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On Sep 2018




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On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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Professor and Head
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Saraswati Dental College
Lucknow
On Sep 2018




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MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




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Best regards,
C.S. Ramesh Babu,
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Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Case Series
Year : 2023 | Month : November | Volume : 17 | Issue : 11 | Page : NR01 - NR04 Full Version

Atypical Presentation of Recurrent Pterygium Leading to Blindness and its Successful Management: A Series of Three Cases


Published: November 1, 2023 | DOI: https://doi.org/10.7860/JCDR/2023/66106.18616
Babi Das, Preety Rekha Das

1. Assistant Professor, Department of Ophthalmology, Lakhimpur Medical College, North Lakhimpur, Assam, India. 2. Senior Resident, Department of Ophthalmology, Lakhimpur Medical College, North Lakhimpur, Assam, India.

Correspondence Address :
Dr. Babi Das,
Qtr. No. 11, Block C, Lakhimpur Medical College, North Lakhimpur-787051, Assam, India.
E-mail: dr.babi.das@gmail.com

Abstract

Recurrence of pterygium is one of the main concerns in pterygium management. Recurrent pterygium is defined as the regrowth of fibrovascular tissue over the previously excised primary pterygium area, extending beyond the limbus and advancing towards the cornea. In most cases, it is characterised by increased conjunctival inflammation, fibroblast proliferation, and a faster progression towards corneal involvement compared to primary pterygium. This rapid regrowth can lead to irregular astigmatism, symblepharon, corneal fibrosis, severe vision impairment, and rarely, blindness. Incomplete removal of the primary pterygium, excessive suturing, the bare sclera technique, smaller conjunctival grafts, thicker conjunctival grafts with Tenon’s capsule, and poor control of postoperative inflammation are some of the most common surgical factors contributing to recurrence. Among all surgical procedures, the bare sclera technique has the highest recurrence rate. In the present case series, the author presented three cases of atypical recurrent pterygium and their successful management. The first case involved recurrent double-headed pterygium with severe symblepharon, resulting in lower fornix obliteration, shortening, diplopia, and corneal neovascularisation. The second case featured Grade-IV pterygium covering the pupillary area, and the third case involved a kissing type of double-headed pterygium. These cases were complications of the bare sclera technique, leading to blindness. Successful treatment of recurrent pterygium can improve visual and cosmetic outcomes. This case series aimed to highlight the burden and consequences of recurrent pterygium as a cause of avoidable blindness.

Keywords

Bare sclera method, Conjunctival limbal autograft, Symblepharon

Pterygium is a benign intraocular fibrovascular growth of the conjunctiva (1). The prevalence rate of pterygium worldwide is 12% (2). Pterygium typically develops nasally and temporally, and double-headed pterygium is rare. Dolezalova V, mentioned that the prevalence of double-headed pterygium was 2.5% (3). Impaired vision, recurrent irritation, induced astigmatism, and aesthetic concerns are common ocular morbidities associated with pterygium, although blindness caused by pterygium is rare (1),(2).

The main treatment for problematic pterygium is surgery. Recurrence is the primary concern in pterygium management. There are several methods for pterygium surgery with varying recurrence rates. The highest recurrence rate is observed in the bare sclera technique (24-89%) (4). However, the Conjunctival Limbal Autograft (CLAG) with or without adjuvant therapy such as Mitomycin-C (MMC) is the most widely accepted method with a low recurrence rate (5). Recurrent pterygium is more aggressive in nature and can be associated with complications such as conjunctival fornix shortening, symblepharon, extensive scar tissue, and accelerated pterygium growth. However, pterygium causing blindness is usually very rare (1),(5).

India, a developing country in the sub-Himalayan region, has a high prevalence of pterygium, as well as, a high recurrence rate due to its demographics and environment. It is recommended to avoid the bare sclera technique as the first choice of treatment to prevent recurrence and associated complications (4),(6). The author believes that a meticulous and complete surgical excision of pterygium with CLAG, with or without adjuvant therapy, can prevent pterygium recurrence or aggressive regrowth. The present case series describes three atypical cases of recurrent pterygium causing blindness and their successful management.

