Textbook of Pterygium Management Namrata Sharma, Tushar Agarwal, Shikha Gupta
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fm1Textbook of Pterygium Managementfm2
fm3Textbook of Pterygium Management
Editors Tushar Agarwal MD Professor Department of Ophthalmology, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India Shikha Gupta MD Assistant Professor Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India Namrata Sharma MD Professor Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
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Textbook of Pterygium Management
First Edition : 2017
9789386261540
fm5Dedicated to
The memory of my father, Dr SP Agarwal
—Tushar Agarwal
While You pen down, I enact to be the writer I bow to You millions of times foreverFor people, assume me to be the Creator!!
—Shikha Gupta
My parents, Dr Ramesh C Sharma and Maitreyi Pushpa, husband Subhash Chandra and daughter Vasavdatta
—Namrata Sharmafm6
fm7Contributors fm9Preface
Pterygium, by definition, is a fleshy ocular mass, most often, on the nasal conjunctiva that may cross the limbus to invade the cornea. In spite of the innocuous description, it has been a resilient adversary for the ophthalmic surgeons.
The entity is known to exist since 1000 BC when Susruta, the first recorded ophthalmic surgeon and the father of Indian surgery, mentioned about it in Susruta Samhita in great details. He described the removal of inflamed and fleshy pterygium by means of hook and a thread with forceps and mentioned about the high probability of recurrence if not excised properly.
This disease has been recognized the world over throughout the centuries. Various medical treatments have been described by Chinese, which inhibit blood vessel formation such as rehmannia, akebia, licorice and ginseng. Dioscorides described the use of gum of acacia, sepia shell power, sweet wood, vinegar and aloe extract and salt to inhibit the recurrence.
With the advent of modern ophthalmic surgery, the surgery for pterygium has been under constant refinement. Though the excision of the lesion is relatively simple, its high predilection for recurrence is what makes it a challenging condition. It continues to be a cause of significant ocular morbidity in various regions of the world. Hence, there are continuously evolving trends in the management of pterygium, both in the terms of experimental drugs and surgeries.
Surgical therapies described in the past used materials such as thread or horse hair, which were used to hook the pterygium to aid its removal. Modern-day surgical therapy involves age old conventions such as simple excision leaving bare sclera underneath, to surgical options such as conjunctival autografts, conjunctival flaps, amniotic membrane grafting, use of chemoadjuvants such as mitomycin C, anti-VEGF molecules like bevacizumab and ranibizumab, and use of B irradiation.
Recurrence after primary lesion is a surgical failure as management of recurrent pterygium is challenging. Despite the abundance of literature on the treatment of pterygium, the sore point remained an unacceptable high recurrence rate of the order of 70–80%, specifically with the technique of bare sclera which was left after the pterygium excision.
The paradigm shift in the management of pterygium was heralded by Kenyon et al. who described the use of conjunctival autograft (CAG) for covering the bare sclera. The conjunctival autograft offered much lower recurrence rates compared with the previous surgical techniques. This development was further strengthened by the introduction of fibrin glue to attach the CAG instead of sutures in 2004 when Koranyi et al. described the modified ‘cut and paste’ technique of pterygium excision with sutureless graft fixation. With the singular step of removal of sutures from the surgery, recurrence rates dropped dramatically.
Over the next decade, this technique was further modified and refined. In the present day, pterygium excision with some form of tissue grafting with the help of fibrin glue appears to have become the gold standard for the treatment of primary pterygium. This technique and its modifications have been described in great detail in the textbook to enable the surgeons to replicate the same.
You will also have the opportunity to view and learn techniques such as extensive tenectomy, narrow strip conjunctival autograft, sandwich technique, autologous blood, mini-flap technique and minor ipsilateral simple limbal epithelial transplantation (mini-SLET).
Despite the advances, challenges still persist in the management of recurrent pterygium. The techniques described in this book for the management of the recurrent pterygium include conjunctival excision with limbal conjunctival autograft with or without mitomycin C/amniotic membrane graft, combined ipsilateral autologous limbus and homologous amniotic membrane transplantation for recurrent symblepharopterygium and ‘sealing the gap’.
Pterygium may be complicated by other coexisting ocular pathologies that may warrant a surgeon's attention while excising the lesion. These special situations include double-headed pterygium, pterygium complicated with co-existing cataract, corneal opacity, ocular surface squamous neoplasia and glaucoma with operated filtering surgery. The steps to manage these variations, have been included in separate chapters.
Despite the best efforts of the surgeons, one might still encounter serious sight-threatening complications such as scleral melt after any form of pterygium surgery and other postsurgical complications with their respective management have been dealt with in the later chapters.
We have deliberately provided minute details of the surgical steps in each chapter. This will ensure that the readers can go on to replicate these techniques in their clinical practice. And that is the ultimate goal of creating the book.
Tushar Agarwal
Shikha Gupta
Namrata Sharmafm10
fm11Acknowledgments
We thank our contributing authors from all over the world. They worked very hard to provide the chapters contained in this book. It is because of their long-term commitments towards teaching and research that this work has been made possible.
We would like to thank Professor (Dr) Atul Kumar, Professor, Head and Chief, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences (AIIMS), New Delhi, India, who has provided us a fertile ground for conducting clinical work and research.
We acknowledge Professor (Dr) JS Titiyal, Head, Cornea, Cataract and Refractive Surgery Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, who has provided us with constant support.
We acknowledge the mentorship provided by Professor (Dr) Rasik B Vajpayee (Vision Eye Institute, Royal Victorian Eye and Ear Hospital, North West Academic Centre, University of Melbourne, Melbourne, Australia). He has inspired us to work on the areas of clinical research that are pertinent to the neediest patients.
The junior and senior residents of Dr Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, deserve a special thanks for their hard work without which the surgical developments described in the book would not have been possible.
We acknowledge the work of the technicians and nurses of Dr Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, whose diligent work makes such projects possible.
We thank Shri Jitendar P Vij (Group Chairman) and Mr Ankit Vij (Group President) of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, whose professionalism, speed of execution and skills in medical publishing can outrival the best in the business.
We would like to thank our families who have sacrificed their precious family time to allow us to spend that time to work on the book.
At the end, we would like to convey our deep sense of gratitude towards our patients, who inspire us everyday with their faith in us, to work better and harder.