Eyeworld

I JUNE/JULY 2020 | EYEWORLD | 37 by Liz Hillman Editorial Co-Director Dr. Hovanesian described three pterygium removal techniques. He most frequently per- forms the classic conjunctival autograft, but it's not his preferred technique. He said he actually gets a lower recurrence rate when he performs conjunctival autograft with an amniotic mem- brane, with the amniotic membrane serving as a biologic membrane surrounding the graft tissue. Dr. Hovanesian said he reserves conjuncti- val autograft plus amniotic membrane for cases that are at higher risk for recurrence because there is not a mechanism to reimburse for the amniotic membrane. The third technique Dr. Hovanesian de- scribed was amniotic membrane alone as the graft. He said this technique is not as technically difficult as conjunctival autografting, but it has a higher recurrence rate. Dr. Hovanesian reserves this technique for cases where there is not con- junctiva (due to scarring, for example) for him to harvest. "Typically though, I don't do that proce- dure because it is possible to harvest conjuncti- va," he said. Taking it all a step further, Dr. Hirst described his intensive P.E.R.F.E.C.T. for PTERYGIUM (pterygium extended removal followed by extended conjunctival transplanta- tion) technique for pterygium surgery, which he has shown in a prospective study to have a 0.1% recurrence rate. 2 But first, he took EyeWorld W hen to take a patient to the OR for primary pterygium surgery depends on several factors. Lawrie Hirst, MD, said the indi- cations for removal can depend on the success of your pre- ferred pterygium surgery. For example, if you can't promise a good cosmetic outcome, he said, you might have more strin- gent indications for doing surgery, which most often are visual changes and irritation. John Hovanesian, MD, said large pterygium can be disfiguring, which is another indication for surgery. Many patients also have dry eye, causing even more irritation with the pterygium. "You can't fix dry eye, but you can manage it. Pterygium you can fix; you can take it out of the picture. Patients, whether they have dry eye or not, tend to have good results with pterygi- um surgery," Dr. Hovanesian said. Removal techniques The seminal paper published more than 30 years ago by Ken Kenyon, MD, is still cited when discussing primary pterygium removal. 1 "In my view the best substitute for con- junctiva is conjunctiva," Dr. Hovanesian said, crediting Dr. Kenyon for this concept. But the technique of conjunctival auto- grafting for primary pterygium surgery has evolved in some ways since the 1985 paper, and there are other techniques for handling these cases. Removal of primary pterygium: Techniques and other considerations continued on page 38 At a glance • There are several methods for primary pterygium removal, but the most common uses a conjunctival autograft. • Typical conjunctival autograft- ing has a recurrence rate from 5–15%, but one surgeon pub- lished a series showing a more surgically involved technique that has a recurrence rate of less than 1%. • Pterygium can be irritating to the ocular surface, and removal of these growths can improve some of the patient's sensations, though it won't resolve underlying dry eye. • Experts did not recommend mitomycin as an adjuvant for pterygium surgery. Large nasal primary pterygium before surgery Four months after P.E.R.F.E.C.T. for PTERYGIUM Source (all): Lawrie Hirst, MD

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