대한안과학회지 2014 년제 55 권제 3 호 J Korean Ophthalmol Soc 2014;55(3):354-360 pissn: 0378-6471 eissn: 2092-9374 http://dx.doi.org/10.3341/jkos.2014.55.3.354 = 증례보고 = 군날개삼중수술의단기결과 김용준 정진권 순천향대학교의과대학서울병원안과학교실 목적 : 새로운군날개수술방법인군날개절제, 결막밑양막삽입, 자가결막이식을이용한삼중수술의단기성적을보고하고자한다. 대상과방법 : 2011 년 8 월부터 2012 년 10 월까지본원에서원발성또는재발성군날개를진단받은환자를대상으로하였다. 삼중수술의경우군날개제거하고노출된공막주변의결막밑으로동결건조양막을삽입한후자가윤부결막을이식하였다. 수술후 6 개월이상추적관찰한 45 안을대상으로수술중, 수술후합병증, 그리고재발률을조사하였다. 재발의정도는 G0 ( 혈관조직이발견되지않는경우 ) 에서 G3 ( 섬유조직이윤부를침범한경우 ) 까지로분류하였다. 결과 : 원발성군날개 43 안, 재발성군날개 2 안에서수술을시행하였다. 대상군의평균연령은 59.87 ± 14.30 세였으며, 추적관찰기간은 12.9 ± 4.6 개월이었다. 술후 1 예에서부분적인창상개열이관찰되었으며다른 1 예에서자가이식결막에단순결막낭종이발생하였으나, 수술중합병증은발견되지않았다. 39 안은 G0 이었으며 6 안은 G1 이었다. G2 및 G3 의임상적으로의미있는재발은관찰되지않았다. 결론 : 군날개삼중수술은군날개재발에생물학적장벽으로작용하는자가윤부결막이식술의장점을그대로유지하면서최소한의양막을이용한간단한삽입시술로혈관신생억제등양막이식술의장점도함께취할수있는유용한수술법으로생각된다. < 대한안과학회지 2014;55(3):354-360> 군날개는섬유혈관성조직의증식및신생혈관, 염증반응을특징으로하는안구표면질환이다. 1-3 최근연구에따르면한국인에서의군날개유병률은성인에서 5.4%, 40세이상에서 8.9% 로보고되고있으며 60세이상에서는 16% 로, 고령에서비교적흔한안과적질환이다. 4 군날개는비교적쉽고간단하게수술적제거가가능하나, 단순군날개절제술의경우 32-88% 의높은재발률을보인다. 5-7 이에재발률을낮추기위한많은방법들이고안되었다. 현재노출된공막을덮는술식으로널리쓰이고있는수술방법중하나인자가결막이식술의경우문헌에따라다소차이가있으나 1.9-13.1% 의재발률이보고되고있으며, 자가결막이식과각막윤부이식을함께시행하는자가윤부결막이식술의경우더욱효과적으로재발을억제하는것이밝혀졌다. 8-14 Received: 2013. 6. 27. Revised: 2013. 8. 30. ccepted: 2014. 1. 28. ddress reprint requests to Jin Kwon Chung, MD Department of Ophthalmology, Soonchunhyang University Seoul Hospital, #59 Daesagwan-ro, Yongsan-gu, Seoul 140-743, Korea Tel: 82-2-709-9354, Fax: 82-2-710-3196 E-mail: schcornea@schmc.ac.kr * This work was supported by the Soonchunhyang University Research Fund. * This study was presented as a narration at the 109th nnual Meeting of the Korean Ophthalmological Society 2013. 노출된공막을덮는다른방법으로는양막이식술이있으며, 양막에포함된다양한기질단백질이조직분화및조직접합을촉진하고상피세포의고사를억제함으로써재발률을낮추는것으로알려졌다. 10,15,16 최근보고된전안부혈관조영술을이용한연구에의하면양막이식술의경우결막으로부터이식편으로의혈관신생을억제하는효과도있다. 14 이러한양막의혈관신생억제는화학주성을억제하여결막의섬유화와반흔형성을줄이는생물학적장벽효과가있음이여러연구를통해밝혀졌다. 14,17,18 여러연구에서자가윤부결막이식술이양막이식술에비해재발률이낮다고보고하고있으나, Tananuvat and Martin 19 은양막이식술과자가윤부결막이식술후재발까지의기간을비교하였을때자가윤부결막이식술의경우 3개월내재발되는반면, 양막이식술은 1년이상재발되지않음을보고하였다. 이들은이러한현상이양막의생물학적장벽효과와연관이있으며장벽이파괴된후군날개가재발한다고설명하였다. 저자들은군날개의재발을최소화하기위해지금까지가장효율적이라고알려진술식인자가윤부결막이식술에더하여결막으로부터의혈관신생을억제하기위해군날개를제거후노출된공막의변연을따라결막밑으로양막을삽입하는삼중수술을고안하여시행하였으며, 삼중수술을시행받은환자를대상으로재발률, 술중및술후합병증을분석하여그단기결과를보고하고자한다. 354
- 김용준 정진권 : 군날개삼중수술의단기결과 - 대상과방법 2011년 8월부터 2012년 10월까지본원에서원발성또는재발성군날개를진단받고군날개삼중수술을시행받은환자중 6개월이상경과관찰이가능했던환자를대상으로하였다. 총 45명의 45안을대상으로후향적연구를시행하였다. 본연구는헬싱키선언에따라양막사용의예상효과와발생가능한합병증에대해충분한설명을듣고서면동의한환자를대상으로진행하였다. 수술전군날개의분류는 Yang et al 20 이제안한 Stage I-III 분류를사용하였으며, 각막윤부와동공의가까운경계사이의거리를반으로나누는가상의수직선을그은후군날개가이선을침범하지않은경우를 Stage I, 선을침범하였으나동공연을침범하지않은경우 Stage II, 동공연을침범한경우를 Stage III로정의하였다 (Fig. 1). 모든수술은 1명의전문의에의하여수술현미경하에서시행되었다. 