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

1. Dr Priya Srinivas,
DO, FRCS, Cornea Fellow- Sankara Nethralaya
Shree Eye Care Mulund

2. Pterygium
triangular shaped growth
consisting of bulbar
conjunctival epithelium and
hypertrophied
subconjunctival connective
tissue encroaching into
cornea

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. 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. Stages—
T1( atrophic),
--episcleral vessels
clearly seen
T 3 ( fleshy)—
episcleral vessels
obscured
T2 ( intermediate )

6. Indications for excision
Irregular astigmatism
Encroachment on visual
axis
Recurrent inflammation
Chronic irritation
Motility restriction
Cosmetic disfigurement

7. Pterygium +
Cataract
Pterygium surgery followed
by cataract surgery after 6
weeks for K stabilization

8. Treatment options
1) Bare sclera excision
2)Excision with conjunctival closure/transposition
3) Excision with adjunctive medical therapy
4) Ocular surface transplantation

9. Ocular surface transplantation
Conjunctival autografting(CAU)
Rotational/ annular autografts
Conjunctival limbal autograft(CLAU)
Amniotic membrane grafting(AMG)

10. Conjunctival autograft (CAU)
Autologous free conj
graft
Obtained from superior
bulbar conjunctiva
Same eye/opposite eye
Gold standard in
pterygium surgery

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

13. 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

14. 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

15. 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

16. 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

17. video

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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.

24. 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

25. Complications
Intra operative
 Corneo scleral perforation
-- Excessive tissue removal
--pseudopterygium
Rectus muscle disinsertion
--severe recurrent pterygia

26. Post op
Graft edema
Graft
hemorrhage
Graft retraction

27. COMPLICATIONS
Graft inversion and necrosis
Dellen
Conjunctival granuloma
Inclusion cysts

28. 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