CLINICAL SCIENCE
Comparison of Pterygium Recurrence Rates After Limbal
Conjunctival Autograft Transplantation and Other
Techniques: Meta-analysis
Kangkeng Zheng, MMed,* Jianhao Cai, MMed,* Vishal Jhanji, MD,* and Haoyu Chen, MD*
Purpose: Meta-analysis to compare pterygium surgery outcomes
using limbal conjunctival autograft (LCAG) and other techniques.
Methods: A comprehensive literature search was conducted
through June 2011 using PubMed, Embase, and the Cochrane
Registry to identify all randomized control trials reported so far,
comparing the recurrence rates of pterygium after LCAG and other
surgical techniques. The odds ratios (ORs) and 95% condence
intervals (CIs) of rates of pterygium recurrence were pooled using
the MantelHaenszel method.
Results: Overall, 13 randomized control trials were included in the
analysis (Jadad score, 13). The pooled OR from individual studies
showed that the recurrence rates after pterygium excision with
LCAG were lower as compared with pterygium excision with bare
sclera technique (95% CI, 0.040.17; pooled OR = 0.08, P , 0.01),
bulbar conjunctival autograft (95% CI, 0.040.23; pooled OR = 0.10,
P , 0.01), or intraoperative mitomycin C (95% CI, 0.090.52;
pooled OR = 0.22, P , 0.01). There was no statistically signicant
difference in the recurrence rates after LCAG and amniotic mem-
brane graft (95% CI, 0.261.70; pooled OR = 0.66, P = 0.39).
Conclusions: According to the current evidence from literature,
recurrence rates after pterygium excision with LCAG are lower when
compared with the use of bare sclera, bulbar conjunctival autograft, or
intraoperative mitomycin C. Although recurrence rates of LCAG were
similar to the amniotic membrane graft, further large-scale random-
ized controlled trials would be required to conrm these results.
Key Words: pterygium, limbal conjunctival autograft, meta-analysis,
treatment, amniotic membrane transplant
(Cornea 2012;31:14221427)
Received for publication June 27, 2011; revision received September 8, 2011;
accepted September 27, 2011.
From the *Joint Shantou International Eye Center, Shantou University and The
Chinese University of Hong Kong, Shantou, China; Department of
Ophthalmology and Visual Sciences, The Chinese University of Hong
Kong, Hong Kong, China; and Centre for Eye Research Australia,
University of Melbourne, Victoria, Australia.
Supported by the National Nature Science Foundation of China (30901646),
Guangdong Medical Research Foundation (B2010230), Science and
Technology Project of Shantou City, China (2009-70), and the Research
Fund of Joint Shantou International Eye Center (2010-027).
The authors state that they have no proprietary interest in the products named
in this article.
Reprints: Haoyu Chen, Joint Shantou International Eye Center, Shantou
University and The Chinese University of Hong Kong, North Dongxia
Rd, Shantou 515041, China (e-mail: drchenhaoyu@gmail.com).
Copyright 2012 by Lippincott Williams & Wilkins
1422 | www.corneajrnl.com
P terygium is a limbal disorder characterized by the growth
of brovascular tissue from the bulbar conjunctiva onto
the cornea. Although it is known to occur worldwide, its
prevalence is particularly high in the pterygium belt
between 30 N and 30 S of the equator.1 Main indications
for surgical excision include chronic ocular irritation and
decreased vision that may be secondary to its growth over
the pupillary axis or induced astigmatism. The major problem
associated with pterygium surgery is the high incidence of
recurrence. The reported rate of recurrence after simple exci-
sion without adjuvant treatment ranges from 24% to 89%.2
Several techniques have been developed to reduce the recur-
rence rate, including limbal conjunctival autograft (LCAG),3
intraoperative or postoperative application of mitomycin
C (MMC),4 bulbar conjunctival autograft (CAT),5 amniotic
membrane transplantation (AMT),6 radiation,7 photodynamic
therapy,8 antiangiogenic agents,9 and the combination of 2 or
more of these methods.10 Although it has been reported that
the use of these techniques can effectively reduce the recur-
rence rates after pterygium surgery, it is difcult to ascertain
the gold standard for surgical management.
