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Anterior Segment 
Surgery 
J. Alberto Martinez, M.D. 
Visionary Ophthalmology 
Rockville, Dec 7, 2014
Doente atado como preparação para 
cirurgia a pterígio 
OUTLINE 
Pterygium 
Conjunctivochalasis 
Limbal stem cell 
deficie...
PTERYGIUM
Pterygium 
• Still a fascinating, mysterious 
disease. 
• Etiology still unknown 
• Optimal management still very 
controv...
Pterygium:Etiology UVR? 
THEORY: 
• UVR>> 
• Mutations>> 
• Proliferation
PTERYS
Pterygium: Genetic 
predisposition 
New evidence: certain populations/families are 
susceptible to pterygium 
• Genetic po...
Ethiology 
• Most researchers feel pterygium is a 
TUMOR 
• P53, tumor suppression gene 
mutations and decreased of P53 
p...
Still a Mystery 
• Many Cases with very little UVR 
exposure and no family history 
• WHY?
Pterygium:Pathology
Pterygium: Pathology
Pterygium: Pathology
State-of-the art…..20 years ago
Procedure 23 years ago 
• Conjuntival autograft 
• 9-0 prolene or 10-0 biosorb sutures 
• Cauthery as needed 
• No amnioti...
Pterygiectomy: Current Procedure 
• No cauterization 
• TISSEEL Fibrin glue; No sutures 
• Amniotic membrane 
• Over donor...
Double Pterigiae 
Pre- 
Op 
12w Post- 
Op
Complications 
• < 1% recurrence rate (Unpublished) 
• 1-2 % Dellen 
• Cornea limbal scarring 
• Ptosis 
• Sub-graft hemat...
Patient KG, after 4 
pterygiectomies in Florida.
Pterygium Study (2002- 
2005) 
• Retrospective 
• 500 Pterygiae (390 Patients) 
• Same surgeon (JAM) in all cases 
• Avera...
Recurrence
Recurrence 
• EVERYONE “CLAIMS” LOW RECURRENCE 
• Published recurrence rates decreasing 
• Most recurrences are unexpected...
Pterygium Research at 
VO 
• Questions: 
• What is our current recurrent rate? 
(DEFINITION?) 
• Does AMT on donor site de...
Pterygium research at VO 
• Data collected in 90+ patients include: 
• PREOP: Full exam, pentacam, ant seg OCT, 
ECC, Osmo...
COSMETIC OUTCOME!? 
The 500 pound 
gorilla in the room
Anterior Segment: Pterygium
Anterior Segment: Pterygium
Anterior Segment: Pterygium
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Anterior Segment: Pterygium

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Petrygium surgery

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Anterior Segment: Pterygium

  1. 1. Anterior Segment Surgery J. Alberto Martinez, M.D. Visionary Ophthalmology Rockville, Dec 7, 2014
  2. 2. Doente atado como preparação para cirurgia a pterígio OUTLINE Pterygium Conjunctivochalasis Limbal stem cell deficiency Glaucoma microimplants
  3. 3. PTERYGIUM
  4. 4. Pterygium • Still a fascinating, mysterious disease. • Etiology still unknown • Optimal management still very controversial • Management is still fraught with complications
  5. 5. Pterygium:Etiology UVR? THEORY: • UVR>> • Mutations>> • Proliferation
  6. 6. PTERYS
  7. 7. Pterygium: Genetic predisposition New evidence: certain populations/families are susceptible to pterygium • Genetic polymorphism (DNA variability) analysis
  8. 8. Ethiology • Most researchers feel pterygium is a TUMOR • P53, tumor suppression gene mutations and decreased of P53 protein • Pterygium can be a precursor of Squamous Cell Carcinoma
  9. 9. Still a Mystery • Many Cases with very little UVR exposure and no family history • WHY?
  10. 10. Pterygium:Pathology
  11. 11. Pterygium: Pathology
  12. 12. Pterygium: Pathology
  13. 13. State-of-the art…..20 years ago
  14. 14. Procedure 23 years ago • Conjuntival autograft • 9-0 prolene or 10-0 biosorb sutures • Cauthery as needed • No amniotic membrane • MMC for recurrent only • 2.16 % recurrence rate
  15. 15. Pterygiectomy: Current Procedure • No cauterization • TISSEEL Fibrin glue; No sutures • Amniotic membrane • Over donor site – single pterygium • Over nasal defect – double pterygium • Intraoperative Mitomycin-C (2 Min.) • Temporal pterygium • Recurrent pterygium
  16. 16. Double Pterigiae Pre- Op 12w Post- Op
  17. 17. Complications • < 1% recurrence rate (Unpublished) • 1-2 % Dellen • Cornea limbal scarring • Ptosis • Sub-graft hematoma>>fenestration • One corneal ulcer in close to 10000 pterygia • 2 Upside down grafts (One necrosed, one regrafted)
  18. 18. Patient KG, after 4 pterygiectomies in Florida.
  19. 19. Pterygium Study (2002- 2005) • Retrospective • 500 Pterygiae (390 Patients) • Same surgeon (JAM) in all cases • Average f/u period: 8.9 mo • Low Recurrence Rate (2.16%) in High Risk Population • Higher Temporal Recurrence (4%)
  20. 20. Recurrence
  21. 21. Recurrence • EVERYONE “CLAIMS” LOW RECURRENCE • Published recurrence rates decreasing • Most recurrences are unexpected (Risk Factors?) • A genetic “recurrence” profile may help predict who may reccur. • Management would be modified. (i.e. MMC)
  22. 22. Pterygium Research at VO • Questions: • What is our current recurrent rate? (DEFINITION?) • Does AMT on donor site decrease healing time? • Does AMT on donor site increase PTOSIS • What happens to goblet cells in donor/host sites • What is the effect of surgery on the endothelium?
  23. 23. Pterygium research at VO • Data collected in 90+ patients include: • PREOP: Full exam, pentacam, ant seg OCT, ECC, Osmolarity, external photos, Impression cytology • INTRAOP: Video recording, Surgical time, speculum separation, size , bleeding rate variations • POSTOP: Blood under graft, graft coverage, elevation, pain scores, ptosis, healing rate
  24. 24. COSMETIC OUTCOME!? The 500 pound gorilla in the room

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