MAY 2013

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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April 2013 EW CORNEA 53 Surgical options for pterygium evaluated by Ellen Stodola EyeWorld Staff Writer D octors employ many different surgical options to treat pterygium, both primary and recurring. But which option is best? At this year's ASCRS Winter Update meeting, Clara Chan, MD, clinical lecturer, Department of Ophthalmology, University of Toronto, discussed pearls and pitfalls when dealing with pterygium. Citing information about specific procedures, her preferences, and a recent American Academy of Ophthalmology report, Dr. Chan went into detail about the options for treating pterygium. EyeWorld followed up with Dr. Chan, as well as other doctors who worked on the report from AAO. said. "Hopefully surgeons will use mitomycin-C sparingly or only in severe cases and with the utmost care to avoid scleral complications." Personal preference for pterygium surgery A preoperative photo of a pterygium AAO's look at pterygium surgery options Dr. Chan said it's important to evaluate the different techniques and how effective each is. "I think historically, surgeons tend to use techniques that they are most comfortable with, which may not necessarily be the most effective or safe," Dr. Chan said. Deborah S. Jacobs, MD, medical director, Boston Foundation for Sight, assistant clinical professor, Harvard Medical School, and faculty member, cornea service, Massachusetts Eye and Ear, Boston, worked on the paper as a member of the AAO's Ophthalmic Technology Assessment Committee that assembles subspecialty committees to do systematic reviews of literature addressing new technologies. "Typically an innovation has to be in use for a while in order for there to be literature to assess," she said. Dr. Jacobs said the idea for a pterygium review came about more than five years ago when the topic of amniotic membrane transplantations came up. The main question that was posed, she said, was if the literature shows that there are advantages to certain adjuvant treatments or not. When it comes to dealing with pterygium, many ophthalmologists think the surgery is trivial, she said. "The recurrence is really the key issue and not removing the pterygium." There are several major conclusions to be drawn from the paper. The most important, Dr. Jacobs said, is that bare sclera is absolutely infe- Postop photo of a different eye at one week after pterygium removal with autologous conjunctival graft and 10-0 vicryl suture Source (all): W. Barry Lee, MD rior and probably should not be performed. She said this approach has an average recurrence rate of nearly 50%, adding that although it is easy to do, it is not worth the risk of a recurrence that is more serious than the first. "The preferred operation for primary pterygium should be conjunctival autograft or judicious use of mitomycin-C, not leaving the sclera bare," Dr. Jacobs said. However, she also noted the challenge of possible complications with mitomycin-C. W. Barry Lee, MD, medical director, Georgia Eye Bank, and practicing partner, Eye Consultants of Atlanta, was another one of the doctors who worked on the AAO report. "A pterygium is a common finding in any eyecare practice, yet the ophthalmic literature demon- strates a wide variety of pterygium excision techniques," he said. Even though there are a number of surgery options, recurrence remains a problem and there is much debate over which method is best. "The AAO's Ophthalmology Assessment Committee felt a review of the literature was warranted to suggest guidelines to enhance postoperative success rates in prevention of pterygium recurrence," he said. Though many surgeons continue to use the technique they were taught in training, some newer techniques seem to lead to a decreased likelihood of pterygium recurrence. "The impact of this study moving forward will hopefully lead to more surgeons using conjunctival/limbal autografts for both primary and recurrent pterygia surgery," Dr. Lee Dr. Chan said a conjunctival or limbal autograft is superior to an amniotic membrane graft for reducing recurrence rates, and this would be her preferred method for a patient with sufficient conjunctiva. An amniotic membrane can also be very expensive. Dr. Chan's preference on surgery options varies depending on the type of pterygium. "For primary pterygium, I prefer to perform pterygium excision and conjunctival autograft with tissue glue since the recurrence rates are acceptably low." However, for recurrent pterygium, she said she would use this same plan of pterygium excision and conjunctival autograft with tissue glue, but in addition, she would apply mitomycin-C 0.02% soaked pieces of Weck-Cel for two minutes to the underside of the retracted conjunctiva. Dr. Chan said she would only use mitomycin-C for recurrent pterygium cases. Dr. Lee said his preference for addressing pterygium is an autologous conjunctival graft technique. "I prefer to perform an excision of the pterygium beginning with removal of the corneal portion using a blunt spatula or blade," he said. "Once the corneal portion is unroofed to the limbus, I use a marking pen to delineate the conjunctival portion that I want to excise and then excise within my marks the conjunctival portion along with meticulous removal of underlying Tenon's capsule." He said he would make sure to identify the rectus muscle and avoid causing surgical trauma to this region, especially avoiding cautery if possible. Dr. Lee said he likes to use a corneal burr to smooth the corneal contour and limbus. "I measure and mark an area of the superior bulbar conjunctiva that is slightly larger than the area of the excised pterygium and place an irreversible letter in the center to always keep the tissue oriented," he said. "I excise this area of conjunctiva without underlying Tenon's capsule, taking care to continued on page 54

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