Elsevier

Ophthalmology

Volume 118, Issue 9, September 2011, Pages 1739-1746
Ophthalmology

Original article
Cosmesis after Pterygium Extended Removal followed by Extended Conjunctival Transplant as Assessed by a New, Web-Based Grading System

Presented at: the American Academy of Ophthalmology Annual Meeting, October, 2010.
https://doi.org/10.1016/j.ophtha.2011.01.045Get rights and content

Objective

To design a web-based system to grade the cosmetic results after pterygium surgery and to use this to assess the aesthetic results of pterygium extended removal followed by extended conjunctival transplant.

Design

A standardized grading system with gradings of normal, excellent, good, fair, poor, and ungradeable was designed and tested by the author (standard gradings). This was then installed on a website where ophthalmologists and lay people could undertake grading and anatomy tutorials, and subsequently grade randomly assigned images in a masked fashion, of eyes after pterygium surgery and control eyes.

Participants and Controls

A sample of 119 postoperative eyes were randomly selected from 279 consecutive surgeries together with 119 control eyes from the contralateral eyes of these patients supplemented with otherwise normal eyes.

Interventions

The author was tested twice on a sample of 40 images and then the full set, with 24 images repeated giving a total of 288 images using the proposed grading system, resulting in an intraobserver reliability score of 0.98. These images were then randomly presented to the graders, of whom 6 were postpterygium patients and 6 were corneal specialist ophthalmologists after they had completed the tutorials and passed a trial grading test.

Main Outcome Measures

The percentage of images of postoperative and controls that were graded in each grading category were obtained and compared with the only existent study of post pterygium cosmetic results.

Results

Six lay people and 6 corneal specialists successfully passed the trial grading test of 40 images with weighted kappa of 0.70 to 0.85 and intraobserver reliability scores of 0.86 to 0.95 for lay graders and 0.90 to 0.92 for ophthalmic graders. Ninety-four percent of all pterygium surgery eyes were graded as acceptable; both ophthalmic and lay graders were unable to distinguish between postoperative and control eyes.

Conclusions

This grading system is robust and user friendly, and pterygium extended removal followed by extended conjunctival transplant provides a very pleasing aesthetic result in most patients.

Financial Disclosure(s)

Proprietary or commercial disclosure may be found after the references.

Section snippets

Photography

Patients undergoing this procedure are routinely photographed before surgery and most are also photographed at approximately 1, 3, and 12 months after the surgery using a Canon 1DS Mark 1 with a MPE 65-mm Canon macro lens set at 2:1 and a ring flash. None of the images were altered or manipulated in any way.

Cases

All patients in whom a primary nasal pterygium was removed from July 2004 to December 2007 and in whom there was no temporal pterygium, were eligible for inclusion in this study. A photo

Methods

This research was conducted under Human Research Ethics Committee approval and conformed to the tenets of the Declaration of Helsinki.

A trial set of images, and then the complete set of images, were graded by the author according to the grading system described below, on 2 separate occasions and with the author masked to the status of the images (cases or controls). The first grading was undertaken >3 months after the selection of the images and the second grading >1 month after that. The

Results

Over the nominated time period from July 2004 to December 2007, a total of 295 eyes underwent primary nasal pterygium excision; 16 had no photographs or had a follow-up photograph of <3 months postoperatively. However, assessment of the written records of 14 of these demonstrated no recurrences and at least a good or better cosmetic grading at the slit lamp. Two patients did not return for follow-up after the first postoperative day. The postoperative time at which photographs were taken ranged

Discussion

Until now, the principal concern of clinicians and researchers when discussing pterygium surgery has been recurrence rates.1 Few studies have attempted to quantitate cosmetic outcomes.3, 10, 16, 17 Other studies describe the cosmetic results without any formal grading system,2, 4, 9, 19 whereas others only mention cosmesis.5, 6, 7 This study formulates a new, web-based grading system with training modules and uses this system to grade the postoperative results of this new technique.18, 19

This

Acknowledgments

The author thanks Dr Praveen K Nirmalan, Director, PRASHASA Health Consultants Pty Ltd, Hyderabad, India, who provided all statistical assistance, and Mr C. Vikram Kumar, Dot Logic Web Solutions Pty Ltd, Hyderabad, India, who designed the web site.

References (20)

There are more references available in the full text version of this article.

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    It is worth noting that direct conjunctival to conjunctival edge apposition such as this paracaruncular suture line, however carefully it is undertaken, always results in some scarring, and suturing a conjunctival edge to the sclera, such as that at the superior and inferior edge of the graft, can oftentimes leave virtually no perceptible scar. There are a number of other modifications associated with this surgery that are worth highlighting and are principally designed to enhance the final cosmetic appearance that, in a previous study,28 was such that graders could not differentiate normal eyes from eyes that had undergone this procedure, and resulted in almost 95% of eyes having an acceptable cosmetic appearance. These include the large graft that is, at an average square area of 176 mm2, about 7 times the size of an average conjunctival autograft measuring 6×4 mm.

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Manuscript no. 2010-1198.

Note. Readers who would like to review the real test with answers highlighted can undertake the test at pterygiumcosmesis.com from November 1, 2010, onward. Researchers who would like to use this web-based cosmesis grading may insert their own images for objective grading assessments by contacting Mr C. Vikram Kumar at [email protected].

Financial Disclosures: The author has made the following disclosure:

The author owns the trademark P.E.R.F.E.C.T. for PTERYGIUM.

Supported in part by the Prevent Blindness Foundation, Brisbane, Australia, which had no role in the design or conduct of the research.

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