EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/1261109
I JUNE/JULY 2020 | EYEWORLD | 39 Bausch + Lomb] four times a day for a week, then I see them 1 week after surgery and adjust accordingly," he said, explaining that he'll taper over a month for low-risk patients and longer for higher-risk patients. Dr. Hirst also said he'll patch for the first night and advises patients wear a patch for the following 2 weeks when taking a bath or shower. He starts patients on intensive topical steroids (prednisolone every 2 hours for the next 2 weeks, then continued four times a day for a further 6 weeks). He also puts them on an antibiotic drop for a week. Dr. Hirst said pa- tients often have pain the first night, but when the patch is removed the following day, 80% don't require further pain medication. Final thoughts from Dr. Hirst Dr. Hirst had a few final thoughts regarding pterygium removal and published research on techniques. First, he said he thinks recurrence needs to be defined as any new fibrovascular growth, not just growth that manages to cross 1–2 mm over the limbus, a threshold set by many studies. "That means that all those people where it has crossed the limbus but less than 1 mm, in these studies, aren't a recurrence," he said. Dr. Hirst said patients need to be followed for at least a year to pick up on 97% of recur- rences. Finally, he added, it's not good enough to just have a low recurrence rate. "You've got to now meet the gold standard and also give patients a good cosmetic appear- ance," Dr. Hirst said. a trivial disease deserving only a simple surgical solution. However, his technique is a complex, difficult surgery. "In all my attempts to find ophthalmolo- gists in Australia who wish to learn this, I've managed to find four," Dr. Hirst said. Howev- er, he said that the technique's low recurrence rate with good, predictable cosmetic outcomes makes the procedure worth it to him and his patients. Mitomycin adjuvant Both Dr. Hirst and Dr. Hovanesian have strong reservations about use of mitomycin in pteryg- ium surgery. Dr. Hirst said mitomycin has its uses in ophthalmic surgery, but not for pteryg- ium. "It's unnecessary and far too dangerous for pterygium surgery," he said. Dr. Hovanesian said that a technique that includes amniotic membrane as the graft would need to be combined with mitomycin, due to its higher recurrence rate. Even in low doses though, Dr. Hovanesian said there is risk for serious complications with mitomycin. "Most people would agree it's best to avoid mitomycin, but it's what you use if you need to," he said. Postop regimen Dr. Hovanesian said his use of a retrobulbar block (bupivacaine mixed with lidocaine 2%) allows the patient to be comfortable on the first night postop. He also patches the eye. The next day, Dr. Hovanesian said the patient is started on a steroid. "I've had good success with Lotemax SM [loteprednol etabonate ophthalmic gel 0.38%, References 1. Kenyon KR, et al. Conjunctival autograft transplantation for ad- vanced and recurrent pterygium. Ophthalmology. 1985;92:1461– 1470. 2. Hirst LW. Prospective study of primary pterygium surgery using pterygium extended removal followed by extended conjunctival transplantation. Ophthalmology. 2008;115:1663–1672. Relevant disclosures Hirst: None Hovanesian: Bausch + Lomb, Katena Preoperatively, this patient had a pterygium extending 2 mm onto the nasal cornea. One month postoperatively, the patient's conjunctival autograft is healing well with mild chemosis that will resolve over time. Source (all): John Hovanesian, MD Contact Hirst: lawrie@tapc.net.au Hovanesian: johnhova@gmail.com