Management of Pterygium Dr VIDYASHANKAR G K Shekar Nethralaya Bangalore 4/19/2017

Pterygium Defn : 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 4/19/2017

Pterygium - Classification Primary Pterygium Recurrent Pterygium Atrophic Pterygium Older pts, thin translucent body with thin vessels Pogressive Pterygium Thick fleshy growth seen in Younger pts Body Neck Head 4/19/2017

Pterygium Grading of pterygium helps for management Variants Depending on Size- Grade 1 Grade 2 Grade 3 Variants Cystic degeneration Bidirectional Pseudo pterygium – present anywhere, neck bridges limbus 4/19/2017

Pterygium- Management Observation Asymptomatic , grade 1 pterygium Medical Management Symptomatic Grade 1 and 2 pterygium Eye drops – Tear substitutes, Decongestants Local injections – anti VEGFs, Steroid Surgical Management 4/19/2017

Pterygium -Surgical Management Indications- Symptomatic patients recurrent irritation, redness and watering Visual need covering visual axis or threatening visual axis causing irregular astigmatism Grade 2 and 3 Pterygium Cosmetic Therapeutic suspected associated neoplastic degeneration motility restriction 4/19/2017

Pterygium -Surgical Management Different 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 4/19/2017

Pterygium -Surgical Management Excision 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 4/19/2017

Pterygium -Surgical Management Adjuvants – to reduce recurrence Mitomycin 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 4/19/2017

Pterygium- Surgical Complications Graft contration Graft edema Graft necrosis Granuloma formation Excessive cautery- scleral necrosis Infection Recurrence Corneal scaring Ocular motility restriction Surgical induced Necrotising Scleritis (SINS) 4/19/2017

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) 4/19/2017

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 4/19/2017

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 method No inflammation, no pain AMG or Conj graft 4/19/2017

Pterygium- Surgical Complications Ocular 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 4/19/2017

Pterygium- Surgical Complications Microbial Infection - rare - Identify organism - culture and sensitivty - antibiotics / antifungals 4/19/2017

Pterygium - Management Recent 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 4/19/2017

Pterygium - Management Recent 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 4/19/2017

THANK YOU 4/19/2017