The limbal epithelium acts as a barrier between
conjunctiva and cornea. Limbal stem cell deciency is
considered to play an important role in the pathogenesis of
pterygium.3 Hence, the transplantation of stem cells by
LCAG may restore the barrier and prevent the recurrence of
pterygium. There are a few published studies, including
randomized controlled trials (RCTs), comparing the recur-
rence rate after LCAG and other techniques for pterygium
excision. However, controversy exists on the choice LCAG
as the best option for surgical management of pterygium.1115
Therefore, we conducted a meta-analysis of the published
clinical trials to compare LCAG with other techniques.
MATERIALS AND METHODS
Search Strategies
Comprehensive literature search was performed on 3
databases, including PubMed (www.ncbi.nlm.nih.gov/pubmed/),
Embase (www.embase.com), and Cochrane Central Register of
Controlled Trials (CENTRAL) using the keyword pterygium.
Article types were limited to randomized control trials in
PubMed, controlled clinical trial or randomized controlled
trial in Embase, and no limit in CENTRAL. The search
was performed on March 10, 2010, and updated on June 5,
2011. No language limit was applied. All retrieved results
Cornea  Volume 31, Number 12, December 2012
Cornea  Volume 31, Number 12, December 2012
were imported into the Endnote software (version X3; Thomson
Reuters, Philadelphia, PA).
Screening of Articles
Two independent reviewers assessed the titles and
abstracts of all literature records retrieved from online search.
Duplicated records and unrelated articles were excluded after
the initial screening. Subsequently, full texts of the relevant
records were obtained and a detailed review was performed.
RCTs with primary or recurrent pterygium and LCAG as one
of the treatment arms were included for analysis. Exclusion
criteria included uncontrolled studies, nonrandomized studies,
studies using 2 or more advanced techniques, such as LCAG,
MMC, or AMT in a single treatment arm, and incomplete
information from published data. For multiple publications
using all or part of the same study population, the most recent
report was used. A third masked reviewer was consulted
when required to resolve any discrepancy.
Data Extraction and Statistical Analysis
The quality of each clinical trial was graded using the
Jadad score.16 Jadad score is used to independently assess
the methodological quality of a clinical trial. It assesses the
quality of published clinical trialbased methods relevant to
random assignment, double blinding, and the follow up of
patients. Studies were scored for the presence or absence of
these 3 key methodological recommendations and were
awarded 1 point for each recommendation. The data from
each included article were extracted by 2 authors indepen-
dently, including sample size, patient characteristics, details
of intervention, and recurrence. Review Manager Software
(version 5.0.18; The Cochrane Collaboration, Copenhagen,
Denmark) was used for statistical analysis. The studies where
the surgical technique was the same as that of the control were
grouped and their results were pooled by meta-analysis.
Within each meta-analysis, studies were subgrouped accord-
ing to the type of pterygia included, whether primary, recur-
rent, or mixed. If the study included both primary and
recurrent pterygia and the raw data of each type were avail-
able, data input was performed into the 2 respective sub-
groups. If the raw data of each group were not available, it
was classied as mixed. Heterogeneity among studies was
assessed by the x2 test. Fixed-effect (MantelHaenszel) mod-
els were used unless statistically signicant heterogeneity was
found (P , 0.05). The comparison of recurrence rate between
2 groups was evaluated using odds ratio (OR) and 95% con-
dence interval (CI). The ORs in individual studies were
pooled and depicted using the forest plots. A forest plot is
a graphical display designed to illustrate the relative strength
of treatment effects in multiple studies addressing the same
question. A Begg funnel plot was used to quantify the poten-
tial presence of a publication bias.
