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Efficacy of Mitomycin C in Pterygium ManagementOFFICE BASED FAMILY MEDICINEABSTRACT34Aims: To determine the efficacy andsafety of using Mitomycin C in themanagement of Pterygium.Methods: A retrospective study of 37eyes (30 patients), with the mean ageof 43 years (30 -55 yesar) attendingthe ophthalmology clinic. 17 eyes(17 patients) were treated by usingMitomycin C; 14 eyes had primarypterygia and 3 eyes had recurrentpterygia. 20 eyes (13 patients) weretreated without use of Mitomycin C;15 eyes had primary pterygia and 5eyes had recurrent pterygia. All eyesreceived the same medications postoperatively.Results: In the Mitomycin C treatedeyes we noted that only 2 eyes(11.7%) had recurrent pterygia, after14 months follow-up, but the recurrencein the non-Mitomycin groupwere higher than that of Mitomycingroup 9 eyes (45%) after the sameperiod of follow-up. Also we notedthat the healing of conjunctiva wasdelayed when we use Mitomycin C incomparison to the other group; whichis a known side effect of MitomycinC.Conclusion: From these results weconclude that the use of MitomycinC in the management of Pterygiumis effective in decreasing the recurrenceof pterygia after excision. Soit is a simple, safe and successfully\procedure that we recommended inall pterygium management.Mohammad Droos, MD (Oph)Correspondence to:Ophthalmology Department, Royal medical services,Amman, JordanTel: 00962-777265101E-mail: droos75@hotmail.comIntroductionA pterygium is an abnormal (noncancerousgrowth of the conjunctiva)a triangular fibrovascular subepithelialingrowth of degenerative bulbarconjunctival tissue over the limbalonto the cornea (1) . The conjunctivais a thin membrane lining the insideof the eyelid and part of the eyeball(located between the sclera, or the“white of the eye” which surroundsthe eyeball).Excessive growth of the conjunctivaleads to a pterygium, which appearsas a fleshy spot; pterygia are nearlyalways preceded and accompaniedby pingueculae (2) .The exact cause of pterygium isunknown. The most common factorsthat contribute to pterygium include:••••••Excessive exposure to sunlightSex: MaleIncreasing ageWorking outdoorsExcessive exposure to harshenvironmental conditions such asdust, dirt, heat, wind, dryness, andsmoke.Excessive exposure to allergenssuch as industrial solvents andchemicals.The symptoms of pterygia includethe following: redness, irritation,tearing, foreign body sensation,dryness, sometime blurring of visionespecially when it causes cornealastigmatism (11) .Management of pterygium can bedivided into:Observation• Periodic eye examination, usuallywhen the pterygium causes no orminimal symptoms• If symptoms increase, additionaltreatments may include:• Medications: prescriptionMIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 6, ISSUE 6antibiotics to prevent infection;corticosteroids to reduceinflammation; ocular lubricants.• Radiation therapy to stoppterygium cells from reforming (7) .• Mitomycin C to aid in healing andto prevent recurrence (8) .SurgeryIndications for pterygium excisioninclude (12) : persistent discomfort,vision distortion, and restricted ocularmotility. Microsurgical excision of apterygium aims to achieve a normal,topographically smooth ocularsurface (3) .Mitomycin (mitomycin C; MMC)is an antibiotic isolated fromStreptomyces caespitosus. The drugis a bioreductive alkylating agentthat undergoes metabolic reductiveactivation, and has various oxygentension-dependent cytotoxic effectson cells, including the cross-linking ofDNA. It is widely used systemically forthe treatment of malignancies, and hasgained popularity as topical adjunctivetherapy in ocular and adnexal surgeryover the past 2 decades (6) , its use hasbeen described in the managementof ocular surface neoplasias (4) ,conjunctival malignant melanomaand primary acquired melanosiswith atypia (5) , and in conjunctivalintraepithelial neoplasia (10) .Complications of topical MitomycinC have been described in theliterature include the following: scleralnecrosis and thinning, perforation,endophthalmitis, endothelialdecompensation, glaucoma, iritis (9) .Materials and MethodsA retrospective study of 37 eyes(30 patients), with the mean age of43 years (30 -55 years) attending theophthalmology clinic.
