Eyeworld

EW CORNEA 24 November 2011 Traditional approach with modern modifications earns kudos W hen it comes to ptery- gium surgery, many surgeons think that a tried-and-true ap- proach with free con- junctival autografts is the best way to prevent recurrences. "I've been using the same tech- niques that I started to use when I finished my fellowship in 1984," said David D. Verdier, M.D., Verdier Eye Center, Grand Rapids, Mich. "Someone had published a study on conjunctival autografts decreasing the incidence of recurrence. I made a point from then on to excise the pterygium to bare sclera and replace the area where the pterygium was with a conjunctival autograft, usu- ally harvested from the superior conjunctiva of the patient. This is still the gold standard, in my opin- ion," he said. Although the introduction of amniotic membrane grafts several years ago initially caused surgeons to switch to the use of those over conjunctival autografts, many found that the recurrence rate with amniotic grafts was higher, said Christopher J. Rapuano, M.D., pro- fessor of ophthalmology, Jefferson Medical College, Thomas Jefferson University, and co-director, Cornea Service, Wills Eye Institute, both in Philadelphia. Although amniotic membrane grafts serve a purpose in select cases, many surgeons subse- quently returned to the use of con- junctival autografts, he said. "When amniotic membrane grafts came out, I used them a lot, and I found my recurrence rates were higher," said Rick Palmon, M.D., Southwest Florida Eye Care, Fort Myers. Like Dr. Verdier, Drs. Rapuano and Palmon primarily use conjuncti- val autografts once the pterygium is removed. "I used to initially do a sliding conjunctival graft and free up some of the conjunctiva above and below, but my recurrence rate was higher than switching to the full free conjunctival graft, where I take healthy tissue from the superior temporal quadrant and bring that down. Since then, my recurrence rate has dropped significantly," said Dr. Palmon. Fibrin glue, post-op trends One advance that these specialists praise is the introduction of fibrin glue over the use of sutures in ptery- gium surgery. "The tissue glue is helpful, and the eyes are quieter," said Dr. Palmon, who sees aggressive ptery- giums in his sun-soaked, farm-heavy area of the country. "The comfort level for patients is significantly bet- ter. With sutures, as they'd dissolve, there would be associated inflamma- tion and that increased the chance of recurrence. I don't see that now," he said. "I used to suture, but now I use fibrin glue," said Dr. Verdier. "People balk at fibrin glue because it's signifi- cantly more expensive, but sutures are not cheap, either. When you add in patient comfort, the bottom line is that tissue glue is the way to go." "I used to use eight to 10 su- tures, but now that I'm using fibrin glue, I'm down to two to three su- tures," Dr. Rapuano said. "Some doc- tors are not using any sutures at all"—something that Dr. Rapuano would not usually feel comfortable doing. Post-operatively, Dr. Rapuano prescribed a tapering course of Tobradex (tobramycin and dexam- ethasone, Alcon, Forth Worth, Texas) over several weeks. Dr. Palmon treats inflammation rapidly to avoid the risk of infection or pterygium recurrence. If the eye gets red or inflamed, he will start the pa- tient back on topical steroids. If that does not elicit a response in the eye, he will give an injection of 5-fluo- rouracil to quiet the area. "Once the pterygium starts to grow back, you're behind the curve, and it's harder to prevent it from coming back," he said. Dr. Verdier uses pressure patch- ing for 24-36 hours. If the patient has dry eye, he aims to keep the eye well-preserved with nonpreserved tears to avoid more scarring. To MMC or not to MMC? Considering mitomycin C (MMC)'s potential long-term effects on pa- tients, the surgeons interviewed for this article generally favor a conser- vative role for the use of MMC dur- ing pterygium surgery. Because of the aggressiveness of pterygiums that Dr. Palmon treats, particularly in farmworkers, fishermen, and golf pros or attendants, he will some- times use MMC. However, he is care- by Vanessa Caceres EyeWorld Contributing Editor Pterygium surgery trends and pearls P terygium is a common prob- lem that, if managed incor- rectly, can lead to a more significant clinical condition post-op. A recurrent pterygium is a differ- ent disease than a primary pterygium. Re- currences are more inflamed, progress more rapidly, lead to more conjunctival scarring, are more difficult to surgically re- move, and are more likely to lead to loss of vision. Therefore surgeons need to use an operative technique that first and foremost reduces the recurrence rate and leads to the best outcome. Clinical trials have de- finitively shown that the bare sclera tech- nique has a very high recurrence rate (25-90%) and should never be used as the sole procedure. Excision with some adjunct therapy is the treatment of choice. Sur- geons have many options available to them and have to make surgical decisions that they feel are the correct options for the particular lesion and patient. Conjuncti- val graft, amniotic membrane, mitomycin C, and sutures vs. tissue glue are some of the choices available. To help sort out these issues, I have asked three experi- enced corneal surgeons, David Verdier, M.D., Chris Rapuano, M.D., and Rick Palmon, M.D., to give us their views on the surgical management of pterygium. Edward J. Holland, M.D., cornea editor A patient with pterygium Source: Rick Palmon, M.D. Cornea editor's corner of the world

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