ContinuingMedicalEducation:EffectsofintraoperativesteroidinjectionontheoutcomeofpterygiumsurgeryAKheirkhah,RNazari,HSa,HGhassemi,MJBehrouzandVKRajuReleasedate:26July2013;Expirationdate:26July2014This activity has been planned and implemented in accordance with the Essential Areas and policiesof theAccreditationCouncil for ContinuingMedical Educationthroughthejoint sponsorshipofMedscape, LLCandNaturePublishingGroup. Medscape, LLCis accreditedbytheACCMEtoprovidecontinuingmedicaleducationforphysicians.Medscape, LLC designates this Journal-based CME activity for a maximum of 1 AMA PRA Category 1Credit(s)t. Physicians should claimonly the credit commensurate with the extent of theirparticipationintheactivity.All other clinicians completing this activity will be issued a certicate of participation. Toparticipateinthisjournal CMEactivity: (1)reviewthelearningobjectivesandauthordisclosures;(2) studythe educationcontent; (3) take the post-test witha70%minimumpassingscoreandcompletetheevaluationatwww.medscape.org/journal/eye;(4)view/printcerticate.LearningObjectivesUponcompletionofthisactivity,participantswillbeableto:K Describe the effects of intraoperativetriamcinolone injection on postoperativeconjunctival inammation and pterygiumrecurrence in patients undergoing ptery-giumsurgery with bare-sclera techniqueandMMCapplication,basedonndingsofaprospectiverandomizedstudyAuthors/EditorsdisclosureinformationAndrewJLoteryhasdisclosedthefollowingrelevant nancial relationships: Received grantsforclinicalresearchfrom:NovartisPharmaceuticalsCorporation.Servedasanadvisororconsultantfor:Allergan,Inc.andNovartisPharmaceuticalsCorporation.Servedasaspeakeroramemberofaspeakersbureaufor:NovartisPharmaceuticalsCorporation.AhmadKheirkhahhasdisclosednorelevantnancialrelationships.RahmanNazarihasdisclosednorelevantnancialrelationships.HamidSahasdisclosednorelevantnancialrelationships.HamedGhassemihasdisclosednorelevantnancialrelationships.MahmoudJabbarvandBehrouzhasdisclosednorelevantnancialrelationships.VadrevuKRajuhasdisclosednorelevantnancialrelationships.JournalCMEauthordisclosureinformationLaurieBarclayhasdisclosednorelevantnancialrelationships.Eye(2013)27,906914&2013MacmillanPublishersLimitedAll rightsreserved0950-222X/13www.nature.com/eyeEffectsofintraoperativesteroidinjectionontheoutcomeofpterygiumsurgeryAKheirkhah,RNazari,HSa,HGhassemi,MJBehrouzandVKRajuAbstractPurpose Toevaluatetheeffectsofintraoperativetriamcinoloneinjectionontheoutcomeofpterygiumsurgery.Methods Thisprospectivestudyincluded54eyeswithprimarynasalpterygiathatunderwentpterygiumsurgerywithabare-scleratechniqueandintraoperativemitomycinCapplication.Patientswererandomizedintotwogroups;thesteroidgroupthatreceivedsubconjunctivalinjectionof12 mgtriamcinoloneacetonideattheendofsurgery,andthecontrolgroupthatdidnotreceivesuchsteroidinjection.Mainoutcomemeasuresincludedpresenceofconjunctivalinammationat1monthpostoperativelyaswellasrecurrenceofpterygium.Results Twelve-monthfollow-upwascompletedin48eyes(23inthesteroidgroupand25inthecontrolgroup).At1monthpostoperatively,differentgradesofconjunctivalinammationwerepresentin11(47.8%)ofthesteroidgroupandin14(56%)ofthecontrolgroup(P0.39).Foreyeswithmoderateorseverepostoperativeinammation,subconjunctivaltriamcinolonewasinjected;theseincluded6(26.1%)and9(36%)inthesteroidandcontrolgroups,respectively(P0.54).Duringfollow-up,surgicalareashowedneepiscleralvesselswithoutbroustissuein1(4.3%)ofthesteroidgroupand3(12.0%)ofthecontrolgroup(P0.33),whichallregressedaftertriamcinoloneinjection.Conjunctivalrecurrenceofpterygiumwasseenin2(8.7%)ofthesteroidgroupandin1(4.0%)ofthecontrolgroup(P0.47).Noeyedevelopedcornealrecurrenceineithergroup.Conclusions Inpterygiumsurgerywithabare-scleratechniqueandmitomycinCapplication,intraoperativetriamcinoloneinjectiondidnotsignicantlyreducepostoperativeconjunctivalinammationorpterygiumrecurrence.Eye (2013)27, 906914;doi:10.1038/eye.2013.142;published online26July 2013Keywords: conjunctivalinammation;pterygium;recurrence;triamcinoloneIntroductionPterygiumischaracterizedbyencroachmentofaeshybrovasculartissuefromthebulbarconjunctivaontothecornea.Althoughpreviouslythoughttobeasolelydegenerativedisease,1newevidencehasdemonstratedtherole