dr vidyashankar g k shekar nethralaya bangalore management of pterygium 8/13/2015 1
TRANSCRIPT
Dr VIDYASHANKAR G KShekar Nethralaya
Bangalore
Management of Pterygium
04/19/231
PterygiumDefn : An Elastotic Degenerative condition of
conjunctiva with a wing like encroachment of conjunctiva on to the Cornea.
Pathogenesis – Environmental causes- UV exposure, dust heat , wind
exposure
Heredity Coroneo Effect -Nasal segment of cornea gets highest UV
exposure effect
Limbal Stem cell defect with Fibroblast Activation
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Pterygium - Classification
Primary PterygiumRecurrent Pterygium
Atrophic PterygiumOlder pts, thin translucent body with thin vessels
Pogressive PterygiumThick fleshy growth seen in Younger pts
Head
NeckBody
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PterygiumGrading of pterygium helps for management
Depending on Size- Grade 1 Grade 2 Grade 3
Variants Cystic degeneration
Bidirectional
Pseudo pterygium – present anywhere, neck bridges limbus
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Pterygium- ManagementObservation
Asymptomatic , grade 1 pterygium
Medical ManagementSymptomatic Grade 1 and 2 pterygiumEye drops – Tear substitutes, DecongestantsLocal injections – anti VEGFs, Steroid
Surgical Management
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Pterygium -Surgical ManagementIndications-
Symptomatic patients - recurrent irritation, redness and watering
Visual need- covering visual axis or threatening visual axis- causing irregular astigmatism - Grade 2 and 3 Pterygium
CosmeticTherapeutic
- suspected associated neoplastic degeneration- motility restriction
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Pterygium -Surgical ManagementDifferent Procedures have been described
Excision - Bare sclera technique
Excision and direct suturing of cut ends of conjunctiva
Excision of Head +Rotation and burial of body in inferior
fornix
Excision + Conj Auto graft (CAG) - most preferred
Excision + MMC + Conj Auto graft
Excision + AMG + Conj Auto graft
Excision + MMC + AMG + Conj Auto graft
Excision + Conjunctivolimbal Auto graft
For recurrent pterygium
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Pterygium -Surgical ManagementExcision
Either from medial conjunctival side or from head
Peeling off pterygium from corneal surface
Smoothening of Corneal surface with 15 no Blade or diamond Burr
Conjuntiva sutured with 8-0 Vicryl suture
Limbal apposition - can be done by 10-0 nylon Monofilament suture
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Pterygium -Surgical ManagementAdjuvants – to reduce recurrenceMitomycin C- For recurrent pterygia
Intra op or post op
Uncommonly used
Late Scleral necrosis & melt
Thiotepa – used post op
Beta radiation with Strontium 90
Excimer Laser in PTK mode – for corneal smoothening
High complications
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Pterygium- Surgical Complications
Graft contration Graft edema Graft necrosis Granuloma formation Excessive cautery-
scleral necrosis Infection
Recurrence Corneal scaring Ocular motility
restriction Surgical induced
NecrotisingScleritis (SINS)
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Pterygium- Surgical Complications
Graft contraction – insufficient size of graft
- more chance for granuloma
- watch for recurrence
Graft edema – almost all cases at 1 wk post op
- no intervention
- can be associated with Dellen formation
Graft necrosis – if graft is placed upside down ( reverse)
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Pterygium- Surgical Complications Recurrence – most common complication
-More in Young pts,
-Surgery for progressive & recurrent perygium
-In bare sclera method
Granuloma – more common
-with bare sclera technique
-in young patients
- can be seen at donor site also
® - increase Steroids
- excision if no response
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Pterygium- Surgical Complications
Sterile Surgical induced Necrotising Scleritis (SINS) -more common with MMC usage
- systemic work up for Autoimmune vasculitic disorders- steroids in high dosage - long term systemic immunosuppression - may need Scleral Patch Graft
Excessive cautery- Scleral necrosis in Bare sclera methodNo inflammation, no painAMG or Conj graft
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Pterygium- Surgical ComplicationsOcular motility restriction –
- Extensive excision causing Symblepharon formation- Intra op Medial Rectus muscle damage- Diplopia in post op period
Corneal scaring – - Poor visual acuity and quality of vision due to
irregular astigmatism - PTK Excimer laser may help
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Pterygium- Surgical ComplicationsMicrobial Infection
- rare- Identify organism- culture and sensitivty - antibiotics / antifungals
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Pterygium - ManagementRecent Advances
Local Injections
Anti VEGF agents- Bevacizumab (Avastin) 0.25 mg (0.1 ml)
For both primary & recurrent pterygia
Steroids –Triamcinolone Acetonide (0.1 ml- 2 mg)
For recurrent pterygia
04/19/2316
Pterygium - ManagementRecent Advances
Fibrin Glue Tisseal glue (Baxter Pharma) use for
Conj Auto graft & Amniotic membrane fixation Less Surgical time Less post op irritation Faster recovery ? More recurrence
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