Conjunctival autograft for pterygium

Elizabeth Clearfield; Valliammai Muthappan; Xue Wang; Irene C Kuo

doi:10.1002/14651858.CD011349.pub2

Cochrane Database of Systematic Reviews

Autoinjerto conjuntival para el pterigión

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DOI:

https://doi.org/10.1002/14651858.CD011349.pub2 Copiar DOI

Base de datos:

Cochrane Database of Systematic Reviews

Versión publicada:

11 febrero 2016see what's new

Tipo:

Intervention

Etapa:

Review

Grupo Editorial Cochrane:

Grupo Cochrane de Salud ocular y de la visión

Copyright:

Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Autores

Elizabeth Clearfield

Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
Valliammai Muthappan

Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, USA
Xue Wang

Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
Irene C Kuo

Correspondencia a: Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, USA

[email protected]

Contributions of authors

Conceiving the review: ICK, VM, XW, CEVG
Designing the review: ICK, VM, XW
Drafting the protocol: ICK, VM, XW
Co‐ordinating the review: EC
Undertaking electronic and manual searches: CEVG
Screening search results: ICK, EC
Organizing retrieved papers against inclusion criteria: EC
Appraising methodological quality of papers: ICK, VM, EC
Abstracting data from papers: ICK, VM, EC, CEVG
Data management of the review: EC
Entering data into RevMan: EC
Analyzing and presenting results: ICK, EC
Interpreting results: ICK, EC
Writing the review: ICK, EC

Sources of support

Internal sources

No sources of support supplied

External sources

National Eye Institute, National Institutes of Health, USA.

Elizabeth Clearfield is supported by the Cochrane Eyes and Vision Group US project Grant 1 U01 EY020522
National Institute for Health Research, UK.
- Richard Wormald, Co‐ordinating Editor for the Cochrane Eyes and Vision Grou (CEV), acknowledges financial support for his CEVG research sessions from the Department of Health through the award made by the National Institute for Health Research to Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology for a Specialist Biomedical Research Centre for Ophthalmology.
- The NIHR also funds the CEV Editorial Base in London.
The views expressed in this publication are those of the authors and not necessarily those of the NIHR, NHS, or the Department of Health.

Declarations of interest

EC: No conflict of interest or financial interest.
VM: No conflict of interest or financial interest.
XW: No conflict of interest or financial interest.
ICK: No conflict of interest or financial interest.

Acknowledgements

The review authors would like to thank Claire Twose and Lori Rosman, Trials Search Co‐ordinators, Cochrane Eyes and Vision Group (CEVG), for designing the search strategies. We thank Sonal Singh and Barbara Hawkins for their comments during the preparation of the review. We also acknowledge the CEVG editorial team's support and peer reviewers for their comments on the review.

Version history

Published

Title

Stage

Authors

Version

2016 Feb 11

Conjunctival autograft for pterygium

Review

Elizabeth Clearfield, Valliammai Muthappan, Xue Wang, Irene C Kuo

https://doi.org/10.1002/14651858.CD011349.pub2

2014 Oct 20

Conjunctival autograft for pterygium

Protocol

Irene C Kuo, Valliammai Muthappan, Xue Wang

https://doi.org/10.1002/14651858.CD011349

Differences between protocol and review

To meet Cochrane standards, we modified our methods to include an assessment of the certainty of the evidence using the GRADE classification. These assessments are presented in the Summary of Findings table.

Keywords

MeSH

Medical Subject Headings (MeSH) Keywords

Medical Subject Headings Check Words

Humans;

PICO

Population

Intervention

Comparison

Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

Figure 1

Study flow diagram.

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Figure 2

Risk of bias graph: review authors' judgments about each risk of bias item presented as percentages across all included studies.

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Figure 3

Risk of bias summary: review authors' judgments about each risk of bias item for each included study.

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Figure 4

Forest plot of comparison: 1 Conjunctival autograft (CAG) versus amniotic membrane transplant (AMT), outcome: 1.1 Recurrence of pterygium at 3 months.

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Figure 5

Forest plot of comparison: 1 Conjunctival autograft (CAG) versus amniotic membrane transplant (AMT), outcome: 1.2 Recurrence of pterygium at 6 months.