수술방법은 Gentian violet을이용하여절제할군날개의결막쪽경계를표시한후 1:100,000 epinephrine 을혼합한 2% lidocaine으로군날개부위결막을국소마취하였다. 표시한경계를따라결막및테논낭을절개한후공막으로부터분리하였고군날개두부는집게및 15번수술칼날을이용하여각막편으로부터박리하여제거하였다. 노출된공막경계부의변성된결막, 테논낭, 그리고섬유화조직을직근부착부위까지충분히제거하였으며출혈부위 는에피네프린 0.1% 용액 (osmin, Jeil pharmaceutical co., LTD., Korea) 을이용하여지혈하였다. 섬유혈관조직의박리된경계부위의결막하에 0.02-0.04% 마이토마이신을적신스폰지로 2-4분간처리하고평형용액으로충분히세척한후노출된공막주변의결막밑으로동결건조양막 (mnisite-cornea, ioland, Korea) 을 3 mm 너비, ' ㄷ ' 자모양으로잘라기저막이위로가도록삽입하여공막위에부착하였다. 삽입된양막은조직접합제 (Greenplast-Q prefilled syringe kit, Green cross corp., Korea) 를이용하여결막밑공간에안정적으로위치시켰다. 이후공막노출부의크기보다 1.5 mm 크게상이측결막에 Gentian violet을이용하여표시후 vannas 가위및 15번수술칼날을이용하여각막윤부조직이포함되도록절제하였다. 절제한윤부결막이식편을공막노출부로이동시켜윤부쪽의방향을맞춘다음, 내측변연은 10-0 Nylon 연속봉합, 이외부분은조직접합제를이용하여자가결막을이식하였다 (Fig. 2). 수술당일에는이식편의안정화를위하여압박안대를시행하였으며, 술후 1일째부터항생제, 스테로이드안약을사용하였다. 술후 1주전후로 10-0 nylon 봉합사를제거하였으며술후 4주까지안약점안을유지하였다. 수술후 6개월이상추적관찰한 45안을대상으로수술중, 수술후합병증및재발률을조사하였다. 재발판정기준으로는 Prabhasawat et al 6 에의해제안된 4가지분류를참조하였으며, G0는수술부위가정상과다름없는경우, G1은군날개가제거된 C Figure 1. Representative pictures showing the different stages of pterygium. () Stage I: head of pterygium did not reach the midline between the limbus and pupillary margin. () Stage II: head of the pterygium passed midline but did not reach the pupil. (C) Stage III: head of the pterygium passed the pupillary margin. 355
- 대한안과학회지 2014년 제 55 권 제 3 호 - C D Figure 2. Surgical steps of triple-procedure in pterygium surgery. () Head of pterygium, abnormal proliferative tissue, and subconjunctival fibrovascular tissue were completely removed. () Preparation of amniotic membrane to be inserted into the subconjunctival area. (C) Place the amniotic membrane underneath the conjunctiva along the excision margin and fixed with tissue adhesive. (D) Limbal conjunctival autograft with the use of tissue adhesive and 10-0 nylon suture. C D E F G H F/53 F/63 F/70 M/60 Figure 3. Preoperative (,, C, D) and 6 months postoperative (E, F, G, H) anterior segment photographs of patients who had triple-procedure for pterygium. 영역에 각막 윤부를 항해 뻗어가는 상공막혈관이 관찰되나 로 평가하였다. 섬유화조직은 발견되지 않는 경우, G2는 군날개가 제거된 영역에 결막에 국한된 섬유화조직이 있는 경우, G3는 각막 결 과 윤부를 침범한 섬유화조직이 있는 경우로 분류하였다. Gu 5 and Lee 의 연구를 참조하여 G0에서 G3까지의 분류 중 섬 군날개 환자 45명의 45안 중 남자는 18안, 여자는 27안 유화조직이 관찰되는 G2와 G3를 임상적 의미가 있는 재발 이었다. 원발성 군날개는 43안, 재발성 군날개는 2안이었 356
- 김용준 정진권 : 군날개삼중수술의단기결과 - Figure 4. Early postoperative complications after triple-procedure in pterygium surgery. () Simple conjunctival cyst on autografted conjunctiva (arrowheads). () Partial wound dehiscence and amniotic membrane exposure (arrowheads). Table 1. Short-term results of triple-procedure in pterygium surgery 고 찰 Variables Postop. recurrence grade, N (%) G0 39 (86.7) G1 6 (13.3) G2 0 (0) G3 0 (0) Complications, N (%) Conjunctival cyst 1 (2.2) Wound dehiscence 1 (2.2) 다. 