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Pterygium Surgery with Sutured Conjunctival

Autografts David S. Rootman, MD, FRCSC

Associate Professor, University of Toronto

Why Sutures When We Can Glue?

l More secure fixation of autograft l  Less likely to dislocate l Stretches out a smaller autograft l  Long track record l No bovine or foreign blood products l  Less messy l Good suturing practice l  Less expensive

Disadvantages of Sutures

l Takes longer l More difficult l Sutures irritate patient l More likelihood of bleeding l May have to remove sutures

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

Keratectomy

l As described by Richard Abbott l  7-0 Silk fixation suture l  Inject under pterygium with 1% xylo with

epi l Angled cut at anterior edge of pterygium l Smooth dissection in anterior stroma l Removal of all scar tissue on cornea l Similar to making a phaco scleral tunnel

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Keratectomy Release of Tenon’s Capsule

l Do not over dissect l Release medial rectus on both sides l Allow conjuctiva to slide back to caruncle l Mark extent of excision l Minimal removal of conjunctiva l Stay away from caruncle

Autograft harvesting

l Measure area of resection l Pull eye downward l Use Gentian violet to mark area l Central mark to help orientation l Rhomboidal shape, wider at posterior

edge l Make graft as thin as possible

Meaure autograft

Alignment of Graft

l Slide conjunctiva on cornea, Tenon up l Appose limbal cells to limbus at site of

excision l Secure with 10-0 monofilament vicryl l Turn graft over after secured at limbus

Suturing of Autograft

l Secure in all four corners with scleral bite l Avoid medial rectus to minimize bleeding l Close nasal conjuntiva to conjunctiva of

graft, no scleral bite here l Close edge to edge superiorly and

inferiorly l No exposed Tenon capsule, prevents

granuloma l Do not advise running suture

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Bandage Contact lens

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

Complications

l Recurrence l  Inflammation l Melting (more common with Mito C) l  Infection l Bleeding l Dellen l Granuloma

Recurrence

Inflammation Necrosis

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Infection Dellen

Conclusions

l Pterygium excision with conjunctival flap is a good procedure with low complication rates

l Using sutures is a good alternative compared with tissue glue