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Pterygium: A Practical Guide to Management
© 2009, Jaypee Brothers Medical Publishers
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher.
First Edition: 2009
Typeset at JPBMP typesetting unit
Printed at Ajanta Offset & Packagings Ltd., New DelhiDedicated to
My colleagues and scholars who believe in good basic medical and surgical principles for pterygium management and set out to diagnose and treat in the most effective manner.
My wife and family for putting up with my “practice” of medicine for so long.Foreword
On my first work day within the Surgery Department at Howard Universty College of Medicine in Washington, DC, I was introduced to Alfred Anduze, MD, MH, Leon Reid, MD and Ghaleb Hatem, MD as first year residents in the Ophthalmology Residency Program of July 1975. All the three residents were easy to teach as they were good listeners, avid readers and compassionate physicians. Fred returned to his home St Croix, Virgin Islands, to begin his 舖maiden voyage舗 with the disease 舖pterygium舗. During his first 15 years of busy practice, he maintained the commitment to elevate both standards of patient care and continuing medical education within the Caribbean nations. To this end, he engaged in the Continuing Medical Education (CME) Department at Howard University College of Medicine to provide educational seminars dealing with the common diseases (diabetes, glaucoma, cataract) within the Virgin Islands. These CME ventures were closely followed by the formation of the Ophthalmic Society of the West Indies (OSWI). During one of our early OSWI scientific sessions, Dr Hugh Vaughn of Kingston, Jamaica and one of its first 4 ophthalmologists, made the comment:”Fred, everybody in the Caribbean is an expert on pterygium.” It is true that every practicing ophthalmologist may “see” a lot of pterygium patients, but a few are hardly “experts.” Only Alfred L Anduze MD, MH has separated himself by refusing to blend into the “treat as usual routine”. The ophthalmic world has 舖thereafter舗 been blessed by his relentless desire to remain a student of (constantly learning) and physician for preventing and treating this disease.
Physicians interested in disease prevention will appreciate the ocular and systemic therapies described in the 舖Prevention舗 chapter. Essentially informative is the simple approach to understand sunglasses, hydration (local and systemic) and the avoidance of maximum sunlight exposure times (10 am to 2 pm). The Chapter that correlates the clinical staging of pterygium with its histopathologic characteristics is critical to understand early preventive therapy. Finally, the surgery section, with the appropriate pre– and postoperative regimes in lace, provides established surgical techniques with low recurrence rates. Thank you, Fred, for being the physician, teacher/educator and humanitarian (family and the world) that we know and for finally sharing a 30-year pterygium experience with the world.
John C Merritt md
Prevention for the People, Inc.
Clinton, North Carolina, USAPreface
A pterygium (Gk), as its name suggests, is a wing-like, fleshy mass of tissue usually located in the medial palpebral fissure and commonly affects both eyes with differing severity. In the Caribbean, it is also known as el pterygio and le ptȳrygion. Colloquially, it is referred to as a ‘fish scale’ in the eye, ‘unio’ and simply, as a ‘flesh’. This book is intended to provide a detailed clinical layout for general and specific pterygium cases. It is a guide for students, residents and practitioners who encounter classical as well as unusual cases. It is a manual of clinical situations and deals with how to approach and get the best results. It is based on 35 years of experience with some basic lesions and some of the most complicated cases seen in extreme tropical conditions. It is my hope and expectation that it will be translated and distributed in the regions of the world where pterygium is endemic and becoming more common.
Alfred L AnduzeAcknowledgment
James V Kasin md
Chapter four on Pathology, preparation and interpretation of histological sections (Australia and Virgin Islands).
Eduardo Alfonso md
For features of a corneal lesion and everything there is to know so far about external diseases.
Juan Batlle md
For developing the Ambiodry technique and sharing his knowledge of pterygium with others.
(Santo Domingo, Dominican Republic)
Alfonso Equiguieren md
For his questioning mind and unquestioned loyalty. May he rest in peace.
