**2. Patients and methods**

Forty consecutive patients (40 eyes) with primary pterygia who attended the eye clinic, Vali-Asr Hospital of Birjand University of Medical Sciences, between 2006 and 2007 were included in this study. All patients had primary pterygium grade I or II and were not previously operated. The grading used was as follows: Grade 1: small primary pterygium, fibrous type, pinguecular, and classical type. Grade II: advanced primary pterygium with no optical zone involvement. Grade III: advanced primary pterygium with optical zone involvement. We selected only grade I and II.

A complete ocular examination, including slit-lamp examination and hematological exami‐ nation, was performed on each patient. All surgeries were performed by one surgeon (Dr.Da‐ vari). Satisfaction of Ethical Clearance Committee accepted and all patients were given an explanation of the procedure and informed consent was obtained from all.

A drop of tetracaine 0.5% was instilled in the involved eye for topical anesthesia and the patients were injected subconjunctivally with a 30-gauge needle on an insulin syringe con‐ taining 0.1 ml of 0.2 mg/ml of MMC (Kyowa Hakko Kogyo Co. Ltd. Tokyo, Japan). The injection was done directly into the pterygium 1mm from limbos (Figure 1).

Subconjunctival Mitomycin C Injection into Pterygium Decreases Its Size and Reduces Associated Complications http://dx.doi.org/10.5772/60090 69

**Figure 1.** (a) Subconjunctival injection of MMC directly into pterygium, (b) After injection of MMC the degree of in‐ flammation reduced.

**Figure 2.** (1A) Before MMC injection, (2A) After MMC injection

The risk factors for pterygium development include exposure to ultraviolet (UV) light, dust,

The primary indication for surgical removal of pterygium is visual acuity reduction. The cause of this phenomenon is extension of remaining scar to visual axis [3]. Irregular astigmatism, reduced vision, discomfort and irritation, difficulty with contact lens wear, refractive surgery,

A wide range of surgical procedures for removal of pterygia have been reported [4]. However, recurrences after excision have been reported to be very high. For example, it has been reported as high as 30% to 80% with the bare sclera technique [5]. The conjunctiva auto graft transplan‐

MMC is an antibiotic, antineoplastic agent that selectively inhibits the synthesis of DNA, cellular division, and protein [9]. The mechanism of action of MMC seems to be inhibition of fibroblast proliferation at the level of the episclera [10, 11, 12].The benefit of MMC is having prolonged, but not permanent, effectiveness on suppressing human fibroblasts [13, 14, 15].

Although multiple studies have reported recurrence rates of approximately 5% to 12% with the use of topical MMC [16, 17], this technique has been associated with rare but significant conjunctival and corneal toxicity [16]. In an attempt to decrease ocular morbidity, the intrao‐ perative administration of MMC was applied directly to the sclera bed, which has gained increasing acceptance. Recently, combined pterygium removal with intraoperative MMC and conjunctiva auto grafting for primary and recurrent pterygium has been described [18].

The purpose of this study was to evaluate effectiveness by applying MMC at low concentration

Forty consecutive patients (40 eyes) with primary pterygia who attended the eye clinic, Vali-Asr Hospital of Birjand University of Medical Sciences, between 2006 and 2007 were included in this study. All patients had primary pterygium grade I or II and were not previously operated. The grading used was as follows: Grade 1: small primary pterygium, fibrous type, pinguecular, and classical type. Grade II: advanced primary pterygium with no optical zone involvement. Grade III: advanced primary pterygium with optical zone involvement. We

A complete ocular examination, including slit-lamp examination and hematological exami‐ nation, was performed on each patient. All surgeries were performed by one surgeon (Dr.Da‐ vari). Satisfaction of Ethical Clearance Committee accepted and all patients were given an

A drop of tetracaine 0.5% was instilled in the involved eye for topical anesthesia and the patients were injected subconjunctivally with a 30-gauge needle on an insulin syringe con‐ taining 0.1 ml of 0.2 mg/ml of MMC (Kyowa Hakko Kogyo Co. Ltd. Tokyo, Japan). The injection

explanation of the procedure and informed consent was obtained from all.

was done directly into the pterygium 1mm from limbos (Figure 1).

and cosmetic deformity are other reasons for surgical intervention [3].

tation effectively prevents pterygium recurrence [6, 7, 8].

wind, heat, dryness, and smoke [2].