RESULTS
A total of 489 articles were retrieved from online
search, including 144 articles from PubMed, 206 from
CENTRAL, and 139 from Embase. During the initial
2012 Lippincott Williams & Wilkins
Pterygium Recurrence After LCAG and Other Techniques
screening, 206 articles identied as duplicated and 256 iden-
tied as unrelated topic were excluded. Another 13 articles
were excluded after applying the exclusion criteria (Fig. 1). The
remaining 13 articles were included in the analysis and sub-
sequently classied into 4 groups depending on the treatment
arms used in each of them (Fig. 1). The techniques used in the
control groups were simple excision with bare sclera in 2
studies,17,18 CAT in 3 studies,1921 intraoperative MMC in
5 studies,1115 and AMT in 3 studies.2224 The Jadad score
of all included studies ranged from 1 to 3 (Table 1). No
statistically signicant heterogeneity was found in any of
the groups (all P . 0.05), and a xed-effect model was used
in all analysis.
Two trials by Du et al17 and Fan et al18 reported lower
recurrence rates with LCAG as compared with the bare sclera
technique in patients with primary pterygium. The pooled OR
was 0.08 (95% CI, 0.040.17, P , 0.00001) (Fig. 2A). The
Begg funnel plot did not show any publication bias or asym-
metry (Fig. 3A).
Comparison of LCAG and CAT was reported in 3
studies. Of these, subjects with recurrent pterygium were
included in 1 study,19 whereas the other 2 studies included
both primary and recurrent pterygia.20,21 The results of these
studies showed that the recurrence rate of pterygium after
LCAG was statistically lower than that after CAT. The pooled
ORs were 0.11 (95% CI, 0.030.43), 0.03 (95% CI, 0.00
0.72), and 0.10 (95% CI, 0.030.33) in primary, recurrent,
and mixed subgroups, respectively, and the overall OR was
0.10 (95% CI, 0.040.23, P , 0.00001) (Fig. 2B). The Begg
funnel plot did not show signicant signs of publication bias
or asymmetry (Fig. 3B).
Five trials compared the outcomes of primary ptery-
gium excision using LCAG or MMC.1115 Although the
recurrence rate after LCAG was lower than that after MMC
in all these trials, 3 studies reported ORs that did not reach
statistical signicance.11,13,15 After pooling the results, the over-
all OR was 0.22 (95% CI, 0.090.52, P = 0.0005; Fig. 2C).
The Begg funnel plot did not show any publication bias or
asymmetry (Fig. 3C).
The recurrence rate of pterygium after LCAG compared
with AMT was reported in 3 RCTs.2224 Cases with recurrent
pterygium were included in 1 study24 and the other 2 studies
had both primary and recurrent pterygia, one of which
reported the raw recurrence data of both primary and recur-
rent pterygia.23 Kkerdnmez et al23 reported better cos-
metic success rate when using the CAT than the AMT
technique. None of the trials reported any signicant differ-
ence between the recurrence rates of LCAG and AMT. The
pooled ORs were 0.96 (95% CI, 0.0616.21), 0.84 (95% CI,
0.233.04), and 0.40 (95% CI, 0.072.15) in primary, recur-
rent, and mixed subgroups, respectively, and the overall OR
was 0.66 (95% CI, 0.261.70, P = 0.39) (Fig. 2D). The Begg
funnel plot did not show signicant sign of publication bias
and asymmetry (Fig. 3D).
DISCUSSION
Pterygium has been classically described as an elastotic
degeneration of the conjunctiva. Pterygia are characterized by
www.corneajrnl.com | 1423
Zheng et al Cornea  Volume 31, Number 12, December 2012

function of the limbus.20 In addition, the development

FIGURE 1. Flow chart depicting the screening process of
retrieved articles.
abnormal subepithelial tissue containing altered collagen
bers that are demonstrable by dye staining for elastins.
The active or proliferative processes in pterygium have also
been noted by proponents of the degenerative theory.
Clinically, there are behavioral features of pterygium that
suggest a proliferative, stationary, or atrophic growth
disorder.
The pathogenesis of development and recurrence of
pterygium is multifactorial. One of the recognized theories is
a deciency of limbal corneal epithelial stem cells, which
provide a junctional barrier for conjunctival migration onto
the corneal surface.25,26 LCAG may therefore achieve a better
anatomic and functional outcome as compared with other
techniques of pterygium removal by restoring the barrier
and recurrence of pterygium involves proliferation of the
conjunctiva and underlying brovascular tissue. Therefore,
application of antiproliferative agents, such as MMC or
5-uorouracil intraoperatively or postoperatively, would
inhibit these changes, subsequently reducing the recurrence
rate. In support of use of AMT in pterygium surgery, it has
been shown that the amniotic membrane could inhibit the
extracellular matrix synthesis by pterygium broblasts,
promote the healing of conjunctival epithelial wound, and
thereby reduce recurrence.27 To date, there is no conclusive
evidence for the most plausible theory on pathogenesis and
hence the most appropriate treatment modality for the surgical
treatment of pterygium. LCAG is by far one of the most
commonly used techniques in clinical practice.