Case Report

Case 1

A 55-year-old male patient, a farmer by occupation, presented to the ophthalmology department with chief complaints of recurrent conjunctival growth and severe impairment of vision in his left eye for the last four months (Table/Fig 1)a. The growth was painless and progressive in nature, starting after the last pterygium surgery performed five months prior to the current visit. The patient reported restricted eye movement in the superior and lateral directions, and to some extent, in the medial gaze. He also complained of severe vision loss in the left eye and occasional diplopia after the last surgery. The patient had a past history of two pterygium excisions over the course of the last 10 years, with the most recent surgery performed five months ago on the left eye. The right eye had a history of pterygium excision six years ago. The patient had a history suggestive of the bare sclera technique and denied any history of trauma, chemical burn, systemic disease, or other medication use.

On examination, the patient had a visual acuity of 6/12 in the right eye and 3/60 in the left eye. A fleshy double-headed pterygium involving the pupillary area with severe symblepharon in the lower lid and fornix obliteration with shortening involving the lower punctum was observed. The lacrimal system was found to be patent upon syringing. The left eye exhibited post-pterygium corneal opacity, corneal neovascularisation, and gross restriction of ocular movements.

A treatment plan was made for pterygium excision with CLAG, symblepharon lysis, and fornix reconstruction surgery. Initially, the patient was prescribed steroid, antibiotic, and artificial tear eye drops to be used four times a day, along with a steroid ointment at bedtime to reduce inflammation. Routine blood investigations and relevant tests were conducted, and informed written consent was obtained.

The surgery was performed under local peribulbar block. A 4.0 silk traction suture was placed at the medial 1/3 and lateral 1/3 of both eyelids for better exposure. Pterygium excision was conducted from the cornea and sclera, with excision of the subconjunctival fibrous growth to the maximum extent possible. There was extensive fibrous growth with cicatrix causing shortening of the inferior fornix and involvement of the punctum. An 8-0 nylon traction suture was also placed at the superior limbal area for improved exposure. After inserting a lacrimal probe in the punctum, meticulous dissection was performed to remove all fibrous growth and restore the punctum to its anatomical position. The subconjunctival fibrous tissue was dissected and excised as much as possible from the lower lid while preserving the conjunctiva. A sponge soaked in 0.02% MMC was placed in the fornix and bare sclera for two minutes and then washed with copious saline irrigation. Fornix-forming sutures were placed in the lower medial 1/3 and lateral 1/3, with a rubber bend on the skin surface to prevent skin erosion. Partial keratectomy with fine needle cauterisation was performed for post-pterygium opacity and corneal neovascularisation. A wire speculum was then placed to facilitate the collection of conjunctival grafts. A conjunctival-limbal autograft was conducted in the nasal part, and a conjunctival rotation graft was performed in the temporal part (Table/Fig 1)b. Both grafts were sutured using interrupted 10.0 nylon sutures. At the end of the surgery, a bandage contact lens was placed (Table/Fig 1)c.

Postoperative management included the administration of steroid antibiotic eyedrops four times a day, antibiotic eye ointment three times a day, and artificial tear drops four times a day for one month. Systemic antibiotics and anti-inflammatory drugs were prescribed for seven days. The conjunctival suture, bandage contact lens, and fornix-forming suture were removed after two weeks (Table/Fig 1)d. The frequency of steroid antibiotic eyedrops and artificial tear drops was later tapered to three times a day and continued for two months. The patient’s postoperative vision improved to 6/18 in the left eye after two months (Table/Fig 1)e. Intraocular pressure monitoring was performed throughout this period. Monthly follow-up visits were conducted for the first three months, followed by six-monthly visits for one year. No recurrence was noted during this period. Subsequently, the patient was advised to have yearly follow-up visits.

Case 2

A 60-year-old male patient, a farmer by occupation, presented to the outpatient department with complaints of recurrent conjunctival growth and severe visual impairment in the left eye over the past four years (Table/Fig 2)a. The conjunctival growth was slowly progressive, painless, but associated with itching and watering. The patient had a similar type of growth in the past, for which he had undergone surgery 10 years ago in both eyes, with a history suggestive of the bare sclera method.

