In summary, my protocol using the Iceberg surgical technique for pterygium involves a complete excision followed by mitomycin C application, which is then followed by a scaffold graft like amniotic tissue, with least traumatic healing incentives (sutureless/glue) resulting in consistent outcomes for patients from all over the world despite different heritage and cultures that encourage me to continue to offer and teach this surgical approach.
The part of the pterygium that is visible is only the tip of the iceberg (Iceberg concept). By removing only this visible portion, the main pathology with its tentacles is not addressed and remains hidden under the conjunctiva.
Though pterygia have been classified in many ways, most usually by the extent of involvement, my experience with varied presentations and outcomes in improving the surgical approach and outcomes over the years encouraged me to add an additional way to classify the pterygium based on the adhesion of the head locally, vascularity, and draw test for surrounding tissue involvement.
15.2 Head/Neck Adhesion
Peripheral/central adhesion can further be classified into diffuse, focal, and density based. In cases of peripheral adhesions, the pterygium easily peels off the cornea.
15.3 Vascularity
Engorged, tortous vessels, and simultaneous conjunctival fold contracture signify a more aggressive pterygium. This same concept can be used to determine outcomes postoperatively.
15.4 Draw Test
On tugging on the cornea, some pterygia may be small in size but outright gritty and deep into the cornea, resulting in thin cornea when removed. Preparation for this before surgery helps plan a smooth outcome (amniotic graft itself can be used as a lamellar fill). In addition, removal of these pterygia is more difficult from the corneal surface.
In the present series, we have used amniotic membrane, the innermost layer of the fetal membrane, for the treatment of pterygium wherein after the removal of proliferative tissue, amniotic membrane was placed on the sclera and adhered to the sclera with glue.
In my surgical approach, I continue to evolve my introduction of a nontraumatic, “no-stitch” technique using the criteria below and treat the pterygium as if it were a corneal scar (remember, with every surgery, I plan for unaided 20/20 and wish for surgery to leave the vision untouched or improved).
Thus, the basis of my surgical steps involves a lamellar corneal approach along with atraumatic yet complete pterygium removal as a conjunctival scar centripetally at the cornea and with full dissection right up to the roots, including all arising heads followed by subconjunctival mitomycin C application and amniotic graft layering on the sclera with glue and reconstructing the fornix in many cases. For simplicity of planning surgical approach and expectations including long-term impact, I have classified the criteria that allow me to custom design my surgery to each patient accordingly.
15.5 Surgical Criteria
Extent of the pterygium.
Density of the pterygium.
Involvement of adjacent structures.
Draw test.
Head/neck adhesion.
Vascularity.
The most common ocular surface pathologies that eye doctors see in their practice are pterygium and pinguecula. 7,8,9 These are intriguing pathologies that present themselves in various tissue distributions and vascular patterns. They can vary from small, atrophic lesions to large, aggressive fibrovascular growths that can, in advanced cases, compromise vision.
It is often suggested that prolonged exposure to the sun may instigate pterygia formation, and given anecdotal observations that it emerges more frequently among surfers and golf enthusiasts than in the general population (with greater prevalence in geographically predisposed areas), the relationship appears valid. I see patients from all over the world seeking the best cosmetic and functional outcome they can find. A decade ago, most patients seeking these services were predominantly models, TV news anchors, movie stars, and celebrities where looks were an integral part of their professional lifestyle. Recently, this trend has encompassed people from all walks of life, men and women alike. These patients present complaining that they are self-conscious about this condition, embarrassed by their appearance, and even depressed, in some cases.
In this chapter, I shall share my technique especially using glued, amniotic graft that I have used over nearly two decades on more than 600 eyes, with gratifying and consistent results (▶ Fig. 15.1, ▶ Fig. 15.2, ▶ Fig. 15.3). It enables not only those with cosmetic pterygia and pinguecula, but even those suffering from recurrent and aggressive vision-threatening pterygia, to expect clear, white eyes 1 day postoperatively. Starting with a sutured technique 20 years ago, and adding amniotic grafting 16 years ago, my method has since evolved into a sutureless procedure that incorporates the healing properties of human placenta. Patients are universally satisfied with their aesthetic results within 24 hours and are able to return to work and other daily activities within a couple of days.
Fig. 15.1 (a) Preoperative pterygium. (b) Postoperative appearance day 1. (c) Pinguecula pre-op. (d) Pinguecula 1 day post-op.
Fig. 15.2 (a) High magnification image of pterygium area at medial canthus (note cut end of remnant stump) post-op. (b) High magnification image of pterygium area at limbus post-op. (c) Iceberg concept: small lesion is clinically visible pterygium; the lesion next to it is the actual size on removal. (d) Same patient day 1 post-op with eye makeup.
Fig. 15.3 Next day in the mirror: day 1 post surgery.
This technique neither threatens nor adversely affects vision because there are no incisions involved in the cornea. While the average pterygium recurrence rate is commonly considered to hover around the 10 to 30% mark and higher, the recurrence rate with my technique is less than 0.5%.
