Following my previous chapter regarding a relentless mindset to deliver pterygium patients an eye that is cosmetically enhanced (▶ Fig. 14.1) and visually improved, 1,2,3 I shall in this chapter discuss my experience with complex pterygium cases and complications.
Fig. 14.1 (a,b) Next day postoperative appearance of pterygium and pinguecula surgery. OS, oculus sinister.
Once again, I want to reiterate the “mindset.”
Aggressive pterygia, recurrent pterygia, symblepharon, corneal scars, scleral melts, etc. should be approached with the unshakable desire to not only restore the ocular anatomy and fix the complication but to also deliver an eye to emmetropic vision and a cosmetic outcome.
With a worldwide referral base for complex pterygia and pinguecula complication cases, I have condensed my observations and approach over nearly three decades to share in this chapter.
Personally, I have seen <0.5% recurrence rate over 16 years with my sutureless amniotic technique despite doing very complex pterygia. Nevertheless, I have witnessed and experienced some adverse outcomes as stated before including self-limiting ones, such as pyogenic granulomas, mild scleral thinning, and subamniotic hemorrhage (▶ Fig. 14.2) while also having been responsible for a case each of muscle adhesion, accidental graft displacement, and pupil deformation.
Fig. 14.2 (a,b) Self-limiting subamniotic hemorrhage.
This only underscores the fact that I insist every patient verbalize full understanding of this surgery despite the wonderful results they may have read about or reviewed in their research as well as make every surgeon accountable for their responsibility toward outcomes which in many cases could be patient or incident dependent.
Once again, I must first emphasize that the mindset associated with treating recurrent pterygia and associated complications is the same as when dealing with the virgin pterygium surgery.
Surgeons should not adopt the notion that the previous surgeon did a bad job, or that they are now trying to help a patient and therefore aim for a mediocre outcome. Rather, the mindset should be the same as when treating the primary pterygium with the expectation of achieving outstanding cosmetic outcomes on the next postoperative day that will remain stable in the future. Every step should not only correct the problem but also enhance the appearance of the eye and possibly improve vision too.
When correcting recurrences and complications arising in pterygia/pinguecula surgery, I have suggested four facets that surgeons must consider 4,5,6:
The recurrence and/or complications of the lesion itself.
Associated conditions, such as fornix shortening, corneal and conjunctival scarring, symblepharon, ischemia, or scleral melts.
Predisposing factor for such a recurrence/complication.
Plan an endpoint that will allow that patient to avail of options for vision corrective surgery, that is, Lasik, premium cataract surgery, etc.
Regardless of the expertise of the surgeon who performed the initial surgery, complications can develop that require devising a treatment plan with realistic expectations for the patient, but without lowering our own desire to achieve excellence.
I always presume and reiterate to patients that their initial surgeon did the best they could of removing the lesion; the goals of the second surgeon now are to pick up the baton and take it to the end zone by beautifying the eye, correcting the comorbidity of associated problems, and enhancing vision.
14.2 Resecting Recurrent Lesions
In summary of my previous book chapter where I have described my “iceberg” surgical concept in detail using sutureless, amniotic graft along with mitomycin C (MMC) application and glue, we should keep the mentality of minimalistic dissection and have a single goal of finding the bare sclera by careful and gentle cut down through the recurrent scar tissue. 7,8
The first surgeon has usually done a nice job of preparing a clear/bare sclera waiting to be discovered. Once we reach that plane, you can take a breath as the most difficult part is over. In most cases, now the rest of the scariform tissue lifts off like a “plate of armor” from the underlying sclera.
Following this approach, there is minimal bleeding (bleeding usually occurs when surgeons chase the scar tissue from different approaches and cut into it causing multiple planes with a messy and distorted anatomy that further complicates surgical steps).
In majority of recurrent cases that are referred to me, I will find the original pterygium only partially removed; therefore, I insist on complete removal of primary pterygium as a basis of consistent success in virgin eyes. Follow the surgical technique as outlined to completion including MMC application and Tisseel glue along with amniotic graft reconstruction (▶ Fig. 14.3 and ▶ Fig. 14.4).
Fig. 14.3 (a,b) Recurrent pterygium excision, next day and long-term the appearance.
Fig. 14.4 Aggressive bitemporal recurrent pterygium with medial and lateral sutureless AMT and sliding Tenon technique laterally. AMT, amniotic membrane transplantation.
14.3 Focusing on Associated Pathology
After the mass of the pterygium is removed, the surgeon should consider the anatomy and methods to improve the ocular appearance and address the associated comorbidities.
One such adjustment is forming the fornices. This is done by redeepening and relieving the conjunctival scarring and symblepharon, clearing the corneal area using a number 64 blade without cutting in a smooth rapid fashion, and then applying an amniotic graft to reconstruct the fornix by deepening it and arranging the conjunctiva in an elaborate fashion such that it is cosmetically hidden under the lids, but is functionally viable.
This amniotic membrane can also be used in layers to reinforce the sclera while creating normal anatomical relations of the ocular surface. The membrane is attached using Tisseel glue (Baxter International). The area of the corneal scar is smoothed, and application of the amniotic membrane can be extended beyond the limbus onto the cornea for better healing. In many of these cases, I use ProKera (Bio-Tissue) or AmbioDisk (Katena) on the day after the surgery.
Sclera melts are another possible complication of pterygium surgery; some of these are self resolving while others require a tissue intervention, such as lamellar cornea, conjunctival, or Tenon’s pedicles, and amniotic graft reconstruction. In severe cases, I also use Tutoplast with amniotic graft combination to further reconstruct and strengthen the sclera (▶ Fig. 14.5, ▶ Fig. 14.6, ▶ Fig. 14.7, ▶ Fig. 14.8, ▶ Fig. 14.9, ▶ Fig. 14.10c).
Fig. 14.5 Recurrent, lateral pterygium sclera reinforced with Tenon’s pedicle anchor.
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