Meta-analysis is a statistical method that is used to
quantitatively synthesize 2 or more independent studies and
integrate their results. The results from a meta-analysis
provide an overview of the comparative effect of treatments
or procedures.28 It can increase the statistical power of
primary endpoints, resolve uncertainty about disparate
reports, and improve estimates on the magnitude of a treat-
ment effect.29 In 1998, there was a meta-analysis published,
comparing the recurrence rate after single resection with
and without MMC and conjunctival autograft for primary
pterygium. It was found that the pooled OR of pterygium
recurrence was 6.1 (95% CI, 1.818.8) and 25.4 (95% CI,
9.066.7) for the patients who received only bare sclera
resection compared with the use of conjunctival autograft
and MMC, respectively. With advances in the understanding
of the pathogenesis of pterygium, increasing importance of
the role of LCAG has been recognized gradually in the past
decade. In the present systematic review and meta-analysis,
we identied 13 RCTs comparing the outcome of pterygium
surgery after LCAG and other techniques and summarized
their results to provide an overall comparative effect. The

TABLE 1. Characteristics of Studies Comparing Pterygium Recurrence Rates After LCAG and Other Surgical Techniques
Jadad Score Group 1 Group 2
Study Randomization Blinded Withdrawal Total P/R Treatment N Recurrence Treatment N Recurrence
17
Du et al 1 0 1 2 P LCAG 112 5 SE 96 41
Fan et al18 1 0 1 2 P LCAG 97 3 SE 98 23
Hu and Gou19 2 0 1 3 R LCAG 53 2 CAT 54 15
Al Fayez20 2 0 1 3 P LCAG 28 0 CAT 22 2
Al Fayez20 2 0 1 3 R LCAG 15 0 CAT 8 4
Cai-Fang et al21 2 0 1 3 P+R LCAG 257 3 CAT 256 27
Sharma et al13 1 0 0 1 P LCAG 20 1 MMC 21 3
Young et al14 1 0 1 2 P LCAG 52 1 MMC 63 10
Biswas et al15 1 0 1 2 P LCAG 30 1 MMC 30 3
Akinci and Zilelioglu11 1 0 0 1 P LCAG 60 2 MMC 52 3
Ari et al12 2 0 1 3 P LCAG 50 2 MMC 50 10
Wei et al22 1 0 0 1 P+R LCAG 57 2 AMT 60 5
Kckerdnmez et al23 2 0 0 2 P LCAG 28 1 AMT 27 1
Kckerdnmez et al23 2 0 0 2 R LCAG 12 2 AMT 11 2
Xia et al24 1 0 0 1 R LCAG 27 3 AMT 30 4
N, number of eyes included; P, primary pterygium; R, recurrent pterygium; SE, simple excision.

1424 | www.corneajrnl.com 2012 Lippincott Williams & Wilkins

Cornea  Volume 31, Number 12, December 2012 Pterygium Recurrence After LCAG and Other Techniques

FIGURE 2. The forest plots of meta-analysis comparing the recurrence rates of pterygium after LCAG and other techniques. A,
LCAG compared with simple excision. B, LCAG compared with CAT. C, LCAG compared with MMC. D, LCAG compared with AMT.

results showed that the recurrence rates of pterygium after
LCAG were statistically lower compared with those after
simple excision with bare sclera techniques, use of CAT
and MMC. The pooled ORs were 0.08, 0.10, and 0.22 resp-
ectively, with all P , 0.01. In addition, we did not nd any
statistically signicant difference between the pterygium
recurrence rate after LCAG and AMT. The results of
LCAG were compared with MMC or bare sclera in primary
pterygia and with CAT or AMT in both primary and
recurrent pterygia.