of cell proliferation and inammation in thepathogenesisofpterygium.Inadditiontothedatasuggestingproliferativefeaturesofpterygium,25the role of inammation has beenproposedbyrevealingtheincreasedlevelsofinammatorycellsandmarkersinpterygium,69andalsobytheclinicaldatathatsteroidsarebenecialinhaltingprogressionofimpendingrecurrentpterygium.10,11Manytechniqueshavebeendevelopedforpterygiumsurgeryovertime.Thesimplemethodofremovingtheheadandbodyofpterygiumandleavingthesclerauncovered,theso-calledbare-scleratechnique,hasbeenassociatedwithhighrecurrenceratesof3288%.1214Toreducetherecurrencerateafterpterygium surgery with a bare-sclera technique,variousadjunctivemodalitieshavebeenusedsuchasbetairradiationandchemicalagentsincludingmitomycinC(MMC),5-uorouracil,andthiotepa.15Furthermore,whenremovalofpterygium is accompanied with a graft, such asFarabiEyeHospital,EyeResearchCenter,TehranUniversityofMedicalSciences,Tehran,IranCorrespondence:AKheirkhah,EyeResearchCenter,TehranUniversityofMedicalSciences,FarabiEyeHospital,QazvinSquare,SouthKargarStreet,Tehran13366,Iran.Tel: 982155418113;Fax: 982155409095.E-mail:Akheirkh@yahoo.comReceived:3August2012Acceptedinrevisedform:20March2013Publishedonline:26July2013CLINICALSTUDYIntraoperativesteroidforpterygiumAKheirkhahetal907conjunctivalautograftoramnioticmembranetransplantation (AMT), lower recurrence rates have beenachieved.1517However, it remains unclear why the bare-scleratechniquehaspooreroutcomewithhigherrecurrenceratesthanotherprocedures.One of the factors that may have a role in the outcomeofpterygiumsurgeryispostoperativeconjunctivalinammation, treatment of which has been demonstratedtoimprovethenaloutcome.18Ithasbeenshownthatpersistent conjunctival inammation around the surgicalsite after pterygium surgery is present in 3184% of caseswithAMT,1820andin15%eyeswithconjunctivalautograft.20However,therateofsuchconjunctivalinammationafterpterygiumsurgerywithabare-scleratechniqueisunknown.Ontheotherhand,ithasbeensuggestedthathigherrecurrenceratesafterpterygiumwith AMT compared with conjunctival autograft may beduetothishigherratesofpostoperativeconjunctivalinammation.20Therefore,itmaybespeculatedthathigherrecurrenceratesafterpterygiumsurgerywithabare-scleratechniqueispartlycontributedbyhigherratesofpostoperativeconjunctivalinammation.Toaddresstheabove-mentionedquestions,thisstudywasdesignedtoevaluatetherateofpostoperativeconjunctivalinammationaroundthesurgicalsiteafterpterygiumsurgerywithabare-scleratechnique.Inaddition,theroleofintraoperativesteroidinjectioninthispostoperativeconjunctivalinammationandthenaloutcomewasalsoinvestigated.MethodsIn thisprospective randomizedstudy,54eyes of 54patients with primary nasal pterygium underwent surgicalexcisionwithabare-scleratechnique andMMCapplication. Thesamplesizewas calculatedbasedonthe mean recurrence rates reported by previous studies forbare-scleratechniquewithintraoperative mitomycinCapplication for primary pterygia, which were 2.738%.2125To detect 10% difference, with a equal to 0.05 and the studypower of80%, atleast 21patientswereneeded in eachgroup.However,alargernumber of patientswereincluded in both groups to compensate for potential loss tofollow-up.Using arandom-numbertable, thepatientswererandomizedintotwogroups;onegroupreceivedintraoperativeinjectionof12 mg triamcinoloneacetonide(27eyes, thesteroidgroup),andtheother groupdid notreceive such a steroid injection during surgery (27 eyes, thecontrol group). The protocol of the study was approved byInstitutional Review Board of Farabi Eye Hospital, Tehran,Iran.TenetsoftheDeclaration ofHelsinkiwerealsofollowedthroughoutthestudy.Beforesurgeryandatallvisitsaftersurgery,eachpatient had a complete ocular examination including slitlampphotography,andmeasurementofbest-correctedvisualacuityandintraocularpressure.Preoperatively,morphology of pterygium was graded according to whatwasdescribedbyTanetal.21Inthisgrading,pterygiaweregradedasgradeT1(atrophicpterygium)inwhichepiscleralvesselswereun-obscuredbythebodyofpterygium,gradeT3(eshypterygium)inwhichepiscleralvesselsweretotallyobscured,andgradeT2(thosebetweengradesT1andT3)withpartiallyobscuredepiscleralvessels.Beforesurgery,detailsofthestudywerefullyexplained