At the Outset<\/strong><\/p>\n\n\n\n When a patient presents with a pterygium, the first thing to decide is whether it\u2019s necessary to do anything at all. Many patients have only mild complaints related to dryness or irritation, and are often best observed or managed medically. Lubrication or topical NSAIDs may help relieve ocular inflammation and reduce the pterygium\u2019s appearance. Protecting the face and eyes from excessive UV exposure may also help, as pterygium is more prevalent in regions that receive strong ultraviolet radiation.<\/p>\n\n\n\n Only a small percentage of pterygium cases warrants surgical excision. Indications for surgery include obstruction of the visual axis, pterygium-induced irregular astigmatism, chronic eye irritation and cosmetic dissatisfaction. <\/p>\n\n\n\n If you do decide to surgically remove the pterygium, your next decision will be to determine how extensive a procedure is required. One day postoperatively, no matter which method you used to remove the pterygium, it\u2019s going to be gone. The question is: Is it going to come back? You want to do everything you can to make sure the answer is \u201cno.\u201d<\/p>\n\n\n\n Surgical Strategy<\/strong><\/p>\n\n\n\n There are many different ways to do a basic pterygium removal, and potentially hundreds of modifications of the surgical technique. The most common method of simple excision takes about five minutes but is associated with a much higher relative risk of the pterygium recurring. For this technique, you simply pry the scar tissue off the cornea and snip it off. It\u2019s effective for about 90 percent of cases, but that means you can expect approximately 10 percent of cases to recur (often with a vengeance). <\/p>\n\n\n\n As a medical adjuvant to the simple snip excision, one might also consider the adjunctive use of antimetabolites such as mitomycin-C on the surgical site. This isn\u2019t something that I usually do however, because mitomycin carries the risk of scleral melting. If you\u2019re concerned enough to pour chemotherapy on the surface of the eye to prevent the pterygium from coming back, then, rather than using the mitomycin technique, the optimal thing to do would be to try the PERFECT technique (explained in detail below<\/em>).<\/p>\n\n\n\n Pterygium Excision<\/strong><\/p>\n\n\n\n We often use a nerve blocker for pterygium excision. Retrobulbar anesthesia is typically most comfortable for the patient because it provides good levels of pain control during the procedure. Take care not to damage the underlying corneal tissue or remove stroma when prying the pterygium off the surface of the eye. <\/p>\n\n\n\n First, make an incision at the limbus where the pterygium begins to encroach over the cornea. Cut it free and peel it from the corneal surface using blunt dissection. Once the pterygium\u2019s been removed, we often polish the cornea with a diamond burr. When the cornea has been repaired, we turn our attention to the sclera and conjunctiva.<\/p>\n\n\n\n Dissect the conjunctiva free from Tenon\u2019s capsule. Remove all of Tenon\u2019s capsule where the pterygium was.<\/p>\n\n\n\n Once you remove the scar tissue from the nasal aspect of the cornea and globe, you must then decide what to put in the gap where the scar tissue used to be. You have a few options:<\/p>\n\n\n\n Option 1: Do nothing. <\/em><\/strong>You can just leave it bare and it\u2019ll re-epithelialize on its own. This has the highest risk of recurrence and induces the most patient discomfort, but it can be done.<\/p>\n\n\n\n Option 2:<\/em><\/strong> Cover the area with a biological material<\/em><\/strong>. Amniotic membrane, which can be placed and glued or sutured over the area of the defect, is a very effective method. We prefer to use glue, since it\u2019s fast and simple. Amniotic membrane makes patients more comfortable and contributes to the healing of the tissue. However, it\u2019s not quite as effective in discouraging recurrence as the third option. <\/p>\n\n\n\n Option 3:<\/em><\/strong> Rotational conjunctival autograft. <\/em><\/strong>This method might not be necessary in every case, but it\u2019s the least likely to lead to recurrence. It\u2019s also the technique I perform most often. <\/p>\n\n\n\n To perform a rotational conjunctival autograft, first measure the conjunctival epithelial defect and how much bare sclera you need to cover. Then, harvest