Slide 1
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Contemporary Techniques in the
Management of Primary and
Recurrent Pterygium
ALLAN R. SLOMOVIC ,MA, MD, FRCS(C)
*ASSOCIATE PROFESSOR, OPHTH, UNIVERSITY
HEALTH NETWORK
*RESEARCH DIRECTOR, CORNEA SERVICE,UHN
*CHAIRPERSON, CONTINUING PROFESSIONAL
DEVELOPMENT, CANADIAN OPHTHALMOLOGICAL
SOCIETY
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Slide 2
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TISSUE GLUE

THE AUTHOR HAS NO FINANCIAL
INTEREST IN THE PRODUCTS
DISCUSSED IN THIS PRESENTATION
Alcon – Paid consultant
 Allergan- Paid consultant
 Bausch and Lomb- Paid consultant
 AMO – Research assistance

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Slide 3
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2 COMPELLING REASONS WHY IT IS
IMPORTANT FOR THE
COMPREHENSIVE
OPHTHALMOLOGIST TO KNOW HOW
TO MANAGE PTERYGIA

1. IT IS A COMMON CONDITION, ESPECIALLY
IN ISRAEL, WHICH CAN ADVERSELY EFFECT
YOUR PATIENT’S QUALITY OF LIFE eg
REDUCED VISION, CHRONIC OCULAR
IRRITATION AND REDNESS

2. EFFECTIVE SURGICAL MANAGEMENT IS
AVAILABLE
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Slide 4
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DEFINITION

“A TRIANGULAR-SHAPED
GROWTH CONSISTING OF
CONJUNCTIVAL
EPITHELIUM AND
HYPERTROPHIED
SUBCONJUNCTIVAL
CONNECTIVE TISSUE,
OCCURRING MEDIALLY
AND LATERALLY IN THE
INTERPALPEBRAL
FISSURE AND
ENCROACHING ON THE
CORNEA.”
– Mark Mannis- Ocular Surface
Disease 2002

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Greek “pterygos” =a small
wing
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DIFFERENTIAL DIAGNOSIS
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
PINGUECULA

SIMILAR IN HISTOLOGY AND
PERHAPS A PRECURSOR.

DISTINGUISHED BY- 1. DOES
NOT INVOLVE THE CORNEA
2.-THE
UNDERLYING FIBROVASCULAR
TISSUE ARE NOT RADIALLY
ORIENTED TOWARDS THE
CORNEAL APEX
Slide 6
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INFLAMMED PINGUCULA

RECURRENT
BOUTS OF
INFLAMMATI
ON RESULT
IN
PTERYGIUM
FORMATION
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Slide 7
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PSEUDOPTERYGIUM

A CONJUNCTIVAL
FIBROVASCULAR
SCAR OCCURRING
2y TO
– MECHANICAL OR
CHEMICAL
TRAUMA,
– PERIFERAL
DEGENERATIONS
(EG, MOOREN’S
ULCER)
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Slide 8
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INDICATIONS FOR SURGERY:
1.ABSOLUTE



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1.INVOLVES OR
THREATENS THE
VISUAL AXIS
2.REDUCED VISION
FROM REGULAR/
IRREGULAR
ASTIGMATISM
3.DIPLOPIA FROM
TRACTION ON
E.O.M.(ESP IN PRIMARY
GAZE)
Slide 9
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INDICATIONS FOR SURGERY:
RELATIVE
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
1. CHRONIC
IRRITATION

2. COSMETIC

3.CONTACT LENS
INTOLERANCE OR
WISHING REFRACTIVE
SURGERY
Slide 10
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OPERATIVE TECHNIQUE

Anaesthetic: topical
tetracaine and subconj
lidocaine

Traction suture, if
necessary

Mark conjunctival
portion pterygium
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OPERATIVE TECHNIQUE
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
57 BEAVER BLADE IS
USED TO DISSECT THE
HEAD & NECK OF
PTERYGIUM BACK TO
LIMBUS

