Publication Exclusive: Surgeon details pterygium surgery technique with auto-limbal conjunctival grafting

Pterygium surgery may be required to improve vision or cosmetic appearance or for symptomatic relief, and often it is challenging both intraoperatively and postoperatively. When pterygium and cataract surgeries are staged as two separate procedures, the significant optical benefits of first performing pterygium excision, including decreased corneal topographic astigmatism and improvement in aberrations, can contribute to better IOL calculations and optimal vision following the second stage cataract surgery.

However, a major surgical challenge and one of the most common complications of pterygium surgery is postoperative recurrence. Although an expanding list of surgical techniques is currently available, there is no consensus on a single ideal surgical procedure. The spectrum of procedures includes pterygium excision (wide excision or mini excision), usually combined with various grafting techniques, use of conjunctival autograft or amniotic membrane, and attachment to the ocular surface to cover the exposed bare sclera using tissue adhesives or sutures, with or without the use of mitomycin C or 5-fluorouracil.

Thomas "TJ" John

In this column, Dr. Coroneo describes his surgical technique of pterygium management, combined with ocular surface inflammation control to provide an overall excellent postoperative result while minimizing pterygium recurrence after surgery.

Thomas “TJ” John, MD, OSN Surgical Maneuvers Editor

Pterygium is a prevalent, largely ultraviolet light-related, sight- and cosmesis-blemishing disease for which a plethora of surgical approaches exist. Key concepts in our approach are control of ocular surface inflammation, reconstructive surgical techniques (rather than destructive), minimization of recurrence rates and attention to refractive outcomes. While there is a paucity of comparative data, a widely accepted technique is pterygium excision with auto-limbal conjunctival grafting. I use this technique routinely because it provides low recurrence and complication rates and excellent cosmesis, but it takes time and skill to perform. In a well-conducted, long-term, single-surgeon series, limbal-conjunctival transplantation had a 1% recurrence rate compared with 10% for conjunctival transplantation. This mirrors our experience. Tenon’s capsule is excised locally, but extended excision is not carried out. In primary pterygium excision, we do not interfere with the medial rectus sheath or check ligaments.

Before surgery, ocular surface health should be optimized with aggressive treatment of dry eye syndrome (a factor in recurrence) and timing of surgery to avoid the summer months. Important issues include education of the patient in sun protection and trainees in surgical technique.

After adequate anesthesia, topical brimonidine is used as a vasoconstrictor (without mydriasis). The leading edge of the pterygium is dried, and the pterygium head is excised using a 23-gauge needle-tip technique, minimizing the amount of corneal tissue excised. Vertical incisions down to the anterior stroma delineate the head to the limbus. A relatively superficial plane of dissection is created. A relatively rough stromal surface is left and reverts to a smooth surface after epithelial healing. Care is taken to minimize limbal damage as the limbus is approached, so that sclera is not excised.

Click here to read the full publication exclusive, Surgical Maneuvers, published in Ocular Surgery News U.S. Edition, August 10, 2015.