Eyeworld

I OCUR SURFACE CONSIDERATIONS FOR SURGERY N FOCUS 38 | EYEWORLD | JUNE/JULY 2020 the conjunctiva to retract to its normal position, which left a huge hole." Dr. Hirst said he filled this hole with a large autograph (13x13–15x15 mm) from the supe- rior conjunctiva. He sutures the graft with two radial incisions to the sclera with no tenons in between. "Ultimately, that made sure the scar was invisible in those two areas. The only area where I still have a scar is nasally … because I'm suturing conjunctiva to conjunctiva," he said. "The way I dealt with that was to excise the semi-lunar fold, and to use the suture line to create a new semi-lunar fold with the scar under the new semi-lunar fold." Dr. Hirst said he has performed more than 4,000 pterygium surgeries (3,500 primary pte- rygia) with this technique and has had only one recurrence following primary pterygium surgery, which he said was more than 8 years ago. While Dr. Hovanesian said the tradition- al conjunctival autograft technique can take about 5 minutes in the OR, Dr. Hirst said his procedure takes upward of an hour. In Aus- tralia—and likely around the globe for that matter—Dr. Hirst said pterygium is viewed as on a history lesson that led to this technique's development. Moving back to Australia in 1986 from the U.S., Dr. Hirst said he was "astounded by the rate and size of pterygia here." At that time, pterygia were snipped off and treated with radiotherapy. This dangerous method, Dr. Hirst said, could have severe complications, such as loss of the eye or thinning of the sclera. It's now rarely used in Australia. Dr. Hirst said he started using Dr. Kenyon's conjunctival autograft technique shortly after the paper was published. "The results were what everyone expected, between 5 and 15% risk of recurrence, and the cosmetic results were frequently horrible. That persuaded me that I needed to do something better," he said. Over the next decade, Dr. Hirst said he slowly expanded the quantity and quality of conjunctival autografting in his practice. One pivotal change he made was performing a large tenonectomy. "When I did that, the recurrence rate dropped to almost zero, but as a secondary phe- nomenon, removing that much tenons allowed continued from page 37 About the doctors Lawrie Hirst, MD The Australian Pterygium Centre Queensland, Australia John Hovanesian, MD Harvard Eye Associates Laguna Hills, California by Neel Desai, MD Eye Institute of West Florida Tampa, Florida Small variations in technique can make the difference be- tween an excellent outcome or any number of intraoperative difficulties or postoperative complications. We must think about pterygium surgery beyond simple excision of the pterygium and low recurrence rates, broadening the definition of success to include recovery speed, cosmesis, avoiding complications, preserving nor- mal conjunctiva, and restoring functional anatomy. An ideal procedure needs to achieve these endpoints while respect- ing our limited OR time. The Tissue Tuck Technique evolved naturally—and by ne- cessity—from lessons learned from leaders in the field like Hirst, Hovanesian, Kenyon, and Tseng. It attempts to inte- grate critical aspects of their unique techniques. Tissue Tuck is admittedly novel only in how it integrates features of other described techniques to arrive at a 10- to 15-minute proce- dure that has a low recurrence rate (<1% in more than 900 cases) and fast cosmesis (1–2 weeks), and is reproducible. To start, a traction suture is placed for better visualization, reduced muscle trauma, and reconstruction of the semi-lu- nar fold with cryopreserved amniotic membrane while the globe is in full abduction, pro- vides cosmesis and unrestricted movement. Subconjunctival extravasation of 2% epi-lido- caine provides anesthesia and separation of natural tissue planes. An extensive tenonec- tomy recesses the gap from which recurrences originate, and bipolar cautery is used to tether the fibrovascular root of the pterygium to tenons posteriorly, taking advantage of tenons' tendency to retract and sealing the gap to recur- rence. Finally, the membrane is placed with fibrin glue and me- ticulously tucked to reconstruct the semi-lunar fold and bar- ricade fibrovascular growth. The membrane functions and handles like a "ready-made" conjunctival autograft without the sacrifice of normal tissue or procedural time. Its active biologics also support rapid re-epithelialization and inhibit inflammation and scarring. Relevant disclosures Desai: Bio-Tissue Contact Desai: desaivision2020@gmail.com Tissue Tuck Technique utilizing the best of many approaches

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