New Grading System to Improve the Surgical Outcome of Multirecurrent Pterygia

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To report a new grading system and surgical outcome by sealing the gap between the conjunctiva and Tenon capsule.


A total of 32 eyes of 30 patients with pterygia were managed at the Ocular Surface Center from January 1, 2002, through December 31, 2010. The eyes were consecutively operated on by recession; sealing of the gap; covering of exposed medial rectus muscle by amniotic membrane, conjunctival autograft, or oral mucosal graft (OMG); and covering of the bare sclera with amniotic membrane. Main outcome measures were recurrence, diplopia, and caruncle morphological characteristics.


Caruncle grading strongly correlated with residual conjunctiva (P = .01), severity of diplopia (P = .001), and overall success rate (P = .05). Amniotic membrane transplantation alone was successful in 23 eyes with residual conjunctiva of 27.8 (10.1) mm, which was significantly longer than those in 6 cases in which amniotic membrane transplantation failed (13.1 [11.4] mm, P = .007) and those in 8 cases in which amniotic membrane transplantation was successful but that required an additional conjunctival autograft or oral mucosal graft (10.9 [10.4] mm, P = .001). During mean (SD) follow-up of 27.5 (20.5) months, 30 of 32 eyes (94%) achieved total success without recurrence and diplopia and normal caruncle in 17 of 21 eyes (81%) with abnormal caruncle before surgery. One eye (3%) developed corneal recurrence and was lost to follow-up, and 1 eye (3%) was left with a depressed caruncle and residual diplopia on adduction.


Caruncle morphological characteristics and residual conjunctiva measurement help grade the severity of recurrent pterygium, guide surgical techniques, and predict outcomes. Sealing of the gap is important to create a strong barrier for preventing recurrence, restoring caruncle morphological characteristics, and regaining full motility in multirecurrent pterygia.

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