연령분포는 40 세에서 92 세까지로평균연령은 59.87 ± 14.30세였다. 수술전검사상군날개의 stage는 stage I이 16안, stage II가 20안, stage III가 9안이었다. 술후환자마다 6개월에서 20개월까지다양한기간동안추적관찰하였으며평균추적관찰기간은 12.9 ± 4.6개월이었다. 수술중합병증이발생한증례는없었으며, 수술후이식자가윤부결막편은모든환자에서관찰기간동안소실또는구축없이유지되었다 (Fig. 3). 각막상피결손은수술 1주후경과관찰시모든증례에서완전한상피화가이루어졌다. 45안중 6안에서자가윤부결막이식편아래로출혈이발생하였으나 1개월추적관찰까지모든증례에서소실되었으며, 수술후상공막신생혈관및염증을동반한심한결막충혈을감소시키기위해마이토마이신점안등의추가시술을시행한증례는없었다. 술후 1예에서부분적인창상개열을통한양막노출이관찰되어재봉합을시행하였으며, 다른 1예에서이식결막에단순낭종이발생하였으나 needling 후소실되었다 (Fig. 4). 감염이나육아종등의심각한합병증은관찰되지않았다. 추적기간중 39안 (86.7%) 은 G0, 6안 (13.3%) 은 G1으로임상적으로의미있는 G2 혹은 G3의섬유화조직을동반한재발은관찰되지않았다 (Table 1). 군날개는눈알결막에서증식한섬유혈관성조직이각막까지침범하는질환으로이물감, 충혈등의경미한증상에서부터난시, 복시등의심한합병증까지일으킬수있다. 2 군날개를이루는섬유혈관성조직은그영양혈관을결막혈관으로부터받는것으로알려졌다. 21 수술적치료는비교적간단하나단순군날개절제의경우재발률이상당히높아재발을줄이기위한다양한술식들이연구되었다. 수술로인한외상과술후염증반응으로인한결막하섬유아세포의활성화, 혈관의증식, 세포외기질단백질의축적등이재발의원인으로생각되고있다. 2,22 술전혈관증식이심할수록재발률이높다는보고가있으며, Prabhasawat et al 6 은군날개재발의분류중첫단계로군날개제거영역에섬유화조직없이가느다란상공막혈관이관찰되는경우를제안하였다. 23 arraquer et al 24 이군날개수술에서결막이식술을소개한이후로군날개절제술의재발률을낮추기위한많은연구가진행되었으며특히각막윤부를포함한자가윤부결막이식술의장점에대해많은문헌에서보고하고있다. 13,25-27 윤부에포함된건강한각막상피줄기세포는결막의각막침범에대한장벽으로작용하며, 국소적윤부결핍은군날개를유발할수있다. 13 자가결막이식편에윤부상피를포함하는자가윤부결막이식술의경우테논낭을포함하지않은결막이식편이비정상조직이각막으로자라들어오는것에대한장벽역할을해주며, 윤부의기능적, 해부학적구조를재건하는장점이있다. 2,8,27 최근에는이러한자가윤부결막이식술이군날개치료에있어가장안전하고효과적인수술법으로여겨진다. 양막이식술에대해서도많은연구가진행되었다. 양막은조직의접합, 이동및분화를촉진하거나상피세포의고사 357
- 대한안과학회지 2014 년제 55 권제 3 호 - 를방지하는여러물질들을포함하고있다. 15,28-31 양막은성장인자와결합하여창상치유를촉진할수있다. 32,33 또한양막은군날개에서관찰되는섬유모세포의 transforming growth factor (TGF) 혹은 CD-44, integrin 등의분비를억제하여, 섬유모세포의세포외기질형성이나흉터형성을억제하는것으로알려졌다. 34 최근에는양막이포함하고있는여러화학적인자가술후이식편에새로운혈관이형성되는것을억제한다는사실이밝혀졌으며, 양막이식술과자가윤부결막이식술후재발까지의기간을비교한연구에서자가윤부결막이식술의경우 3개월내로재발하였으나, 양막이식술의경우 1년내외로재발하였다는연구결과가있다. 17,19,33 Küçükerdönmez et al 14 은전안부인도시아닌그린혈관조영술을통해군날개절제후양막이식을시행한군에서이식편의혈관신생이현저하게지연되었다고보고하였다. 군날개수술의재발률및술후합병증발생률을개선하고자, 결막이식과양막이식을함께시행하는수술법이국내외에서연구되었다. Kim et al 2 은결막이식후결막이식편위로일시적양막이식술을시행한군에서자가결막이식술만시행한군에비해재발률이더낮음을보고하였으며, Shimazaki et al 26 은안구운동장애나검구유착을보이는군날개환자에서양막이식후양막이식편위로부분적으로자가결막을이식하여효율적으로군날개를치료하였음을보고하였다. 기존의연구와달리, 본연구에서는군날개절제후노출된공막의내측및상하측변연결막아래에국한하여양막을기저부위가위쪽으로가도록삽입하여공막에부착후노출된공막부분에자가윤부결막을이식하는삼중수술을시행하였으며, 수술을받은모든환자에서임상적으로유의한재발이관찰되지않았다. 이는삼중수술이현재가장효율적인수술법으로알려진자가윤부결막이식술의장점에각종인자를공급하여섬유화와혈관신생을억제하는양막삽입의장점을동시에취할수있기때문으로생각된다. 군날개를이루는섬유혈관성조직이결막혈관으로부터영양혈관을공급받는것을고려할때, 군날개절제후노출된공막의변연에삽입한양막은기존결막에서이식결막판으로의혈관신생을억제함으로써자가윤부결막이식술단독술식에비해더욱효율적으로재발을줄일수있을것으로생각된다. 조직접합제만을이용하여자가결막을이식하였던삼중수술시행초기환자 1예에서부분적창상개열에의한양막노출이관찰되었으나이후자가결막이식후내측변연에봉합을추가하여수술한증례에서는창상개열이나양막노출은발생하지않았다. 본연구는후향적의무기록조사로시행된점그리고재발률에대한결론을도출하기에는추적관찰기간과대상군 의수가부족하다는한계점이있다. 또한양막을사용하지않은대조군과의비교연구를시행하지않아두가지수술기법간의재발방지효과를판단할수없었다. 그러나단기추적관찰결과임상적으로의미있는재발이나심각한합병증을보인증례가없는것으로미루어군날개를효과적으로치료할수있는수술방법중하나로고려될수있을것으로생각한다. 결론적으로군날개삼중수술은자가윤부결막이식술의장점을그대로유지하면서, 최소한의양막사용으로양막이식술의장점도함께취할수있는유용한수술방법이라생각된다. 