for the patients and all consented to participateinthestudy.Allsurgerieswereperformedbysinglesurgeonunderretrobulbaranesthesia.Forsurgery,thehead and body of the pterygium were rst removed by asimilartechniqueinallpatients,withresectionofthebodyat2 mminfrontofplicasemilunaris.Thiswasfollowedbyremovalofsubconjunctivalbrovasculartissuefor2 mmbeyondtheconjunctivaledges,andpolishing of the cornea by a diamond burr. After minimalcauterizationofbleedingvessels,MMCwasappliedfor3 min both on the bare sclera and under the conjunctivaledgesbyusingpiecesofWeck-Celsurgicalspongesoakedin0.02%MMCsolution.Afterwashingtheeyesurfacewith100 mlofbalancedsaltsolution,theconjunctivaledgesweresuturedtotheunderlyingepisclerausinginterrupted10-0nylonsutureswithoutconjunctivaladvancement.Finally, attheendofsurgery,12 mgoftriamcinoloneacetonidewasinjectedsubconjunctivallyaround the surgicalsite forpatientsinthesteroidgroup.Patientsinthecontrolgroupdidnotreceiveanysteroidinjectionintraoperatively.Aftersurgery,allpatientsreceivedanidenticalregimenofatopicalantibioticfor2weeksandtaperingtopicalsteroidsfor3months.Thelatterincluded0.1%betamethasone four times a day for 1 month followed by0.1% uorometholone 4/day for 2 weeks, 3/day for2 weeks, 2/day for 2 weeks, and 1/day for 2 weeks.Postoperative follow-up examinations were performed at1day,1week,2weeks,1month,and3,6,9,and12months after surgery. Sutures were removed after 1 weekpostoperativelyinbothgroups.Presenceofpostoperativeconjunctivalinammationaroundthesurgicalsitewasassessedat1monthaftersurgeryandgradedas0(none),I(mild),II(moderate),andIII(severe)asdescribedbefore.18Eyeswithgrade2and 3 inammation received subconjunctival injection of12 mg triamcinolone acetonide. Postoperative outcome ofpterygium surgery was reported using a grading systempreviously described.13This grading included grade 1 asnormalconjunctivaatthesurgicalarea,grade2 asthepresenceofneepiscleralvesselswithoutbroustissuein the surgical area, grade 3 as the presence brovasculartissueinsurgicalareabutwithoutinvasionontotheIntraoperativesteroidforpterygiumAKheirkhahetal908Eyecornea(conjunctivalrecurrence),andgrade4 astruerecurrence in which the brovascular tissue invaded ontothecornea(cornealrecurrence).Foreyeswithgrade2outcome,12 mgoftriamcinoloneacetonidewasinjectedsubconjunctivally.Eyeswithconjunctivalrecurrenceofpterygium(grade3)receivedeitheronesinglesubconjunctivalinjectionof12 mgtriamcinoloneacetonideortwoweeklyintralesionalinjectionsof5 mg5-uorouracil.StatisticalanalysiswasperformedusingSPSSversion16(SPSSInc.,Chicago,IL,USA).Chi-squaretestandStudentttestwereusedtocomparequalitativeandcontinuousquantitativevariables,respectively,betweenthesteroidgroup and thecontrol group. P-values p0.05wereconsideredasstatisticallysignicant.ResultsOf54eyesincludedinthisstudy,12-monthfollow-upwascompletedin48eyesof48patients(36menand12women)withameanageof41.811.6years(range,2468 years). These included 23 eyes in the steroid groupand25eyesinthecontrolgroup.Therewerenostatisticallysignicantdifferencesinage,gender,andgradeofpreoperativepterygiummorphologybetweenthe two groups (Table 1). No intraoperative complicationwasnotedinanyeyeineithergroup.At1monthaftersurgery,examinationrevealedconjunctival inammation around the surgical area, mostnotablyatthecaruncularborder,in11eyes(47.8%)and14 eyes (56%) in the steroid group and the control group,respectively(P0.39)(Table1).Inthesteroidgroup,gradingofthispostoperativeinammationincludedgradeI(mild)in5eyes(21.7%),gradeII(moderate)in4eyes(17.4%),andgradeIII(severe)in2eyes(8.7%).However,inthecontrolgrouptheinammationwasasgradeIin5eyes(20.0%),gradeIIin8eyes(32%),andgradeIIIin1eye(4%).Subconjunctivalinjectionoftriamcinolone acetonide was performed in 6 eyes (26.1%)and9eyes(36.0%)inthesteroidandcontrolgroups,respectively(P0.54).Thisinjectionresultedinresolutionoftheinammationinalltheseeyes.Duringthefollow-up,grade2ofpostoperativeoutcome was observed in 1 eye (4.3%) and 3 eyes (12.0%)ofthesteroidgroupandthecontrolgroup,respectively(P0.33,Figure1).Thispostoperativeappearancewasnoticedat3-monthvisitinallcases.Onesinglesubconjunctivalinjectionof12mgtriamcinoloneacetonideresultedinregressionofthenevesselsinallthese4cases(Figure1).Grade3outcome(conjunctivalrecurrence) was seen in 2 eyes (8.7%) of the steroid groupandin1eye(4.0%)ofthecontrolgroup,withnostatisticallysignicancedifferencebetweenthetwogroups(P0.47,Figure2).Therecurrencewasnotedat5monthspostoperativelyinonepatientofthesteroidgroup and at 6-month visit in 2 other cases. The eyes withconjunctivalrecurrencereceivedeitheronesinglesubconjunctivalinjectionof12mgtriamcinoloneacetonide(oneeyeinsteroidgroup)ortwoweeklyintralesionalinjectionsof5mg5-uorouracil(twoeyes,oneineachgroup);nonedevelopedtruecornealrecurrenceduringthefollow-up.SurgicaloutcomesinvariousgradesofconjunctivalinammationaftersurgeryhavebeenshowninTable2.Inthesteroidgroup,grade2or3outcomeswereobservedin2eyes(11.8%)ofcaseswithnoneormildinammation,andin1eye(16.7%)ofpatientswithmoderateorsevereinammationthatreceivedsteroidinjection(P0.62).Inthecontrolgroup,grade2or3outcomeswereseenin2eyes(12.5%)ofpatientswithnone or mild inammation, and in 2 eyes (22.2%) of caseswithmoderateorsevereinammationthatreceivedtriamcinoloneinjection(P0.46).Pyogenicgranulomadevelopedin1eye(4.3%)ofthesteroidgroupat3monthspostoperativelyandin2eyes(8.0%) of the control group, both at 1 month after surgery(Table1).Allpyogenicgranulomatawerenotedatthenasalborderofthesurgicalarea.Inthecontrolgroup,oneeyehadgradeIIconjunctivalinammationandalargepyogenicgranulomaat1monthpostoperatively(Figure2h).DespiteresolutionofinammationandTable1 Clinical ndingsofpatientswithprimarypterygiumand their postoperative outcome after surgery with a bare-scleratechnique and mitomycin C application with (the steroid group)or without (the control group) intraoperative triamcinoloneinjectionSteroidgroupControlgroup P-valueNo.ofeyes 23 25Age(year) 40.612.8 43.914.9 0.41Gender(male/female) 17/6 19/6 0.56Pterygium morphology 0.96T1 4 5T2 13 14T3 6 6PostoperativeComplicationsConjunctival inammation 0.65Grade0 12(52.2%) 11(44.0%)GradeI 5(21.7%) 5(20.0%)GradeII 4(17.4%) 8(32.0%)GradeIII 2(8.7%) 1(4.0%)Pterygium outcome 0.53Grade1 20(87.0%) 21(84.0%)Grade2 1(4.3%) 3(12.0%)Grade3(conjunctivalrecurrence)2(8.7%) 1(4.0%)Grade4(corneal recurrence) Pyogenicgranuloma 1(4.3%) 2(8.0%) 0.53IntraoperativesteroidforpterygiumAKheirkhahetal909Eyegranulomawithtriamcinoloneinjection,thiseyesubsequentlydevelopedconjunctivalrecurrenceat6months postoperatively (Figure 2i). Increased intraocularpressurewasnotedinoneeyeinthesteroid,whichwascontrolled medically. No MMC-related complication wasobservedinanyeyeduring12monthsoffollow-up.DiscussionThisprospectiverandomizedstudyshowedthatconjunctivalinammation was present in approximatelyhalfofthepatientsat1monthafterpterygiumsurgerywithabare-scleratechniqueandintraoperativeMMCapplication.InadditiontouseofMMC,aggressivecontrolofpostoperativeconjunctivalinammationwithsteroidsresultedinalowrecurrencerateofpterygiumaftersurgery.However,intraoperativeinjectionoftriamcinoloneacetonidedidnotsignicantlyreducethepostoperativeconjunctivalinammationorpterygiumrecurrence.Inourstudy,at1monthpostoperatively11eyes(47.8%)inthesteroidgroupand14eyes(56%)inthecontrol group had conjunctival inammation around thesurgical site, most notably at the caruncular border. SuchinammationhaspreviouslybeenreportedafterpterygiumsurgerywithothertechniquesincludingconjunctivalautograftandAMT.1820Withoutintraoperativesteroidinjection,previousstudieshaveshowedratesof15%or3184%forsuchpostoperativeconjunctivalinammationafterpterygiumsurgerywithconjunctivalautograftorAMT,respectively.1820Thecauseforsuchpersistentinammationanditsvaryingratesafterdifferentsurgicaltechniquesareunknown.Althoughlongerdurationofsuturestayhadbeenspeculatedtobe partlyresponsibleforthe higherrateintheAMTgroup,20thispostoperativeinammationhasalsobeenobservedwithusingbringlueinsteadofsuturesforAMT,eventhoughwithlowerincidence(21.4%vs61.5%).18Intraoperativeinjectionoftriamcinoloneacetonideinourstudywasassociatedwithalowerrateofconjunctivalinammationat1monthaftersurgery(47.8%vs56%);however,thedifferencewasnotstatisticallysignicant(P0.39).ApreviousFigure1 