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Figure 6

Forest plot of comparison: 1 Conjunctival autograft (CAG) versus amniotic membrane transplant (AMT), outcome: 1.3 Adverse events.

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Analysis 1.1

Comparison 1 Conjunctival autograft (CAG) versus amniotic membrane transplant (AMT), Outcome 1 Recurrence of pterygium at 3 months.

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Analysis 1.2

Comparison 1 Conjunctival autograft (CAG) versus amniotic membrane transplant (AMT), Outcome 2 Recurrence of pterygium at 6 months.

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Analysis 1.3

Comparison 1 Conjunctival autograft (CAG) versus amniotic membrane transplant (AMT), Outcome 3 Adverse events.

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Summary of findings for the main comparison. Summary of findings for conjunctival autograft compared to amniotic membrane transplant

Conjunctival autograft compared to amniotic membrane transplant for pterygium
Patient or population: people with primary or recurrent pterygium Intervention: conjunctival autograft Comparison: amniotic membrane transplant
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	No. of eyes (studies)	Quality of the evidence (GRADE)	Comment
	Risk with amniotic membrane transplant	Risk with conjunctival autograft
Recurrence of pterygium follow‐up: 3 months	Study population		RR 0.87 (0.43 to 1.77)	538 (6 RCTs)	⊕⊝⊝⊝ VERY LOW ^1,2,3
	89 per 1000	77 per 1000 (38 to 158)
Recurrence of pterygium follow‐up: 6 months	Study population		RR 0.53 (0.33 to 0.85)	1021 (10 RCTs)	⊕⊕⊕⊝ MODERATE¹
	189 per 1000	100 per 1000 (62 to 161)
Clinical improvement (non‐recurrence risk) follow‐up: 3 months	See comment					One study reported the risk of non‐recurrence as 93.8% for participants in the conjunctival limbal autograft group and 93.3% in the amniotic membrane transplant group at 3 months after surgery
Need for repeat surgery	See comment					2 studies reported the need for repeat surgery but did not provide time points. In 1 study, 1 participant in the amniotic membrane transplant group developed suture lysis, and amniotic membrane revision was performed. In the other study, 1 participant in each surgical group had surgery again
Mean change in visual acuity	See comment					No study reported mean change. 1 study reported the logMAR at baseline and postoperatively, and there was no difference (mean difference 0.00, 95% CI ‐0.66 to 0.66)
Quality of life	None of the included studies reported on quality of life measures after the 2 surgeries
Direct and indirect costs	None of the included studies reported on direct or indirect costs after the 2 surgeries
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; RCT: randomized controlled trial; RR: risk ratio
GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to that of the estimate of the effect. Moderate quality: We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low quality: Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low quality: We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
¹Allocation concealment unclear in every study and evidence of possible attrition bias. ²Estimate is not precise, ranging from 0.43 to 1.77. ³Individual study results are inconsistent.

Summary of findings for the main comparison. Summary of findings for conjunctival autograft compared to amniotic membrane transplant

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Table 1. Sensitivity Analysis

	Estimates Including Paes 2010 Study		Estimates Not Including Paes 2010 Study
Outcome	Number of Studies (Participants)	Risk Ratio (M‐H, Random, 95% CI)	Number of Studies (Participants)	Risk Ratio (M‐H, Random, 95% CI)
Recurrence of pterygium at 3 months	6 (538)	0.87 [0.43, 1.77]	5 (310)	0.62 [0.30, 1.27]
Participants with primary pterygium	5 (488)	0.92 [0.37, 2.30]	4 (260)	0.62 [0.24, 1.60]
Participants with primary or recurrent pterygium	1 (50)	0.62 [0.21, 1.85]	1 (50)	0.62 [0.21, 1.85]
Recurrence of pterygium at 6 months	10 (1,021)	0.53 [0.33, 0.85]	9 (793)	0.43 [0.30, 0.62]
Participants with primary pterygium	7 (815)	0.58 [0.27, 1.27]	6 (587)	0.43 [0.27, 0.69]
Participants with recurrent pterygium	3 (96)	0.45 [0.21, 0.99]	3 (96)	0.45 [0.21, 0.99]
Participants with primary or recurrent pterygium	2 (110)	0.38 [0.15, 0.95]	2 (110)	0.38 [0.15, 0.95]

