Dr Priya Srinivas,
DO, FRCS, Cornea Fellow- Sankara Nethralaya
Shree Eye Care Mulund
Pterygium
triangular shaped growth
consisting of bulbar
conjunctival epithelium and
hypertrophied
subconjunctival connect...
Aetiology
1) Growth disorder characterised by conjunctivalisation
of the cornea due to
localised ultraviolet induced damag...
Grading/staging
 Grade 1-- midway between
limbus and pupil border
 Grade2-- extends up to pupil
border
 Grade 3-- cross...
Stages—
T1( atrophic),
--episcleral vessels
clearly seen
T 3 ( fleshy)—
episcleral vessels
obscured
T2 ( intermediate )
Indications for excision
Irregular astigmatism
Encroachment on visual
axis
Recurrent inflammation
Chronic irritation
...
Pterygium +
Cataract
Pterygium surgery followed
by cataract surgery after 6
weeks for K stabilization
Treatment options
1) Bare sclera excision
2)Excision with conjunctival closure/transposition
3) Excision with adjunctiv...
Ocular surface transplantation
Conjunctival autografting(CAU)
Rotational/ annular autografts
Conjunctival limbal autogr...
Conjunctival autograft (CAU)
Autologous free conj
graft
Obtained from superior
bulbar conjunctiva
Same eye/opposite eye...
Literature
Clinical study- Fernandes et al
Analysis of pterygium outcomes over 14 years
CAG – an effective modality for...
Why CAU ?
Excellent cosmesis and
low recurrence .
Risks of MMC:
Scleral necrosis,
Cataract, perforation,
glaucoma
Need...
Recurrence
 Conjunctival autograft (CAU)– 12.2%
 AMG -26.7%
 CLAU ( Conjunctivolimbal autograft)-17.3%
 Bare Sclera- 1...
Risk factors for recurrence
Young males ( age below 40)
Recurrent ones
Morphology ( fleshiness of pterygium)
.
 Tan D...
Surgical technique
Steps and principles
1) Complete removal of pterygium at Bowmans plane
and scleral surfaces
2) Harve...
video
Surgical technique
Anaesthesia- Peribulbar block
GA –recurrent pterygium with marked muscle
restriction and scarring
Ex...
Surgical technique
Using the beaver microblade pterygium can be peeled
from the sclera and limbus
Detach all pterygium i...
Recurrent pterygium
Isolation of recti muscles
More difficult surgery
Dissection of scar tissue around the muscle is
ne...
Graft harvesting
Conjuctival autograft harvested from the superior site
, ensuring a superficial ,tenon free dissection a...
SECURING GRAFT
10-0 Nylon sutures
8-0 Vicryl sutures
Fibrin glue
superior to sutures and has almost replaced sutures
i...
FIBRIN GLUE
 Significantly lesser operating time
 Lesser post operative discomfort
 Less recurrence
 No increased risk...
Post op regime
Topical steroids( Prednisolone eye drops) qid tapered
over 4 weeks
Topical antibiotics for one week
Tear...
Complications
Intra operative
 Corneo scleral perforation
-- Excessive tissue removal
--pseudopterygium
Rectus muscle d...
Post op
Graft edema
Graft
hemorrhage
Graft retraction
COMPLICATIONS
Graft inversion and necrosis
Dellen
Conjunctival granuloma
Inclusion cysts
Late post op complications
Conjunctival scarring at
the donor site
Steroid induced ocular
hypertension
Astigmatism and
...
Pterygium Clinical Considerations
Pterygium Clinical Considerations
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Pterygium Clinical Considerations

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The EBAI CME 2013 - 21st and 22nd of September 2013, Golden Valley Resort, Ghodbunder Road, Thane West, Mumbai.

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Pterygium Clinical Considerations

