Evaluation of topical vasoconstrictors in pterygium surgery.pdf

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0365-6691/$ - see front matter 2010 Sociedad Espaola de Oftalmologa. Published by Elsevier Espaa, S.L. All rights reserved.

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ARCH SOC ESP OFTALMOL. 2011;86(2):5457

Original article

Evaluation of topical vasoconstrictors in pterygium surgery

and their role in reducing intraoperative bleeding

E. Villegas Becerril,a,b,* L. Prula de Torres,cM. Bergillos Arillo,b,dC. Villegas del Cuvilloe

aClnica de Oftalmologa MASER, Crdoba, SpainbEmpresa Pblica de Hospitales del Alto Guadalquivir. Hospital de Alta Resolucin de Puente Genil, Servicio de Oftalmologa,

Crdoba, SpaincUnidad Docente de Medicina de Familia y Comunitaria, Distrito Sanitario de Crdoba, Crdoba, SpaindClnica de Oftalmologa OFTALMOCOR, Crdoba, SpaineClnica de Oftalmologa, Crdoba, Spain

ARTICLE INFORMATION

Article history:

Received on July 20, 2010

Accepted on Oct. 26, 2010

Keywords:Pterygium

Vasoconstrictors

Bleeding

Complications

Phenylephrine

*Corresponding author.

E-mail: [email protected] (E. Villegas Becerril).

A B S T R A C T

Objective: To reduce vascularisation before surgery through the application of topical

vasoconstrictors, decreases the rate of intraoperative bleeding, improves the dynamics of

the surgery and reduces the difficulty in surgical performance.

Methods: Only patients with primary pterygium were included in the study. A prospective

randomized clinical trial was designed to compare intraoperative bleeding, need forcauterization and surgical time a group that was administered phenylephrine. preoperatively

and one which did not receive it. The sample was divided into two groups: 1st (n=27)

received topical phenylephrine (F) 0.1ml (10%), twice in 5minutes before surgery. 2nd (n=30)

did not receive phenylephrine (NoF). The technique was similar in both groups using

conjunctival autograft suturing. In both groups, the subconjunctival aneasthesia was

performed with 0.5% bupivacaine hydrochloride with epinephrine 1:200,000.

Results:A total of 57 patients were included in the study. The mean operation time for

group F was 15.57minutes (SD: 1.8min) and the NoF group 16.51min (SD to 1.82min, P=.057).

In the group F, it was necessary to use diathermy in 2 patients (7.4%) and in the NoF group

cauterisation was used in 14 patients (46.7%, Chi-Square=10.848, P=.001. There is a relative

risk 6.3 (95% CI 1.57 - 25.27) times greater than having to cauterise without phenylephrine

when used phenylephrine.

Conclusions:The use of topical vasconstrictors prior to pterygium surgery reduces the rateof bleeding and the time of surgery.

2010 Sociedad Espaola de Oftalmologa. Published by Elsevier Espaa, S.L.

All rights reserved.

ument downloaded from http://www.elsevier.es, day 14/06/2013. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.


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ARCH SOC ESP OFTALMOL. 2011;86(2):5457 55

Introduction

Recent etiological theories affirm that pterygium is not only

a degenerative disease but also a proliferative inflammation.1

Surgical extirpation is the treatment of choice. The literature

suggests that simple excision leaving the sclera free is the

only technique with high recurrence rates of between 30%

and 70%.2 Autogenous conjunctival graft seems to be the

best surgical method as it exhibits a low recurrence rate in

addition to less secondary effects.3

It has recently been demonstrated that the Hispanic race

is a risk factor for increased pterygium recurrence rates,

even if the technique is utilized after the primary excision

and conjunctival autograft (CAG).4 The contribution of UV

radiation to the pathogenesis of pterygium has been supportedby epidemiologic data on ocular solar exposure5. In addition,

immunohistochemical studies demonstrate the mutations of

protein p53 due to the damages caused by UV radiation. This

damage induces the production of cytokines, growth factors

and metaloproteinases of the metrics responsible for the

growth of pterygium.6,7

Existing references demonstrate the difficulties due to

intra-op hemorrhage, occasionally requiring the use of

monopolar coagulation or suspending the intervention due to

excessive bleeding. This gives rise to numerous interruptions

and increased surgery times.8-11

Our hypotheses is that the reduction of previous and

intra-op vascularization through the prior application of

vasoconstrictors before surgery diminishes the rate of

intraoperative bleeding, improves the surgery dynamics andreduces the difficulty of the surgical procedure.

Subjects, material and methods

A prospective randomized clinical trial was designed

to compare intraoperative bleeding and cauterization

requirements and surgery times between a group which was

administered phenylephrine before the operation and a group

which was not. An informed consent was requested from each

patient and the study was carried out between September

2009 and February 2010.

