Pterygium is common in dry climates with the highest incidence between the ages of 20 and 40 years. It has the highest prevalence rate (0.7%-31%) among individuals over the age of 40 years in different populations, depending on location, altitude and ethnicity.7 In addition to corneal topographical changes, pterygium creates optical irregularities and distortions other than intrusion into the visual axis.1 Pterygium patients frequently consult physicians for discomfort, ocular surface inflammation, red eyes, and/or when their vision is affected. The indications for pterygium surgery include visual impairment due to significant alterations in the refractive state and corneal curvature prior to entry into the optical zone,8 ocular motility restriction and diplopia, symblepharon, chronic inflammation and cosmetic effects.9
It has been long known that pterygium has an effect on corneal topography. Nevertheless, changes in the corneal topographical parameters attributable to pterygium are more or less reversible after surgery.10 Besides, corneal refractive status has recently been documented with different results following pterygium surgery.11–15 Ozdemir et al.,16 reported early significant improvement in pterygium-induced corneal topographical parameters. Normal corneal topography patterns are, however, established in the late post-operative period. Different pterygium surgeries have been associated with post-operative steeper cornea and high mean refractive power.11,13 It is however uncertain to what extent a particular pterygium surgical technique may have an impact on both anterior and posterior corneal topographical parameters. Moreover, substantial reduction in pterygium-induced astigmatism after different surgical techniques has been reported before.17–19
The current study investigated and compared post-operative corneal topographical parameters between baseline and one-month data. Similar to Ozdemir et al.,16 there were early significant changes in pterygium-induced corneal topographical parameters. The mean age (46.94 ± 10.34 years) of pterygium patients, most of whom (51 %) had grade 2 pterygium, was consistent with the previous reports. Patients undergoing pterygium surgery had primarily cosmetic problems, ocular irritation and/or visual impairment due to pterygium. As regards pterygium surgical techniques, both were comparably associated with significantly improved post-operative BCVA. Pterygium patients usually have normal pre-operative BCVA. Still, they frequently have subjective visual complaints that improve post-operatively and correlate with corneal topographical parameters.
To the best of our knowledge, this is the first study to investigate the impact of specific pterygium surgical techniques on posterior corneal astigmatism using the Pentacam Scheimpflug imaging system, in addition to the anterior corneal topographical parameters. Post-operative assessment of posterior corneal changes using Pentacam Scheimpflug tomography showed no significant posterior corneal changes after different pterygium surgical techniques with sutures, i.e. bare sclera technique (36 eyes), amniotic membrane transplantation (34 eyes), or free conjunctival autograft (26 eyes), using 0.02 % mitomycin C.3 However, there was a significant change in the orientation of posterior astigmatism, from against-the-rule to with-the-rule astigmatism, suggesting a strong influence on the axis of astigmatism. Further, significantly reduced corneal astigmatism in the anterior and posterior corneal surfaces has been documented in another study in which 152 eyes underwent conjunctival autograft with 10 − 0 absorbable polyglycolic sutures and 11 eyes underwent amniotic membrane transplantion.20 In the same study, significant corneal steepening as the mean keratometric power of the anterior surface was also recorded. But, there was no significant post-operative change in the posterior corneal surface. Correspondingly, post-operative improvement in corneal astigmatism and increase in corneal steepening have also been reported by Yilmaz et al.,12 in which bare sclera, mitomycin C excision, limbal-conjunctival autograft and conjunctival autograft techniques were performed, and by Razmjoo et al.,21 in which pterygium excision with conjunctival autograft was performed using mitomycin C.
Similar changes in corneal topographical parameters after pterygium surgery were observed in the current study, which were accompanied by significant changes, particularly on the anterior corneal surface. Comparison of the conjunctival autograft and the anchored conjunctival rotational flap techniques revealed non-significant differences in pre- and post-operative anterior corneal astigmatism as well as Kf values. However, intra-group analysis of these parameters revealed statistically significant differences in both groups, with the conjunctival autograft technique being associated with a greater change in anterior corneal astigmatism and slightly less change in Kf compared to the anchored conjunctival rotational flap technique. On the other hand, despite the evident changes in Ks and posterior corneal astigmatism, their differences in pre- and post-operative values between the two techniques were not statistically significant. This was also the same for intra-group differences. However, the conjunctival autograft technique was associated with a much higher reduction in Ks and slightly lower reduction in posterior corneal astigmatism compared to the anchored conjunctival rotational flap technique. With regard to these findings, the conjunctival autograft technique seems to be particularly effective in the correction of pterygium-induced anterior corneal distortions. On the other hand, pterygium-induced posterior corneal distortions are likely to improve significantly using the conjunctival rotational flap technique. Other clinical implications of such techniques have been described elsewhere in this study.