68 Advances in Eye Surgery

and low volume.

**2. Patients and methods**

selected only grade I and II.

**Figure 3.** (1B) Before MMC injection, (2B) After MMC injection

(a) (b)

**Figure 4.** (a) Before MMC injection, (b) After MMC injection

(a) (b)

**Figure 5.** (a) Before MMC injection, (b) After MMC injection

(a) (b)

**Figure 6.** (a) Before MMC injection, (b) After MMC injection

Subconjunctival Mitomycin C Injection into Pterygium Decreases Its Size and Reduces Associated Complications http://dx.doi.org/10.5772/60090 71

(a) (b)

**Figure 7.** (a) Before MMC injection, (b) After MMC injection

(a) (b)

**Figure 8.** (a) Before MMC injection, (b) After MMC injection

All patients received one drop of chloramphenicol 0.5% and betamethasone 0.1% eye drops that were instilled four times daily for two days. After injection, patients were followed up at one day, one week, one month, six months, and one year. All patients were examined by a slit lamp at all visits for conjunctiva erythematic, epithelial defects, intraocular pressure, and other complications (complete slit-lamp examinations). The changes of pterygium size were evaluated by biomicroscope measurement (slit-lamp). (Base) × (apex) × (length) vs. mean size before and after MMC injection: (base means: up to down of pterygium in limbos, apex means: end of pterygium in cornea). The changes of refraction were also evaluated with topography and keratometer before and after injection.

Exclusion criteria were collagen vascular disease or other autoimmune diseases; pregnancy; ocular surface pathology or infectious, previous limbal surgery; and type III of pterygium.

#### **3. Result**

(a) (b)

(a) (b)

(a) (b)

**Figure 4.** (a) Before MMC injection, (b) After MMC injection

70 Advances in Eye Surgery

**Figure 5.** (a) Before MMC injection, (b) After MMC injection

**Figure 6.** (a) Before MMC injection, (b) After MMC injection

Of the 40 patients who participated in this study, 18 (45%) were males and 22(55%) were females. The mean age was 41.50 years. 16 (40%) left eye and 24 (60%) right eye. The patients

were followed up from 12 to 14 months after injection (the mean follow-up period was 12 months). According to this study, 22.50% were farmers, 45% were housewives, and 32.50% had other occupations.

Within 1–3 days after the subconjunctival injection of MMC, 6 patients complained of irritation accompanied with mild conjunctiva swelling, hyperemia, and tearing (15%). These processes were controlled completely by using betamethasone 0.1% more frequently within 1 week. The pterygia were less vascular and less inflamed at the 6th-month visit after MMC injection.

We detected the reduced size of pterygium (mean size before MMC injection: 5.3mm (base) ×2.3 (apex) ×2.4(length) vs. mean size after MMC injection: 5mm (base) ×2.1mm (apex) ×1.56mm (length)) with mean 0.48 mm (base means: up to down of pterygium in limbos, apex means: end of pterygium in cornea that were evaluated by biomicroscope measurement (slit-lamp)). The size of pterygium was reduced in 83% of cases, and in all cases there were not seen progression and reduced the amount of astigmatism (mean 0.27 diopter) in 70% cases that were evaluated by topography and keratometry {p=0.00} (Table 2). We also detected no significant change in visual acuity and intraocular pressure.



**Table 1.** The prevalence of study participant according to sex, job, age, and affected eye

**Table 2.** Dear Authors, please add Caption


**Table 3.** Complication of MMC injection in 6 patients
