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,
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
12.
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
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
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