COMPLETE REMOVAL
OF ALL PTERYGIUM
TISSUE AT BOWMAN’S
MEMBRANE WHICH
HELPS TO MINIMIZE
POSTOP SCARRING
AND ASTIGMATISM
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OPERATIVE TECHNIQUE

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UNDERMINE THE
CONJUNCTIVAL
PORTION OF THE
PTERYGIUM WITH
BLUNT WESCOTT
SCISSORS
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OPERATIVE TECHNIQUE

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SHARP DISSECTION
OF CONJUNCTIVAL
PORTION OF
PTERYGIUM
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OPERATIVE TECHNIQUE

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POLISH/SMOOTH
THE LIMBUS WITH
BEAVER BLADE OR
DIAMOND DUSTED
BURR
Slide 15
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OPERATIVE TECHNIQUE
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Slide 23
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1 week
1 week
1 month
3 months
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Slide 24
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“Fibrin Glue Versus Sutures for Attaching the
Conjunctival Autograft during Primary Pterygium
Surgery”
BJO 2008
S Srinivasan, M Dollin, P McAllum, Y Berger, D S Rootman, A R Slomovic
40 eyes 40 patients
20 Tisseel; 20 10-0 vicryl
Results:



1.
2.

–
“ The degree of postoperative inflammation was significantly less in eyes
undergoing pterygium surgery with fibrin glue at 1 and 3
mospotoperatively (p=0.19) “
“Conjunctival grafts secured with fibrin glue were as stable as those
obtained with sutures”
Conclusion:
“This is the 1st prospective clinical study to demonstrate that the
conjunctival graft secured with fibrin glue during pterygium surgery
are not only as stable as those obtained with sutures, but also
produce significantly less inflammation at 1 and 3 months postoperatively”
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Slide 25
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Application of Fibrin Glue to
Conjunctival Autograft During
Primary Pterygium surgeryASCRS 2007
Sathish Srinivasan, Allan Slomovic
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Results


Single center retrospective chart review
Medical records of 65 eyes of 62 patients
underwent primary pterygium surgery with
fibrin glue over a 5 month period (between
April to September 2005).
30 / 62 (46%) were females.

The median age of this cohort was 53 years
(range 31-81 years).

The mean follow-up time was 9.5 months
(range 9 to 14 months).
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RESULTS

There were no intraoperative complications.

Post operatively conjunctival graft
displacement was noted in 2/65 eyes (3.1%).

At 9 ½ months followup there was no
evidence of recurrence that required repeat
surgery.
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Slide 28
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Management of Recurrent Pterygium with
Intraoperative Mitomycin C and Conjunctival Autograft with
Fibrin Glue
AJO in print
Raneen Shehadeh Mashor, MD; Sathish Srinivasan , MD; Corey Boimer; Kenneth Lee
; Oren Tomkins, MD; Allan R Slomovic , MD,MA,FRCSC
--------------------------------------------------------------------28 eyes 28 patients with recurrent pterygia who underwent
P.E.C.A.
– 0.02% MMC for 2 minutes
– Tisseel to adhere the conj autograft
Conclusion:
1. 1st published report P.E.C.A. using fibrin glue combined
with intraoperative MMC 0.02%
2. Safe and effective surgical option for treating recurrent
pterygium.
3. Recurrence rate =3.5%
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Slide 29
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RECURRENCE RATE
TISSEEL (2005)
– N=65 eyes
SUTURES (9-0 VICRYL)
(1995) n=95 eyes




0/65 RECURRENCESprimary Pterygium
3.5%- Recurrent Pterygium
(AJO 2011)
POSTOP COMPLICATIONS
– GRAFT DISPLACEMENT-2
EYES
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