My no-stitch technique utilizes human placenta as a scaffold bandage and chemical facilitator. It lends an elegant appearance to the eye and provides comfortable and expedited healing. My pterygia removal technique is called the “Gulani Iceberg Technique” because the part of the pterygium that is visible is just the tip of the iceberg, while the actual growth tends to be much deeper, and this surgical procedure addresses that.
15.6 Preparation to Surgery
In majority of cases, dry eye and ocular surface instability is an associated pathology and symptomatology (▶ Fig. 15.4 and ▶ Fig. 15.5). It is critical to take care of this not only for comfort, but also for long-term healing post pterygium surgery including anecdotally decreasing the progress of coexistent lesions, such as pinguecula in the same or contralateral eye.
Fig. 15.4 and 15.5 Ocular surface analysis with tear film management along with meibomian gland dysfunction stabilization prior to surgery.
Fig. 15.5 MGD, meibomian gland dysfunction; MGP, meibomian gland probing.
Lacrimal plugs are an easy procedure that alleviates dry eye symptoms successfully in many aqueous-deficient cases. I usually select the lower lids to perform this procedure.
Meibomian gland dysfunction (MGD) is a commonly associated condition that can be addressed with ocular therapy including meibomian gland probing (MGP) using disposable probes (Rhein Medical, Tampa, FL) with topical anesthesia using a gel mixture made up of lidocaine and jojoba.
Having performed well over a 1,000 MGP procedures over the last 7 years, we have been extremely gratified with patient responses and satisfaction, not to mention an anecdotal improvement in postoperative surgical healing I have seen when clinically comparing my own postoperative care to that of 7 years ago, the surgical technique being the same.
Various technologies can be used for lid cleaning along with pharmaceutical adjuvants for lid and meibomian gland cleansing before or after accordingly.
Ocular surface stabilization before proceeding with pterygium surgery should be an integral function for a successful preoperative platform.
15.7 Step-by-Step Technique 10,11,12
After a detailed informed consent and having planned my approach using the surgical criteria, my suture-free, three-step, pterygium and pinguecula removal technique includes mitomycin C, amniotic tissue, and Tisseel glue, to completion with patient’s reaction next day in the mirror, observing the recently operated eye for appearance, comfort, and vision.
In a typical case, after topical anesthesia in the form of TetraVisc is applied with preoperative topical antibiotic drops, I begin with a fixation stitch at the opposite limbus using 7-o black silk and then mark the extent of the pterygium and visible interpalpebral area with a sterile marking pen. Intralesional anesthesia in the form of lidocaine with epinephrine is used (1–2 mL). (This can also delineate the extent of the pterygium in obscure or recurrent cases.) Depending on the appearance and draw test, I will decide to approach the pterygium at the contracted medial conjunctival fold and proceed nasal to limbal (centripetal approach) or from the limbal head toward the medial conjunctival fold (centrifugal approach).
My mental attitude does not change whether the case is primary, recurrent, complex, or complicated (▶ Fig. 15.6, ▶ Fig. 15.7, ▶ Fig. 15.8, ▶ Fig. 15.9, ▶ Fig. 15.10, ▶ Fig. 15.11, ▶ Fig. 15.12, ▶ Fig. 15.13, ▶ Fig. 15.14, ▶ Fig. 15.15, ▶ Fig. 15.16, ▶ Fig. 15.17, ▶ Fig. 15.18). At the start of the procedure, the head of the pterygium is delineated from the cornea underneath. This can be done with posterior-to-anterior sweep using the Gulani pterygium cross-action spreader. In cases of mild adhesions, the pterygium can be easily separated from the cornea (mostly peripheral pterygia) or be effectively peeled in a single centrifugal movement.
Fig. 15.6 (a) Central, focal, pterygium pre-op. (b) One day post-op. (c) One week post-op. (d) One year post-op. (e,f) 1 day post-op OD. (g,h) 12 years post-op OS. OD, oculus dexter; OS, oculus sinister.
Fig. 15.7 (a) Central, diffuse, translucent pre-op. Next day post-op (b) peripheral and focal, (c) peripheral and diffuse, and (d) central, diffuse, and dense.
Fig. 15.8 (a,b) Aggressive medial impacting and raised bullous pterygium to cosmetic outcomes next day.
Fig. 15.9 Tissue grading system.
Fig. 15.10 Vascular grading system.
Fig. 15.11 (a) Recurrent, aggressive pterygium pre-op. (b) Day 1 postoperative appearance of same patient. (c) Multiple recurrent, aggressive pterygium pre-op. (d) One year postoperative appearance of the same patient.
Fig. 15.12 (a) Recurrent, aggressive pterygium pre-op. (b) Day 1 postoperative appearance of same patient. (c) Multiple recurrent, aggressive pterygium pre-op. (d) One year postoperative appearance of the same patient.
Fig. 15.13 (a-d) Lateral pterygium pre and post-op.
Fig. 15.14 (a-d) Carcinoma in situ pre-op and post-op.
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