized their treatmentinto either oral or iv steroids. They found that inpatients with active and severe GravesOphthalmopathy, IV glucocorticoids were moreeffective and better tolerated than oral steroids.In a study done by Aktaran S et al (2) , 52consecutive patients with untreated, moderatelysevere and active Graves Ophthalmopathy wererandomly treated with either IVGC or OGCtherapy for 12 weeks. IVGC therapy achieved amore rapid and significant improvement thanOGC therapy according to clinical activity score.Other studies indicated that IVMP therapy waseffective in 73-78% of the cases.Tagami et al (3) reported that high dose IVMPshowed an improvement in diplopia in 78% ofpatients, decreased proptosis in 52% andimprovement in VA in around 30% patients, seenimmediately after pulse therapy and before the

226 AIOC 2009 PROCEEDINGSsubsequent use of oral OGC to consolidate theefficacy.This retrospective observational study confirmsthe favourable effects of IV methylprednisolonein moderately severe and active TAO. IVMPachieved a rapid and effective immunosuppression.The need for repeating the IVMP pulsedtherapy must be considered and emphasized inall non responders. The severity and clinicalactivity of TAO are important in determining theneed for IVMP therapy. Controlled largerandomized trials will be required for judgingthe absolute effects of IVMP in the treatment of1. Kahaly G J, Pitz S, Hommel G et al. Randomized,Single Blind Trial of Intravenous versus OralSteroid Monotherapy in Graves’ Orbitopathy.Journal of Clinical Endocrinology and metabolism 2005;90:5234-40.2. Aktaran S,Akarsu E, Erbağci I et al. Comparison ofintravenous methylprednisolone therapy vs. oralPterygium (Greek pterygos' a wing) is afrequently occurring ocular surface lesionwith characteristic wing shaped fleshy growth,encroaching from conjunctiva upon the cornea. Itis a very common degenerative condition seen inthe Indian subcontinent. Till date no topicalmedication has been developed that may stop orprevent pterygium in its early stage and surgicalexcision with limbal conjunctival autograftremains the modality of choice.The presence of an unsighty lump on the surfaceof the eye is usually an indication enough forsurgical removal. Less common indications areinterference with vision, either by occluding theoptical axis or by inducing astigmatism andrarely, it may cause limitation of ocularmovements and induce diplopia.Pterygium is known to affect refractiveastigmatism, which can have a significant impacton vision. Several mechanisms have beensuggested to explain the induced astigmatism.ReferencesTAO. It is not clear yet to which dosage andperiod of time after IVMP that TAO showsbeneficial effects. In addition, we need to knowif the dose of IVMP needs to be titrated againstthe clinical response while simultaneouslyevaluating the lowest effective dose that shouldbe given for as short a time as possible. Thisapproach may minimize the potentiallyserious side effects of high dose long termoral glucocorticoids especially in patientsnot responding to this. IVMP should alwaysbe considered prior to contemplating majororbital decompression surgeries.methylprednisolone therapy in patients withGraves' ophthalmopathy. International journal ofclinical practice 2006;61:45-51.3. Tagami T, Tanaka K, Sugawa H. High-doseintravenous steroid pulse therapy in thyroidassociatedophthalmopathy. Endocr J.1996;43:689-99.Pterygium Excision and Limbal ConjunctivalAutografting–Astigmatism and CosmetismDr. Ankur Midha, Dr. Poonam Jain, Dr. Mukesh Sharma(Presenting Author: Dr. Poonam Jain)These include pooling of the tear film at theleading edge of the pterygium and mechanicaltraction exerted by the pterygium on cornea. Inthe present study an attempt was made toascertain the role of pterygium excision andlimbal conjunctival autografting in meanastigmatic correction and cosmesis after surgery.Materials and MethodsThe study was conducted on 100 eyes of 100patients, who presented to the department ofophthalmology, SMS Hospital, Jaipur, withprimary pterygia. All patients between 20-50years of age and having nasal primary pterygium(progressive or stationary) covering more than 2mm of cornea were included in the study. Aninformed consent was obtained from all patients.After detailed ocular and systemic history, athorough ocular examination including visualacuity, refraction, keratometry, ocularmovements, fluorescein staining and slit lampexamination was done.

