EyeWorld India September 2020 Issue

EWAP SEPTEMBER 2020 13 FEATURE Dr. Hovanesian said that a technique that includes amniotic membrane as the graft would need to be combined with mitomycin, due to its higher recurrence rate. Even in low doses though, Dr. Hovanesian said there is risk for serious complications with mitomycin. “Most people would agree it’s best to avoid mitomycin, but it’s what you use if you need to,” he said. Postop regimen Dr. Hovanesian said his use of a retrobulbar block (bupivacaine mixed with lidocaine 2%) allows the patient to be comfortable on the first night postop. He also patches the eye. The next day, Dr. Hovanesian said the patient is started on a steroid. “I’ve had good success with Lotemax SM [loteprednol etabonate ophthalmic gel 0.38%, Bausch + Lomb] four times a day for a week, then I see them 1 week after surgery and adjust accordingly,” he said, explaining that he’ll taper over a month for low-risk patients and longer for higher-risk patients. Dr. Hirst also said he’ll patch for the first night and advises patients wear a patch for the following 2 weeks when taking a bath or shower. He starts patients on intensive topical steroids (prednisolone every 2 hours for the next 2 weeks, then continued four times a day for a further 6 weeks). He also puts them on an antibiotic drop for a week. Dr. Hirst said patients often have pain the first night, S mall variations in technique can make the difference between an excellent outcome or any number of intraoperative difficulties or postoperative complications. We must think about pterygium surgery beyond simple excision of the pterygium and low recurrence rates, broadening the definition of success to include recovery speed, cosmesis, avoiding complications, preserving normal conjunctiva, and restoring functional anatomy. An ideal procedure needs to achieve these endpoints while respecting our limited OR time. The Tissue Tuck Technique evolved naturally—and by necessity—from lessons learned from leaders in the field like Hirst, Hovanesian, Kenyon, and Tseng. It attempts to integrate critical aspects of their unique techniques. Tissue Tuck is admittedly novel only in how it integrates features of other described techniques to arrive at a 10- to 15-minute procedure that has a low recurrence rate (<1% in more than 900 cases) and fast cosmesis (1–2 weeks), and is reproducible. To start, a traction suture is placed for better visualization, reduced muscle trauma, and reconstruction of the semi-lunar fold with cryopreserved amniotic membrane while the globe is in full abduction, provides cosmesis and unrestricted movement. Subconjunctival extravasation of 2% epi-lidocaine provides anesthesia and separation of natural tissue planes. An extensive tenonectomy recesses the gap from which recurrences originate, and bipolar cautery is used to tether the fibrovascular root of the pterygium to tenons posteriorly, taking advantage of tenons’ tendency to retract and sealing the gap to recurrence. Finally, the membrane is placed with fibrin glue and meticulously tucked to reconstruct the semi-lunar fold and barricade fibrovascular growth. The membrane functions and handles like a “ready-made” conjunctival autograft without the sacrifice of normal tissue or procedural time. Its active biologics also support rapid re-epithelialization and inhibit inflammation and scarring. but when the patch is removed the following day, 80% don’t require further pain medication. Final thoughts from Dr. Hirst Dr. Hirst had a few final thoughts regarding pterygium removal and published research on techniques. First, he said he thinks recurrence needs to be defined as any new fibrovascular growth, not just growth that manages to cross 1–2 mm over the limbus, a threshold set by many studies. “That means that all those people where it has crossed the limbus but less than 1 mm, in these studies, aren’t a recurrence,” he said. Dr. Hirst said patients need to be followed for at least a year to pick up on 97% of recurrences. Finally, he added, it’s not good enough to just have a low recurrence rate. “You’ve got to now meet the gold standard and also give patients a good cosmetic appearance,” Dr. Hirst said. EWAP References 1. Kenyon KR, et al. Conjunctival autograft transplantation for advanced and recurrent pterygium. Ophthalmology. 1985;92:1461– 1470. 2. Hirst LW. Prospective study of primary pterygium surgery using pterygium extended removal followed by extended conjunctival transplantation. Ophthalmology. 2008;115:1663–1672. Editors’ note: Dr. Hirst practices at the Australian Pterygium Centre, Queensland, Australia, and declared no competing interests. Dr. Hovanesian practices at Harvard Eye Associates, Laguna Hills, California, and has relevant interests with Bausch + Lomb and Katena. Tissue Tuck Technique utilizing the best of many approaches by Neel Desai , MD, Eye Institute of West Florida Tampa, Florida