On examination, his visual acuity was PL+ in the left eye and 6/18 in the right eye. An advanced Grade-IV pterygium was observed in the left eye, crossing the visual axis and extending from the nasal side to the superior temporal cornea, covering the pupillary margin. The patient also had mild involutional ectropion in both eyes. The rest of the anterior segment could not be evaluated in the left eye due to the Grade-IV pterygium. The right eye exhibited Grade-II pterygium and Grade-I Nuclear Cataract according to the Lens Opacities Classification System (LOCS) (7).

Surgical management involved planned pterygium excision with CLAG in the left eye. Written informed consent was obtained prior to the operation. All routine investigations were performed, and successful excision was carried out under local anaesthesia. Complete dissection of the pterygium, subconjunctival Tenon’s tissue, and surrounding fibrovascular tissues was performed. The conjunctival edge was trimmed, and the corneal surface was gently scraped and cleaned as much as possible. CLAG was harvested from the superior conjunctiva and attached to the bare sclera area using 10.0 nylon sutures (Table/Fig 2)b.

Postoperatively, the patient received antibiotic steroid eye drops and artificial tear eye drops for three weeks. The conjunctival sutures were removed after 10 days. A follow-up visit was conducted after six weeks, and the patient’s Best Corrected Visual Acuity (BCVA) was found to be 6/12 (Table/Fig 2)c. Subsequent follow-ups were scheduled after three months and after one year. No recurrence was observed during this period. After one year, the patient was advised to undergo regular yearly eye check-ups.

Case 3

The patient is a 48-year-old female housewife, belonging to a farming family, who presented to the Outpatients Department (OPD) with a history of recurrent growth and severe vision loss in her left eye for five years (Table/Fig 3)a. The growth was painless, progressive, and slowly led to impaired vision. The patient had a past history of nasal pterygium excision eight years ago, which was performed using the bare sclera method, as documented.

On examination, her visual acuity was hand movement in the left eye and 6/12 in the right eye. The patient had a double-headed kissing pterygium in her left eye, causing a complete loss of vision. Grade-I nasal pterygium was noted in the other eye. Slit lamp examination revealed a double-headed pterygium that almost covered the entire cornea. The rest of the anterior segment could not be evaluated in the left eye due to the pterygium. The posterior segment appeared normal on B-scan Ultrasound Sonography (USG) in both eyes (Table/Fig 3)b. In the right eye, ophthalmic findings were unremarkable except for Grade-I pterygium. Routine laboratory findings were within normal limits.

Surgical management involved the successful excision of the double-headed pterygium under local anaesthesia. Vertical split conjunctival autograft with MMC was performed for both the temporal and nasal parts of the left eye, after obtaining signed informed consent. Both grafts were sutured to the surrounding conjunctiva using interrupted 10.0 nylon sutures.

Postoperative management included the administration of antibiotic steroid eye drops and artificial tear eye drops for three weeks (Table/Fig 3)c. Conjunctival suture removal was performed after 10 days. After six weeks, her best corrected visual acuity was 6/12. No recurrence was observed after one year, and the patient was advised to undergo regular yearly eye check-ups.

Discussion

Pterygium is a common benign intraocular condition. One of the main concerns in pterygium management is its recurrence, which typically occurs within the first six months after surgery (8). When fibrovascular tissue regrows over the area of a previously excised primary pterygium, it is referred to as recurrent pterygium (8). Treatment of recurrent pterygium can be challenging, as it is difficult to completely remove and often associated with significant fibrosis and adherence. CLAG is recommended for the treatment of recurrent pterygium, with a recurrence rate ranging from 0 to 18% (5),(8),(9),(10),(11). On the other hand, the bare sclera method has a high recurrence rate (24-89%) (4).

Although, the bare sclera technique is not recommended worldwide, it is still used in India due to its simplicity and cost-effectiveness (4),(6). Impaired vision, induced astigmatism, and recurrent inflammation are common complications associated with pterygium, but blindness caused by pterygium is rare (1),(4). In this report, we present three atypical cases of recurrent pterygium with severe vision loss, leading to temporary blindness in the affected eye. These cases appeared to be complications of the bare sclera method. Poverty, ignorance, and negligence also contribute to the advancement of pterygium leading to blindness.

