Strategies for handling complex pterygium surgery, complications
Spotlighting aggressive pterygia, recurrent pterygia, symblepharon, corneal scars, scleral melts
Take-home message: In this second of a two-part series on pterygia and pinguecula surgery with cosmetic expectations, Arun C. Gulani, MD, addresses the complex pterygia and complications.
Jacksonville, FL—With a worldwide referral base for complex pterygia and pinguecula complication cases, I have condensed my observations and approach over the past two decades to share in this column.
Personally I have seen less than 1% recurrence rate over 14 years with my technique despite doing very complex pterygia. Additionally, I have had a case of muscle adhesion and a case of pupil abnormality (probably ischemia) in aggressive bitemporal cases.
My approach always as emphasized in the first part of this column (http://bit.ly/1NGKqiJ) is to make sure patients understand the seriousness of this surgery and that complications can happen.
Once again, I must first emphasize that the mindset associated with treating recurrent pterygia and associated complications is the same as when dealing with the virgin pterygial surgery.
Surgeons should not adopt the notion that the previous surgeon did a bad job or that they are now trying to help a patient and therefore aim for a mediocre outcome. Rather, the mindset should be the same as when treating the primary pterygium with the expectation of achieving outstanding cosmetic outcomes on the next postoperative day that will remain stable in the future. Every step should not only correct the problem but also enhance the appearance of the eye and possibly improve vision.
When correcting recurrences and complications arising in pterygia/pinguecula surgery, I have suggested three facets that surgeons must consider: the recurrence and or complications of the lesion itself; the associated conditions such as fornix shortening, corneal and conjunctival scarring, symblepharon, and ischemia or scleral melts; and the predisposing factor for such a recurrence/complication.
Regardless of the expertise of the surgeon who performed the initial surgery, complications can develop that require devising a treatment plan with realistic expectations for the patient but without lowering our own desire to achieve excellence.
I always presume and reiterate to patients that their initial surgeon did the best they could to remove the lesion; the goals of the second surgeon now are to pick up the baton and take it to the end zone by beautifying the eye, correcting the comorbidity of associated problems, and enhancing vision.