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 1% recurrence rate (Unpublished)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