FLAPS Surgery With Autograft Implant Cosmetically Improves Pterygium

Close-up of a Pterygium or surfer’s eye which is the growth of the conjunctiva or mucous membrane covering the white part of of the eye over the cornea – Large Image of eye examination
A report shows the beneficial effect of an ultrathin conjunctival autograft in conjunction with the procedure.

A research team ranked the cosmetic outcomes ultrathin conjunctival autograft (CAG) placement in conjunction with femtosecond laser-assisted pterygium surgery (FLAPS) “excellent” in patients with primary pterygium in a report published in Eye and Vision.

The investigators conducted a prospective, interventional case series (NCT02866968) that included 29 eyes from 29 patients to assess the cosmetic outcome of FLAPS with conjunctival autograft. Of particular interest was whether thinner CAGsled to better cosmetic outcomes, as well as the correlation of these outcomes with multiple perioperative factors. 

Researchers used the Tan grading system — based on preoperative clinical pterygium appearance on a slit-lamp — to score each pterygium. T1 represented atrophic/mild pterygium, T2 represented intermediate/moderate, and 3 represented fleshy/severe. Postoperative cosmetic outcomes were assessed at 3, 6, and 12 months after surgery. Cosmetic outcomes were graded using the Hirst grading system on a scale of 1 to 5. 

Mean patient age was 62 (±10.1) years (80% men) and patients were primarily Chinese (83%). Baseline severity of pterygium was mild in 7% of patients, moderate in 62% of patients, and severe in 31% of patients, respectively. 

In total, 224 assessments based on 61 slit-lamp images were conducted and evaluated by graders.  “Excellent” cosmetic outcomes following FLAPS were seen as early as 3 months after surgery, with similar results at 6 and 12 months postoperatively. At month 12, 83% and 10% of patients achieved an “excellent” or “good” cosmetic outcome; 3% had poor outcomes due to incomplete inferior pterygium removal and poor glue adhesion. No frank recurrence of pterygium was noted during the study period. 

The investigators also analyzed the potential predictive factors of cosmetic outcomes, including age, gender, preoperative pterygium severity, intraoperative CAG thickness, and postoperative CAG thickness. 

Mean CAG thickness was 74.5 (±9.8) µm intraoperatively, 199.9 (±74.0) µm at 1-day postoperative, and 174.7 (±86.6) µm at 1-year postoperative; no significant change was observed during the study period (P =.88). CHS thickness was measured as 318.9(±89) µm at 1 day postoperative and reduced to 270.1(±77.7) µm at 1 year postoperative (P =.22). 

A weak but borderline significant correlation between positive cosmetic outcomes and reduced postoperative CAG thickness was noted (r=0.38; P =.06), but no correlations were noted between age, gender, preoperative pterygium severity, or intraoperative CAG thickness. 

Study limitations include the small sample size and the single-surgeon experience. 

“An excellent cosmetic outcome can be achieved at short- and long-term time points following FLAPS,” according to the report. “An ultrathin CAG can be consistently fashioned by femtosecond laser and may have a beneficial effect on cosmetic outcomes.”  


Ting DSJ, Lui Y-C, Lee YF, et al. Cosmetic outcome of femtosecond laser-assisted pterygium surgery. Eye Vis. 2021;8(1):7. doi:10.1186/s40662-021-00230-w