추후군날개삼중수술의장기적인재발률및유용성, 합병증을평가하기위해보다많은증례와장기간의추적관찰을통한연구가필요할것이다. REFERENCES 1) Lee JS, Lee SW, Lee SJ, Kim NM. Effects of cyclosporin on pterygium fibroblasts. J Korean Ophthalmol Soc 2012;53:466-72. 2) Kim JW, hn J, Kook KH, Yang H. Recurrence rates of conjunctival autograft transplantation with aminiotic membrane transplantation in primary pterygium surgery. J Korean Ophthalmol Soc 2011;52:163-8. 3) Coroneo MT, Di Girolamo N, Wakefield D. The pathogenesis of pterygia. Curr Opin Ophthalmol 1999;10:282-8. 4) Yoon KC, Mun GH, Kim SD, et al. Prevalence of eye diseases in South Korea: data from the Korea national health and nutrition examination survey 2008-2009. Korean J Ophthalmol 2011;25:421-33. 5) Gu Y, Lee S. Effects of temporary amniotic membrane patch after surgical excision of primary pterygium. J Korean Ophthalmol Soc 2012;53:749-60. 6) Prabhasawat P, arton K, urkett G, Tseng SC. Comparison of conjunctival autografts, amniotic membrane grafts, and primary closure for pterygium excision. Ophthalmology 1997;104:974-85. 7) Tan DT, Chee SP, Dear K, Lim S. Effect of pterygium morphology on pterygium recurrence in a controlled trial comparing conjunctival autografting with bare sclera excision. rch Ophthalmol 1997;115:1235-40. 8) Li M, Zhu M, Yu Y, et al. Comparison of conjunctival autograft transplantation and amniotic membrane transplantation for pterygium: a meta-analysis. Graefes rch Clin Exp Ophthalmol 2012; 250:375-81. 9) Panda, Das GK, Tuli SW, Kumar. Randomized trial of intraoperative mitomycin C in surgery for pterygium. m J Ophthalmol 1998;125:59-63. 10) ae SG, Kim JK, Lee JK, Park DJ. The effectiveness of mitomycin C on pterygium surgery with amniotic membrane transplantation. J Korean Ophthalmol Soc 2012;53:200-7. 11) Cho JW, Chung SH, Seo KY, Kim EK. Conjunctival mini-flap technique and conjunctival autotransplantation in pterygium surgery. J Korean Ophthalmol Soc 2005;46:1471-7. 12) Todani, Melki S. Pterygium: current concepts in pathogenesis and treatment. Int Ophthalmol Clin 2009;49:21-30. 13) l Fayez MF. Limbal-conjunctival vs conjunctival autograft trans- 358
- 김용준 정진권 : 군날개삼중수술의단기결과 - plant for recurrent pterygia: a prospective randomized controlled trial. JM Ophthalmol 2013;131:11-6. 14) Küçükerdönmez C, kova Y, ltinörs DD. Vascularization is more delayed in amniotic membrane graft than conjunctival autograft after pterygium excision. m J Ophthalmol 2007;143:245-9. 15) Ma DH, See LC, Liau S, Tsai RJ. mniotic membrane graft for primary pterygium: comparison with conjunctival autograft and topical mitomycin C treatment. r J Ophthalmol 2000;84:973-8. 16) Kim HJ, Lee S. Comparison of permanent amniotic membrane transplantation and temporary amniotic membrane patch after primary pterygium excision. J Korean Ophthalmol Soc 2012;53: 1236-46. 