EXTERNAL DISEASES SESSION227The patients were randomly allocated to 2groups, group G and group S according to themodality used for the attachment of the limbalstem cell conjunctival graft, i.e. fibrin glue andsutures respectively.FIBRIN GLUE (ReliSeal TM , a fibrin sealantprepared by Reliance Life Sciences), consists ofkey plasma derivatives, which when applied,mimics the last stages of the natural homeostaticcascade i.e., conversion of fibrinogen into fibrinmonomers and crosslinking to form a firm fibrinclot. This in turn secures the graft over the scleralbed.Under local anesthesia (peribulbar block),pterygium was excised using Bard Parker No.15surgical blade. Conjunctival autograft washarvested by the technique described by Starcket al. and taken to the exposed scleral bed forattachment.For Group G, a drop of reconstituted solutionwas put on the graft bed (dried) by the applicatorsystem. Then the graft was secured in the placeimmediately. Proper care was taken to ensurethat the spatial orientation was maintained andthat the sides of the graft were apposed to theedges of the recipient conjunctiva. After dryingperiod of 5 minutes, the lid speculum wasremoved and patient was asked to blink severaltimes to check the graft adherence and mobility.We used the reconstituted solution in about 5 – 6patients. For Group S, 5-6 interrupted absorbable(vicryl 8-0) sutures were used to secure the graft.Sutures were removed as required.S/c antibiotic injection of gentamycin anddexamethasone was given away from the graftsite. Then antibiotic ointment was placed and apatch was applied for 24 hours.Various parameters like operative time (startingfrom placement of lid speculum to its removal atthe end of surgery), post operative symptomsand signs and recurrences were noted.Follow up was done on 1st, 3rd, 10th, 30th, 90thand 180th post operative day.ResultsFor the early post operative period (~ 30 days)the group G patients were having fewersymptoms and cosmetically more satisfied. Butat final visit patients of both groups were equallysatisfied.Table-1: Comparison between keratometric value (in dioptres) for corneal curvature, pre operativelyand post operatively along steepest and flattest meridian (At the end of study)Mean ±SD Keratometry(Dioptres) Mean Change P-Value SignificancePre-Op Post-Op ±SDKeratometry reading Group G 45.40 ± 2.06 44.17 ± 1.41 1.23 ± 1.55 .05 NSTable-2: Comparison between corneal astigmatism preoperatively and post operatively in the studygroups (at the end of study)Mean ± SD Astigmatism Mean Change ± SD P-Value SignificancePre-Op Post-OpGroup G 1.92 ± 1.80 0.78 ± 0.84 1.14 ± 1.46 < .001 HSGroup S 1.88 ± 1.78 0.80 ± 0.78 1.08 ± 1.4 < .001 HSTable-3: Correlation between Astigmatism and preoperative size of Pteygium (Both groups combined)Correlation r- value P-value SignificancePre-op astigmatism v/s Size + 0.708 < .01 SigChange in astigmatism v/s Size + 0.552 < .01 SigTable 3 shows the positive correlation between the astigmatism induced to the size of the pterygium. It also shows thepositive correlation between the astigmatism correction after the surgery.

