Eyeworld

EW RESIDENTS 60 January 2015 by Vanessa Caceres EyeWorld Contributing Writer Pearls to effectively remove a pterygium T he need to effectively remove pterygia goes beyond cosmetic reasons, said Stephen C. Kaufman, MD, PhD, professor and vice-chairman of ophthalmology, and director of cornea and refractive surgery, State University of New York-Downstate, New York. "Some can be quite aggressive, affecting vision and even restricting movement of the eye," he said. Thanks to recent research from Dr. Kaufman and other ophthalmol- ogists interviewed by EyeWorld for this article, guidelines on how to best approach pterygia are clearer since the publication of their 2013 report "Options and adjuvants in surgery for pterygium: A report by the American Academy of Ophthalmology." 1 Study investiga- tors analyzed well-designed clinical studies to evaluate the best ap- proaches for pterygium surgery. Optimal techniques For primary pterygium, investiga- tors found that a conjunctival or limbal autograft procedure is more efficacious than amniotic mem- brane placement alone. "Excision with conjunctival autograft has the lowest recurrence rate and the best cosmetic outcome," said Sophie X. Deng, MD, PhD, associate professor of ophthalmology, cornea division, Jules Stein Eye Institute, Los Angeles. In contrast, the study found that surgeons would want to avoid bare sclera excision of primary pterygium, said Deborah S. Jacobs, MD, assistant clinical professor of ophthalmology, Harvard Medical School, Boston. "Bare sclera incision is an in- ferior procedure to those in which an adjuvant such as conjunctival or limbal autograft or mitomycin is used," Dr. Jacobs said. Research found that bare sclera incision has the highest recurrence rate of all techniques and the high- est risk for complications, said W. Barry Lee, MD, Atlanta. "My personal opinion is that sclera should not be left bare after any conjunctival excision, except in cases of suspected or known malig- nancy," Dr. Jacobs said. For recurrent pterygium, Dr. Deng performs excision with con- junctival autograft if the first surgery did not involve a conjunctival auto- graft. If the latter was performed, she favors excision followed by intraop- erative 0.02% mitomycin-C (MMC) for 1–2 minutes and repeat con- junctival autograft. It is important to confine the MMC in the subcon- junctival fibrotic area. After treat- ment the MMC should be rinsed off the ocular surface with a copious amount of balanced salt solution. Dr. Jacobs also weighed in. "My preference is to recommend a com- bination of conjunctival or limbal autograft plus judicious dosing of mitomycin at the low end of re- ported concentrations and duration of application in cases of recurrent pterygium," she said. MMC remains controversial The use of MMC is still controversial for pterygium surgery, surgeons said. "Mitomycin-C inhibits fibrosis," Dr. Deng said. "Yet if not used properly, it will cause scleral melt and limbal stem cell damage." "I personally don't feel it is needed in primary pterygium surgery," Dr. Lee said. "If I have a large recurrent pterygium in which healthy con- junctiva is not present and amniotic membrane is needed, mitomycin-C use may help reduce the risk of recurrence," he said. On the other hand, he prefers not to use it in pri- mary pterygium surgery, noting that it is associated with a higher risk of vision-threatening complications from anterior segment damage. "If mitomycin-C is used, it should be used with extreme cau- tion and unfortunately, its ischemic effects may not be seen for several years. It also has a risk of creating or exacerbating limbal stem cell deficiency," Dr. Lee said. "Our paper made it clear not to use mitomycin-C indiscriminately," Dr. Kaufman said. If he has to use it, Dr. Kaufman will place MMC with a small sponge on a spear on the underside of the conjunctiva and against Tenon's capsule and follow a specified but time-consuming approach to remove the Tenon's. Although it's not common for all surgeons to devote a greater deal of time to Tenon's excision, he said the approach has promising results. Amniotic membrane graft Amniotic membrane can be useful as a grafting technique when the conjunctiva is damaged or there is concern about using the conjuncti- va because of significant glaucoma or the possible need for glaucoma filtration surgery in the future, Dr. Lee said. "Amniotic membrane is Tackling pterygia Nasal pterygium One year after pterygium excision using a conjunctival autograft and 10-0 vicryl sutures Source (all): W. Barry Lee, MD T he management of pterygia can be a double-edged sword. While it is technically straightforward and easy to perform, the intraoperative time required and the perioperative management can be more extensive. Patients require diligent follow-up, with every effort to mitigate inflammation, including expedited re-epithelialization and therapies in order to prevent recurrence. The patient's perioper- ative management needs to be customized to how the individual is healing, and can include a large diameter therapeutic contact lens, intralesional steroid, or 5-fluorouracil injections and long-term topical anti- inflammatories. Drs. Deng, Jacobs, Kaufman, and Lee offer their insights on the surgical management of pterygia and how to successfully prevent recurrences. Elizabeth Yeu, MD, Cataract and refractive surgical fundamentals editor Cataract and refractive surgical fundamentals

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