OFFICE BASED FAMILY MEDICINEWe divided the patients into twomain groups; in the first group weused Mitomycin C, in the second weexcise the pterygium.17 eyes (17 patients) were treatedby using Mitomycin C; 14 eyes hadprimary pterygia and 3 eyes withrecurrent pterygia. 20 eyes (13patients) were treated without useof Mitomycin C; 15 eyes had primarypterygia and 5 eyes had recurrentpterygia. All eyes received the samemedications postoperatively.The examination included:• Visual Acuity-a test to measure theability to see and read the smallestletters on an eye chart (by usingTopcon chart projector (visiontesterVT-SE; Topcon Co, Japan) with Eletters at a distance of 6 meters.• Slit Lamp Examination - a brightlight with magnification used toview the eye.• Photo Documentation -Photography to record the degreeof growth of a pterygium.The cornea and conjunctiva wereexamined by using binocular slitlamp microscope with magnification,and we chose the patient that hadpterygium indicated for surgicalexcision (one that caused one ofthese; visual impairment, persistentdiscomfort, and restriction of ocularmotility).We excluded from this study;pingueculae, simple pterygia thatcauses no or minimal symptoms.In this study we applied 0.4 mg/mlMitomycin C intraoperatively for 3minutes following pterygium excision.Table 1: Recurrent rate in Mitomycin GroupPre-op.PrimaryRecurrentResultsOf the 37 eyes (30 patients)Mitomycin C treated eyes (17 eyes) we noted that only 2 eyes (11.7%)had recurrent pterygia, after 14months follow-up (see Table 1) , butthe recurrence in the non-Mitomycingroup (20 eyes) was higher thanthat of the Mitomycin group 9 eyes(45%) after the same period of followup(see Table 2) . Also we notedthat the healing of conjunctiva wasdelayed when we use Mitomycin C incomparison to the other group; whichis a known side effect of Mitomycin C;and it is not a significant complicationbecause we use it in a minimal dosefor a short period of time.The postoperative recurrentpterygia in the Mitomycin groupwere not from the primary pterygia ,but only from the recurrent pterygia(preoperative). The recurrent pterygiain the non-Mitomycin group were fromboth primary and recurrent pterygia.DiscussionPterygium is a common disorderaffecting conjunctiva and corneaespecially in hot and dry environmentalareas. It is insignificant when it issimple and not causing discomfortto the patient and dies not needaggressive management exceptobservation and some medicationssuch as antibiotics to prevent theinfections, corticosteroids to reduceinflammation; and ocular lubricants.Pterygium is significant when itcauses patient discomfort (persistent),visual impairment, and restriction ofocular motility; these are indicationsfor excision of pterygium which canbe either excision alone or excisionPost-op.PrimaryMales 9 2 0 1Females 5 1 0 1Total 14 3 0 2Recurrence rate 2 eyes (11.7%)Recurrentwith using adjunctive therapy such asMitomycin C, 5 fluorouracil , etcThe former studyhad a highrecurrence rate which is annoying forthe patient, in opposition to the latter.In this study we use Mitomycin Cintra-operatively with the excision ,and we follow up these patients, withgood results; recurrence of pterygiawas decreased and with minimalcomplications. From these resultswe recommend to use Mitomycin Cin pterygium management becauseit is a simple, safe and successfulprocedure.References1. Jack J. kanski, Jay Menon. Clinical Ophthalmology,a systemic approach, fifth ed. 2003;82-3.2. Thomas J, Lirsegang, Jacksonville, Florida.American Academy of Ophthalmology. 2002; section8:339-341.3. Thomas J, Lirsegang, Jacksonville, Florida.American Academy of Ophthalmology. 2002; section8:394-396.4. E G Kemp, A N Harnett, and S Chatterjee. Preoperativetopical and intraoperative local mitomycin Cadjuvant therapy in the management of ocular surfaceneoplasias, Br J Ophthalmol. 2002 January;86(1): 31-34.5. Demirci H, McCormick SA, Finger PT. Topical mitomycinchemotherapy for conjunctival malignantmelanoma and primary acquired melanosis withatypia. Arch Ophthalmol 2000;118:885-91.6. Abraham, Lekha M.; Selva, Dinesh; Casson, Robert;Leibovitch, Igal. Mitomycin: Clinical Applicationsin Ophthalmic Practice. Drugs, Volume 66, Number3, 2006 , pp. 321-340(20).7. Parida DK; Agarwal S; Rath GK, The role of radiotherapyin the management of Pterygium.The IndianPractitioner. 1999 Jul; 52(7): 466-8.8. Anduze AL. Pterygium surgery with mitomycin-C:ten-year results. Ophthalmic Surg Lasers. 2001 Jul-Aug;32(4):341-5.9. Tsai YY, Lin JM, Shy JD. Acute scleral thinning afterpterygium excision with intraoperative mitomycin C.Cornea. 2002;21:227-229.10. Rozenman Y, Frucht-Pery J. Treatment of conjunctivalintraepithelial neoplasia with topical drops ofmitomycin C. Cornea 2000;19:1-6.11. Kampitak K.The effect of pterygium on cornealastigmatism. J Med Assoc Thai. 2003 Jan;86(1):16-23.12. Assia E. Surgical management of pterygium. IsrMed Assoc J. 2002 Dec;4(12):1138-9.Table 2: Recurrence rate in Non-Mitomycin GroupPre-op.PrimaryRecurrentPost-op.PrimaryMales 10 3 2 3Females 5 2 1 3Total 15 5 3 6Recurrence rate 9 eyes (45%)RecurrentMIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 6, ISSUE 6 35
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