Pterygium Surgery Technique and Complication Management Arie L

Pterygium Surgery Technique and Complication Management Arie L Marcovich MD Director of Cornea Service Kaplan Medical Center, Rehovot, Israel No financial interest

Pterygium Surgery - Anesthesia n Subpterygial Lidocaine 2% infiltration n Addition if needed

Excision with conjunctival graft

Extensive resection vs minimal approach n Hirst advocates large conjunctival resection and extensive tenonectomy. He reported a series of 2000 consecutive primary pterygia and 250 consecutive recurrent pterygia without a single recurrence Hirst LW. Prospective study of primary pterygium surgery using pterygium extended removal followed by extended conjunctival transplantation. Ophthalmology 2008; 115: 1663– 1672 Hirst LW. Recurrent pterygium surgery using pterygium extended removal followed by extended conjunctival transplant: recurrence rate and cosmesis. Ophthalmology 2009; 116: 1278– 1286 n Others advocate limited tenonectomy, small conjunctival resection and a small conjunctival graft Massaoutis P et al. Clinical outcome of a modified surgical technique for pterygium excision. Can J Ophthalmol 2006; 41: 704 -708 n Limited tenonectomy creates less bleeding, avoids rectus muscle involvement. It simplifies surgery and reduces surgical time

Amniotic membrane vs conjunctival graft n Amniotic membrane was less efficient than conjunctival graft in preventing recurrence Prabhasawat P et al. Comparison of conjunctival grafts, amniotic membrane and primary closure for pterygium excision. Ophthalmology 1997; 104: 974 -985 n Cosmetic results with amniotic membrane were inferior to conjunctival grafts Luanratanakorn P et al. Randomised controlled study of conjunctival autograft versus amniotic membrane graft in pterygium excision. Br J Ophthalmol 2006; 90: 1476– 1480 n Amniotic membrane advantageous in large pterygia and scarred conjunctiva, or glaucoma patients who need filtration surgery

Post operative management: n Bandage contact lens for 10 - 30 days n Prolonged n Careful topical steroid treatment follow up

Nasal & temporal pterygia n Simultaneous excision: 1 month post-op Sup conj healed

Complications Dellen n Patch with antibiotic ointment n Bandage contact lens n Tarsorrhaphy Treat aggressively to avoid thinning and inflammation and reduce risk of recurrence

Scleromalacia M. A. 59 year-old man pterygium OS Excision bare sclera, MMC 0. 02% drops bid - 3 days 5 years P/O Operation: Lamellar corneal graft & conjunctival graft from fellow eye 7 years P/O 9 years P/O 3 months P/O

Infection V. Y. 66 year-old man pterygium OD Excision bare sclera, MMC 0. 02% applied for 3 min n Avascular sclera n Corneoscleral ulcer n Pseudomonas aeruginosa n Melting & perforation 1 month P/O 1 year P/O

Recurrence management n Usually n More occurs within 6 months common in younger patients n Persistent n Premature inflammation increases risk cessation of topical steroids may lead to recurrence

Recurrence management n Recurrence OS after excision with intraoperative MMC 0. 02% n Op: limbal transplantation from OD Young AL et al. A randomised trial comparing 0. 02% MMC and limbal conjunctival autograft after excision of primary pterygium. Br J Ophthalmol. 2004; 88: 995– 997.

Recurrence OS Op: limbal transplantation from OD OS OD 1 m post limbal harvesting 1 m post pterygium excision & limbal conjunctival graft OD OS 1 year postoperatively

Recurrence management n OD: pterygium recurred twice n Limbal conjunctival graft from superior limbus n No recurrence Invasion of pseudopterygium at harvest site

Pterygium – astigmatism n Induces astigmatism with-the-rule n Excise pterygium before refractive surgery

Pterygium surgery & cataract n Pterygium excision increases spherical power of cornea and reduce astigmatism n K values stabilize after 1 month n Important with premium IOLs Tomidokoro A et al. Effects of pterygium on corneal spherical power and astigmatism. Ophthalmology 2000; 107: 1568 -71.

Recurrent pterygium – astigmatism n Avascular scarring post pterygium excision may induce high astigmatism n This scarring can be misdiagnosed as corneal opacification Pterygia as cause of post-cataract with-the-rule astigmatism. Holladay JT et al. J Am Intraocul Implant Soc 1985; 11(2): 176 -9 The effect of recurrent pterygium on corneal topography. Walland, Stevens, Steele. Cornea 1994; 13(5): 463 -4

Astigmatism M. K. 79 year old male pterygium OD Excision bare sclera, MMC 0. 02% applied for 3 min UCVA RE: 20/200 BCVA 20/40 - 6 + 10 X 70 1 m P/O UCVA 20/40 BCVA 20/25 – 2 + 0. 5 X 90

Astigmatism post pterygium surgery n Non removal of leading edge n Recurrence n Scarring n Deep excision Stocker’s line

Pterygium – surgical approach n Gentle corneal scraping n Minimal n Avoid conjunctival and Tenon excision Mitomycin C n Bandage contact lens for 10 -30 days n Prolonged n Limbal topical steroid treatment transplantation for recurrent cases