Grade 2outcomeafterpterygium surgerywith abare-sclera technique andintraoperativeMMC application. An eye withgradeT2ofpterygiummorphology(a)inthesteroidgroupdevelopedneepiscleral vesselsat3-monthvisit(b). Subconjunctivalinjection of triamcinolone resulted in regression of the vessels with no recurrence of pterygium during 12 months of follow-up (c). AneyewithgradeT2pterygium(d)inthecontrolgroupshowedgrade2outcomeat3monthspostoperatively(e). Regressionofthevesselsensuedaftertriamcinoloneinjection(f).Table 2 Correlation of the surgical outcome with postoperative conjunctival inammation at 1 month after pterygium surgery with abare-scleratechniqueandmitomycinCapplicationwith(thesteroidgroup) orwithout (thecontrol group) intraoperativesteroidinjectionConjunctival inammation SurgicaloutcomeSteroidgroup ControlgroupGrade1 Grade2 Grade3 Grade4 Grade1 Grade2 Grade3 Grade4Grade0 11(91.7%) 1(8.3%) 10(90.9%) 1(9.1%) GradeI 4(80%) 1(20%) 4(80%) 1(20%) GradeIIa4(100%) 6(75%) 1(12.5%) 1(12.5%) GradeIIIa1(50%) 1(50%) 1(100%) aEyeswithgradesIIandIIIinammationat1monthpostoperativelyreceivedsteroidinjectioninbothgroups.IntraoperativesteroidforpterygiumAKheirkhahetal910Eyeretrospective non-randomized study also showed lack ofthecorrelationbetweenintraoperativetriamcinoloneinjectionandtheconjunctivalinammationat1monthafterpterygiumsurgerywithAMT.18Triamcinoloneacetonideisanintermediate-actingsteroidthathasadurationofeffectfor1521daysintheconjunctiva.11Astheinammationwasevaluatedat1monthpostoperatively,itmaybespeculatedthatbythattimetheeffectsofthesteroidmighthavealreadybeenwornoff.Thismayexplainthenon-signicantdifferenceinincidenceoftheconjunctivalinammationbetweenthetwogroupsinourstudy.Usageofsteroidswithlongerdurationofeffectmaybemoreeffectiveinsuppressingsuchinammation,eventhoughtheymaybeassociatedwithhigherratesofsteroid-relatedcomplications.Inourstudyduring12monthsoffollow-upafterpterygiumsurgeryusingabare-scleratechniquewithMMCapplication,conjunctivalrecurrences(grade3outcome) were noted in 2 eyes (8.7%) and 1 eye (4.0%) inthesteroidgroupandthecontrolgroup,respectively(Figure 2). These cases received subconjunctival injectionofeither5-uorouracilortriamcinolone,asdescribedbefore,10,11resultinginnocornealrecurrenceineithergroupduringthefollow-up.Surgeryforprimarypterygiumusingabare-scleratechniquewithintraoperativeMMCapplicationandwithoutintraoperativesteroidinjectionhaspreviouslybeenreportedtohaverecurrenceratesof2.738%.2126However,thesestudieshavemostcommonlyincludedonlycaseswithcornealrecurrenceandnottheconjunctival recurrence. The better outcome of our studymaybeattributedtotheremovalofsubconjunctivalbrovasculartissue,19,27andaggressivecontrolofpostoperativeinammationwithsteroidinjection.Inthepresentstudy,intraoperativetriamcinoloneinjectiondidnotsignicantlyreducetherecurrenceratecomparedwiththecontrolgroup(P0.47).Inonepreviousstudyon51patientswithprimarypterygium,surgery using a bare-sclera technique with intraoperativeMMC application and subconjunctival injection of 20 mgdepotsteroidresultedinnorecurrenceduring414monthsoffollow-up.28However,nocontrolgroupwasincluded.Ontheotherhand,ithasalsobeendemonstratedthattreatmentof1-monthpostoperativeconjunctivalinammationbysteroidinjectionimprovedthesurgicaloutcomeofpterygium.18,20Notonlyinadequatepostoperativetopicalsteroidshavebeenassociatedwithhigherrecurrencerates,29butonestudyalsoshowedthatineyeswithriskfactorsforrecurrence(includingconjunctivalinammationandgranulomaFigure 2 Grade 3 outcome after pterygium surgerywith abare-sclera technique andintraoperative MMC application. An eyewithgrade T3 of pterygium morphology (a) in the steroid group had grade I conjunctival inammation at 1 month postoperatively (b). Thepatientdevelopedaconjunctivalrecurrenceat5monthsaftersurgery(c).AneyewithgradeT3pterygium(d)inthesteroidgroupshowednoconjunctival inammationat1monthaftersurgery(e). However, aconjunctival recurrencewasobservedat6monthspostoperatively that did not progress to the corneal recurrence after injection of