Having mastered the art of performing pterygium and pinguecula surgery to a cosmetic outcome with minimal refractive inducement on the cornea leads us to offer premium cataract and laser vision surgery to these patients who otherwise were relegated to the category of “not a candidate” (▶ Fig. 16.1, ▶ Fig. 16.2). Fig. 16.1 (a,b) Next-day cosmetic outcomes and 16 years’ experience lead to confidence in planning for a visual platform besides aiming for cosmetic appearance. Postop, postoperatively. Fig. 16.2 (a-c) Aggressive pterygium with scar with clearance and stability at 12 years postop. On the other end of this spectrum are cases of successful Lasik and premium cataract surgery who may have developed subsequent pterygium or pinguecula surgery, and it is our responsibility to maintain or enhance that good vision is achieved while operating on their ocular surface. These two goals at the end of a large spectrum highlight my desire to conquer and share the final frontier in ocular surface surgery: Look Good, See Good! So, let us first understand the gravity of this situation and need for recognition enough to make us visually accountable while performing ocular surface surgery including pterygium surgery. Even if my practice has a global referral base of complex cases, I am sure in most practices, pterygium or pinguecula patients usually present with associated ammetropia be it myopia, hyperopia, or astigmatism and of course, presbyopia in some cases. Many of these patients cannot wear contact lenses comfortably due to irregular eye globe contour caused by existent pterygium mass or irregular corneal contour due to associated corneal involvement by pterygium or scars. Additionally, even if some of them fit well, most of these cases have ocular surface instability and dry eyes, which make their contact lens wearing an uncomfortable experience even with a good fit. Also, since millions of patients worldwide have undergone vision corrective surgery as Lasik or cataract surgery, we must honor the vision that their previous surgeon had delivered for them, 1,2 and thus be very conscious in our pterygium surgery dissection to avoid any refractive error inducement. I have stratified the impact of pterygium on vision and refractive surgery into the following anatomically related categories: Tear film instability and deficiency Bulk effect in distorting globe contour Bulk effect in distorting globe contour Forniceal distortion and irregular conjunctival distortion thus making it difficult for suction based technology, i.e., Lasik, INTACS, and femtosecond cataract surgery Scar, which affects vision directly Irregular ammetropia (most usually astigmatism) Higher order aberrations Inaccurate refractive and keratometry measurements, thus impacting accurate Laser vision or cataract surgery In summary, all of the above categories need to be normalized and made accurately measureable to proceed with any vision corrective surgery. You can see now how performing pterygium surgery or pinguecula surgery, or for that matter, any ocular surface surgery becomes an intense technique where you have to worry about vision, to either maintain or enhance it with your surgery while aspiring for a cosmetic outcome. For the sake of simplifying this full-spectrum pterygium surgical allocations, 3,4 I have divided them into two basic categories to aid kerato-lenticulo-refractive endeavors: Prepare the cornea and ocular surface. Repair the cornea and ocular surface. These two categories will summarize majority of the cases we see in our everyday practice with a desire to either take every patient to cosmetic outcomes and also provide options for premium refractive surgery or at least, maintain their best vision if they have had refractive surgery in the past. As I always teach, no eye surgery is complete without addressing the patient’s vision. For instance, the elegance of this no-stitch amniotic graft technique enables many patients who were initially non-candidates for laser refractive surgery or premium lens refractive surgery (due to tissue-induced irregular astigmatism, corneal scars, tear film instability, or higher order aberrations) to be safely prepared for vision corrective surgery, such as Lasik, laser surface ablation, and even premium IOL (intraocular lens implant) cataract surgery. The removal of corneal scars and pterygium tissue, and the resultant clear and measurable optical system, in essence safely and elegantly convert patients from non-refractive surgery candidates into refractive surgery candidates. Given the active lifestyles of patients of all age groups today along with their demands for cosmetic appeal and vision freedom we can therefore plan vision corrective surgery fowling a foundation of successful ocular surface surgery (▶ Fig. 16.3). Fig. 16.3 We see this active couple who underwent my pterygium surgery to a cosmetic outcome which also simultaneously restored their corneal irregularity to a smooth measurable refraction so we could confidently then allow them to elect for Premium Cataract surgery with Multifocal Lens implants to 20/20 vision at all distances without glasses. At 11 years postoperative gate they are still enjoying sparkling white eyes with 20/20 vision without any glasses and actively pursuing life’s many sporty endeavors.
16.2 Ocular Surface
16.3 Conjunctival
16.4 Corneal
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