Anterior Segment: Pterygium
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Petrygium surgery
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Anterior Segment: Pterygium
- 1. Anterior Segment Surgery J. Alberto Martinez, M.D. Visionary Ophthalmology Rockville, Dec 7, 2014
- 2. Doente atado como preparação para cirurgia a pterígio OUTLINE Pterygium Conjunctivochalasis Limbal stem cell deficiency Glaucoma microimplants
- 3. PTERYGIUM
- 4. Pterygium • Still a fascinating, mysterious disease. • Etiology still unknown • Optimal management still very controversial • Management is still fraught with complications
- 5. Pterygium:Etiology UVR? THEORY: • UVR>> • Mutations>> • Proliferation
- 6. PTERYS
- 7. Pterygium: Genetic predisposition New evidence: certain populations/families are susceptible to pterygium • Genetic polymorphism (DNA variability) analysis
- 8. Ethiology • Most researchers feel pterygium is a TUMOR • P53, tumor suppression gene mutations and decreased of P53 protein • Pterygium can be a precursor of Squamous Cell Carcinoma
- 9. Still a Mystery • Many Cases with very little UVR exposure and no family history • WHY?
- 14. State-of-the art…..20 years ago
- 15. Procedure 23 years ago • Conjuntival autograft • 9-0 prolene or 10-0 biosorb sutures • Cauthery as needed • No amniotic membrane • MMC for recurrent only • 2.16 % recurrence rate
- 16. Pterygiectomy: Current Procedure • No cauterization • TISSEEL Fibrin glue; No sutures • Amniotic membrane • Over donor site – single pterygium • Over nasal defect – double pterygium • Intraoperative Mitomycin-C (2 Min.) • Temporal pterygium • Recurrent pterygium
- 18. Double Pterigiae Pre- Op 12w Post- Op
- 19. Complications • < 1% recurrence rate (Unpublished) • 1-2 % Dellen • Cornea limbal scarring • Ptosis • Sub-graft hematoma>>fenestration • One corneal ulcer in close to 10000 pterygia • 2 Upside down grafts (One necrosed, one regrafted)
- 20. Patient KG, after 4 pterygiectomies in Florida.
- 21. Pterygium Study (2002- 2005) • Retrospective • 500 Pterygiae (390 Patients) • Same surgeon (JAM) in all cases • Average f/u period: 8.9 mo • Low Recurrence Rate (2.16%) in High Risk Population • Higher Temporal Recurrence (4%)
- 22. Recurrence
- 23. Recurrence • EVERYONE “CLAIMS” LOW RECURRENCE • Published recurrence rates decreasing • Most recurrences are unexpected (Risk Factors?) • A genetic “recurrence” profile may help predict who may reccur. • Management would be modified. (i.e. MMC)
- 25. Pterygium Research at VO • Questions: • What is our current recurrent rate? (DEFINITION?) • Does AMT on donor site decrease healing time? • Does AMT on donor site increase PTOSIS • What happens to goblet cells in donor/host sites • What is the effect of surgery on the endothelium?
- 26. Pterygium research at VO • Data collected in 90+ patients include: • PREOP: Full exam, pentacam, ant seg OCT, ECC, Osmolarity, external photos, Impression cytology • INTRAOP: Video recording, Surgical time, speculum separation, size , bleeding rate variations • POSTOP: Blood under graft, graft coverage, elevation, pain scores, ptosis, healing rate
- 27. COSMETIC OUTCOME!? The 500 pound gorilla in the room
Editor's Notes
- Typical histologic features of Pterygium: In the advancing head of thepterygium, conjunctival-like epithelium merges abruptly with corneal epithelium. The underlying bowman’s layer is fragmented and precedes a fibrovascular stroma(asterisc)
- Goblet cell hyperplasia. Note double arrows. B: Pterygium C: normal conjunctiva.
- Elastotic changes