We believe that results of this meta-analysis match the
current practice guidelines used for the management of
pterygium. However, we could not conclusively demonstrate
the efcacy of AMT when compared with LCAG in
pterygium surgery. This may be attributed to the lack of
clinical trials comparing these 2 treatment modalities. The

FIGURE 3. The Begg funnel plots of

the meta-analysis of the pterygium
recurrence rates after LCAG and
other techniques. A, LCAG com-
pared with simple excision. B, LCAG
compared with CAT. C, LCAG com-
pared with MMC. D, LCAG com-
pared with AMT.

2012 Lippincott Williams & Wilkins www.corneajrnl.com | 1425

Zheng et al
absence of statistically signicant difference between the
pterygium recurrence rate after LCAG and AMT as shown in
the studies included in the present meta-analysis actually
weakens the rationale of any advantages of the stemness of
LCAG, unless the amniotic membrane will be demonstrated
to be able to promote stem cell proliferation. AMT has been
used in pterygium surgery in several other studies to cover
large areas of bare sclera after extensive surgical dissection.
Recurrence rates between 3.0% and 15% have been reported
using this technique for primary pterygia and between 9.5%
and 38% for recurrent pterygia.3034 Tananuvat and Martin35
compared the efcacy and safety of AMT with conjunctival
autograft as an adjunctive therapy after surgical excision of
primary pterygium in 86 eyes with primary pterygium. They
found 18 recurrences (40.9%) in the AMT group and 2
(4.76%) in the conjunctival graft group (P , 0.007). Essex
et al36 found that AMT for pterygium surgery had a high
recurrence rate. By 12 months postoperatively, 64% of the
eyes in their study had developed corneal recurrence and 9%
developed a limbal recurrence.36 The study found no associ-
ation between pterygium recurrence and pterygium size,
amniotic membrane graft dimension, patient age, or sex.36
Luanratanakorn et al37 performed an RCT comparing the
outcomes of pterygium surgery using AMT with conjunctival
autograft in 287 eyes with either primary or recurrent ptery-
gium. The overall recurrence rate was 28.1% and 13.1% in
both groups, respectively.37 Other studies have observed no
statistically signicant difference in recurrence rates between
AMT and conjunctival autograft in the treatment of primary
and recurrent pterygia.32,38 It is noteworthy that that the extent
of corneal involvement differed between these trials. Despite
an apparent higher recurrence rate in pterygia, amniotic
membrane grafting seems to be a useful adjunctive therapy
when a conjunctival autograft is not available or contraindi-
cated. Overall, the clear benet of use of AMT in the treat-
ment of pterygium remains controversial and more studies are
encouraged to reach a denite consensus.
As mentioned previously, pterygium has been spe-
culated to represent a local limbal deciency. Accordingly,
inclusion of limbal epithelium in the conjunctival graft for
pterygium surgery would achieve better anatomic and
functional reconstruction after pterygium removal and, by
restoring barrier function of the limbus, could reduce
recurrence as compared with a conjunctival autograft.
Nevertheless, none of the trials have assessed whether
a minimum amount of limbal stem cells have been really
repositioned and/or have survived after surgery.
Our study has certain limitations inherent to a meta-
analysis. Although a total of 13 trials were involved, some
of the trials did not provide details of method of random-
ization. None of the trials blinded the investigator who
evaluated the recurrence of pterygium. Publication bias is
also a limitation to any meta-analysis. The result of this
meta-analysis should be renewed along with the appearance
of new evidence of clinic research. The availability of novel
treatment modalities, such as photodynamic therapy and
antiangiogenic agents, for prevention of recurrence would
generate more systematically planned RCTs and can be the
basis of new research areas.
1426 | www.corneajrnl.com
Cornea  Volume 31, Number 12, December 2012
In conclusion, we summarized the current evidence for
the use of LCAG in pterygium surgery. LCAG results in a lower
rate of pterygium recurrence compared with bare sclera
techniques, CAT and intraoperative MMC application. How-
ever, we did not nd a statistically signicant difference between
the pterygium recurrence rate after LCAG versus AMT. Further
large-scale RCTs are needed to determine if there is a difference
in pterygium recurrence rate between these 2 techniques.
