Original article
Large pterygium surgery: When coverage of the scleral bed justifies graft rotation
Cirugía del gran pterigión: cuando la cobertura del lecho justifica la rotación del injerto
A. Gargallo-Benedicto
, D. Hernández Pérez, Á. Olate-Pérez, E. Betancur-Delgado, M. Cerdà-Ibáñez, A. Duch-Samper
Corresponding author
Servicio de Oftalmología, Hospital Clínico Universitario de Valencia, Valencia, Spain
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(A) The eye is coupled with the laser lens by means of the Softfit™ interface (SoftFit-LenSxContac Lens, Alcon; Arlington, TX, USA). (B) Capsulotomy centering and programming lens fracture. (C) Corneal incision in 3 planes. (D) Laser emission.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J.O. Moya Romero, G.A. Ochoa Máynez, M.A. Cantero Vergara, C.A. Gómez Cortes" "autores" => array:4 [ 0 => array:2 [ "nombre" => "J.O." "apellidos" => "Moya Romero" ] 1 => array:2 [ "nombre" => "G.A." "apellidos" => "Ochoa Máynez" ] 2 => array:2 [ "nombre" => "M.A." "apellidos" => "Cantero Vergara" ] 3 => array:2 [ "nombre" => "C.A." 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Gargallo-Benedicto, D. Hernández Pérez, Á. Olate-Pérez, E. Betancur-Delgado, M. Cerdà-Ibáñez, A. Duch-Samper" "autores" => array:6 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Gargallo-Benedicto" "email" => array:1 [ 0 => "agargallobenedicto@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "D." "apellidos" => "Hernández Pérez" ] 2 => array:2 [ "nombre" => "Á." "apellidos" => "Olate-Pérez" ] 3 => array:2 [ "nombre" => "E." "apellidos" => "Betancur-Delgado" ] 4 => array:2 [ "nombre" => "M." "apellidos" => "Cerdà-Ibáñez" ] 5 => array:2 [ "nombre" => "A." "apellidos" => "Duch-Samper" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Oftalmología, Hospital Clínico Universitario de Valencia, Valencia, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Cirugía del gran pterigión: cuando la cobertura del lecho justifica la rotación del injerto" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1168 "Ancho" => 1500 "Tamanyo" => 286389 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Summary of the surgery. (A) Pterygium head cleavage and surface keratectomy with Crescent 2.5<span class="elsevierStyleHsp" style=""></span>mm scalpel (Beaver-Visitec Labs, Waltham, MA, USA). Note the width of the scleral bed. (B) Conjunctival graft turned over the cornea after releasing the limbus, with the basal side facing upwards. (C) Placing the graft over the scleral bed with a hinge maneuver after applying Tissucol<span class="elsevierStyleSup">®</span>. Note the orientation of the limbal edge, identified with the asterisk. (D) Appearance after surgery.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0010" class="elsevierStylePara elsevierViewall">The main challenge in pterygium surgery is avoiding relapse which, instead of being a simple reproduction of the primary process, becomes a more aggressive chronic inflammatory process that courses with more symptoms and patient dissatisfaction. Corneal stroma infiltration, the presence of irregular advanced lines with multiple and oblique pathways and firm adherence to underline tissue, which are typical symptoms of relapse, turn a second surgery into a very laborious and complex operation.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Among the various techniques and adjuvant therapies described for treating pterygium, a good option for preventing relapse is resection combined with limbal conjunctival self-graft.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1,2</span></a> Even though relapses can appear up to one year after surgery, 90% occur between month 3 and 6 post-surgery.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">3</span></a> Risk factors comprise sex (male), previous surgery history, occupation, exposure to ultraviolet rays, Latin American ethnic origin or exposure to warm climates within 30° latitudes North or South of the equator, while age and broad Tenon capsule dissection during surgery are associated to higher success rates.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">4–7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The objective of this paper is to study the efficacy and safety of pterygium surgery by means of exeresis and conjunctival self-graft adhered with Tissucol<span class="elsevierStyleSup">®</span>(Tissucol Duo, Laboratorios Baxter, Vienna, Austria), with variation in graft orientation vis-à-vis conventional limbal self-graft technique in selected cases. To this end, 10 active pterygium cases underwent surgery and were followed up during a 12-month period.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Subjects, material and method</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Design of the study</span><p id="par0025" class="elsevierStylePara elsevierViewall">A prospective, not controlled, not randomized study. All patients signed an informed consent both for the surgery procedure and the study. The protocol was approved by the Ethics Committee of the authors’ institution and it complies with the guidelines of the Helsinki Declaration as well as with Spanish legislation in force.