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Simplified pterygium surgery helps reduce recurrence
The key is removal of subconjunctival tissue, surgeon says.
Pterygium is a simple ocular surface disorder, and an operation to remove pterygium is in the category of minor surgery. But the recurrence rate of pterygium is high and, no matter what type of surgery is done, we are often turning a simple disease into a malignant entity. That is, sometimes recurred pterygium invades the sclera, requiring great skill on the part of the surgeon to remove the growth without perforating the sclera.
A common surgical procedure is to bury the pterygium into the conjunctival cul de sac. In the beginning of my ophthalmic career, I was doing transplantation of pterygium into the upper or lower cul de sac, but since 1970 I have devised a very simple operation based on the pathology of the disease. I believe that it is the subconjunctival tissue that gets stimulated or irritated to grow forward. Hence I believe this tissue must be eradicated forever.
Technique described
After surface anesthesia and placing of the speculum, 0.2 cc of xylocaine is injected under the body of the pterygium to facilitate dissection. The apex is dissected out carefully and is lifted upward. The assistant holds its tip, and the surgeon dissects the subepithelial tissue of the pterygium towards the base.
All attachments of this tissue are freed from all sides. Then it is slightly pulled up and artery forceps are applied to the base of this tissue. It is cut off just above the artery forceps.
The cut end held by the forceps is cauterized and released. This tissue, because of its elasticity, recedes back deep into the orbit, from which there is no chance of its growing forward. The apex of the pterygium is cut, and the upper and lower edges of the conjunctiva are closed by placing two sutures, leaving a small bare area of sclera.
The idea is that by the time the denuded cornea is covered by epithelium, the conjunctiva will grow to the limbus. Mitomycin-C is available in India as a 2 mg vial of powder. We add 5 cc of water to this to make an eye drop. One drop is placed daily 3 times a day starting 48 hours postoperatively. On the operating table, antibiotic ointment is applied and the eye is bandaged.
After 24 hours the eye is left open, and any steroid-antibiotic combination eye drop is prescribed three times a day for 1 week.
In the case of a recurrent pterygium, the same procedure is performed, but the subconjunctival tissue does not have as much elasticity as in a primary surgery. Hence the tissue is pushed backwards as much as possible.
In the past 32 years I have done a large number of primary pterygium surgeries using this technique with no recurrence. I have also done the technique in 21 cases of recurrent pterygium, and none of them recurred.
For Your Information:
- N.C. Singhal, DOMS, DO(Lond), FRCS, can be reached at C-115, Greater Kailash-I; Opp. Gurdwara, New Delhi, India 110048; +91-11-6-22-91-24; +91-11-6-42-60-99.