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1 ESCRS meeting Milan 2012
Arie Marcovich, MD
Pterygium Surgery
Technique and Complication
Management
Arie L Marcovich MD
Director of Cornea Service
Kaplan Medical Center, Rehovot, Israel
No financial interest
Complications Dellen
Patch with antibiotic ointment
Bandage contact lens
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
9 years P/O 7 years P/O 5 years P/O
Operation:
Lamellar
corneal graft &
conjunctival
graft from
fellow eye 3 months P/O
Infection V.Y. 66 year-old man pterygium OD
Excision bare sclera, MMC 0.02% applied for 3 min
Avascular sclera
Corneoscleral ulcer
Pseudomonas aeruginosa
Melting & perforation
1 month P/O 1 year P/O
Usually occurs within 6 months
More common in younger patients
Persistent inflammation increases risk
Premature cessation of topical steroids may lead to recurrence
Recurrence management Extensive resection vs minimal approach
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
Limited tenonectomy creates less bleeding, avoids rectus muscle involvement. It simplifies surgery and reduces surgical time
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
2 ESCRS meeting Milan 2012
Arie Marcovich, MD
Amniotic membrane vs conjunctival graft
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
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
Amniotic membrane advantageous in large pterygia and scarred conjunctiva, or glaucoma patients who need filtration surgery
Recurrence OS after excision with intraoperative MMC 0.02%
Op: limbal transplantation from OD
Recurrence management
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
1 m post pterygium excision
& limbal conjunctival graft
1 m post limbal
harvesting
OS OD
OS OD
1 year postoperatively
OD: pterygium recurred twice
Limbal conjunctival graft from superior limbus
No recurrence
Invasion of pseudopterygium at harvest site
Recurrence management
Induces
astigmatism
with-the-rule
Pterygium – astigmatism
Excise pterygium before refractive surgery
Pterygium surgery & cataract Pterygium excision increases spherical power of
cornea and reduce astigmatism
K values stabilize after 1 month
Important with premium IOLs
Tomidokoro A et al. Effects of pterygium on corneal spherical power
and astigmatism. Ophthalmology 2000;107:1568-71.
3 ESCRS meeting Milan 2012
Arie Marcovich, MD
Recurrent pterygium – astigmatism
Avascular scarring post pterygium
excision may induce high astigmatism
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
Non removal of leading edge
Recurrence
Scarring
Deep excision
Stocker’s line
Pterygium – surgical approach
Gentle corneal scraping
Minimal conjunctival and Tenon excision
Avoid Mitomycin C
Bandage contact lens for 10-30 days
Prolonged topical steroid treatment
Limbal transplantation for recurrent cases