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Subjects</span><p id="par0030" class="elsevierStylePara elsevierViewall">All 10 cases were selected from a group of patients with pterygium diagnostic referred to the authors’ hospital for surgical treatment. All patients underwent a complete ophthalmological examination with clinic history, anamnesis and slitlamp biomicroscopy with presurgery photographic control of the lesion. Age, sex and ethnic belonging of patients were recorded. The pterygium grade was established on the basis of the corneal involvement extension: grade <span class="elsevierStyleSmallCaps">i,</span> beyond the limbus; grade <span class="elsevierStyleSmallCaps">ii</span>, half way between the limbus and pupil margin; grade <span class="elsevierStyleSmallCaps">iii</span>, reaching the pupil margin; grade <span class="elsevierStyleSmallCaps">iv</span>,beyond the pupil margin. The inclusion criteria comprised the diagnostic of primary or recurring pterygium grade <span class="elsevierStyleSmallCaps">II</span>or higher, with limbal involvement extension of 8<span class="elsevierStyleHsp" style=""></span>mm or more and upper conjunctiva in healthy and mobile condition. Patients with any different condition or associated disease that could hinder follow-up or surgery were excluded.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Surgical technique</span><p id="par0035" class="elsevierStylePara elsevierViewall">The same surgical technique was applied on all patients by the same surgeon. After marking the limits of the lesion and subconjunctival anesthesia infiltration (0.2<span class="elsevierStyleHsp" style=""></span>ml of 2% lidocaine with 1/200,000 adrenalin), pterygium exeresis was performed, initially releasing the fibrovascular axis, followed by pterygium head resection and elimination of the altered cornea with superficial keratectomy, achieving a dissection plane without residual steps. In recurrent cases, the procedure was more laborious due to greater inflammation and adherence to deep levels. Subsequently, the perilesional Tenon capsule was dissected in full detail, obtaining a receiving area with smooth edges free of Tenon. In all cases a broad exposed scleral bed was obtained, similar to a parallelogram (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). In the present series, the mean size of the bed sides was 10<span class="elsevierStyleHsp" style=""></span>mm for the long sides running parallel to the limbus and 5<span class="elsevierStyleHsp" style=""></span>mm for the short perpendicular sides, making a mean perimeter of 30<span class="elsevierStyleHsp" style=""></span>mm and 8 mean surface of 50<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span>. Accordingly, it was necessary to obtain a large conjunctival graft to ensure complete stress-free cover.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">In order to position the graft preserving the juxtalimbar-limbus orientation, the graft should have its long sides parallel to the limbus (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>a), although carving is difficult and sometimes smaller than planned. For this reason, the surgeon preferred to make the short sides parallel to the limbus and the long sides perpendicular. In this way, larger grafts were obtained which facilitated dissection (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>b).</p><p id="par0045" class="elsevierStylePara elsevierViewall">The graft limits were marked over the upper conjunctiva with the same rectangular geometric shape as the bed and a size of 1<span class="elsevierStyleHsp" style=""></span>mm larger on all sides. The Tenon-free conjunctival graft was desiccated with care, avoiding the formation of eyelets and fringes on the edges. The graft was turned over the cornea with the basal face looking upwards and, after releasing it from the limbus, it was slid over the cornea. A hinge maneuver was carried out to place the basal surface of the graft with the scleral bed, with prior sequential application of the 2 Tissucol<span class="elsevierStyleSup">®</span> components to avoid the use of sutures (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). In this way, the limbar edge of the graft was located in the inferior side of the bed, losing the limbus-limbus orientation in contrast with the conventional technique (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1b and 2c</a>). The conjunctival defect of the donor area was left open for cicatrization with second intention.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">After ocular occlusion during 24<span class="elsevierStyleHsp" style=""></span>h, treatment was initiated with chloramphenicol cream 10<span class="elsevierStyleHsp" style=""></span>mg/g and disodium dexamethasone phosphate 0.5<span class="elsevierStyleHsp" style=""></span>mg/g (Oftalmolosa cusí, Icol<span class="elsevierStyleSup">®</span>) (Pomada oftálmica 0.5/10<span class="elsevierStyleHsp" style=""></span>mg, Laboratorios Alcon, El Masnou, Barcelona, Spain), once during the night for one week together with dexamethasone 1<span class="elsevierStyleHsp" style=""></span>mg/ml (Laboratorios Alcon, El Masnou, Barcelona, Spain) every 6<span class="elsevierStyleHsp" style=""></span>h in descending frequency during 4 weeks, followed by fluorometholone: FML eyedrops in 0.1% solution (Laboratorios Allergan, Mayo, Ireland) in decreasing dosage during 8 additional weeks for all patients. No antimetabolites or other adjuvant therapies were applied.