228 AIOC 2009 PROCEEDINGSDiscussionThe findings of our study are in concert with thefindings of Ashaye AO. (1990), Lin A, Stern G.(1998) and Maheshwari S. (2003).Ashaye AO. in his study showed that there wasa statistically significant association betweenrefractive astigmatism and the presence ofpterygium (P < 0.01). Astigmatism was the rule inmost patients. Surgical removal caused areduction in refractive astigmatism. The changein refractive astigmatism was as high as 1.50DC.According to Lin A. and Stern G., once pterygiareach a critical size, they induce visuallysignificant central with-the-rule astigmaticchanges that may not be apparent by subjectiverefraction. This finding helps to identify those1. Stern G, Lin A. Effect of pterygium excision oninduced corneal topographic abnormalities. Cornea1998;17:23-7.2. Oldenburg JB, Garbus J, McDonnell JM.Conjunctival Pterygia: Mechanism of cornealtopographic changes. Cornea 1990;9:200-4.3. Avisar R, Mekler S, Savir H. Effect of pterygiumOcular surface comprising of conjunctiva andcornea has got a covering of continuouslayer of epithelium which helps in maintainingprecorneal tear film. This ensures properwettability of cornea, leading to its normalsparkling lustre and maintenance of a clear,transparent and healthy state.Various factors are responsible for themaintenance of ocular surface health. Thesefactors include proper, continuous and smoothepithelial lining of the surface, tear film havingproper concentration of the constituents andhealthy lids.The breach in any of the above mentioned factorsleads to the ocular surface ill health. The mainintruders are infections, trauma, burns, growths(benign or malignant), lid abnormalities orglandular dysfunction.Many techniques / methods like intensive usageof lubricating drops, tarsorrhaphy and bandageReferencespatients who may benefit from surgicalintervention.Maheshwari S. in his study verifies that as thesize of pterygium increases, the amount ofinduced astigmatism increases in directproportion. Successful pterygium surgeryreduces the pterygium-induced refractiveastigmatism and improves the visual acuity.We can reinstate the fact that Pterygium steepensthe vertical meridian as its excision lead to asignificant improvement in the Keratometryreadings of vertical meridian only. Meanastigmatic correction in both the groups was thesame. In terms of cosmesis, fibrin glue has adefinite advantage over suturing at least in theearly post operative period.excision on keratometric readings. Harefuah1994;126:111-2.4. Walland MJ, Stevens JD, Steele AD. The effect ofrecurrent pterygium on corneal topography. Cornea1994;13:463-4.5. Ashaye AO. Refractive astigmatism and pterygium.Afr J Med Sci 1990;19:225-8.Amniotic Membrane Transplantation – Role RedefinedDr. Vikas Paliwal, Dr. Ankur Midha, Dr. Poonam Jain, Prof. Indu Arora(Presenting Author: Dr. Ankur Midha)contact lens have been used to some effect. Allthese methods enhance healing by virtue of thecompromised original ocular tissue. To enhancehealing by providing factors from outside is themajor idea behind the usage of AmnioticMembrane transplantation.The concept was reintroduced by Kim and Tsengin 1995 and since then it has become a modalityof wide usage as a temporary patch or as areconstitution graft in the lesions of cornea andconjunctiva. We also decided to harness thehealing properties of amniotic membrane andcompare its efficacy in ocular surfacereconstruction in various ocular pathologies.Materials and MethodsThe study was undertaken in the Department ofOphthalmology, SMS Hospital, Jaipur over aperiod of 3 years.40 patients were included andwere grouped as follows: Group A, cases with

EXTERNAL DISEASES SESSION229acute chemical and thermal burn (n=15); GroupB, cases with conjunctival tumors (n=15); GroupC, complicated and recurrent pterygia (n=10).The patients selected were of 5 to 60 yrs of age,less than ten days old chemical or thermal burnsof grade 2 to 3, having ocular surface tumorrequiring wide conjunctival resection andrecurrent and complicated pterygium.The patients not willing for the surgery, havingactive ocular infection, chronic chemical andthermal burns, having grade 4 burns and preexistingconjunctival or corneal pathology likecorneal dystrophy or degeneration and dry eyewere not included in the study.A detailed history was taken from all the patientsand various parameters like visual acuity, ocularmovement, conjunctival and corneal condition(grading of burns, sensations, Schirmer tests etc.),fluorescein staining pattern, anterior segmentevaluation, posterior segment evaluation wererecorded meticulously. The prognosis wasexplained in detail and a written consent wastaken.Procurement and preservation of amnioticmembrane was done following standardprocedure suggested by Kim and Tseng. It wasobtained under sterile conditions after electivecaesarean delivery. The woman's serum wasnegative for human immunodeficiency