1. Pterygium Surgery with Sutured Conjunctival Autografts David S. Rootman, MD, FRCSC Associate Professor, University of Toronto

2. Why Sutures When We Can Glue? More secure fixation of autograft More secure fixation of autograft Less likely to dislocate Less likely to dislocate Stretches out a smaller autograft Stretches out a smaller autograft Long track record Long track record No bovine or foreign blood products No bovine or foreign blood products Less messy Less messy Good suturing practice Good suturing practice Less expensive Less expensive

3. Disadvantages of Sutures Takes longer Takes longer More difficult More difficult Sutures irritate patient Sutures irritate patient More likelihood of bleeding More likelihood of bleeding May have to remove sutures May have to remove sutures

4. Seven Principles of Procedure 1. Smooth partial keratectomy 2. Release of Tenon’s capsule constriction 3. Thin autograft 4. Alignment of graft 5. Secure suturing of graft 6. Bandage contact lens

6. Keratectomy As described by Richard Abbott As described by Richard Abbott 7-0 Silk fixation suture 7-0 Silk fixation suture Inject under pterygium with 1% xylo with epi Inject under pterygium with 1% xylo with epi Angled cut at anterior edge of pterygium Angled cut at anterior edge of pterygium Smooth dissection in anterior stroma Smooth dissection in anterior stroma Removal of all scar tissue on cornea Removal of all scar tissue on cornea Similar to making a phaco scleral tunnel Similar to making a phaco scleral tunnel

7. Keratectomy

8. Release of Tenon’s Capsule Do not over dissect Do not over dissect Release medial rectus on both sides Release medial rectus on both sides Allow conjuctiva to slide back to caruncle Allow conjuctiva to slide back to caruncle Mark extent of excision Mark extent of excision Minimal removal of conjunctiva Minimal removal of conjunctiva Stay away from caruncle Stay away from caruncle

9. Autograft harvesting Measure area of resection Measure area of resection Pull eye downward Pull eye downward Use Gentian violet to mark area Use Gentian violet to mark area Central mark to help orientation Central mark to help orientation Rhomboidal shape, wider at posterior edge Rhomboidal shape, wider at posterior edge Make graft as thin as possible Make graft as thin as possible

10. Meaure autograft

11. Alignment of Graft Slide conjunctiva on cornea, Tenon up Slide conjunctiva on cornea, Tenon up Appose limbal cells to limbus at site of excision Appose limbal cells to limbus at site of excision Secure with 10-0 monofilament vicryl Secure with 10-0 monofilament vicryl Turn graft over after secured at limbus Turn graft over after secured at limbus

12. Suturing of Autograft Secure in all four corners with scleral bite Secure in all four corners with scleral bite Avoid medial rectus to minimize bleeding Avoid medial rectus to minimize bleeding Close nasal conjuntiva to conjunctiva of graft, no scleral bite here Close nasal conjuntiva to conjunctiva of graft, no scleral bite here Close edge to edge superiorly and inferiorly Close edge to edge superiorly and inferiorly No exposed Tenon capsule, prevents granuloma No exposed Tenon capsule, prevents granuloma Do not advise running suture Do not advise running suture

14. Bandage Contact lens Apply at end of procedure Apply at end of procedure More comfort for patient More comfort for patient No patch needed No patch needed Leave on for 2 weeks Leave on for 2 weeks Lessens chance of Dellen Lessens chance of Dellen Steroids for 6 weeks qid or until eye white Steroids for 6 weeks qid or until eye white

15. Complications Recurrence Recurrence Inflammation Inflammation Melting (more common with Mito C) Melting (more common with Mito C) Infection Infection Bleeding Bleeding Dellen Dellen Granuloma Granuloma

16. Recurrence

17. Inflammation

18. Necrosis

19. Infection

20. Dellen

21. Conclusions Pterygium excision with conjunctival flap is a good procedure with low complication rates Pterygium excision with conjunctival flap is a good procedure with low complication rates Using sutures is a good alternative compared with tissue glue Using sutures is a good alternative compared with tissue glue