Low recurrence rate achievable with TissueTuck pterygium technique
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Historically, pterygium excision techniques were complicated and inconsistent, undermining many surgeons’ confidence and often leading to delays in surgery until the pterygium had progressed into the visual axis.
Recurrence remains a challenge, with varying rates described in literature. In one study, researchers found pterygium recurrence rates as high as 88% with an uncovered bare sclera and as low as 5.8% among patients who had pterygium excision with adjunctive amniotic membrane (AM) transplantation and intraoperative mitomycin C.
The TissueTuck technique described below addresses not only the inflammatory root cause of pterygium but also the many shortcomings of traditional pterygium surgery while achieving the lowest recurrence rate of 0.7% in peer-reviewed literature.
TissueTuck technique
A foundational principle of the TissueTuck technique is performing a meticulous and extensive dissection and resection of fibrovascular tissue and Tenon’s. This creates a smooth tissue transition, ensuring functional healing and great cosmesis. Regardless of pterygium size, the technique is the same. Likewise, planned in accordance with the position of the eyelids, the margins of resection remain the same, keeping the wound margins hidden by the upper and lower eyelid margins. Only the clean AM covering the scleral bed is visible in the interpalpebral region for cosmesis and prevention of graft dislocation caused by blinking.
Another key foundational principle is reconstruction of the semilunar fold. Whereas most other techniques only remove the pterygium, our procedure places equal importance on using AM as a platform to reconstruct a semilunar fold while the eye is in full abduction during surgery. The technique employs a traction suture and placement of the eye in abduction for good exposure to flatten out the muscle belly against the globe. We do not violate the muscle or muscle sheath to allow for reconstruction of the semilunar fold so that, postoperatively, the eye can only abduct as far as we had it in traction. The gap is sealed with the eye in full abduction and further sealed when the eye returns to primary gaze so that the wound margins are even better hidden, further recessing the root of the pterygium posteriorly.
No other surgical technique described to date has detailed reconstruction of the semilunar fold. By simultaneously sealing that gap between conjunctiva and Tenon’s where recurrence will begin, this procedure provides a double layer closure of that gap, reconstructs the semilunar fold, and contributes to functional healing and cosmesis, all with a sutureless technique and without MMC. Because this technique does not involve autograft, it can be performed more efficiently and comfortably, with faster healing of one primary surgical site instead of two.
Clinical outcomes
Our center performed a retrospective review of patients with primary or recurrent pterygium who underwent surgery using the TissueTuck technique with cryopreserved amniotic membrane (CAM) between January 2012 and May 2019. A total of 582 eyes were included in what is, to date, the largest study of pterygium surgery in the ophthalmic literature.
We found a 0.7% recurrence rate with a median follow-up of 24.5 months in cases with primary pterygium without MMC. The overall recurrence rate of 2.3% included patients with double-headed pterygium, previous recurrence and/or ethnic predisposition to recurrence. At the last follow-up, best corrected visual acuity improved from logMAR 0.23 at baseline to logMAR 0.19. Average surgical time was 14.7 minutes, and postoperative complications included granuloma formation (7.9%) and scarring (3.8%).
Our study design and reporting were inherently unique. Data from many previous studies reflect varied surgical techniques, often across multiple sites or by multiple surgeons. Even studies featuring AM are not internally consistent regarding type of AM (dehydrated vs. cryopreserved) or method of use. Our study reports on a highly consistent, reproducible technique performed by a single surgeon.
Although prior studies have strictly defined recurrent pterygium and/or featured relatively shorter follow-up, our retrospective analysis included lower reporting thresholds and extended follow-up to more accurately reflect success and complication rates. For instance, a recurrence was defined as any fibrovascular or scar tissue anywhere in the surgical site, regardless of crossing the limbus at that point. In addition, our protocol designated 10 to 20 seconds of 0.02% MMC exposure vs. 2 to 5 minutes reported by other researchers.
Cryopreserved amniotic membrane
By conveying powerful biologics, CAM provides faster regenerative healing, facilitates functional reconstruction and inhibits scar tissue formation. While conjunctival autograft may be associated with lower recurrence than in methods using different AMs in vastly different techniques, CAM specifically demonstrated remarkably lower recurrence rates in our study with excellent cosmetic results in reduced operative times.
Having now been reproduced by more than 250 surgeons nationwide, the TissueTuck technique has lowered the bar, helping surgeons — myself included — feel more confident in surgical management of pterygium. Rather than waiting for a visually debilitating pterygium with potential for higher complication rates, we now offer patients proactive therapy with far greater confidence in the long-term outcome.
- References:
- Desai NR, et al. Cornea. 2023;doi:10.1097/ICO.0000000000003111.
- Nuzzi R, et al. Clin Ophthalmol. 2018;doi:10.2147/OPTH.S186543.
- Rosen R. Cornea. 2018;doi:10.1097/ICO.0000000000001407.
- For more information:
- Neel R. Desai, MD, of The Eye Institute of West Florida, can be reached at desaivision2020@gmail.com.
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