In the first case, recurrent pterygium was associated with advanced symblepharon, causing lower fornix obliteration, lower punctal distortion, diplopia, and corneal neovascularisation, which is highly unusual. Proper pterygium excision with CLAG can help prevent such extensive postoperative complications (5). There have been a few reports on recurrent pterygium with severe symblepharon (4),(9),(12). The development of recurrent pterygium with severe symblepharon is mainly due to the destruction of the barrier function in the limbal area, tissue injury, and severe fibrosis (4). In the first case, after performing a large CLAG for the nasal side and a rotational graft for the temporal side, along with the application of MMC, there was no regrowth. The author believe that long-term follow-up is necessary in such cases. CLAG with MMC, conjunctival rotation graft with MMC, and free conjunctival graft techniques are all effective methods for the treatment of recurrent pterygium (13),(14). MMC is used as an adjuvant treatment for pterygium. However, some studies have shown that the combination of conjunctival-limbal autograft excision and intraoperative MMC is more effective in reducing the recurrence rate compared to when the two techniques are applied separately (15),(16). The recurrence rate of conjunctival autograft excision with intraoperative MMC has been reported to be 0-2% (17).

Another option for double-headed pterygium is conjunctival split graft, which was performed in the third case. Studies have shown a recurrence rate of 2.10 to 3.45% in vertical split conjunctival grafts, and they are equally effective in treating double-headed pterygium as CLAG (18),(19). Double-headed pterygium creates a large conjunctival defect, making it challenging to cover the entire area with split CLAG. In the third case, there was a sufficiently large nasal graft, but the temporal side graft was slightly smaller. However, since it provided limbal tissue and restored the barrier effect in both the nasal and temporal sides, it serves as a good alternative to prevent recurrence (19). Surgical excision combined with conjunctival autograft transplantation and either rotational or vertical split graft as a one-time intervention has proven to be effective and cost-effective for the treatment of double-headed pterygium.

In the second case, the recurrent pterygium was large enough to cover the pupillary margin, leading to total blindness. This type of advanced pterygium-induced blindness is rare (6). A large CLAG was performed in this case, and the result was satisfactory.

It is known that the demographic and environmental factors of patients also contribute to the recurrence of pterygium (6). Along with surgical causes, other factors may have also contributed to the recurrence, such as working in dry, hot climates, being of Asian race, and prolonged exposure to Ultraviolet (UV) radiation (6). As India falls within the pterygium belt and the environment is favourable for recurrence, CLAG with or without adjuvant therapy, such as intraoperative application of MMC, is more effective in surgically treating pterygium and prevention recurrence and its complications compared to the bare sclera method (6). In rural areas of India, healthcare resources are inadequate, and many patients are lost to follow-up. Therefore, a one-time intervention proves to be both more effective and cost-efficient in terms of treatment. Importantly, no recurrences were observed in any of the three cases during the follow-up period.

Conclusion

Meticulous excision of the complete pterygium tissue with CLAG, with or without MMC, or rotational conjunctival graft with MMC, or vertical split conjunctival graft with MMC, are some of the effective methods for advanced recurrent nasal and double-headed pterygium. In the present report, the authors have presented three atypical cases of recurrent pterygium with satisfactory visual and cosmetic outcomes.