4% (2/52EYES)- 1e
PTERYGIA
10% (4/41 EYES)RECURRENT PTERYGIA
POST OP COMPLICATIONS
• NECROTIC GRAFT -2
EYES
• DELLEN-1 EYE
Slide 30
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EYE RUBBING CAUSING CONJUNCTIVAL
GRAFT DEHISCENCE FOLLOWING
PTERYGIUM SURGERY WITH FIBRIN GLUE
Eye (2007), 1–3

2 out of a cohort of 65 eyes
 Instructed not to remove the eye pad for 24hrs
and not to rub eye for the 1st 2 days
 Both patients admitted to premature removal of
the eye pad and to intense rubbing of the eye
from day 1
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Pt no: 30, male, 47yrs, graft
displacement noted on day 4
post op, repositioned and
secured with interrupted 10-nylon
sutures.
Pt no: 43, 51 yrs male, graft
displacement noted on day 5,
graft refloated with glue and
secured with 2 anchoring
episcleral sutures.
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Slide 33
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CONCLUSION:
Application of Fibrin Glue to Adhere the Conjunctival Autograft
During Pterygium surgery
Safe and Effective Method of Managing Both Primary and
Recurrent Pterygia

TISSEEL OFFERS SEVERAL ADVANTAGES OVER
SUTURES:
1.
2.
3.
4.
5.
DECREASED PATIENT PAIN (OPERATIVE AND POSTOPERATIVE),
REDUCED SURGICAL TIME
SIGNIFICANT REDUCTION IN POSTOP INFLAMMATION,
RECURRENCE RATE=0%
MINOR AND CORRECTABLE POSTOPERATIVE COMPLICATIONS
•
2 CONJUNCTIVAL GRAFT DISLOCATION- BOTH REPAIRED W/O
RECURRENCE
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Slide 35
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
EXTRA SLIDES
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Slide 36
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Tisseel kit-2.Duplojet
Injector Syringe
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Slide 37
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© 2003 By Default!
Slide 38
Tisseel

A commercial human fibrin
glue
 Used in other areas of
Medicine (neuro-surgery,
cardiology, orthopedics,
urology, ENT) and
Ophthalmology
(Glaucoma, Strabismus,
Refractive Surgery)
 Properties: sealing, gluing
and hemostasis
– Compelling case for using
Tisseel in pterygium
management
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Slide 39
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TISSUE GLUE

OFF LABEL USE
 EVIDENCE-BASED
INFORMATION IN
PEER-REVIEWED
JOURNALS HAVE
DOCUMENTED THE
ADVANTAGES OF
USING TISSUE GLUE
IN THE CONTEXT OF
PTERYGIUM
MANAGEMENT
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Slide 40
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ADVANTAGE OF USING
TISSEEL IN PECA
1.
LESS PAIN
 INTRAOPERATIVENO SUTURES ARE
PLACED
 POSTOPERATIVE –
NO NEED TO
REMOVE SUTURES
2.
FASTER
3.
Less
Inflammation…
perhaps decreased
recurrence rate
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Slide 41
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Tisseel Glue

Contains two of the
components that makes the
blood clot: Fibrinogen and
Thrombin
1. Sealant protein composed of
human plasminogen,
fibrinogen, fibrinonectin
factor XIII reconstituted with
human aprotinin.
2. Sealant setting solution
composed of human
thrombin reconstituted with
calcium chloride.
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Slide 42
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Tisseel kit-2.Duplojet Injector
Syringe
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Slide 43
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Safety Record of Tisseel

Human plasma pools are tested for presence of
genome sequences of HIV, HBV and HCV

Tisseel is vapor-heated to inactivate viruses

No evidence of disease transmission
» 33 YEARS OF USE
» 50 COUNTRIES
» 17 MILLION APPLICATIONS
» 3500 PUBLICATIONS IN SURGICAL JOURNALS
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Slide 44
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Tisseel - the kit

Choose SLOW setting time
• 2 SETTING TIMES BASED ON THROMBIN
CONCENTRATION

SLOW- allows 90 seconds placement and
adjustment of the conjunctival graft, after
tissue glue has been applied
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