Conjunctival autograft for pterygium

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

doi:10.1002/14651858.CD011349.pub2

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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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