Surgical Technique for Primary Pterygium

Estimated surgery time: 20 minutes. (See Pterygium Key Surgical Step Slides & Key Surgical Step Video)

 

 

 

 

 

 

 

     Primary Pterygium Before        Primary Pterygium After

Insert a 15 mm solid blades Speculum (K1-5014 Katena), apply Epinephrine (1:1000) for hemostasis and 2% lidocaine gel (Astra Zeneca) for Topical Anesthesia P.S. Avoid peribulbar anesthesia which may distort the tissue plane

Place 7-0 Vicryl Traction Suture at the superior and inferior limbal sclera for adequate exposure and fixation of the globe 

Excise pterygium head and body by using 0.12 forceps to pick up the conjunctiva in front of the semilunar fold (Fig. 1), and use scissors to make a conjunctival peritomy up and down. Then pick up the fibrovascular pterygium tissue toward the surgeon while using scissors to truncate it from the fornix without damaging the muscle or the Tenon(Fig. 2).

  Figure 1                                 Figure 2

Apply MMC (0.02% to 0.04%): Cut strips from a Weckcel’s slant edges, soak them in the MMC solution, and apply approximately 2-3 sponges to subconjunctival fibrovascular tissue at the fornix edge (Fig. 3)of the conjunctiva above the Tenon for 2 min for mild, for 3 min for moderate, and 4 min for severe pterygium while using a Q-tip to dry the bare sclera (Fig. 4). Irrigate the contact surface with half a bottle of BSS after the incubation.

 Figure 3                                  Figure 4

Seal the gap between the conjunctiva and Tenon using fibrin glue: Apply one drop of each of the two components to the gap and then seal it by approximating them with two 0.12 forceps (Fig. 5) 

  Figure 5

Transplant Cryopreserved Amnion Graft with Fibrin Glue: Peel the cryopreserved AmnioGraft off from the nitrocellulose paper. Lay it on the bare sclera with the  sticky/stromal surface facing down. Flip one half of the graft up to cover the other half revealing the bare sclera.

Apply the fibrinogen oily/cloudy solution to the bare sclera and/or the stromal side of the graft. Next, apply the thrombin/watery/clear solution to the same area.

Using two 0.12 forceps to flip back the graft to re-cover the bare sclera. Stretch and flatten the graft with two forceps at different areas for a total of 45 sec before final smoothening by a muscle hook. Repeat the above steps to the other half of the membrane. Trim any excess membrane and fibrin glue from around the defect and then tuck the graft underneath the conjunctival edge and seal the conjunctiva over the graft with fibrin glue placed in between (Fig. 6).

Always check the adhesion strength at the edge of the graft by 0.12 forceps. If the graft detaches, do “touch up” by applying fibrin glue to the unsecured areas.

  Figure 6

See Primary Pterygium Minimal Dissection Video

Video of Suturing Cryopreserved Amniotic Membrane after pterygium excision Click here for video of suturing cryopreserved amniotic membrane during primary pterygium surgery.


Additional Points:

  • Minimize cauterization to blood vessels to avoid inflammation or ischemia.
  • Engorged vessels are intrinsically normal and invariably regress.
  • Avoid isolation of recti muscles by hook.
  • It is not necessary to cover superficial corneal epithelial defect with the graft or a contact lens.
  • Inject Kenalog in the surrounding host conjunctiva if it is too inflamed at the end of surgery.

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