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Follow-up</span><p id="par0055" class="elsevierStylePara elsevierViewall">Intraoperative surgical complications and difficulties were recorded, and post-surgery checkups were made on day 1, 15, 30 and 60 and at 12 months after surgery, including anterior segment photographs and recording the relapse signs in each visit (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). In addition, the checkups at days 30 and 60 included intraocular pressure (IOP) measurement with applanation tonometry. All patients checkups were performed by the same ophthalmologists.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Data analysis</span><p id="par0060" class="elsevierStylePara elsevierViewall">The main efficacy measures were conjunctival or corneal relapse signs. Safety measures comprised the appearance of complications.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Conjunctival recurrence was defined as conjunctival injection or any protuberance on the conjunctival surface that may cause dellen, fibrovascular proliferation or the appearance of tractional fibrous scars. Corneal recurrence was defined as a fibrovascular tissue invasion larger than 1.5<span class="elsevierStyleHsp" style=""></span>mm in the previous cleavage area.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">The study analyzed the data of 10 intervened eyes (5 right and 5 left) belonging to 10 patients (6 males and 4 females) with ages comprised between 51 and 79 (mean 60.6<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>8.23). Five of these were of Latin American origin, 8 had grade <span class="elsevierStyleSmallCaps">II</span>pterygium, one had grade <span class="elsevierStyleSmallCaps">III</span> and one grade <span class="elsevierStyleSmallCaps">IV</span>. Three cases were relapses who previously underwent simple resection and exhibited oblique advance areas. In all cases, the follow-up comprised 12 months.</p><p id="par0075" class="elsevierStylePara elsevierViewall">None of the patients exhibited severe intra-or postoperative complications. No intra-surgery complications were registered other than the complications inherent in the conventional graft technique in the limbus-limbal position.</p><p id="par0080" class="elsevierStylePara elsevierViewall">One case exhibited eyelet opening during the conjunctival graft dissection which was under 1<span class="elsevierStyleHsp" style=""></span>mm diameter and healed during the early post-surgery without noteworthy events.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Two cases exhibited dehiscence of the graft nasal edge under 1<span class="elsevierStyleHsp" style=""></span>mm on day one post-surgery, which epithelized during the first week without repercussions. An additional case exhibited a pyogenic granuloma on the donor conjunctiva bed 2 weeks after surgery, which was resolved with increased corticoids, observing a secondary increase of IOP (30<span class="elsevierStyleHsp" style=""></span>mmHg) that responded to topical hypotensor treatment and disappeared after withdrawing corticoids. IOP values and the rest of patients were normal. After one year follow-up no limbal insufficiency signs have been observed.</p><p id="par0090" class="elsevierStylePara elsevierViewall">The success rates of the present series was 100% at 12 months, with esthetic effects that cannot be differentiated from those of the conventional graft technique placed in the limbus-limbal position (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">High recurrence rates associated to simple resection pterygium treatment, ranging between 29% and 89% in different series,<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">8</span></a> has made it necessary to develop new procedures which, associated to resection, enable the highest possible reduction of post-surgery relapses. Accordingly, the development of various conjunctival plasty techniques such as the rotational conjunctival flap,<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">9–11</span></a> limbal conjunctival self-graft,<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">2,12–16</span></a> amniotic membrane implant and adjuvant treatments such as mitomycin C or 5-fluoroacyl, among others, have improved results and made them comparable.<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">7,17,18</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Resection combined with limbal conjunctival self-graft provides good results in resection in what concerns postoperative relapse rates. Since the success of this procedure was first described in 1985,<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">19</span></a> numerous studies have been published with highly variable relapse rates due to the methodology of each study, age and ethnic group of patients, the nature of pterygium, the definition of recurrence, the follow-up time and the number of studied patients as well as surgeon experience or self-graft mode with the inclusion or not or limbar cell, among other factors.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Taking into account that the limbar epithelium acts as a barrier to conjunctival overgrowth and that pterygium represents a local limbal deficiency,<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">4</span></a> the inclusion of limbal cells in the conjunctival graft preserving the limbus-limbal orientation can restore the barrier function of the limbus and prevent recurrences. Several studies have demonstrated its effectiveness, with variable relapse rates according to the series between zero and 13.3%.