Horizontal corneal flattening seems to be the most frequent topographical corneal shape associated with pterygium.14,22 However, this change often tends to decrease after pterygium surgery,11 as has also been demonstrated in the current study in which significant changes in Kf and Ks were observed after surgery. Corneal astigmatism in the eyes with pterygium represents the combined effects of naturally occurring astigmatism and pterygium-induced astigmatism.13,23,24 In the current study, significant change in corneal astıgmatism, particularly anterior corneal astigmatism was revealed after both pterygium excisional techniques.
Several reports on horizontal pterygium-induced corneal flattening mechanisms have been published.22 However, the specific pathophysiology of corneal flattening has yet to be clarified. The tear meniscus formation between the corneal apex and the elevated pterygium, which causes an apparent flattening of the normal corneal curvature in the area that may be measured by corneal topography, is considered to be one of the potential mechanisms.25
Another potential mechanism of pterygium-induced corneal distortion is the tensile strength of the contractile elements inside the pterygium that mechanically distort and flatten the cornea.23 It may therefore be deduced that pterygium with a higher tensile strength or a larger amount of contractile tissue may potentially be associated with more severe pterygium-induced corneal distortion. Sub-epithelial fibrosis below the pterygium head may have a direct traction effect on the underlying stroma, resulting in localized corneal flattening. There is, however, a high discrepancy with this mechanism because there are no myofibroblast cells in the head and body of the pterygium tissue specimen.25 Myofibroblast cells, on the other hand, have recently been detected in the fibrovascular tissue around the head and body of pterygium using immunostaining with cell specific markers and ultrastructural assessment.26 This finding could illuminate the pterygium-induced traction effect.
The conjunctival autografting first described by Kenyon et al.,27 in 1985 is considered to be the most effective method for the pterygium treatment. But, compared to this technique, the conjunctival rotational flap technique28 has some clinical benefits. The conjunctiva and Tenon’s capsule orientation is readily identifiable in this technique. There is also no need for a suture on the pedicle, hence reducing surgery time. Besides, there is a lower incidence of flap edema compared to that of conjunctival autograft, which may be attributable to the retention of the vascular network in the limbus around the pedicle.29 Notably, the flap technique demonstrated comparable post-operative changes in corneal topographical parameters and BCVA improvement to the conjunctival autograft technique in the current study. The conjunctival rotational flap differs from the conjunctival autograft technique due to flap orientation. The comparable post-operative corneal topographical modifications between these two different techniques suggest that flap orientation is not associated with undesirable corneal topographical impacts as long as it is not "inverted." But guaranteeing the potential effect of the limbal barrier in condition of the limbal-conjunctival autograft makes flap orientation crucial.
In addition to the surgical technique,12 pre-operative astigmatism,12,13 age and ethnicity of the patient, clinical characteristics of pterygium30 and the type of suture material have an impact on post-operative modifications in corneal topography and subsequent recurrences.31,32 However, no intra- or post-operative complications such as the flap and/or graft edema, and early recurrence were observed in the current study in which all pterygium surgeries were using fibrin tissue adhesive. All patients were of Turkish descent, predominantly with grade 2 pterygium and no sutures were used in the current study that could have a negative impact not only on the anterior but also on the posterior corneal topographical parameters. Moreover, cauterization and classical adjuvant drugs such as 5-FU or MMC33 were not used in the current study. Potentially associated complications related to these materials and processes were hence avoided.
In the current study limitations, despite the relatively larger study participants, there was a lack of an appropriate randomization method as well as a control group. The conjunctival flap or autograft procedures are performed more frequently in recurrent cases in clinical practice. Thus, only primary nasal pterygium investigation may be subject to additional limitation. The current study has shown significant topographical changes even in a short post-operative period. However, investigating the corneal topographical changes only one month after surgery may be another limitation to the current study. After all, cornea has been demonstrated to stabilize one month after pterygium surgery by time-range analysis.34 Additional long-term prospective studies with more participants incorporating not only different pterygium surgical techniques but also different topographical devices for the anterior and posterior corneal topographical assessment may be worthwhile.
In conclusion, considerably more changes in anterior corneal astigmatism and Ks were identified after successful conjunctival autograft technique. The anchored conjunctival rotational flap technique was accompanied by relatively greater changes in posterior corneal astigmatism and Kf. Thus, the former technique may be indicated in pterygium patients with relatively higher pre-operative anterior corneal topographical distortions measured by Pentacam Scheimpflug imaging system. Those characterized by significant pre-operative posterior corneal topographical changes, however, may respond well with the latter technique.