Selection of patients and methods

We selected a group of patients (n=57) with an inclusion

criteria of pterygium diagnostic. Only the patients with

primary pterygium were included in the study. The patients

who underwent previous filtration surgery, corneal transplant

or had a history of ocular trauma and exposure to chemical

products were excluded from the study group. The sample

was divided into groups: the first group (n=27) received

topical phenylephrine 0.1ml (10%) on 2 occasions 5 min. prior

to the surgery. The second group (n=30) was not administered

phenylephrine or any other topical vasoconstrictor. The

administration of phenylephrine to each patient was masked

Palabras clave:

Pterigin

VasoconstrictoresSangrado

Complicacin

Felilefrina

Evaluacin de vasoconstrictores tpicos en la ciruga del pterigin y su papelen la disminucin del sangrado intraoperatorio

R E S U M E N

Objetivo: Reducir la vascularizacin previa a la ciruga mediante la aplicacin de vasocon-

strictores tpicos disminuye la tasa de sangrado intraoperatorio, mejora la dinmica de la

ciruga y reduce la dificultad de la actuacin quirrgicaMtodos: Slo los pacientes con pterigin primario se incluyeron en el estudio. Un ensayo

clnico aleatorizado prospectivo fue diseado para comparar el sangrado intraoperatorio,

necesidad de cauterizacin y tiempo de ciruga entre los grupos a los que se les administr

o no fenilefrina preoperatoriamente. La muestra se dividi en dos grupos: 1 (n = 27) recibi-

eron fenilefrina tpica (F) 0,1ml (10%) por dos veces 5 minutos antes de la ciruga; 2 (n = 30)

no se administr fenilefrina (NoF). La tcnica fue similar en ambos grupos, mediante autoin-

jerto conjuntival y sutura. En ambos, la anestesia subconjuntival se realiza con 0,5% de

clorhidrato de bupivacana con epinefrina 1:200.000.

Resultados:Un total de 57 pacientes se incluyeron en el estudio. La media del tiempo quirr-

gico para el grupo F fue de 15,57 minutos (SD: 1,8 min) y para el grupo de NoF de 16,51 min

(SD; 1,82 min; p = 0,057). En el grupo F, fue necesario usar la diatermia en 2 pacientes (7,4%),

en el NoF se us la cauterizacin en 14 pacientes (46,7%; Chi-cuadrado = 10,848; p = 0,001.

Existe un riesgo relativo 6,3 (IC 95%: 1,57 a 25,27) veces mayor de tener que cauterizar sinfenilefrina que cuando se usa fenilefrina.

Conclusiones:El uso de vasconstrictores tpicos previos a la ciruga de pterigin disminuye la

tasa de sangrado y reduce el tiempo de ciruga.

2010 Sociedad Espaola de Oftalmologa. Publicado por Elsevier Espaa, S.L.

Todos los derechos reservados.



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56 ARCH SOC ESP OFTALMOL. 2011;86(2):5457

for the only surgeon who carried out all the surgeries in

order to avoid a bias, and in addition it was randomized.

The surgical technique was similar in both groups, with

conjunctival autograft and stitch described by Harvey et al

(2005)11. According to the description of this author, the need

to utilize diathermia was established for intra-op bleeding.

In both groups, subconjunctival anesthesia was performed

with a combination of anesthesia and vasoconstrictor: 0.5%

bupivacaine chlorhydrate with epinephrine in 1:200.000.

Evaluation and follow-up

After the operation, the subjects of both groups were treated

with tobramycine and dexamethasone eyedrops four times a

day, with a gradually diminishing prescription through a four-

week period. All the subjects were assessed 24 hours after the

surgery and one week, one month and 3 months after the

intervention. In each postop visit a slit lamp biomicroscopy

and applanation tonometry was performed.

Statistical analysis

A descriptive statistical analysis was performed, followedby an analysis of the comparability of both groups according

to age and sex. To verify the existence of differences between

both groups the adjustment of the quantitative variables

to normal distribution was previously verified through

the Shapiro-Wilk or Kolmogorov-Smirnov tests. As these

variables followed a normal distribution, the T for Student

test for independent samples was applied. For comparing

qualitative variables the Chi Square test was utilized,

assuming a value of p


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ARCH SOC ESP OFTALMOL. 2011;86(2):5457 57

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Br J Ophthalmol. 1972;56:120-5.3. Hall RC, Logan AJ, Wells AP. Comparison of fibrin glue withsutures for pterygium excision surgery with conjunctivalautografts. Clin Experiment Ophthalmol. 2009;37:584-9.

4. Kandavel R, Kang JJ, Memarzadeh F, Chuck RS. Comparisonof pterygium recurrence rates in Hispanic and white patientsafter primary excision and conjunctival autograft. Cornea.2010;29:141-5.

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