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">2,12–16</span></a> At present, this is the most accepted pterygium surgery technique for young patients at risk of relapse.</p><p id="par0110" class="elsevierStylePara elsevierViewall">However, we can find difficulties in this technique in recurrent pterygium cases with broad limbal involvement, oblique pathways or dual advanced areas in which, after resection the lesion, broad scleral beds are obtained that require large conjunctival grafts to ensure complete covering without producing stress. It is precisely in these cases where the technique described herein is useful as it enables better cover for the entire bed because the graft limits are marked on the basis of the receptor area morphology and the dimensions obtained after resection. This ensures the best possible cover without the restriction of preserving limbal orientation.</p><p id="par0115" class="elsevierStylePara elsevierViewall">No corneoconjunctival recurrence signs were recorded during the 12 month follow-up, and it can be concluded that the restoration of the limbal area in the present cases is not a factor that determines the absence of recurrences. Hypothetically, it could be said that by eradicating damaged in limbal cells and not placing in that area new stem cells which are susceptible to undergo subsequently the same mutations that gave rise to pterygium, we could be adding a factor that prevents recurrence.</p><p id="par0120" class="elsevierStylePara elsevierViewall">On the other hand, during surgery it was easier to carve the graft because, having a narrower limbal base, subepithelial dissection was faster and diminished the risk of forming eyelets.</p><p id="par0125" class="elsevierStylePara elsevierViewall">As conclusion of the results of the present series, it can be said that meticulous surgery with cleavage and broad dissection of Tenon's capsule, dissecting an adequately sized conjunctival graft adapted to the morphology of the scleral bed in order to ensure sufficient stress-free cover, provides good surgical results independently of the preservation of the limbus-limbus orientation, without any case of relapse after 12 months follow-up. The authors propose a safe and efficient technique that can be considered for large pterygium cases, with or without recurrence and with broad limbal involvement that require larger scleral cover by traction-free healthy conjunctiva. However, randomized controlled studies are necessary with a larger number of patients and longer follow-up periods to analyze the influence of other factors related to relapse in order to confirm the present results and compare them with those of other techniques.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicts of interest</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors state that they do not have commercial interests and have not received financial support.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres733547" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec737375" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres733548" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec737376" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Subjects, material and method" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Design of the study" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Subjects" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Surgical technique" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Follow-up" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Data analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0040" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0045" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-07-31" "fechaAceptado" => "2016-03-18" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec737375" "palabras" => array:4 [ 0 => "Pterygium recurrence" 1 => "Pterygium surgery" 2 => "Conjunctival autograft" 3 => "Limbal stem cells" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec737376" "palabras" => array:4 [ 0 => "Recurrencia del pterigión" 1 => "Cirugía de pterigión" 2 => "Autoinjerto conjuntival" 3 => "Células madre limbares" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To perform a 12 month follow-up study to assess the safety and effectiveness of resection and conjunctival autograft fixed with Tissucol<span class="elsevierStyleSup">®</span> in selected cases of large pterygium. The orientation of the graft was adapted to the morphology of the scleral bed for a better coverage free of traction, with limbal position being lost.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A prospective, non-comparative study of 10 cases of grade <span class="elsevierStyleSmallCaps">II</span> or superior pterygium (7 primary, 3 recurrent) with at least 8<span class="elsevierStyleHsp" style=""></span>mm of limbal extension. A wide scleral bed was obtained after pterygium and Tenon resection, with larger grafts being required to cover the defects. A superior conjunctival autograft was harvested and fixed to bare sclera using Tissucol. The orientation was adapted to the morphology of the scleral bed and limbal position was lost. Patients were periodically assessed for recurrence and complications for a period of 12 months.