EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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42 EW CORNEA December 2012 Improving pterygium recovery odds by Rich Daly EyeWorld Contributing Writer Recurrent pterygium Research echoes surgeons��� experience about patients at risk for pterygium A lthough growing evidence suggests certain patients are at greater risk for recurrence of pterygia, surgeons have found improvements in surgical technique can improve their odds. One of the latest studies examining risk factors for recurrence found that both male gender and high sun exposure were strongly and independently related to surgical success after the removal of pterygia.1 The prospective study of 36 patients with primary or recurrent pterygia examined a range of patient and pterygia characteristics as well as surgical treatments and adjunctive therapies. Only male patients in the study had a recurrence, and the hours of sun exposure through their life was independently related to surgical success. Such findings reflect the clinical experience of some surgeons, such as Francis Mah, M.D., in private practice, La Hoya, Calif. ���When I lived in Pittsburgh I didn���t see that many pterygia, whereas now that I���m in San Diego there���s a whole lot of pterygia; I think that goes with the region,��� said Dr. Mah. Robert Nasser, M.D., assistant clinical professor of ophthalmology, University of California, San Francisco, agreed that most of his pterygia patients work outdoors in agriculture or construction. Additionally, he has found a higher inci- Primary pterygium dence among Hispanic patients, in whom the lesions are more inflamed and exuberant. Audrey Talley Rostov, M.D., in private practice, Seattle, also has found more aggressive pterygia among both Latino patients and those of Southeast Asian heritage. The key decision after diagnosis of pterygia is whether and when to operate. For Dr. Nasser, the decision to operate is made on the basis of symptoms, progression, and apparent activity. Dr. Mah opts for surgical removal if the pterygium is affecting the vision and in cases where it is causing chronic irritation. ���If patients are visiting you on a regular basis and you are having to prescribe steroids to quiet the eye, its another strong indication for recommending excision,��� Dr. Mah said. Continuing high exposure to sunlight and environmental irritants are also primary causes for the recurrence that Dr. Nasser sees in less than 2% of his pterygia patients. But for the factors that they can control, the surgeons credit treatment advances for generally reducing recurrence rates. Among their surgical highlights, Drs. Mah, Nasser, and Talley Rostov emphasized the importance of removing the underlying Tenon���s tissue. ���That is really the factor that seems to be the issue with the tissue changing and growing over the limbus,��� Dr. Mah said. ���I cut the head of the epithelium off and get the underlying fibrous tissue.��� Additionally, Dr. Mah noted that in cases of small peripheral inflamed pterygia that have just started and are not yet chronically inflamed, there is comparatively little underlying fibrous tissue to excise. ���Oftentimes in such patients I���ll aim to get ahead of the pterygium and remove the underlying fibrous tissue and just leave it open; there isn���t that much space or bare sclera to cover,��� Dr. Mah said about smaller, inflamed peripheral pterygia. In cases of large nasal and lateral lesions in one eye, Dr. Nasser uses autograft on the most involved side (usually nasal) and an amnio graft on the other. He places a mark on the superior conjunctiva so that the epithelial surface of the graft��� measured to fit and never taken closer than 1.5 mm from the limbus���is easily identified. Dr. Talley Rostov echoed the effectiveness of the autograft-glue combination but noted that in rare cases she uses amniotic membrane if the area is extremely large. Glue advantage Although the use of conjunctival autograft and tissue glue was not conclusively advantageous over sutures in the recent study, Dr. Mah credits the adhesive with decreasing inflammation and shortening post-op recovery. ���I used to suture the whole thing and it caused a lot of irritation and it also took a lot longer,��� said Dr. Mah. ���I would anchor the tissue with 8-0 Vicryl; now I found I don���t need any Vicryl to anchor the tissue because glue does an excellent job of keeping that tissue in place.��� Source (all): Audrey Talley Rostov, M.D. Similarly, Dr. Nasser has seen benefits from using tissue glue. That includes after placing the graft and allowing it to adhere, applying tissue glue over the corneal epithelial defect. That allows it to act as a bandage and greatly improves patient comfort. Dr. Nasser said in recurrent or very luxuriant cases he may place MMC 0.02% on the scleral bed for 20-30 seconds. Additionally, he urged minimal use of cautery in order to avoid aggressive vascular ingrowth. Finally, the key post-op component of a quick recovery from pterygium surgery for Dr. Mah is the use of anti-inflammatories to keep the eye very quiet. ���You don���t want an inflamed eye post-operatively,��� he said. ���I try to use steroids for 3 months. I���ll taper them down, but I try to keep the patient on some kind of steroid for several months until the eye is white and quiet.��� Dr. Talley Rostov uses post-op topical steroids for at least 6-8 weeks. EW Reference Torres-Gimeno, et al. Preoperative factors in���uencing success in pterygium surgery. BMC Ophthalmology, 2012 Aug 8;12(1):38. Epub ahead of print. Editors��� note: Drs. Mah, Nasser, and Talley Rostov have no financial interests related to this article. Contact information Mah: Mah.Francis@Scrippshealth.org Nasser: rnasser@mac.com Talley Rostov: atalleyrostov@nweyes.com