IC-54_Marcovich_Handout
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Transcript IC-54_Marcovich_Handout
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
Subpterygial Lidocaine 2% infiltration
Addition if needed
Excision with conjunctival graft
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
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
Limited tenonectomy creates less bleeding, avoids
rectus muscle involvement. It simplifies surgery and
reduces surgical time
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
Post operative management:
Bandage contact lens for 10 - 30 days
Prolonged topical steroid treatment
Careful follow up
Nasal & temporal pterygia
Simultaneous excision: 1 month post-op
Sup conj healed
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
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
Avascular
sclera
Corneoscleral
ulcer
Pseudomonas
aeruginosa
Melting &
perforation
1 month P/O
1 year P/O
Recurrence management
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
Recurrence OS
after excision
with
intraoperative
MMC 0.02%
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
OD: pterygium recurred twice
Limbal conjunctival graft from superior limbus
No recurrence
Invasion of pseudopterygium at harvest site
Pterygium – astigmatism
Induces
astigmatism
with-the-rule
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.
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