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Minor complications occurred in 4 eyes. In one case a buttonhole was formed during dissection of the graft. Two presented with small limbal dehiscence, but epithelialisation was completed in the first week. In a third case, it was necessary to increase topical corticosteroids for pyogenic granuloma on the donor site, with secondary increased intraocular pressure (IOP). There were no recurrences after 12 months follow-up.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A conjunctival graft of appropriate size adapted to the morphology of the scleral bed to ensure good coverage free of tension, provides good surgical results in selected cases of pterygium, regardless of the conservation the limbal orientation, with no recurrences after one year follow-up.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Evaluar la eficacia y seguridad de la resección y autoinjerto conjuntival adherido con Tissucol<span class="elsevierStyleSup">®</span> en casos seleccionados de pterigión de gran tamaño en los que la orientación del injerto se adapta a la morfología del lecho escleral para una mejor cobertura libre de tracción, perdiendo la orientación limbo-limbo, con un seguimiento de 12 meses.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Método</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio prospectivo, no comparativo, de 10 casos de pterigión grado <span class="elsevierStyleSmallCaps">II</span> o superior (7 primarios, 3 recurrentes) con al menos 8<span class="elsevierStyleHsp" style=""></span>mm de extensión limbar. Después de la resección de la lesión se obtuvo un lecho escleral amplio, con necesidad de injerto grande para cubrir el defecto. Se disecó el autoinjerto conjuntival superior y se fijó a esclera mediante Tissucol<span class="elsevierStyleSup">®</span>, adaptando la orientación a la morfología del lecho, perdiéndose la posición limbar. Se realizó seguimiento periódico de la recurrencia y complicaciones durante un año.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se registraron complicaciones menores en 4 ojos. En un caso se formó un ojal al tallar el injerto. Dos presentaron una pequeña dehiscencia limbar, que epitelizó completamente durante la primera semana. En otro caso fue necesario aumentar los corticosteroides tópicos por granuloma piógeno en la zona donante, con aumento secundario de la presión intraocular (PIO). No hubo ningún caso de recurrencia después de 12 meses de seguimiento.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Un injerto conjuntival de tamaño adecuado adaptado a la morfología del lecho escleral que asegure una buena cobertura libre de tensiones proporciona buenos resultados quirúrgicos en casos de pterigión seleccionados, independientemente de la conservación de la orientación limbo-limbo, sin recidivas tras un año de seguimiento.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Gargallo-Benedicto A, Hernández Pérez D, Olate-Pérez Á, Betancur-Delgado E, Cerdà-Ibáñez M, Duch-Samper A. Cirugía del gran pterigión: cuando la cobertura del lecho justifica la rotación del injerto. Arch Soc Esp Oftalmol. 2016;91:469–474.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">This paper was partially presented at the 91st Congress of the Ophthalmology Society of Spain, held in Seville, September 23–26, 2015.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 357 "Ancho" => 995 "Tamanyo" => 63793 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Distribution of conjunctival graft edges over the parallelogram-shaped scleral bed. (A) Preserving limbal orientation. (B) Rotating the graft, without juxtalimbar-limbus matching.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1168 "Ancho" => 1500 "Tamanyo" => 286389 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Summary of the surgery. (A) Pterygium head cleavage and surface keratectomy with Crescent 2.5<span class="elsevierStyleHsp" style=""></span>mm scalpel (Beaver-Visitec Labs, Waltham, MA, USA). Note the width of the scleral bed. (B) Conjunctival graft turned over the cornea after releasing the limbus, with the basal side facing upwards. (C) Placing the graft over the scleral bed with a hinge maneuver after applying Tissucol<span class="elsevierStyleSup">®</span>. Note the orientation of the limbal edge, identified with the asterisk. (D) Appearance after surgery.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2275 "Ancho" => 3337 "Tamanyo" => 739007 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Photographic follow-up of 5 cases. Note the post-surgery appearance, identical to that of conventional technique, and the excellent results after one year.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:19 [ 0 => array:3 [ "identificador" => "bib0100" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Outcome of different techniques of pterygium excision with conjunctival autografting in pediatric population: our experience in central India" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A.R. Yadav" 1 => "K.R. Bhattad" 2 => "P.A. Sen" 3 => "E.B. Jain" 4 => "A. Sen" 5 => "B.K. 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