the conjunctiva approximately 90 degrees or 3 to 4 clock hours away from the resected site, usually in the superior globe, with Wescott scissors. Dissect the conjunctiva free from the underlying Tenon\u2019s capsule to an extent that matches the surface area of the pterygium. Create a pedicle flap and rotate it down to cover the area. Glue or suture the flap to the bed with 8-0 vicryl. If using glue, aim for as little glue as possible. Postoperatively, prescribe topical antibiotic drops such as fluoroquinolone q.i.d. for a week, and a steroid drop such as prednisolone acetate q.i.d., tapered over one to three months. <\/p>\n\n\n\n In terms of graft stability, gluing and suturing will give you the most peace of mind. A third technique, autologous in situ<\/em> blood coagulum, will also work if you don\u2019t have access to glue and you do have an extra 10 minutes to hold pressure on the site. The patient\u2019s natural bleeding in the area will coagulate and anchor the amniotic membrane; however, you can\u2019t be as sure as with glue or suture that the tissue will still be adherent after a day or a week. Besides, glue and suture are expensive, but the most expensive thing of all is time in the operating room\u2014holding tissue down with your fingers for 10 minutes is quite expensive.<\/p>\n\n\n\n Recurrence (discussed below) is the most serious postop complication of pterygium excision. Additionally, you have to be concerned about scarring. When you\u2019re cutting on the eye you\u2019re generating scar tissue, so you need to be careful that you don\u2019t end up with a tangled, fibrous mess. This is entirely possible, especially with multiple surgeries. <\/p>\n\n\n\n Other complications you may encounter include scleral melt due to the use of mitomycin-C; fibrosis, especially around the extraocular muscle in that location; infection, which is rare; and ocular surface discomfort, which can last for weeks or even months. Typically, the steroids help ease discomfort, but we also encourage the use of lubricant drops. Keep these complications in mind when forming your surgical strategy.<\/p>\n\n\n\n Recurrence<\/strong><\/p>\n\n\n\n Young people are generally at increased risk for recurrence, as are African Americans and Hispanics of all ages, who tend to have more inflammatory phenotypes. Additionally, patients with double pterygia (on both the nasal and temporal aspects of the cornea) and bilateral double pterygia are at extremely high risk for recurrence. In these patients, you need to take every possible precaution and be very careful if you do any surgery on them.<\/p>\n\n\n\n It\u2019s critical that these patients be watched carefully for recurrence. If you notice the area you\u2019ve resected is starting to grow back, usually at a millimeter-by-millimeter pace, begin aggressive topical steroids immediately, since you want to do everything in your power to avoid a second surgery. If the eye is red and inflamed, that\u2019s the time for drops, not surgery. <\/p>\n\n\n\n However, if you lose the battle\u2014whether you\u2019re inattentive, or the patient comes back years later, or was referred elsewhere and upon their return to you, the pterygium is growing over the visual axis\u2014then it\u2019s time to consider reoperating. <\/p>\n\n\n\n In the event that the pterygium recurs, I recommend trying the PERFECT technique. This technique, which stands for Pterygium Extended Removal Followed by Extended Conjunctival Transplant, was pioneered by Australian ophthalmologist Lawrence Hirst, MBBS, MD, MPH, who runs The Australian Pterygium Centre. It has by far the lowest risk of recurrence, at just 0.1 percent (Figure 1<\/em>). This method involves extensive removal of Tenon\u2019s capsule from the area of the pterygium and surrounding areas and is meant to be used on patients who have recurrent pterygium after previous surgical removal. This procedure has very good cosmetic outcomes, with most patients reporting being unable to tell which eye had surgery. <\/p>\n\n\n\n The PERFECT technique for pterygium consists of three components that each take about 15 to 20 minutes to perform. Following are the steps of the technique as described by Prof. Hirst in a video of the procedure.<\/p>\n\n\n\n![\"\"](\"https:\/\/www.reviewofophthalmology.com\/CMSImagesContent\/2021\/01\/RP\/029_rp0121_cas-1.jpg\")
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