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    Strategies for handling complex pterygium surgery, complications

    Spotlighting aggressive pterygia, recurrent pterygia, symblepharon, corneal scars, scleral melts


    To perform minimal dissection, the goal is to identify the bare sclera by careful and gentle cut down through the recurrent scar tissue.

    The first surgeon has usually done a nice job of preparing a clear/bare sclera. Once that plane is reached the most difficult part is over. In most cases now the rest of the scariform tissue lifts off like a “plate of armor” from the underlying sclera.

    Following this approach there is minimal bleeding. Bleeding usually occurs when surgeons chase the scar tissue from different approaches and cut into it causing multiple planes with a messy and distorted anatomy that further complicates the surgical steps.

    In most recurrent cases referred to me, the original pterygium was removed only partially. The surgical steps described in Part 1 of this column can now be followed. These include mitomycin C application and application of Tisseel Glue (Baxter International) along with amniotic graft reconstruction.

    Focusing on associated pathology

    After the mass of the pterygium is removed, the surgeon should consider the anatomy and methods to improve the ocular appearance and address the associated comorbidities.

    One such adjustment is forming the fornices. This is done by redeepening and relieving the conjunctival scarring and symblepharon, clearing the corneal area using a number 64 blade without cutting in a smooth rapid fashion, and then applying an amniotic graft to reconstruct the fornix by deepening it and arranging the conjunctiva in an elaborate fashion such that it is cosmetically hidden under the lids but is functionally viable.

    As described in part 1 of this column, the amniotic membrane can be used to cover the sclera. This can also be multilayered to strengthen the thin sclera. The membrane is attached using Tisseel Glue. The area of the corneal scar is smoothed and application of the amniotic membrane can be extended beyond the limbus onto the cornea for better healing. In many of these cases, I use ProKera (Bio-Tissue) or AmbioDisk (IOP Ophthalmics) on the day after the surgery.

    Sclera melts are another possible complication of pterygium surgery; some of these are self-resolving while others require a tissue intervention such as lamellar cornea, conjunctival, or Tenon’s pedicles, and amniotic graft reconstruction. In severe cases, I also use Tutoplast (Tutogen Medical GmbH) with amniotic graft combination to further reconstruct and strengthen the sclera.

    Next: Predisposing comorbidities + Slideshow

    Arun C. Gulani, MD
    Dr. Gulani is director of refractive surgery and chief, cornea & external disease, as well as assistant professor, department of ...

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