Khalil Fakim md
For the mucosal graft surgery protocol and complications.
Sam Jones (Artist)
Surgical Technique Illustrations
(St Croix, Virgin Islands)
Jean-Christophe Joyaux md
For encouragement, support and the conjunctival autograft technique and photos.
(Martinique and Bordeaux, France)
John C Merritt md
For inspiration, motivation, unwavering support and repeated reminders to get this work done.
(Clinton, North Carolina)
Basil Morgan md
For continued interest and suggestions on VEGF research.
Raymond Richer md
For sharing conjunctival autograft cases and exposing the positives and negatives of our various techniques.
(Fort-de-France, Martinique, France)
Cyril Reifer md
Of Barbados: First to use conjunctival flaps technique when it was the merest sclera and stick with it, with good results. (Bridgetown, Barbados)
Michel Sickenberg md
For the complicated cases and FRAS and anti-inflammatory treatments prior to and after surgery.
Garth Taylor md
For his solid support and incredible wisdom to see the value of trying new techniques. We will never forget him.
William Trattler md
For trying the conjunctival flaps technique with mitomycin C, realizing its value, expanding on it and sharing his knowledge with others.
Sheffer Tseng MD, phd
Genius of the ocular surface; for the amniotic membrane graft technique and video and your timely advice with complicated cases. (Miami, Florida)
Hugh Vaughn md
For disagreeing (often) and offering alternative solutions such as transposition and bare sclera with beta radiation.
The Ophthalmic Society of the West Indies (OSWI) 舰for providing a forum in which to discuss controversial findings, and its members for being so resistant as to make defining and refining the work a necessity.
Doctors in Hungary, Tunisia, Libya, Egypt, the Netherlands and Mexico, who showed enough interest in the treatment of pterygium to share their views and cases and provide a forum for discussion.Inroduction
Most books and articles on pterygium focus on outcomes. This practical guide identifies the features of a particular case and the reasons for using a particular method.
All of the management strategies are the surgeon's preference and are based on more than 30 years of experience with large, active, tropical pterygia. The repeated themes of protection from UV radiation, inflammation control and restoration of tear film refer to the elements of pathogenesis which have been observed as leading directly to prevention and successful medical and surgical management. Clinical situations involving preoperative treatments, intra-operative techniques and postoperative care are derived from actual patient cases. By following the basic principles and practices of good medicine, initial growth and recurrence of pterygia can be prevented. For the practitioners who see and do 4 or 5 cases a year as well as those who do more than 100 cases, the most effective approaches with the lowest acceptable recurrence rate (<1%) will be highlighted. Recommen-dations and suggestions are based on observed and documented results of over 5000 pterygium cases managed by the author.
For an excellent reference on historical and in-depth perspectives, the textbook, Pterygium Surgery by Lucio Burratto and associates is a comprehensive anthology with excellent information and references and should be used as such.
Most of the information, suggestions and deductive findings in this manual are based on empirical data in the forms of direct and indirect observation of results as well as research studies and is to be used for clinical interpretation and management of the individual case. Much of the content is based on articles written over the years by the author and others from regions in which pterygium is prevalent. Some of the information is anecdotal and will be designated as such. The ideas and suggestions presented are based on logic and experience. Some are controversial and may appear to be circumstantial. This is a clinical, practical guide. It is comprised of management strategies that work. However, when the decision on management of a particular case is made, the practitioner should do what is the most appropriate and effective in his/her hands.
I did my first pterygium operation in 1978, upon my return to the Virgin Islands.
There was a backlog of cases, half of which were recurrences done elsewhere. I used the bare sclera technique which was merely suggested in the textbook without any detailed management and was rewarded with the customary 50% recurrence rate. On the timely, advice from a doctor in Puerto Rico with more experience than I, phenol 30% was tried as an adjunct. It reduced the recurrence rate to about 20% but left the eyes white with thin scleras and poor corneal healing. From that time, prevention made more sense than the endless repeated surgeries and dissatisfied patients. Shortly after, my own pterygium had made an appearance and was responding positively to low dose decongestants and tear film replacement, a regimen that I still use today.