REFERENCES
1. Detels R, Dhir SP. Pterygium: a geographical study. Arch Ophthalmol.
1967;78:485491.
2. Jaros PA, DeLuise VP. Pingueculae and pterygia. Surv Ophthalmol.
1988;33:4149.
3. Basti S, Rao SK. Current status of limbal conjunctival autograft. Curr
Opin Ophthalmol. 2000;11:224232.
4. Prez-Rico C, Benitez-Herreros J, Montes-Mllon MA, et al. Intraoper-
ative mitomycin C and corneal endothelium after pterygium surgery.
Cornea. 2009;28:11351138.
5. Nieuwendaal CP, van der Meulen IJ, Mourits M, et al. Long-term follow-
up of pterygium surgery using a conjunctival autograft and tissucol.
Cornea. 2011;30:3436.
6. Jain AK, Bansal R, Sukhija J. Human amniotic membrane transplantation
with brin glue in management of primary pterygia: a new tuck-in
technique. Cornea. 2008;27:9499.
7. Viani GA, Stefano EJ, De Fendi LI, et al. Long-term results and prog-
nostic factors of fractionated strontium-90 eye applicator for pterygium.
Int J Radiat Oncol Biol Phys. 2008;72:11741179.
8. Fossarello M, Peiretti E, Zucca I, et al. Photodynamic therapy of ptery-
gium with verteporn: a preliminary report. Cornea. 2004;23:330338.
9. Razeghinejad MR, Hosseini H, Ahmadi F, et al. Preliminary results of
subconjunctival bevacizumab in primary pterygium excision. Ophthal-
mic Res. 2010;43:134138.
10. Frucht-Pery J, Raiskup F, Ilsar M, et al. Conjunctival autografting
combined with low-dose mitomycin C for prevention of primary ptery-
gium recurrence. Am J Ophthalmol. 2006;141:10441050.
11. Akinci A, Zilelioglu O. Comparison of limbal-conjunctival autograft and
intraoperative 0.02% mitomycin-C for treatment of primary pterygium.
Int Ophthalmol. 2007;27:281285.
12. Ari S, Caca I, Yildiz ZO, et al. Comparison of mitomycin C and limbal-
conjunctival autograft in the prevention of pterygial recurrence in
Turkish patients: a one-year, randomized, assessor-masked, controlled
trial. Curr Ther Res Clin Exp. 2009;70:274281.
13. Sharma A, Gupta A, Ram J. Low-dose intraoperative mitomycin-C
versus conjunctival autograft in primary pterygium surgery: long term
follow-up. Ophthalmic Surg Lasers. 2000;31:301307.
14. Young AL, Leung GY, Wong AK, et al. A randomised trial comparing
0.02% mitomycin C and limbal conjunctival autograft after excision of
primary pterygium. Br J Ophthalmol. 2004;88:995997.
15. Biswas MC, Shaw C, Mandal R, et al. Treatment of pterygium with
conjunctival limbal autograft and mitomycin Ca comparative study.
J Indian Med Assoc. 2007;105:200, 202, 204.
16. Jadad AR, Moore RA, Carroll D, et al. Assessing the quality of reports of
randomized clinical trials: is blinding necessary? Control Clin Trials.
1996;17:112.
17. Du Z, Jiang D, Nie A. Limbal epithelial autograft transplantation in
treatment of pterygium [in Chinese]. Zhonghua Yan Ke Za Zhi. 2002;
38:351354.
18. Fan JH, Li XX, Pan DP. The excision of pterygium with gliding trans-
plantation of the corneal limbal stem cells beside pterygium neck. Int J
Ophthalmol. 2008;8:177179.
19. Hu Z, Gou Y. Recurrent pterygium treated by limbal epithelial autograft
transplantation and conjunctival autograft transplantation. Chin Ophthal-
mic Res. 2000;18:356357.
20. Al Fayez MF. Limbal versus conjunctival autograft transplantation
for advanced and recurrent pterygium. Ophthalmology. 2002;109:
17521755.
