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