An update on the surgical management of pterygium and the role of loteprednol etabonate ointment

Figures & data

Figure 1 Structure of loteprednol etabonate.

Table 1 Clinical studies comparing LE with vehicle, in the treatment of postoperative pain and inflammation following cataract surgery*

Parameter	Study
	Stewart et al^Citation22	LE postoperative study group^Citation23	Comstock et al^Citation24	Fong et al^Citation25	Rajpal et al^Citation26
LE formulation	Suspension	Suspension	Ointment	Gel	Gel
Total patients randomized	227	203	805	407	406
Proportion of patients with resolution of ACI at the final study visit	LE: 64%	LE: 55%	LE: 46%	LE: 54.9%	LE: 47.3%
	Vehicle: 29%	Vehicle: 28%	Vehicle: 21%	Vehicle: 28.4%	Vehicle: 22.2%
	P<0.001	P<0.001	P<0.001	P<0.001	P<0.001
Patients with IOP elevations of	LE: 3 (1.4%)	LE: 0 (0.0%)	LE: 3 (0.7%)	LE: 1 (0.5%)	LE: 1 (0.5%)
≥10 mmHg over baseline, n (%)	Vehicle: 0 (0.0%)	Vehicle: 1 (1.0%)	Vehicle: 1 (0.2%)	Vehicle: 0 (0.0%)	Vehicle: 1 (0.5%)

Note:

* In all studies, patients received LE or vehicle four times daily for 14 days.

Abbreviations: ACI, anterior chamber inflammation (sum of anterior chamber cells and flare); IOP, intraocular pressure; LE, loteprednol etabonate.

Table 2 Surgical techniques for pterygium in order of complexity

Rank by complexity	Procedure
1	Local excision of pingueculum and pterygium with a single small rotational conjunctival flap, closed with buried 10-0 nylon suture
2	Addition of topical mitomycin C to the procedure
3	More extensive conjunctival excision with both an inferior and a superior rotational conjunctival flap, closed with 10-0 nylon suture
4	Diffuse conjunctival excision necessitating either a superotemporal free conjunctival autograft or an amniotic membrane graft to completely cover all bare sclera
5	Consideration of autologous serum glue, using only local hemorrhage to bind a small amniotic membrane or conjunctival graft
6	Fibrin tissue glue (Evicel [Ethicon, Inc., Somerville, NJ, USA] or Tisseel [Baxter International, Inc., Deerfield, IL, USA]) to secure the rotational and grafted ocular surface, often supplemented with buried 10-0 nylon suture
7	Additional deep dissection of rectus insertion cicatrix
8	Additional dissection, grafting, or sequential surgery to correct symblepharon and forniceal cicatrization

Figure 2 Untreated pterygium recurrence 3 years following successful surgery.

Notes: Traction on the nasal conjunctiva and lipid exudate adjacent to the redundant corneal vascular anomalies are markers for chronicity.

Table 3 Strategies for pterygium recurrence

1. Topical steroid therapy enhanced by increased frequency or potency

2. Oral doxycycline, especially in patients with ocular rosacea

3. Topical azithromycin, particularly for patients intolerant of oral doxycycline

4. Subconjunctival injection of antifibrotic agents: dexamethasone or triamcinolone + 5-fluorouracil + lidocaine

5. Subconjunctival injection of an anti-VEGF agent: bevacizumab (Avastin^®; Genentech Inc., South San Francisco, CA, USA)

6. Locally applied argon laser photocoagulation, enhanced by topical photosensitizer, such as sodium fluorescein

Abbreviation: VEGF, vascular endothelial growth factor.

Figure 3 Early pterygium recurrence 2 months after successful surgery.

Notes: The early vascular tufts can be treated with injections (steroid, 5-fluorouracil, or bevacizumab) or with focal argon laser therapy, as well as with increased topical steroid therapy.

Figure 4 Typical fibrovascular nasal pterygium amenable to a superior and inferior rotational conjunctival graft procedure.

Figure 5 Pterygium case (A) preoperatively and (B) 2-weeks postoperatively.

Figure 6 Mansur–Aran Graft Harvesting Pterygium Debunking Scissors (Rhein Medical Inc., St Petersburg, FL, USA): (A) tip and (B) full view.

Figure S1 Sheppard conjunctival forceps (Bausch & Lomb, Rochester, NY, USA): (A) full view and (B) forceps tips.

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