Split thickness buccal mucous membrane grafts and â irradiation in the treatment of recurrent pterygium

Background—Pterygium is a common problem and after surgical removal may recur in up to 80% of cases, depending on the technique of primary excision. Recurrent pterygia can be aggressive and repeated excision may result in severe conjunctival scarring and shortening, resulting in insuYcient conjunctiva to perform further grafting and lid surgery. When there is insuYcient autologous conjunctiva, mucous membrane must be obtained from other sites. Full thickness buccal mucous membrane grafts have been described, but they may result in a beefy red appearance, with graft contraction and a poor tear film. Method—The use of split thickness buccal mucous membrane grafts is described in three patients with recurrent pterygium, two in combination with lamellar keratoplasty. â Irradiation was used as adjuvant therapy in all cases. Results—In all three cases an acceptable cosmetic appearance was achieved, with no recurrence of the pterygium, and a good range of eye movements. Conclusions—It is recommended that split thickness buccal mucosal grafts, combined with â irradiation, should be considered in complex cases of pterygium recurrence when there is insuYcient autologous conjunctiva and conjunctival shortening with restricted eye movements. (Br J Ophthalmol 1998;82:1420–1423) Pterygium is a commonly encountered problem and although frequently asymptomatic, may cause symptoms due to irritation, astigmatism, and reduced visual acuity which necessitate its removal. 2 Current first line surgical procedures include simple excision leaving bare sclera; excision and conjunctival closure by primary anastomosis or conjunctival grafts; and excision combined with â irradiation, mitomycin, or thiotepa. The commonest complication is recurrence of the pterygium. The reported frequency of recurrence for primary pterygium varies widely for diVerent procedures, ranging from 24–67% of cases after simple excision by the bare sclera technique, to 0–47% of cases after excision combined with conjunctival autografting or adjuvant therapy. Recurrences may grow aggressively, rapidly reaching and even overtaking the size of the original pterygium. Many diVerent techniques have been suggested for dealing with recurrent pterygia, including excision combined with lamellar keratoplasty, autologous conjunctival grafts, â irradiation, and antimitotics such as mitomycin C, 5-fluorouracil, and thiotepa, resulting in further recurrence of the pterygium in up to 30% of such cases. 4 6 9 11–15 Cases of repeated recurrence may develop severe conjunctival scarring and shortening, resulting in insuYcient conjunctiva to perform further grafting and lid surgery, and restricted eye movements. Patients from tropical countries may also have trachomatous scarring and xerosis, which reduces the amount of conjunctiva available for autologous grafting. Under these circumstances, mucous membrane must be obtained from other sites. Full thickness buccal mucous membrane grafts are commonly used to reconstruct the fornices or orbital sockets in cases of severe conjunctival contracture, by plastic and adnexal surgeons. 18 However there are few records of buccal mucous membrane grafts in pterygium surgery and most of these are over 20 years old. 19–23 More recently Fine, and Dash and Boparai have described the use of full thickness buccal mucous membrane grafts in pterygium surgery but some authors have actively disparaged the technique. 11 24 The use of split thickness buccal mucous membrane has advantages over full thickness grafts, resulting in a better cosmetic appearance, and possibly less contraction. To our knowledge, the use of split thickness buccal mucous membrane has not been previously described for the management of pterygium. We present three case reports of patients who had repeated surgery for pterygium, and who eventually had split thickness buccal mucous membrane grafting combined with â irradiation with good results. In two cases, lamellar keratoplasty was also performed. Method All patients were attending Moorfields Eye Hospital and surgery was performed under general anaesthesia. They all had severe recurrent pterygia with limitation of extraocular movements, and insuYcient conjunctiva in either eye to permit a conjunctival flap or graft. If the cornea was suYciently thick, a split thickness buccal mucous membrane graft was used on its own, but if previous surgery had resulted in corneal thinning, a lamellar keratoplasty was also performed. Br J Ophthalmol 1998;82:1420–1423 1420 Moorfields Eye Hospital, City Road, London EC1V 2PD