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Middle East African Journal of Ophthalmology Middle East African Journal of Ophthalmology
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LETTER TO THE EDITOR
Year : 2012  |  Volume : 19  |  Issue : 4  |  Page : 437-438  

Preoperative subconjunctival injection of mitomycin C as an adjunctive treatment 24 hours before excision of primary pterygium


Department of Ophthalmology, University College of Medical Sciences and G. T. B. Hospital, Delhi, India

Date of Web Publication20-Oct-2012

Correspondence Address:
Ved P Gupta
275, Ground Floor, Gagan Vihar, Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-9233.102774

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How to cite this article:
Gupta VP, Gupta P. Preoperative subconjunctival injection of mitomycin C as an adjunctive treatment 24 hours before excision of primary pterygium. Middle East Afr J Ophthalmol 2012;19:437-8

How to cite this URL:
Gupta VP, Gupta P. Preoperative subconjunctival injection of mitomycin C as an adjunctive treatment 24 hours before excision of primary pterygium. Middle East Afr J Ophthalmol [serial online] 2012 [cited 2021 Oct 26];19:437-8. Available from: http://www.meajo.org/text.asp?2012/19/4/437/102774

Sir,

We read the article by Ghoneim et al. [1] with keen interest and have the following comments:

Recurrence of pterygium is the most enigmatic complication of pterygium surgery. The bare sclera technique is associated with a recurrence rate of 37% to 91%. Subconjunctival mitomycin C (SC-MMC) before excision of pterygium is a new adjunctive therapy with very low recurrence rates. [1],[2] Literature on this technique is rare. We thank the authors [1] for presenting this interesting modification of SC-MMC prior to pterygium excision.

The authors [1] did not discuss the detailed mechanism of prevention of reccurence due to their modification. Moreover, they [1] did not perform the histopathology or ultrastructural study of excised specimens of pterygia which could have demonstrated the effect of MMC on fibrovascular tissues in stroma of the the pterygia, 24hrs after injection. Readers would be very eager to know the effect of 24hrs exposure of MMC on pterygium tissue compared to a control group.

Donnenfeld et al, waited one month after the injection of MMC before performing bare sclera pterygium surgery on the basis of their previous experience with SC-MMC for pemphigoid, where the inflammation decreased at one month. [2] Histopathology of recurrent pterygia pretreated with SC-MMC injection one month before pterygium excision also showed evidence of an inhibitory effect of MMC on vascular endothelium and stromal fibroblasts. [2] Transmission electron microscopy of excised specimens of pterygium one month after SC injection of 0.1 mL of 0.15 mg/mL MMC demonstrated inhibition of fibrovascular activity in the pterygial stroma, leading to degeneration of the extracellular matrix and nerve axons. [3] The ultrastructural changes verified the effectiveness of SC-MMC injection one month before pterygium excision in decreasing the risk of pterygium recurrence. [3]

The authors mention that excision of pterygium was performed 24hrs after SC-MMC to reduce the exposure time of tissues to MMC to avoid complications related to MMC. [1] However, we believe that 24hrs after SC-MMC does not appear to be a short exposure time to MMC. Vass et al. [4] studied the effect of varying the application time of MMC on the scleral concentration of MMC and found that 64% of the MMC was delivered to the sclera within the first minute. In fact, a five minute intraoperative treatment with MMC resulted in prolonged inhibition of treated SC and scleral tissue fibroblasts for at least 30 days in rabbits. [5] One study concluded that extra- and intra- ocular concentrations of MMC were highest after SC injection. [6] MMC is distributed in extraocular and intraocular tissues resulting in a rapid decrease in MMC concentration from the conjunctiva and sclera at the injection site after a single SC injection of the drug. [7] Thus, we believe that in Ghoneim et al.'s modification [1] the residual MMC at and surrounding the surgical site after excision of pterygium may be adequate to inhibit the fibrovascular activity to reduce the recurrence of pterygium. This modification [1] enjoys all the advantages of SC-MMC and does away with the drawback of waiting for I month for the second stage.

 
   References Top

1.Ghoneim EM, Abd-El Ghny AA, Gab-Allah AA, Kamal MZ. Preoperative subconjunctival injection of mitomycin C versus intraoperative topical application as an adjunctive treatment for surgical removal of primary pterygium. Middle East Afr J Ophthalmol 2011;18:37-41.  Back to cited text no. 1
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2.Donnenfeld ED, Perry HD, Fromer S, Doshi S, Solomon R, Biser S. Subconjunctival mitomycin C as adjunctive therapy before pterygium excision. Ophthalmology 2003;110:1012-6.  Back to cited text no. 2
[PUBMED]    
3.Chang YS, Chen WC, Tseng SH, Sze CI, Wu CL. Subconjunctival mitomycin C before pterygium excision: An ultrastructural study. Cornea 2008;27:471-5.  Back to cited text no. 3
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4.Vass C, Georgopoulos M, El Menyawi I, Radda S, Nimmerrichter P. Impact of mitomycin-C application time on the scleral mitomycin-C concentration. J Ocul Pharmacol Ther 2001;17:101-5.  Back to cited text no. 4
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5.Khaw PT, Doyle JW, Sherwood MB, Grierson I, Schultz G, McGorray S. Prolonged localized tissue effects from 5-minute exposures to fluorouracil and mitomycin C. Arch Ophthalmol 1993;111:263-7.  Back to cited text no. 5
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6.Kawase K, Matsushita H, Yamamoto T, Kitazawa Y. Mitomycin concentration in rabbit and human ocular tissues after topical administration. Ophthalmology 1992;99:203-7.  Back to cited text no. 6
[PUBMED]    
7.Mietz H, Diestelhorst M, Rump AF, Theisohn M, Klaus W, Krieglstein GK. Ocular concentrations of mitomycin C using different delivery devices. Ophthalmologica 1998;212:37-42.  Back to cited text no. 7
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