References

1.
Fekadu SA, Assem AS, Adimassu NF. Prevalence of pterygium and its associated factors among adults aged 18 years and above in Gambella town, Southwest Ethiopia, May 2019. Plos One. 2020;15(9):e0237891. [crossref][PubMed]
2.
Rezvan F, Khabazkhoob M, Hooshmand E, Yekta A, Saatchi M, Hashemi H. Prevalence and risk factors of pterygium: A systematic review and meta-analysis. Surv Ophthalmol. 2018;63(5):719-35. [crossref][PubMed]
3.
Dolezalova V. Is the occurrence of a temporal pterygium really so rare? Ophthalmologica. 1977;174(2):88-91. [crossref][PubMed]
4.
Mukherji P, Kumar V, Kumari S. Recent advances in management of pterygium. International Journal Dental and Medical Sciences Research. 2022;4(1):505-10.
5.
Dekaris I, Gabric N, Karaman Z, Mravicic I, Kastelan S. Limbal-conjunctival autograft transplantation for recurrent pterygium. Eur J Ophthalmol. 2002;12(3):177-82. [crossref][PubMed]
6.
Singh SK. Pterygium: Epidemiology prevention and treatment. Community Eye Health. 2017;30(99):S5-S6.
7.
Chylack LT, Leske MC, Sperduto R, Khu P, McCarthy D. Lens opacities classification system. Arch Ophthalmol. 1988;106(3):330-34. [crossref][PubMed]
8.
Mutlu FM, Sobaci G, Tatar T, Yildirim E. A comparative study of recurrent pterygium surgery: Limbal conjunctival autograft transplantation versus mitomycin C with conjunctival flap. Ophthalmology. 1999;106(4):817-21. [crossref][PubMed]
9.
Yao YF, Qiu WY, Zhang YM, Tseng SCG. Mitomycin C, amniotic membrane transplantation and limbal conjunctival autograft for treating multirecurrent pterygia with symblepharon and motility restriction. Graefes Arch Clin Exp Ophthalmol. 2006;244(2):232-36. [crossref][PubMed]
10.
Al Fayez MF. Limbal versus conjunctival autograft transplantation for advanced and recurrent pterygium. Ophthalmology. 2002;109(9):1752-55. [crossref][PubMed]
11.
Shimazaki J, Yang HY, Tsubota K. Limbal autograft transplantation for recurrent and advanced pterygia. Ophthalmic Surg Lasers. 1996;27(11):917-23. [crossref][PubMed]
12.
Ayanniyi AA, Badmos KB, Olatunji FO, Owoeye JF, Sanni TO. Blindness caused by pterygium– a case report. Sierra Leone Journal of Biomedical Research. 2011;3(1):60-62. [crossref]
13.
Paracha Q, Ayoob M, Dawood Z, Mirza SA. Recurrence rate with use of intraoperative Mitomycin C versus Conjunctival Autograft following pterygium excision. Pak J Med Sci. 2014;30(6):1243-46. [crossref][PubMed]
14.
Ari S, Caca I, Yildiz ZO, Sakalar YB, Dogan E. Comparison of mitomycin C and limbal-conjunctival autograft in the prevention of pterygial recurrence in Turkish patients: A one-year, randomized, assessor-masked, controlled trial. Curr Ther Res Clin Exp. 2009;70(4):274-81. [crossref][PubMed]
15.
Frucht-Pery J, Raiskup F, Ilsar M, Landau D, Orucov F, Solomon A. Conjunctival autografting combined with low-dose mitomycin C for prevention of primary pterygium recurrence. Am J Ophthalmol. 2006;141(6):1044-50. [crossref][PubMed]
16.
Segev F, Jaeger-Roshu S, Gefen-Carmi N, Assia EI. Combined mitomycin C application and free flap conjunctival autograft in pterygium surgery. Cornea. 2003;22(7):598-603. [crossref][PubMed]
17.
Ucakhan OO, Kanpolat A. Combined “symmetrical conjunctival flap transposition” and intraoperative low-dose mitomycin C in the treatment of primary pterygium. Clin Exp Ophthalmol. 2006;34(3):219-25. [crossref][PubMed]
18.
Kodavoor SK, Ramamurthy D, Tiwari NN, Ramamurthy S. Double-head pterygium excision with modified vertically split-conjunctival autograft: Six-year long-term retrospective analysis. Indian J Ophthalmol. 2017;65(8):700-04. [crossref][PubMed]
19.
Elhamaky TR, Elbarky AM. Outcomes of vertical split conjunctival autograft using fibrin glue in treatment of primary double-headed pterygia. J Ophthalmol. 2018;2018:9341846.[crossref][PubMed]

DOI and Others

DOI: 10.7860/JCDR/2023/66106.18616

Date of Submission: Jun 21, 2023
Date of Peer Review: Aug 26, 2023
Date of Acceptance: Sep 30, 2023
Date of Publishing: Nov 01, 2023

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jun 22, 2023
• Manual Googling: Aug 22, 2023
• iThenticate Software: Sep 26, 2023 (12%)

ETYMOLOGY: Author Origin

EMENDATIONS: 6

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