virus,syphilis, hepatitis B virus, or hepatitis C virus.Under a lamellar flow hood, the placenta wasfirst washed free of blood clots with sterile saline.The inner amniotic membrane was separatedfrom the rest of the chorion by blunt dissection(through the potential spaces between these twotissues), and rinsed in sterile saline (2 litres) andlater in BSS containing antibiotics Vancomycin,Amikacin and Amphotericin-B. The membranewas then flattened onto a nitrocellulose paper,with the epithelium/basement membranesurface up. The amniotic membrane was then cutinto 5 × 5 cm pieces. Each of them was placed ina sterile vial containing Dulbeccos modifiedEagle’s medium and glycerol (1:1). The vials werefrozen at 70°C. The membrane was defrostedimmediately before use by warming thecontainer to room temperature for 10 minutes,and rinsed three times in saline.After retrobulbar or general anaesthesia anddealing with the underlying pathologies ingroups A, B and C, the amniotic membrane wassecured with interrupted 8-0 Vicryl sutures.Postoperative care consisted of preservative-freeprednisolone acetate 1% eye drops four times aday and preservative-free tear substitutes andantibiotics.The post operative evaluation was done in termsof symptomatic relief to the patient, epithelialhealing and improvement in visual acuity.Follow up was done for 3 months.ResultsTable-1: Comparison of Pre-operative andPost-operative symptoms (Pain, photophobiaand lacrimation) of different groupsPre-Op Post-Op symptomaticsymptomatic Day 1 Day 7 Day 30 Day 90Group A 15/15 15/15 6/15 2/15 1/15Group B 5/15 13/15 5/15 2/15 1/15Group C 1/10 10/10 6/10 2/10 0/10Table-1 shows that the symptomatic relief wasfound to be most significant in acute cases ascomplaints regarding pain, photophobia andlacrimation reduced significantly from all the 15patients preoperatively to 6 patients by the 7thday and only 1 patient after 3 months.Table-2: Comparison between epithelial healingof different groupsDay 1 Day 7 Day 30 Day 90Group A 1/15 13/15 14/15 14/15Group B 9/15 15/15 15/15 15/15Group C 2/10 10/10 10/10 10/10Table-2 shows that by the 7th post operative day,the epithelium healed satisfactorily in 13 out of15 patients in Group A, and all the patients inGroup B and C.Table-3: Comparison between pre-operativeand post-operative (3 months) visual acuity ofdifferent groupsGroup A Group B Group CVisual Pre Post Pre Post Pre Postacuity -op -op -op -op -op -opCF – 6/60 15 4 16/60 – 6/24 6 9 8 4 36/24 – 6/12 5 6 6 3 56/ 12 – 6/9 1 2 2

230 AIOC 2009 PROCEEDINGSTable-3 shows that after 3 months of follow up,10 out of 15 patients showed improvement of 2or more lines of Snellen visual acuity in Group A.There was no significant improvement in GroupB and C.DiscussionAmniotic membrane has been used as surgicalmaterial for transplantation for ages. A literaturereview indicates that amniotic membrane haspreviously been used as a graft for skin burns,chronic ulcers of leg, for repairing omphalocele etc.In 1993, Kim and Tseng put the AMT in a totallydifferent perspective and successfullyreintroduced and revived the concept of AMT.By applying today’s concepts of cell biology theyinitially used the membrane as a “substrate” forreconstruction of the limbus in the partial limbalstem cells deficiency in rabbits.The special properties like promotion of reepithelisationand wound healing, inhibition of1. Van Herendael BJ, Oberti C, Brosens I.Microanatomy of the human amniotic membrane: alight microscopic, transmission and scanningmicroscopic study. Am J Obstet Gynecol1978;131:872-80.2. Prabhasawat P, Barton K, Burkett G, et al.Comparison of conjunctival autografts, amnioticmembrane grafts, and primary closure forpterygium excision. Ophthalmology 1997;104:974-85.Referencesvascular invasion and fibrosis, antimicrobial andanti-inflammatory activity and relativetransparency and immunological inertness makeamniotic membrane a very efficient graftmaterial.In our study, the results show that AMT workswell for most of the cases but has got a specialrole in the acute burn cases. It provides bestresults in terms of change in post operative statusregarding symptoms, epithelial healing andvisual acuity of acute burn cases.The results in the study are comparable to thestudy of Maller D, Pires RT, and Mark RJ et al(2000) and Scheffer C.G. Tseng, PinnitaPrashawant et al (2001).AMT was effective to promote corneal healing inalmost all the cases but visual and symptomaticimprovement was much better in acute burns.Although other newer treatment options may beavailable, AMT has immense value inmanagement of acute cases.3. Tseng SCG, Prabhasawat P, Lee S-H. Amnioticmembrane transplantation for conjunctivalsurface reconstruction. Am J Ophthalmol1997;124:765-74.4. Tseng SCG, Prabhasawat P, Barton K, et al.Amniotic membrane transplantation with orwithout limbal allografts for corneal surfacereconstruction in patients with limbal stem celldeficiency. Arch Ophthalmol 1998;116:431-41.