triamcinolone (f). An eye with grade T1 pterygium (g)inthe control grouphadgrade II conjunctival inammationanda large pyogenic granuloma at 1 monthpostoperatively(h).Despite resolution of inammation and granuloma with triamcinolone injection, a conjunctival recurrence was noted at 6 months aftersurgery(i).IntraoperativesteroidforpterygiumAKheirkhahetal911Eyeformation)postoperativesubconjunctivalinjectionofsteroidleadstoanimprovedsurgicaloutcome.11Therefore, it seems postoperative steroid therapy tailoredtotheconjunctivalinammationhasamoreimportantrolethanintraoperativesteroidsdo.Inthepresentstudy,grade2outcomedevelopedin4eyes(8.3%),including1eye(4.3%)inthesteroidgroupand3eyes(12%)inthecontrolgroup(Figure1).Althoughthedifferencebetweenthetwogroupsseemstobeclinicallysignicant,itwasnotstatisticallysignicant(P0.33),whichmaybeduetothesmallsamplesize.Theincidenceandsignicanceofgrade2outcomeafterpterygiumsurgeryhavenotbeencompletelydescribedintheliterature.Inaddition,itisnotclearwhethersuchnevesselswillinvariablyprogresstotheconjunctivalrecurrenceifleftuntreated.Asacautionarymeasure,alleyeswithgrade2outcomeinourstudyreceivedsubconjunctivaltriamcinoloneinjection,whichresultedinregressionoftheneepiscleralvesselsinallcases(Figure1).Interestingly,inallthesecasesgrade2outcomewasnoticedatthe3-monthvisit.Noneofthecaseswithgrade3outcome,whichweredetectedat56monthspostoperatively,hada prior grade 2 outcome. This may be due to the fact thatinthese casesgrade2outcomedevelopedatsomepointbetweenthe3-monthvisitandthediagnosisoftheconjunctival recurrence. Therefore, more frequent patientvisitsduringthis timeperiodtodetectand treat grade2outcomesmightbeareasonablemeasuretopreventpossibleprogressiontotheconjunctivalrecurrence.Further studies are required to determine the signicanceofgrade2outcomesafterpterygiumsurgeryanditsoptimalmanagement.Correlationofthesurgicaloutcomewiththegradeofconjunctivalinammationat1monthaftersurgeryrevealedthattherecurrencerateswerecomparablebetween those with grade 0 or 1 inammation and caseswithmoresevereconjunctivalinammationthathasbeen treated with steroid injection (Table 2). This was thecasein boththe steroidgroup and thecontrolgroup.Astheroleofpostoperativeconjunctivalinammationinpterygiumrecurrencehaswellbeendocumentedbefore,18the data showed the benecial role of treatmentofpostoperativeinammationinthenalsurgicaloutcome.Interestingly,oneeyewithmoderateinammationandlargepyogenicgranulomaat1monthpostoperativelydevelopedconjunctivalrecurrencedespitetriamcinoloneinjection(Figure2,Bottomrow).Caseswithsuchexuberantpostoperativereactionmayneedmoreaggressiveanti-inammatoryand/oranti-VEGFtreatment.Thisstudywasperformedinaprospectiverandomized fashion and patients in the two groups weresimilarintermsofage,gender,andmoreimportantly,gradeofpterygiummorphologypreoperatively.Ontheotherhand,patientswerefollowedfor1yearaftersurgery, which is long enough to detect the vast majorityof pterygium recurrences. However, it is not sufcient toobservethepossiblecomplicationsofMMC,suchasnecrotizingscleritisorscleralmeltingandcalcication,whichmaydevelopyearslater.30Withtheselimitationsin mind, our study showed that pterygium surgery withabare-scleratechniqueusingintraoperativeMMCapplicationandaggressivecontrolofconjunctivalinammation resulted in a good surgical outcome with alowrecurrencerate.Therewasnosignicantadditionalbenetofusingintraoperativetriamcinoloneinjection.SummaryWhatwasknownbeforeK After pterygium surgery with intraoperative mitomycin Capplication,conjunctivalinammationaroundthesurgicalsitedevelopsin3184%ofcaseswithamnioticmembranetransplantationandin15%ofeyeswithconjunctivalautograft.K Afterpterygiumsurgery,treatmentofconjunctivalinammationwithsteroidsimprovesthenaloutcome.WhatthisstudyaddsK After pterygium surgery with a bare-sclera technique andintraoperativemitomycinCapplication,conjunctivalinammation around the surgical site develops in 48% or56%ofcaseswithorwithoutintraoperativesteroidinjection,respectively.K Intraoperativetriamcinoloneinjectiondoesnotsignicantlyreducepostoperativeconjunctivalinammationorpterygiumrecurrence.ConictofinterestTheauthorsdeclarenoconictofinterest.References1 