Table 1. Sensitivity Analysis

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Table 2. Adverse events

Event	Time point	Number of studies (reference)	Conjunctival autograft, n (%)	Amniotic membrane transplant, n (%)	Risk ratio (95% CI)
Chemosis	6 months	1 (Salman 2011)	4 (20.0)	2 (10.0)	2.00 (0.41 to 9.71)
Conjunctival contraction	1 month	1 (Besharati 2008)	3 (12.5)	4 (15.4)	0.81 (0.20 to 3.26)
	3 months	1 (Besharati 2008)	1 (4.2)	3 (11.5)	0.36 (0.04 to 3.24)
	6 months	1 (Besharati 2008)	2 (8.5)	5 (19.2)	0.43 (0.09 to 2.03)
Conjunctival inflammation ‐ grade 1 to 3	During study	1 (Kheirkhah 2011)	3 (15)	16 (84.2)	0.18 (0.06 to 0.51)
Corneal scar	1 month	1 (Besharati 2008)	16 (66.7)	16 (61.5)	1.08 (0.72 to 1.64)
	3 months	1 (Besharati 2008)	16 (66.7)	16 (61.5)	1.08 (0.72 to 1.64)
	6 months	1 (Besharati 2008)	16 (66.7)	16 (61.5)	1.08 (0.72 to 1.64)
Conjunctivitis	Overall	1 (Aragonés Cruz 2008)	0 (0)	1 (3.6)	0.33 (0.01 to 7.85)
Diplopia	3 months	1 (Besharati 2008)	0 (0)	1 (3.8)	0.36 (0.02 to 8.43)
Diplopia	6 months	1 (Besharati 2008)	0 (0)	2 (7.7)	0.22 (0.01 to 4.28)
Epithelial defect (lasting more than 5 days)	During study	1 (Katircioglu 2014)	1 (3.3)	0 (0)	0.67 (0.20 to 2.22)
Eye movement restriction	3 months	1 (Besharati 2008)	0 (0)	1 (3.8)	0.36 (0.02 to 8.43)
Eye movement restriction	6 months	1 (Besharati 2008)	0 (0)	1 (3.8)	0.36 (0.02 to 8.43)
Eyelid edema and conjunctival hyperemia edema	12 months	1 (Liang 2012)	8 (9.9)	12 (23.1)	0.43 (0.19 to 0.98)
Foreign body sensation or discomfort	12 months	1 (Liang 2012)	11 (13.6)	17 (32.7)	0.42 (0.21 to 0.81)
Graft dehiscence/suture dehiscence	1 month	1 (Besharati 2008)	3 (12.5)	1 (3.8)	3.25 (0.36 to 29.16)
	3 months	1 (Besharati 2008)	3 (12.5)	1 (3.8)	3.25 (0.36 to 29.16)
	6 months	1 (Besharati 2008)	3 (12.5)	1 (3.8)	3.25 (0.36 to 29.16)
	During study	1 (Toker 2016)	2 (5.4)	2 (5.6)	0.97 (0.14 to 6.54)
	Overall	1 (Aragonés Cruz 2008)	0 (0)	1 (3.6)	0.33 (0.01 to 7.85)
Graft reaction	During study	1 (Küçükerdönmez 2007)	1 (7.1)	0 (0)	2.80 (0.12 to 63.20)
Granuloma	During study	3 (Aragonés Cruz 2008;Pérez Parra 2008;Salman 2011)	4 (4.3)	6 (6.5)	0.71 (0.23 to 2.18)
Increased intraocular pressure	6 months	2 (Luanratanakorn 2006;Salman 2011)	8 (6.7)	5 (3.0)	2.52 (0.91 to 7.00)
Increased intraocular pressure	During study	1 (Tananuvat 2004)	5 (11.9)	4 (9.1)	1.31 (0.38 to 4.55)
Infection	1 month	1 (Besharati 2008)	0 (0)	1 (3.8)	0.36 (0.02 to 8.43)
Inflammation	During study	1 (Pérez Parra 2008)	2 (4.4)	0 (0)	5.00 (0.25 to 101.31)
Graft edema	During study	1 (Küçükerdönmez 2007)	0 (0)	2 (15.4)	0.19 (0.01 to 3.56)
Other defect taking > 10 days to heal	During study	1 (Katircioglu 2014)	4 (13.4)	5 (20)	2.52 (0.11 to 59.18)
Pyogenic granuloma	1 month	1 (Besharati 2008)	4 (16.7)	2 (7.7)	2.17 (0.44 to 10.78)
	3 months	1 (Besharati 2008)	4 (16.7)	2 (7.7)	2.17 (0.44 to 10.78)
	6 months	2 (Besharati 2008;Luanratanakorn 2006)	8 (5.6)	5 (2.6)	1.99 (0.67 to 5.90)
	During study	3 (Kheirkhah 2011;Perry 2000; Tananuvat 2004)	1 (1.3)	5 (7.0)	0.33 (0.07 to 1.55)
Severe pain	During study	1 (Katircioglu 2014)	4 (13.4)	2 (8.0)	1.67 (0.33 to 8.36)
Subconjunctival hemorrhage	Overall	1 (Aragonés Cruz 2008)	4 (14.2)	0 (0)	9.00 (0.51 to 159.70)
Superficial punctate keratitis	Overall	1 (Aragonés Cruz 2008)	3 (10.7)	3 (10.7)	1.00 (0.22 to 4.54)
Superficial punctate keratitis	2 years	1 (Chen 2012)	1 (2.2)	2 (4.4)	0.50 (0.05 to 5.32)
Symblepharon	6 months	1 (Besharati 2008)	0 (0)	1 (3.8)	0.36 (0.02 to 8.43)
	2 years	1 (Chen 2012)	1 (2.2)	1 (2.2)	1.00 (0.06 to 15.50)
	During study	1 (Perry 2000)	1 (12.5)	0 (0)	3.00 (0.14 to 64.26)
Wound healing	2 years	1 (Chen 2012)	3 (6.7)	3 (6.7)	1.00 (0.21 to 4.69)
CI: confidence interval