The modified conjunctival flaps technique developed out of common sense and successful outcomes. If you cover the sclera, control inflammation and restore the tear film, you remove the stimulus for the pterygium to grow back. It works. The statements and conclusions that appear in this manual that could seem controversial or circumstantial are derived from solid observations of improvement in structure and function of the eye following appropriate pterygium management.
Pertaining to the layout of the book, note that the themes of Epidemiology and Pathogenesis are closely related to Pathology. Understanding the pathology is essential to the demonstration of behavior of the lesion which determines its character. By identifying its character, a classification and staging can be directly applied to determine the most appropriate surgical treatment.
A chapter on Prevention has been included in this manual in response to the many statements in the medical literature that there is no prevention except for the “possible use of sunglasses”. This is perhaps the most important section as pterygium is a preventable lesion and all the sequences need not occur if a few basic measures are adopted. Early cases have been presented and before and after photos have been provided.
The chapter on Surgery has been simplified to give step by step methods of pterygium treatment to make the patient comfortable and confident in a positive outcome. The conjunctival flap method has been detailed more than the others as this gives the best results by far and has been corroborated by worldwide agreement of those surgeons doing the most cases in the endemic regions. Newer techniques have been included and indications for use specified accordingly.
The surgical correction of pterygium has always commanded all the glory. Likewise, a recurrence receives the shame and stigma of something done incorrectly. The section on recurrence, how to prevent it and how to fix it, is highlighted in Complications. It includes explicit examples and how to avoid them as well as how to fix them. In Clinical Correlations, routine cases are provided so that the practitioner can apply some of the techniques in management directly to clinical practice. Unusual cases with successful outcomes can be used to compare with your own.
Finally, Summary includes a wrap-up of highlights and pearls.
During the early years of my experience with pterygia, while on a celebratory trip to London, I encounterd a set of ancient surgical eye instruments in the Egyptian section of the British museum. These instruments along with the alleged words of the 16th Century French surgeon, Ambroise Parȳ, (in a different section) pertaining to pterygium that “it always grows back”舰 set me to thinking and trying and striving to arrive at the perfect (or near perfect) solution to the pterygium “problem”.
The ultimate purpose of this work is to stimulate interest in pterygium research and publication of journal articles particularly from practitioners and scholars in areas of the tropics where it is endemic. Better methods of prevention should be investigated and more convenient and effective techniques of handling difficult cases should be established. Moreover, those who are presented with challenging cases should consult with those who have been there and are willing to share the experience.
In following some of the suggestions included in this guide, it is my sincere conviction that your outcomes will be successful.
The author has no financial interest in any of the products mentioned in this book.
“When you see multiple viewpoints, you are less attached to your own.”
Questions Most Often Posed by Visiting Ophthalmologists
- What is the pathogenesis of a pterygium?
- Which eyes are most susceptible to pterygium formation?
- Which environment has the highest incidence of pterygium?
- How does a pingueculum become a pterygium?
- What can I do to prevent a pterygium from growing?
- What are the indications for pterygium surgery and when can it be left alone?
- What is the best technique for a specific type of pterygium?
- What is the best way to do surgery to prevent recurrence?
- What is the best way to gain patient confidence, ensure the most comfort and get the best results?
- What is the most important factor in preventing complications?
- What is the basic pathology of the average pterygium?
- Is mitomycin C as bad as the early articles portrayed? What is the most effective and safest dose?
- Is cosmetic pterygium surgery practical?
- Why should bare sclera never be done?
- What are the main causes of postoperative inflammation and how do I avoid them?
- How much astigmatism does pterygium cause and how do I treat it?
- When do you use adjunctive therapy?
- What are the causes of recurrence and how do you prevent them?
- What are some of the vision threatening complications of pterygium surgery?
- Who is to blame when there is a recurrence?