One-Year Outcome of Argon Laser Photocoagulation of Pinguecula Seong Joon Ahn, MD,* Kyung-Hoon Shin, MD,† Mee Kum Kim, MD,‡ Won Ryang Wee, MD,‡ and Ji Won Kwon, MD† Cornea 2013;32:971–975 R4백지원/AP.김수영 2013.10.23

Introduction : Pinguecula Cornea옆 conjunctiva의 a round, yellowish elevated 주로 nasal perilimbal conjunctiva에 생김 Histopathologically Hyalinized subepithelial collagen with elastotic degeneration Conjunctival epithelium 정상 or 위축 or 과각질화 최근 AS-OCT images pterygium과는 다르게 wedge-shaped mass confined to the conjunctiva - Tx Generally, no Tx Irritation 이나 cosmetic problem 있을 때만 primary excision 광화학 변화 자외선 노화 코의 측면서 반사되는 빛 때문에 비측이 흔하다? 윤부를 침범하면 군날개 – 검열반에 군날개로 진행하는 것은 controversal 군날개 조직학적으로 비슷하나 혈관이 많고 섬유 모세포가 많은 특징 증상 있을 때 윤활제 스테로이드 NSAID Gauche dz 갈색 검열반 이상각화증 종양

Purpose Pinguecula photocoagulation의 1년 경과 efficacy 와 safety 를 알아보기 위함

Methods Retrospective interventional case series Patients (2005-2011) Excision group(23) : treated with surgical excision Photocoagulation group(21) : laser The exclusion criteria residual, recurrent, or active ocular diseases 이전 수술/외상에 의한 conjunctival scarring Healing impairing내과적 질환 이나 국소 전신적 medication uveitis, keratoconjunctivitis sicca, herpetic keratitis, conjunctivitis, and anterior basement membrane disease

Procedure : Excision group Alcaine 점안 + 국소 subconj lidocaine GV로 pinguecula margin 표시 pinguecula와 overlying conjunctiva를 Westcott scissors로 excision Suture Small size(4안) : superior and inferior conjunctival edges 를 맞춰 10-0 nylon or 8-0 vicryl 으로 simple conjunctival closure Large size(19안) : surgical excision 후 epithelial side up으로 amniotic membrane transplantation 함. interrupted 10-0 nylon Suture 사용. The 10-0 nylon suture removal : 6 – 14일 후

Procedure : Photocoagulation group 514nm 파장의 argon green laser 사용. Laser setting Alcaine 점안마취 pingueculae 위의 conjunctival epithelium 먼저 지짐 full-thickness pingueculae를 spot이 완전히 겹치지 않게 옮겨가면서 Tenon 과 sclera는 손상되지 않게 Conjunctival defects 는 술후 self re-epithelialization 두 group 다 수술 후 Cravit x4/predforte x4 점안 1달 spot size 200um /duration 0.1sec /power 300-360mW

Evaluation ophthalmic examination diameter of the pinguecula (by slit-lamp) 술 후 AS-OCT 및 ant seg photo 를 review AS-OCT 술전 piguecula의 extent 와 elevation 측정 Height 측정 pain (0-10)/ conjunctival injection grading : 술 1주후 TFBUT and Schirmer I test : 술 전 & 2년 후 Cosmetic evaluation (excision 14안, laser 모든안) excellent, good, acceptable, poor, very poor. Statistical Analyses Mann–Whitney test : between the 2 groups Wilcoxon signed-rank test : before and after treatment Absence of injection was graded 0, and mild injection with readily visible deep scleral vessels was graded 1. Moderate injection with edema of the conjunctiva and hazy view of the deep scleral vessels was graded 2, and severe injection obscuringvisualization of the deep scleral vessels was graded 3.

Results

Ant Seg Photo before & after laser

AS OCT before & after laser Pre op 1wk Preoperative AS-OCT demonstrating a protruding mass (arrow), conjunctival epithelium (arrowheads), and corneal limbus (asterisk). B, One week after laser treatment, the surface contour was flattened as the pinguecula was completely removed, and a defect on the conjunctival epithelium, that is, the area between the 2 arrowheads,was observed. C, Two weeks after treatment, complete healing osf the conjunctival epithelium was noted, and the surface showed no protrusion. D, At 1 year after treatment, there was no recurrence of the pinguecula. 2wks 1yr 1년후 19안(90.5%)에서 D같은 모습, 2안에서 residual pinguecula Complete healing은 두 군에서 4주 경, 유사한 양상

Cosmetic outcome Cosmetic outcomes after argon laser photocoagulation and surgical excision for pingueculae. There was no significant difference in cosmetic scores between the 2 treatment modalities (P = 0.15 by Fisher exact test).

Post op Cx & Sx Post op complication significantly higher in the excision group posttreatment conjunctival hemorrhage 8 eyes(34.8%) vs. 0 P=0.003 scarring with an irregular surface 7 eyes(30.4%) vs. 1 eye (4.8%) P=0.048 Tear function (photocoagulation group) BUT : Significant improvement P=0.001 Schirmer 1 : No change P=0.896 Post op symptoms conjunctival injection lasted for 1 month ocular pain lasted for 1 week No recurrence at 1 yr f/u Posttreatment symptoms and signs included ocular pain and conjunctival injection in the photocoagulation group. The mean pain score during the laser procedure was 5.4 6 0.85. However, the pain gradually decreased, and the patients were almost free of ocular discomfort at 1 week after laser treatment (pain score: 0.1 6 0.32). At postoperative 1 day, the mean conjunctival injection score was 2.1 6 0.6. At 1 week and 1 month, the mean scores were 0.8 6 0.8 and 0.1 6 0.4, respectively. Posttreatment conjunctival injection lasted for ,1 month in most cases, whereas ocular pain lasted for ,1 week.

Discussion duration of tx. : ≤ 10 minutes Argon laser photocoagulation for pinguecula - office-based laser tx. duration of tx. : ≤ 10 minutes - does not require aseptic techniques

Discussion good control of the depth & extent of removal Argon laser photocoagulation for pinguecula good control of the depth & extent of removal - damage to the surrounding tissues ↓ - subconj. hemorrhage & conj. scarring ↓ Good cosmetic outcomes TFBUT ↑, tear film stability ↑

Discussion Recommendation small (< 3 mm) pingueculae are good candidates patients with coagulopathy a history of conjunctival surgery,