Table 2. Adverse events

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Comparison 1. Conjunctival autograft (CAG) versus amniotic membrane transplant (AMT)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Recurrence of pterygium at 3 months Show forest plot	6	538	Risk Ratio (M‐H, Random, 95% CI)	0.87 [0.43, 1.77]

1.1 Participants with primary pterygium	5	488	Risk Ratio (M‐H, Random, 95% CI)	0.92 [0.37, 2.30]
1.2 Participants with primary or recurrent pterygium	1	50	Risk Ratio (M‐H, Random, 95% CI)	0.62 [0.21, 1.85]
2 Recurrence of pterygium at 6 months Show forest plot	10	1021	Risk Ratio (M‐H, Random, 95% CI)	0.53 [0.33, 0.85]

2.1 Participants with primary pterygium	7	815	Risk Ratio (M‐H, Random, 95% CI)	0.58 [0.27, 1.27]
2.2 Participants with recurrent pterygium	3	96	Risk Ratio (M‐H, Random, 95% CI)	0.45 [0.21, 0.99]
2.3 Participants with primary or recurrent pterygium	2	110	Risk Ratio (M‐H, Random, 95% CI)	0.38 [0.15, 0.95]
3 Adverse events Show forest plot	8		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

3.1 Pyogenic granuloma during the study	3	141	Risk Ratio (M‐H, Fixed, 95% CI)	0.33 [0.07, 1.55]
3.2 Pyogenic granuloma at 6 months	2	337	Risk Ratio (M‐H, Fixed, 95% CI)	1.99 [0.67, 5.90]
3.3 Granuloma during study	3	186	Risk Ratio (M‐H, Fixed, 95% CI)	0.71 [0.23, 2.18]
3.4 Increased IOP at 6 months	2	327	Risk Ratio (M‐H, Fixed, 95% CI)	2.52 [0.91, 7.00]

Comparison 1. Conjunctival autograft (CAG) versus amniotic membrane transplant (AMT)

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