21. Cai-Fang Y, Jiang LP, Zhang L, et al. Curing the pterygium: pterygium
cutting and the transplantation of the patients limbus of cornea stem cells
2012 Lippincott Williams & Wilkins
Cornea  Volume 31, Number 12, December 2012
versus pterygium cutting and the transplantation of conjunctival pedicle
ap. J Clin Rehabil Tissue Eng Res. 2007;11:56525653.
22. Wei SR, Chan LB, Cui YL. Limbal epithelial autograft and amniotic
membrane transplantation for pterygium in 107 cases. Int J Ophthalmol.
2005;5:583585.
23. Kckerdnmez C, Akova YA, Altnrs DD. Comparison of conjunctival
autograft with amniotic membrane transplantation for pterygium surgery:
surgical and cosmetic outcome. Cornea. 2007;26:407413.
24. Xia YC, Zhang MC, Lu WX. [Limbal corneal epithelial stem cell auto-
graft combined with amniotic membrane transplantation for patients with
recurrent pterygium]. Int J Ophthalmol. 2008;6.
25. Dushku N, Reid TW. Immunohistochemical evidence that human pter-
ygia originate from an invasion of vimentin-expressing altered limbal
epithelial basal cells. Curr Eye Res. 1994;13:473481.
26. Tseng SC. Concept and application of limbal stem cells. Eye (Lond).
1989;3(pt 2):141157.
27. Tseng SC, Espana EM, Kawakita T, et al. How does amniotic membrane
work? Ocul Surf. 2004;2:177187.
28. Taylor-Halvorsen K, Burdick E, Colditz GA, et al. Combining
results from independent investigationsmeta-analysis in clinical re-
search. In: Bailar JC III, Mosteller F, eds. Medical Uses of Statisitics.
Boston, MA: NEJM Books, Massachusetts Medical Society; 1992:
413426.
29. Sacks HS, Berrier J, Reitman D, et al. Meta-analysis of randomized con-
trol trialsan update of the quality and methodology. In: Bailar JC III,
Mosteller F, eds. Medical Uses of Statisitics. Boston, MA: NEJM Books,
Massachusetts Medical Society; 1992:427442.
2012 Lippincott Williams & Wilkins
Pterygium Recurrence After LCAG and Other Techniques
30. Solomon A, Pires RT, Tseng SC. Amniotic membrane transplantation
after extensive removal of primary and recurrent pterygia. Ophthalmol-
ogy. 2001;108:449460.
31. Prabhasawat P, Barton K, Burkett G, et al. Comparison of conjunctival
autografts, amniotic membrane grafts, and primary closure for pterygium
excision. Ophthalmology. 1997;104:974985.
32. Ma DH, See LC, Liau SB, et al. Amniotic membrane graft for primary
pterygium: comparison with conjunctival autograft and topical mitomy-
cin C treatment. Br J Ophthalmol. 2000;84:973978.
33. Ivekovic R, Mandic Z, Saric D, et al. Comparative study of pterygium
surgery. Ophthalmologica. 2001;215:394397.
34. Tekin NF, Kaynak S, Saatci AO, et al. Preserved human amniotic
membrane transplantation in the treatment of primary pterygium.
Ophthalmic Surg Lasers. 2001;32:464469.
35. Tananuvat N, Martin T. The results of amniotic membrane transplanta-
tion for primary pterygium compared with conjunctival autograft.
Cornea. 2004;23:458463.
36. Essex RW, Snibson GR, Daniell M, et al. Amniotic membrane grafting in
the surgical management of primary pterygium. Clin Experiment
Ophthalmol. 2004;32:501504.
37. Luanratanakorn P, Ratanapakorn T, Suwan-Apichon O, et al. Rando-
mised controlled study of conjunctival autograft versus amniotic mem-
brane graft in pterygium excision. Br J Ophthalmol. 2006;90:14761480.
38. Katircioglu YA, Altiparmak UE, Duman S. Comparison of three
methods for the treatment of pterygium: amniotic membrane graft,
conjunctival autograft and conjunctival autograft plus mitomycin C.
Orbit. 2007;26:513.
www.corneajrnl.com | 1427