17) Hao Y, Ma DH, Hwang DG, et al. Identification of antiangiogenic and antiinflammatory proteins in human amniotic membrane. Cornea 2000;19:348-52. 18) Koizumi NJ, Inatomi TJ, Sotozono CJ, et al. Growth factor mrn and protein in preserved human amniotic membrane. Curr Eye Res 2000;20:173-7. 19) Tananuvat N, Martin T. The results of amniotic membrane transplantation for primary pterygium compared with conjunctival autograft. Cornea 2004;23:458-63. 20) Yang SF, Lin CY, Yang PY, et al. Increased expression of gelatinase (MMP-2 and MMP-9) in pterygia and pterygium fibroblasts with disease progression and activation of protein kinase C. Invest Ophthalmol Vis Sci 2009;50:4588-96. 21) Chan CM, Chew PT, lsagoff Z, et al. Vascular patterns in pterygium and conjunctival autografting: a pilot study using indocyanine green anterior segment angiography. r J Ophthalmol 2001;85:350-3. 22) Mutlu FM, Sobaci G, Tatar T, Yildirim E. comparative study of recurrent pterygium surgery: limbal conjunctival autograft transplantation versus mitomycin C with conjunctival flap. Ophthalmology 1999;106:817-21. 23) Tan DT, Chee SP, Dear K, Lim S. Effect of pterygium morphology on pterygium recurrence in a controlled trial comparing conjunctival autografting with bare sclera excision. rch Ophthalmol 1997;115:1235-40. 24) arraquer JI, inder PS, uxton JN. Etiology and treatment of pterygium; Symposium on Medical and Surgical Disease of the Cornea. Transactions of the New Orleans cademy of Ophthalmology. St. Louids: Mosby, 1980;167-78. 25) Luanratanakorn P, Ratanapakorn T, Suwan-pichon O, Chuck RS. Randomised controlled study of conjunctival autograft versus amniotic membrane graft in pterygium excision. r J Ophthalmol 2006;90:1476-80. 26) Shimazaki J, Kosaka K, Shimmura S, Tsubota K. mniotic membrane transplantation with conjunctival autograft for recurrent pterygium. Ophthalmology 2003;110:119-24. 27) Kenyon KR, Tseng SC. Limbal autograft transplantation for ocular surface disorders. Ophthalmology 1989;96:709-22; discussion 722-3. 28) Fukuda K, Chikama T, Nakamura M, Nishida T. Differential distribution of subchains of the basement membrane components type IV collagen and laminin among the amniotic membrane, cornea, and conjunctiva. Cornea 1999;18:73-9. 29) Khodadoust, Silverstein M, Kenyon DR, Dowling JE. dhesion of regenerating corneal epithelium. The role of basement membrane. m J Ophthalmol 1968;65:339-48. 30) Meller D, Tseng SC. Conjunctival epithelial cell differentiation on amniotic membrane. Invest Ophthalmol Vis Sci 1999;40:878-86. 31) oudreau N, Sympson CJ, Werb Z, issell MJ. Suppression of ICE and apoptosis in mammary epithelial cells by extracellular matrix. Science 1995;267:891-3. 