  1. 1. Dr Priya Srinivas, DO, FRCS, Cornea Fellow- Sankara Nethralaya Shree Eye Care Mulund
  2. 2. Pterygium triangular shaped growth consisting of bulbar conjunctival epithelium and hypertrophied subconjunctival connective tissue encroaching into cornea
  3. 3. Aetiology 1) Growth disorder characterised by conjunctivalisation of the cornea due to localised ultraviolet induced damage to the limbal stem cells. 2 ) Aggressive pterygial fibroblasts are also responsible for corneal invasiveness.
  4. 4. Grading/staging  Grade 1-- midway between limbus and pupil border  Grade2-- extends up to pupil border  Grade 3-- crosses pupil  Indian J Ophthalmol. 2007:Pterygium-induced corneal refractive changes; Sejal Maheshwari,
  5. 5. Stages— T1( atrophic), --episcleral vessels clearly seen T 3 ( fleshy)— episcleral vessels obscured T2 ( intermediate )
  6. 6. Indications for excision Irregular astigmatism Encroachment on visual axis Recurrent inflammation Chronic irritation Motility restriction Cosmetic disfigurement
  7. 7. Pterygium + Cataract Pterygium surgery followed by cataract surgery after 6 weeks for K stabilization
  8. 8. Treatment options 1) Bare sclera excision 2)Excision with conjunctival closure/transposition 3) Excision with adjunctive medical therapy 4) Ocular surface transplantation
  9. 9. Ocular surface transplantation Conjunctival autografting(CAU) Rotational/ annular autografts Conjunctival limbal autograft(CLAU) Amniotic membrane grafting(AMG)
  10. 10. Conjunctival autograft (CAU) Autologous free conj graft Obtained from superior bulbar conjunctiva Same eye/opposite eye Gold standard in pterygium surgery
  11. 11. Literature Clinical study- Fernandes et al Analysis of pterygium outcomes over 14 years CAG – an effective modality for primary and recurrent pterygia Bare sclera technique- unacceptably high recurrence rates Comparison among CAG/CLAG/AMG requires more prospective studies
  12. 12. Why CAU ? Excellent cosmesis and low recurrence . Risks of MMC: Scleral necrosis, Cataract, perforation, glaucoma Need long term studies to justify the routine use in pterygium surgery
  13. 13. Recurrence  Conjunctival autograft (CAU)– 12.2%  AMG -26.7%  CLAU ( Conjunctivolimbal autograft)-17.3%  Bare Sclera- 19.4%  M.Fernandes : Outcome of pterygium surgery: analysis over 14 years. Eye(2005)1182-1190  Bare sclera +MMC- 0 to 38%  Bare sclera -24% to 89 %  CAU- 2 to 39 %  Donald T H Tan: Conjunctival autograft. Ocular Surface Disease and Management. 175- 193
  14. 14. Risk factors for recurrence Young males ( age below 40) Recurrent ones Morphology ( fleshiness of pterygium) .  Tan DT et al .Effect of pterygium morphology on pterygium recurrence in a controlled trial comparing conjunctival autografting with bare sclera excision. Arch Ophthalmol. 1997 Oct;115(10):1235-40
  15. 15. Surgical technique Steps and principles 1) Complete removal of pterygium at Bowmans plane and scleral surfaces 2) Harvesting and suturing in place a thin, Tenon free conj graft of adequate size
  16. 16. video
  17. 17. Surgical technique Anaesthesia- Peribulbar block GA –recurrent pterygium with marked muscle restriction and scarring Exposure- SR bridle / corneal traction suture at 12 o clock Excision- initiate at neck /body not too far from limbus
  18. 18. Surgical technique Using the beaver microblade pterygium can be peeled from the sclera and limbus Detach all pterygium in one piece, no remnant tissue tags on the cornea Where it is deeply adherent in the stroma, avoid deep dissection and tissue loss near head of pterygium
  19. 19. Recurrent pterygium Isolation of recti muscles More difficult surgery Dissection of scar tissue around the muscle is necessary Release of symblepharon Best performed by an experienced ocular surface surgeon
  20. 20. Graft harvesting Conjuctival autograft harvested from the superior site , ensuring a superficial ,tenon free dissection and adequate size to account for retraction Cautery should be avoided on the graft Maintain graft orientation
  21. 21. SECURING GRAFT 10-0 Nylon sutures 8-0 Vicryl sutures Fibrin glue superior to sutures and has almost replaced sutures in pterygium surgery Pan HW, Zhong JX, Jing CX. Comparison of fibrin glue versus suture for conjunctival autografting in pterygium surgery: a meta-analysis. Ophthalmology. 2011 Jun;118(6):1049-54
  22. 22. FIBRIN GLUE  Significantly lesser operating time  Lesser post operative discomfort  Less recurrence  No increased risk of complications .  Uy HS, Reyes JM, Flores JD, Lim-Bon-Siong R. Comparison of fibrin glue and sutures for attaching conjunctival autografts after pterygium excision. Ophthalmology. 2005 Apr;112(4):667-71 .  Ratnalingam V Fibrin adhesive is better than sutures in pterygium surgery. Cornea. 2010 May;29(5):485-9.
  23. 23. Post op regime Topical steroids( Prednisolone eye drops) qid tapered over 4 weeks Topical antibiotics for one week Tear substitutes Review on POD 1, 7 and one month
  24. 24. Complications Intra operative  Corneo scleral perforation -- Excessive tissue removal --pseudopterygium Rectus muscle disinsertion --severe recurrent pterygia
  25. 25. Post op Graft edema Graft hemorrhage Graft retraction
  26. 26. COMPLICATIONS Graft inversion and necrosis Dellen Conjunctival granuloma Inclusion cysts
  27. 27. Late post op complications Conjunctival scarring at the donor site Steroid induced ocular hypertension Astigmatism and scarring SINS- very rare  Jain V et al .Surgically induced necrotizing scleritis after pterygium surgery with conjunctival autograft. Cornea 2008. Jul 27(6): 720-1

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