Anterior Segment
Surgery
J. Alberto Martinez, M.D.
Visionary Ophthalmology
Rockville, Dec 7, 2014
Doente atado como preparação para
cirurgia a pterígio
OUTLINE
Pterygium
Conjunctivochalasis
Limbal stem cell
deficiency
Glaucoma
microimplants
PTERYGIUM
Pterygium
• Still a fascinating, mysterious
disease.
• Etiology still unknown
• Optimal management still very
controversial
• Management is still fraught with
complications
Pterygium:Etiology UVR?
THEORY:
• UVR>>
• Mutations>>
• Proliferation
PTERYS
Pterygium: Genetic
predispositionNew evidence: certain populations/families are
susceptible to pterygium
• Genetic polymorphism (DNA variability) analysis
Ethiology
• Most researchers feel pterygium is a
TUMOR
• P53, tumor suppression gene
mutations and decreased of P53
protein
• Pterygium can be a precursor of
Squamous Cell Carcinoma
Still a Mystery
• Many Cases with very little UVR
exposure and no family history
• WHY?
Pterygium:Pathology
Pterygium: Pathology
Pterygium: Pathology
State-of-the art…..20 years ago
Procedure 23 years ago
• Conjuntival autograft
• 9-0 prolene or 10-0 biosorb sutures
• Cauthery as needed
• No amniotic membrane
• MMC for recurrent only
• 2.16 % recurrence rate
Pterygiectomy: Current Procedure
• No cauterization
• TISSEEL Fibrin glue; No sutures
• Amniotic membrane
• Over donor site – single pterygium
• Over nasal defect – double pterygium
• Intraoperative Mitomycin-C (2 Min.)
• Temporal pterygium
• Recurrent pterygium
Pre-
Op12w Post-
Op
Double Pterigiae
Complications
• < 1% recurrence rate (Unpublished)
• 1-2 % Dellen
• Cornea limbal scarring
• Ptosis
• Sub-graft hematoma>>fenestration
• One corneal ulcer in close to 10000 pterygia
• 2 Upside down grafts (One necrosed, one
regrafted)
Patient KG, after 4
pterygiectomies in Florida.
Pterygium Study (2002-
2005)• Retrospective
• 500 Pterygiae (390 Patients)
• Same surgeon (JAM) in all cases
• Average f/u period: 8.9 mo
• Low Recurrence Rate (2.16%) in High Risk Population
• Higher Temporal Recurrence (4%)
Recurrence
Recurrence
• EVERYONE “CLAIMS” LOW RECURRENCE
• Published recurrence rates decreasing
• Most recurrences are unexpected (Risk Factors?)
• A genetic “recurrence” profile may help predict
who may reccur.
• Management would be modified. (i.e. MMC)
Pterygium Research at
VO
• Questions:
• What is our current recurrent rate?
(DEFINITION?)
• Does AMT on donor site decrease healing time?
• Does AMT on donor site increase PTOSIS
• What happens to goblet cells in donor/host sites
• What is the effect of surgery on the endothelium?
Pterygium research at VO
• Data collected in 90+ patients include:
• PREOP: Full exam, pentacam, ant seg OCT,
ECC, Osmolarity, external photos, Impression
cytology
• INTRAOP: Video recording, Surgical time,
speculum separation, size , bleeding rate
variations
• POSTOP: Blood under graft, graft coverage,
elevation, pain scores, ptosis, healing rate
COSMETIC OUTCOME!?
The 500 pound
gorilla in the room