32) Casey ML, MacDonald PC. Keratinocyte growth factor expression in the mesenchymal cells of human amnion. J Clin Endocrinol Metab 1997;82:3319-23. 33) Koizumi NJ, Inatomi TJ, Sotozono CJ, et al. Growth factor mrn and protein in preserved human amniotic membrane. Curr Eye Res 2000;20:173-7. 34) Lee S, Li DQ, Tan DT, et al. Suppression of TGF-beta signaling in both normal conjunctival fibroblasts and pterygial body fibroblasts by amniotic membrane. Curr Eye Res 2000;20:325-34. 359
- 대한안과학회지 2014 년제 55 권제 3 호 - =STRCT= Short-Term Result of Triple Procedure in Pterygium Surgery Yong Joon Kim, MD, Jin Kwon Chung, MD Department of Ophthalmology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea Purpose: To evaluate the success and complication rates of triple procedure, including pterygium excision, marginal amniotic membrane insertion beneath the conjunctiva, and limbal-conjunctival autograft in pterygium surgery. Methods: We conducted a retrospective study on 45 eyes of 45 patients who underwent pterygium surgery between ugust 2011 and October 2012. fter pterygium excision, amniotic membrane was placed beneath the conjunctiva along the margin of the exposed sclera followed by a limbal conjunctival autograft. Success rates, intraoperative and postoperative complications were evaluated. Results: Forty-three eyes with primary pterygium and 2 eyes with recurrent pterygium were enrolled in the present study. The mean age of the patients was 59.87 ± 14.30 years with a mean follow-up of 12.9 ± 4.6 months. There were no complications during surgery. Early postoperative complications included partial wound dehiscence in 1 eye and a simple conjunctival cyst on the autografted conjunctiva in the another eye. No clinically significant recurrence (G2, G3) was noted during the observational periods. Thirty-nine (86.7%) and 6 (13.3%) eyes were graded as G0 and G1, respectively. Conclusions: Our surgical technique not only has the benefits of the limbal conjunctival autograft acting as a barrier against fibrovascular invasion of the cornea and supplying stem cells to the corneal epithelium but also has antiangiogenic effects of amniotic membrane with minimal use. In addition, this technique is a safe surgical method in primary and recurrent pterygium. J Korean Ophthalmol Soc 2014;55(3):354-360 Key Words: mniotic membrane, Limbal conjunctival autograft, Pterygium, Triple procedure ddress reprint requests to Jin Kwon Chung, MD Department of Ophthalmology, Soonchunhyang University Seoul Hospital #59 Daesagwan-ro, Yongsan-gu, Seoul 140-743, Korea Tel: 82-2-709-9354, Fax: 82-2-710-3196, E-mail: schcornea@schmc.ac.kr 360