AustinP,JakobiecFA,IwamotoT.Elastodysplasiaandelastodystrophyasthepathologicbasesofocularpterygiaandpinguecula.Ophthalmology1983;90:96109.2 Bradley JC, Yang W, Bradley RH, Reid TW, Schwab IR. Thescienceofpterygia.BrJOphthalmol2010;94:815820.3 Bai H, Teng Y, Wong L, Pang CP, Yam GH. Proliferative andmigratoryaptitudeinpterygium.HistochemCellBiol2010;134:527535.4 MortadaA,HamdiEE,ShiwiTE,EineinGA.Histopathologyofrecurrenttruepterygium.BullOphthalmolSocEgypt1968;61:117122.5 HillJC,MaskeR.Pathogenesisofpterygium.Eye(Lond)1989;3(Pt2):218226.6 AwdehRM,DeStafenoJJ,BlackmonDM,CummingsTJ,Kim T. The presence of T-lymphocyte subpopulations (CD4andCD8)inpterygia:evaluationoftheinammatoryresponse.AdvTher2008;25:479487.IntraoperativesteroidforpterygiumAKheirkhahetal912Eye7 TekeliogluY,TurkA,AvundukAM,YulugE.Flowcytometricalanalysisofadhesionmolecules,T-lymphocytesubpopulationsandinammatorymarkersinpterygium.Ophthalmologica2006;220:372378.8 WenZ,LiuZ.Theabnormalexpressionofinterleukine-1familyinpterygium.YanKeXueBao2003;19:133136.9 DiGirolamoN,McCluskeyP,LloydA,CoroneoMT,WakeeldD.ExpressionofMMPsandTIMPsinhumanpterygiaandculturedpterygiumepithelialcells.InvestOphthalmolVisSci2000;41:671679.10 PrabhasawatP,TesavibulN,LeelapatranuraK,PhonjanT.Efcacy of subconjunctival 5-uorouracil and triamcinoloneinjectioninimpendingrecurrentpterygium.Ophthalmology2006;113:11021109.11 ParisFdosS,deFariasCC,MeloGB,DosSantosMS,BastistaJL,GomesJA.Postoperativesubconjunctivalcorticosteroidinjectiontopreventpterygiumrecurrence.Cornea2008;27:406410.12 ChenPP,AriyasuRG,KazaV,LaBreeLD,McDonnellPJ.ArandomizedtrialcomparingmitomycinCandconjunctivalautograftafterexcisionofprimarypterygium.AmJOphthalmol1995;120:151160.13 PandaA,DasGK,TuliSW,KumarA.RandomizedtrialofintraoperativemitomycinCinsurgeryforpterygium.AmJOphthalmol1998;125:5963.14 Frucht-Pery J, Ilsar M, Hemo I. Single dosage of mitomycinCforpreventionofrecurrentpterygium:preliminaryreport.Cornea1994;13:411413.15 HirstLW.Thetreatmentofpterygium.SurvOphthalmol2003;48:145180.16 Ang LP, Chua JL, Tan DT. Current concepts and techniquesinpterygiumtreatment.CurrOpinOphthalmol2007;18:308313.17 Marcovich AL, Bahar I, Srinivasan S, Slomovic AR. Surgicalmanagementofpterygium.IntOphthalmolClin2010;50:4761.18 Kheirkhah A, CasasV,Sheha H, RajuVK.Tseng SCG. Roleofconjunctivalinammationinsurgicaloutcomeafteramnioticmembranetransplantationwithorwithoutbringlueforpterygium.Cornea2008;27:5663.19 SolomonA,PiresRTF,TsengSCG.Amnioticmembranetransplantationafterextensiveremovalofprimaryandrecurrentpterygia.Ophthalmology2001;108:449460.20 Kheirkhah A, Nazari R, Nikdel M, Ghassemi H, Hashemi H,BehrouzMJ.Postoperativeconjunctivalinammationafterpterygiumsurgerywithamnioticmembranetransplantationversusconjunctivalautograft.AmJOphthalmol2011;152:733738.21 TanDT,CheeSP,DearKB,LimAS.Effectofpterygiummorphologyonpterygiumrecurrenceinacontrolledtrialcomparingconjunctivalautograftingwithbarescleraexcision.ArchOphthalmol1997;115:12351240.22 Prabhasawat P, Barton K, Burkett G, Tseng SC. Comparisonofconjunctivalautografts,amnioticmembranegrafts,andprimary closure for pterygium excision. Ophthalmology 1997;104:974985.23 Sanchez-Thorin JC, Rocha G, Yelin JB. Meta-analysis on therecurrence rates after bare sclera resection with and withoutmitomycinCuseandconjunctivalautograftplacementinsurgeryforprimarypterygium.BrJOphthalmol1998;82:661665.24 KoranyiG,ArtzenD,SeregardS,KoppED.IntraoperativemitomycinCversusautologousconjunctivalautograftinsurgeryofprimarypterygiumwithfour-yearfollow-up.ActaOphthalmol2012;90:266270.25 AvisarR,GatonDD,LoyaN,AppelI,WeinbergerD.IntraoperativemitomycinC0.02%forpterygium:effectofdurationofapplicationonrecurrencerate.Cornea2003;22:102104.26 Frucht-PeryJ,SiganosCS,IlsarM.IntraoperativeapplicationoftopicalmitomycinCforpterygiumsurgery.Ophthalmology1996;103:674677.27 LevyRL,NaiduS,JacobsonL.SafetyandefcacyofthetechniqueofcompletetenonsmembraneexcisionandmitomycinCinpterygiumsurgery.EyeContactLens2005;31:105108.28 MpyetC,OkoH.Resultsofintra-operative0.5mg/mlmitomycinCwith20mgdeposteroidinthetreatmentofprimarypterygium.CentAfrJMed2000;46:330332.29 