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『復發型翼狀贅片』---切除合併羊膜移植覆蓋

眼翳(pterygium)又稱翳狀贅片(如圖1,2,3),這個常見的眼科疾病起因於長期戶外工作受到紫外線的照射、風沙刺激、強光刺激…等,在眼球的表面形成一片增生血管纖維組織,會隨著時間慢慢增大、增厚,雖然此疾病沒有要立即手術處理的必要,但是如果面積太大就會需要手術,因為會影響外觀、遮蔽視力、造成高度散光、眼球轉動時受到限制,也會引起視力模糊、眼睛易紅、易酸澀…等問題。
標題3圖1 各種型式的翼狀贅片
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圖2 各種型式的翼狀贅片
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圖3 各種型式的翼狀贅片
我們一般處理翳狀贅片是採用手術切除刮除的方式,但是單純使用此手術方式的病人需忍受約一個月的手術後眼睛紅及疼痛,而且手術後又再長翼狀贅片的機率相當高(約90%)。目前我們有商品化的羊膜可以使用,健保無給付需自費,效果及反應均非常良好。

我們的實際案例:這是一位59歲的男性病人,他在12年前有手術過右眼翼狀贅片,由於上次手術後2周內就復發了,於是沒有信心且害怕就沒有再處理了直到3個月前來到我們診所,希望做一個復發率較低且較不疼痛的處理方式。

於是我們安排再切除一次,不同的是這次加上「排多癌(Amniotic membrane transplantation AMT)覆蓋傷口及排多癌(Mitomycin-c)的治療」

在翼狀贅片(pterygium)手術時,使用羊膜移植覆蓋(amniotic membrane transplantation AMT)的好處:
1.  減低復發率:減少手術後再長翼狀贅片的機率

2. 減低手術後的疼痛感:由於羊膜可以扮演類似人工皮的功能,在手術後的當下可以成為眼球表面的替代表皮

3. 增進眼球結膜表皮的復原:羊膜上有幹細胞及增生因子,可以促進傷口癒合及促進眼結膜、角膜的表皮生長

4. 減少手術後的發炎反應
 
點選看羊膜移植手術影片5:07


病人手術後至今,情況良好,手術後無疼痛感、眼睛不紅、也沒有再復發的現象。所以,翼狀贅片切除的同時,再加做羊膜的移植覆蓋,可以減少復發率、減少發炎、增加傷口復原、並大幅減低手術後眼睛的疼痛。

參考資料:
Recurrent pterygium is a challenging condition that usually resists to conventional surgery and its rate of recurrence after surgery is also high. Moreover, recurrent pterygium surgery is usually accompanied by scarring, more risk of intra and post- complications. This video aims to generate amniotic membrane and mitomycin-c as treatment modality for recurrent pterygium.

Management of primary and recurrent pterygium using amniotic membrane transplantation.

This review discusses the relative merits of the various techniques used in pterygium surgery with particular reference to the growing interest in the use of amniotic membrane transplantation (AMT)because it is safe, effective, and may be employed in conjunction with other techniques, such as limbal transplantation. The efficacy of AMT is comparable to the established method of conjunctival autograft transplantation (CG) and it is especially indicated when there exists a very large conjunctival defect to cover as in primary double-headed pterygium, or in the context of preserving superior bulbar conjunctiva for future glaucoma surgeries. The authors explain how current management principles (eg, use of anti-inflammatory agents, adequate removal of fibrovascular tissue) are based on known differences in pathogenesis and clinical behavior between primary and recurrent pterygium.

Adjunctive use of AMT and short exposure of MMC can reduce recurrence after pterygium surgery. The procedure is less tedious and less time consuming, resulting in early recovery while saving the conjunctiva for future surgeries.

Key Words: amniotic membrane, fibrin glue, mitomycin C, pterygium, recurrence

Pterygium is a wing-shaped superficial overgrowth on the ocular surface, which is characterized by inflammation, fibrovascular conjunctival proliferation, and invasion of the corneal surface. It is presumably due to ultraviolet-induced damage to the limbal stem cells and hence considered as focal limbal stem cell deficiency. Surgical excision is indicated for either optical or cosmetic reasons. In the former, visual disturbances are caused by irregular astigmatism, blocking of the visual axis, or restricted ocular motility.

The most daunting challenge of pterygium surgery is the high incidence of recurrence, as high as 88% with simple excision involving an uncovered bare sclera. Surgical techniques in more recent years, in which scleral defects are covered with conjunctival autograft or cryopreserved amniotic membrane (CAM) with or without mitomycin C (MMC), have resulted in much better outcomes, with less than 10% recurrence rates and minimal complications postoperatively. However, some debate still continues regarding which graft offers the better outcome.

The purpose of this retrospective analysis is to provide compelling long-term evidence that CAM grafts,combined with short exposure to MMC, can reduce recurrence and complications after pterygium surgery. To the best of our knowledge, this is the largest sample size reported with a long-term follow-up.
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