are used several times daily for excessive irritation. Patients are examined at 1 day postoperatively, 1 week postoperatively, 1 month postoperatively, and every 1Ð2 months thereafter for the Þrst year. If a large epithelial defect is present, patients may need to be seen more frequently following the 1 day postoperative visit to ensure adequate healing without cornea ulceration.

Patients are maintained on a topical steroid medication for a minimum of 1 year following surgery. Initially, topical prednisolone is used four times daily and the drop is decreased by one drop per month until a drop of once daily is being used. At this point, if the eye is quiet, a switch is made to topical loteprednol due to the associated lower side effect proÞle. If at any point the patient develops an increase in intraocular pressure while on topical prednisolone, a switch is made to topical loteprednol.

If during the follow-up period we note an early recurrence of the pterygium, 0.1 mL of dexamethasone 4 mg/mL is administered subconjunctivally with the hope of halting the Þbrovascular response.

4.3.5 Recurrent Pterygium

A pterygium recurrence is deÞned as a regrowth of pterygium onto the surgical limbus. Tan et al. developed a grading scale that can be employed at the slit lamp to help the surgeon predict recurrence rates for a pterygium [1]. It is based on the relative translucency of the body of the pterygium [1]. A T1 grade pterygium is thin and atrophic and has the lowest rate of recurrence [1]. A T3 grade pterygium is thick and ßeshy and has a higher rate of recurrence [1]. A T2 grade pterygium falls in between these. While surgical technique is related to recurrence rate, recurrence after pterygium removal is also believed to be more common in patients with thick, ßeshy pterygia, usually young adults, compared to the more atrophic lesions that are seen in elderly adults [1].

Surgical technique is highly related to pterygium recurrence. Fifty percent of pterygium recurrences occur within the Þrst 120 days post removal, and 97% occur within the Þrst year [4]. Tan et al. noted that 86% of recurrences occurred by 6 months after surgery and 93% occurred by 12 months [11]. Conjunctival autografts have been associated with a recurrence rate in the range of 2Ð39% [2, 4, 12]. Tan et al. have

demonstrated that surgeon experience is a factor in the rate of recurrent pterygium formation following conjunctival autografting [11]. Surgeons performing ten or more procedures have less recurrence than those performing four to Þve procedures and those performing this number of procedures have less recurrence than surgeons who have performed none [11]. Recurrences usually arise around the superior and inferior borders of the conjunctival autograft indicating that the graft may not have been large enough. Techniques other than conjunctival autografting have typically been associated with higher rates of recurrence.

4.3.6Other Techniques in Pterygium Removal

4.3.6.1 Bare Scleral Technique

In this technique, the pterygium is removed and the sclera is left bare. This technique has been associated with a recurrence rate ranging from 24% to as high as 89% [11, 12]. This technique is associated with the highest rate of recurrence and is not recommended.

4.3.6.2 Adjunctive Agents

Mitomycin C

MMC is an antibiotic alkylating agent produced by the bacteria Streptomyces caespitosus. Its mechanism of action involves the inhibition of DNA synthesis, resulting in long-term inhibition of TenonÕs Þbroblast proliferation [13]. Its use in pterygium surgery as an adjunctive agent was Þrst reported in Japan in 1963 [13]. It use was Þrst reported in the United States in 1988 [13].

The concentration of intraoperative MMC typically used ranges from 0.01 to 0.04%, with 0.02% being the most common concentration used [2]. Some surgeons prefer to use MMC eyedrops postoperatively. Again, 0.02% is the concentration most commonly used and the drops are applied four times a day for 5Ð14 days with a mean duration of application of 10 days [2].

In addition to pterygium surgery, MMC has been successfully used in the treatment of ocular surface neoplasia, symblepharon repair, glaucoma Þltration surgery, and others [13]. Numerous studies have reported