Surgeons weigh merits of pterygium management techniques
Click Here to Manage Email Alerts
Welcome to another edition of CEDARS/ASPENS Debates. CEDARS/ASPENS is a society of cornea, cataract and refractive surgery specialists, here to discuss some of the latest hot topics in ophthalmology.
This month, Sumitra Khandelwal, MD, discusses the use of conjunctival autografts for patients with pterygium, while Neel R. Desai, MD, discusses a novel technique that uses amniotic membrane.
Kenneth A. Beckman, MD, FACS
OSN CEDARS/ASPENS Debates Editor
Conjunctival autograft
I favor conjunctival autograft for a few reasons, and it is my go-to method of treating patients. With experience, it is a quick and easy method, especially with tools such as Tisseel glue (Baxter) that allow us to do the procedure more quickly and with less inflammation. Even the trainees can learn the steps for an autograft and perform them within 15 to 20 minutes.
It also costs less for the surgical center because we do not have to order amniotic membrane, which is not always reimbursed by insurance companies. Because we operate here at the VA and at our county hospital, access and cost have to be considered. When you do a primary conjunctival autograft, you are using the patient’s own tissue. Therefore, you are not incurring an additional cost for the membrane.
Studies have shown that various techniques of conjunctival autograft have a lower recurrence rate compared with amniotic membrane. It is exciting to see newer techniques of using amniotic membrane, especially the technique Dr. Desai discusses. However, I also need technologies that are repeatable in all hands, including my trainees. For these newer procedures, we need more published data in which multiple surgeons are doing it with similar outcomes.
Multiple peer-reviewed studies show primary conjunctival autograft is better than amniotic membrane. Our county hospital, for example, showed increased recurrence with amniotic membrane compared with autograft, especially in high-risk populations such as Hispanic patients and African American patients.
There are times amniotic membrane is needed, such as a large defect or poor quality conjunctiva. However, sometimes we still use conjunctival autograft at the limbus to start and then layer amniotic membrane graft on top. That allows for double coverage without having to use too much tissue from the patient.
I think we are all open to using other techniques as well, but the steps to a conjunctival autograft pterygium excision are important for all anterior segment surgeons to know.
- For more information:
- Sumitra Khandelwal, MD, can be reached at Baylor College of Medicine, 1977 Butler Blvd., 2nd Floor, Houston, TX 77030; email: sumitra.khandelwal@bcm.edu.
Amniotic membrane
It bears mentioning that pterygium surgery is not a popular surgery among surgeons or patients. It can be fraught with complications such as recurrence, granuloma formation, scarring and restrictive diplopia. To top it off, patients are unhappy because it can be a prolonged healing process, and it is an uncomfortable surgery that may not yield a good cosmetic result.
In my center, we have been working on a new technique we call the tissue tuck technique that uses amniotic membrane in a sutureless fashion. The technique is predicated on doing an extensive excision of the fibrovascular tissue, as well as the surrounding Tenon’s, before functional reconstruction of the semilunar fold with the amniotic membrane graft while the eye is on full traction in full abduction. That gives us better exposure and operative visibility and tightens up the muscle.
When the eye is returned to primary gaze, the so-called gap that the pterygium root originates from is well sealed with the amniotic membrane in a redundant fashion, reconstructing the semilunar fold and providing adequate conjunctival laxity to allow the eye to have a full range of motion without restriction.
We recently presented a study in which we looked at 582 eyes from patients who had at least 6 months of follow-up to capture a recurrence rate. We found that among patients with primary single-headed pterygia, in whom the tissue tuck technique was used without mitomycin C, the recurrence rate was 0.7%.
As for other complications, we saw a granuloma formation rate of 7%, and scarring of any kind was 4%. There were seven cases of reported mild restrictive diplopia and extreme lateral gaze. The median time for surgery was 13.7 minutes. This technique is not only fast and efficient, but it ultimately has low recurrence rates. We feel that it is an improvement over conjunctival autograft, which inherently takes more time for the patient to heal.
The tissue tuck technique is now being used by more than 250 surgeons across the country after we trained them in our center. We hope that by calling more attention to this technique and its key features, we can improve patient outcomes.
- For more information:
- Neel R. Desai, MD, can be reached at The Eye Institute of West Florida, 1225 West Bay Drive, Largo, FL 33770; email: desaivision2020@gmail.com.
Collapse
Read more about
Click Here to Manage Email Alerts