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    Strategies for handling complex pterygium surgery, complications

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


    The Tenon’s pedicle can be used to supply vascularity to a usually ischemic sclera and the lamellar cornea can be used in cases with superficial scleral thinning and glued in place for a cosmetically appealing endpoint.

    Granulomas also can occur in some case and can resolve spontaneously with steroids or gentle cautery excision.

    In extensive and deeper scleral involvement, I also have used Tutoplast and tried to always keep it the least bulky as possible. While these are salvage cases, the extraocular movement and appearance should be preserved as best as possible.

    These cases can look cosmetically appealing the next day after surgery and remain that way for years to come. An anchor suture can be used if needed. Clearing and strengthening are the main objectives, although cosmesis and vision are the primary desires.

    Corneal scars can be easily addressed using Laser Corneoplastique principles as explained in previous columns (Decoding Corneal Scars) and the patients can achieve emmetropia.

    Predisposing comorbidities

    If predisposing conditions such as rheumatoid arthritis, Sjögrens syndrome, dry eye, or collagen vascular diseases are present, we must involve the patient’s physician for a systemic workup and management.

    In addition, every attempt at surgery raises the chances of a recurrence so we must strive to do it right the first time following the principles of the Iceberg concept.

    This minimalistic approach results in surprisingly good results for these patients with its elegant arrangement of tissue. The cosmetic outcomes, high functionality, and improved vision are the final goals of this surgery regardless of the preoperative appearance. Therefore, recurrent pterygia can be addressed in the same fashion but with a slightly different approach and the same mindset as the initial surgeries.

    Importantly, numerous patients of mine who have undergone complex pterygial surgery and complication correction have also undergone subsequent laser vision surgery and premium Cataract surgery with excellent visual outcomes.

    Next: A caveat + 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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