YaisawangS,PiyapattanakornP.Roleofpost-operativetopicalcorticosteroidsinrecurrencerateafterpterygiumexcisionwithconjunctivalautograft.JMedAssocThai2003;86(suppl2):S215S223.30 HardtenDR,SamuelsonTW.Oculartoxicityofmitomycin-C.IntOphthalmol Clin1999;39:7990.IntraoperativesteroidforpterygiumAKheirkhahetal913EyeEffectsofintraoperativesteroidinjectionontheoutcomeofpterygiumsurgeryToobtaincredit, youshouldrst readthejournal article.Afterreadingthearticle, youshouldbeabletoanswerthefollowing, related, multiplechoicequestions. Tocompletethe questions (with a minimum 70% passing score) and earncontinuingmedical education(CME) credit, please gotowww.medscape.org/journal/eye.Creditcannotbeobtainedfor tests completedonpaper, althoughyoumayuse theworksheet below to keep a record of your answers.You must be a registered user on Medscape.org. If you are notregisteredonMedscape.org, pleaseclickonthenewusers: FreeRegistration link on the left hand side of the website to register.Onlyoneansweriscorrect foreachquestion. Onceyousuccessfullyanswerallpost-testquestionsyouwillbeableto view and/or print your certicate. For questionsregarding thecontentofthisactivity,contacttheaccreditedprovider, CME@medscape.net. For technical assistance,contactCME@webmd.net.American Medical Associations Physicians RecognitionAward (AMAPRA) credits are accepted in the US as evidenceof participation in CME activities. For further information onthisaward, pleaserefertohttp://www.ama-assn.org/ama/pub/category/2922.html. The AMA has determined thatphysicians not licensedinthe US who participate inthisCMEactivityareeligibleforAMAPRACategory1Creditst.Through agreements that the AMA has made with agencies insome countries, AMAPRAcredit may be acceptable asevidence of participationinCMEactivities. If youare notlicensed in the US, please complete the questions online, printtheAMAPRACMEcreditcerticateandpresentittoyournationalmedicalassociation for review.1. Your patient is a 45-year-oldmale witha primarynasal pterygium. Youare contemplating pterygiumsurgerywithbare-scleratechniqueandmitomycinC(MMC) application. Based on the prospectiverandomizedstudybyDr. Kheirkhahandcolleagues,which of the following statements about theeffects of intraoperative triamcinolone injection onpostoperative conjunctival inammation is mostlikelycorrect?AAsignicantly lower proportion of eyes in thesteroid group vs the control group had conjunctivalinammationat1monthpostoperativelyBModerateorsevere postoperativeinammationforwhichsubconjunctival triamcinolonewas injectedoccurred in about 26% of the steroid group and 36%ofthecontrolgroupCThere was a highly statistically signicant between-groupdifferenceinmoderateorseverepostopera-tive inammation for which subconjunctival triam-cinolonewasinjectedDDuringfollow-up, ne episcleral vessels withoutbrous tissue in the surgical area occurred insignicantlyfewereyesinthesteroidgroupthaninthecontrolgroup2. BasedontheprospectiverandomizedstudybyDr.Kheirkhah and colleagues, which of the followingstatementsabouttheeffectsofintraoperativetriamci-nolone injection on pterygiumrecurrence is mostlikelycorrect?AConjunctival recurrence of pterygium occurred in 2eyes in the control group and in 1 eye in the steroidgroupBThe between-group difference in conjunctival recur-renceofpterygiumwasstatisticallysignicantCCornealrecurrenceofpterygiumoccurredin2eyesin the control group and in 1 eye in the steroid groupDAggressive control of postoperative conjunctivalinammation with steroids resulted in a lowoverallrecurrencerateofpterygiumaftersurgeryActivityevaluation1.Theactivitysupportedthelearningobjectives.Stronglydisagree Stronglyagree1 2 3 4 52.Thematerialwasorganizedclearlyforlearningtooccur.Stronglydisagree Stronglyagree1 2 3 4 53. The content learned from this activity will impact my practice.Stronglydisagree Stronglyagree1 2 3 4 54. The activity was presented objectively and free of commercialbias.Stronglydisagree Stronglyagree1 2 3 4 5IntraoperativesteroidforpterygiumAKheirkhahetal914EyeReproduced with permission of the copyright owner. Further reproduction prohibited withoutpermission.