PTERYGIUM.pptx

Pterygium

1. PTERYGIUM Dr Jeel Garala Ophthalmology Dept CU Shah Medical college

2. DEFINITION PTERYGIUM is a triangular encroachment of the vascularized granulation tissue covered by conjunctiva in the interpalpebral area. It is the degenerative condition of the conjunctiva.

3. ETIOLOGY Pterygium is a response to prolonged effect of environmental factors such as: Exposure to sun (ultraviolet rays) Dry heat High wind Abundance of dust

4. PATHOGENESIS Pterygium is degenerative and hyperplastic condition of conjunctiva. The subconjunctival tissue undergoes elastotic degeneration and proliferates as vascularised granulation tissue under the epithelium. It ultimately encroaches the cornea. It destroys the superficial layers of stroma and bowman’s membrane. Formation of dense fibrous tissue leads to development of corneal astigmatism .

5. CLINICAL FEATURES (1) DEMOGRAPHY: Age: Usually common in old age. Sex: more common in males doing outdoor work than females. It is usually bilateral and more common on nasal side.

6. CLINICAL FEATURES (2) SYMPTOMS: Foreign body sensation Irritation Diminution of vision as it encroaches the pupillary region of cornea and due to corneal astigmatism. Cosmetic intolerance Diplopia

7. CLINICAL FEATURES (3) SIGNS: Triangular fold of conjunctiva encroaching the cornea. Parts of fully developed pterygium are: Head- Apical part present on the cornea. Neck- Constricted part present in the limbal area. Body- Scleral part extending between the limbus and canthus. Cap- Semilunar whitish infiltrate just present in front of the head.

8. TREATMENT CONSERVATIVE: Artificial tears Protective moisture retaining glasses Punctal occlusion Topical and systemic steroids Dapsone Immunosuppressive therapy

9. TREATMENT SURGICAL: Indications for surgery- Cosmetic disfigurement Recurrent irritation, redness & watering Visual impairment Continued progression threatening to encroach onto the pupillary area Diplopia due to interference in ocular movements Motility restriction Suspected associated neoplastic degeneration

10. SURGICAL METHODS Surgical excision with free conjunctival limbal autograft(CLAU) Surgical excision with amniotic membrane graft and mitomycin-C (MMC) Surgical excision with lamellar keratectomy and lamellar keratoplasty

11. PREOPERATIVE MANAGEMENT A detailed history is taken and slit lamp examination done preoperatively and appropriate grading should be done Past history of similar complain should be noted History of recurrence is asked as there is a risk of fibrosis due to previous surgery Occupation history should be noted Acute inflammed condition should be ruled out and managed medically first and the patient should be advised for surgery in follow up

12. PREOPERATIVE MANAGEMENT Blood pressure Routine blood investigations CBC RBS Urine – R & M HIV & HBsAg Antiplatelet medication should be stopped as per physician & anesthetist advice Obtain an informed & written consent

13. Anesthesia The surgery can be done under local anesthesia – Peribulbar block or can also be done under topical anesthesia if the patient is cooperative Anesthetist should be stand by if the patient is having any cardio-respiratory or any other systemic abnormality

14. Procedure After anesthesia is given, painting and draping of the affected eye is done Head of the pterygium is avulsed from the cornea in a centrifugal manner Corneal scrapping done with 15 no. knife or crescent knife

15. Procedure Subconjunctival Tenon’s tissue is separated Head of the pterygium is cut and hemostatis is achieved

16. Procedure Conjunctival autograft is taken from the superior aspect or the superotemporal aspect Conjunctival autograft is rotated and placed on the bare sclera

17. Procedure The graft is sutured with the conjunctiva with vicryl 8-0/9-0 suture Double pad bandage done with antibiotic moxifloxacin & CMC(0.5%) eye drops

18. Procedure If the surgery is done with fibrin glue – then the preparation of the glue should be done prior to surgery The refrigerated components of the glue are allowed to settle at normal room temperature 30 mins prior to surgery or put in a lukewarm saline for 20-30 min The component A & B are prepared under aseptic precaution in different syringes indicated as per the manufacturer Both syringes should be marked accordingly & put in the trolley prior to surgery The Component A & B should be applied over the bare sclera one after the another and then the CAG is placed over the sclera within 5-10 seconds Double pad bandage is done without any topical medications

19. Procedure The amniotic membrane should also be used in stead of CAG & topical mitomycin – C is advised to prevent the recurrence

20. Complications Intraoperative Puncture wound in the body of pterygium while dissecting the Tenon’s tissue Injury to the medial rectus due to over dissection of the Tenon’s tissue Injury to the superior rectus while taking the CAG superiorly Injury to the cornea while scrapping

21. Complications Postoperative Displacement of the graft from the original position Extensive subconjunctival haemorrhage due to poor handling of tissue during surgery Graft oedema Granuloma formation Scleritis Persistent epithelial defect Dellen Endophthalmitis Late postoperative Opacification over cornea Recurrence

22. Thank you Reference : Kanski’s clinical ophthalmology – 9 th edition