Indication for surgery
- Progression
- Recurrent pain and redness despite topical steroid therapy
- Induction of astigmatism (increase)
- Growth into the visual axis
- Cosmetically bothersome
Differential diagnosis
- Pseudopterygium -> determine cause, treat conservatively if possible
- Neoplasms (e.g., carcinoma in situ, CIN) -> excision with histology or topical chemotherapy
- Pinguecula -> excision only for recurrent inflammation or cosmetic concerns
- Corneal pannus -> monitor; excision and potential reconstruction only if the visual axis is threatened
Alternative therapy
- UV protection, protection from wind, dust, and sand
- Intensive lubrication with drops and ointments
- For redness
- Steroid eye drops (e.g., FML Liquifilm® 4x/day for 1 week, then 3x/day, 2x/day, 1x/day; no long-term therapy)
- Non-steroidal anti-inflammatory drugs (e.g., Yellox® eye drops 2x/day for 2 weeks)
- For itching
- Topical antihistamines and mast cell stabilizers (e.g., Zaditen® eye drops, Opatanol® eye drops)
Preoperative
- Diagnostics (incl. photo documentation, corneal topography)
- Patient education
- Risk of scleral and corneal melting in patients with pre-existing rheumatic conditions -> preoperative assessment and adjustment of immunomodulation if necessary
- Risk of recurrence (depending on age, morphology, etc.)
- Out-of-pocket service (fibrin glue and diamond burr)
- Fibrin glue instead of suturing the graft -> shorter surgery time, faster healing, less postoperative pain and foreign body sensation, better aesthetic results, lower risk of recurrence1
- Removal of cosmetically bothersome stromal changes using a diamond burr -> better aesthetic results
- Anesthesia (topical anesthesia, subconjunctival anesthesia, conscious sedation)
Preparation
- Preoperative: none
- Day of surgery
- 3x Tetracaine SDU ®1% eye drops (every 5 minutes)
- 2x Iopidine® 1% eye drops (every 10 minutes)
Surgery
Operating table
- Supine position, head level, height adjusted for seated surgeon
- Microscopic surgery
Instrument table
- Devices
- Corneal burr (packaged in a sterile glove) (for self-pay package)
- Reusable instruments
- Sterile microscope handles
- Bangerter lid speculum
- Hockey knife
- Westcott blunt scissors
- Castroviejo-Schachar calipers
- McPherson tying forceps
- Diamond burr sterile (for self-pay package)
- Vannas scissors (not for self-pay package)
- Castroviejo needle holder
- Disposable materials
- Hibidil® solution
- BSS 25 milliliters in 10 milliliter syringe with blunt 25 G cannula
- Cataract set
- Gloves
- Rapidocain 10mg/ml with epinephrine 5 mcg/ml in a 5 ml syringe with a 30G sharp needle
- Colibri forceps
- PVA eye spears
- Disposable thermal cautery (400-600°C)
- Vicryl® 8-0 Rapide suture (not included in self-pay package)
- Fibrin glue (TISSEEL® 2ml, warm in hands shortly before application) (included in self-pay package)
- Bandage contact lens (Air Optix® Night & Day Aqua) (not included in self-pay package)
- Floxal® eye ointment
- 2x Eycopad® eye compresses
Surgical procedure
Topical anesthesia. Thorough disinfection of the skin and eyelashes. Dry with round swabs after the contact time has elapsed. Sterile draping. Disinfection of the conjunctiva, followed by irrigation. Marking and subconjunctival infiltration anesthesia in the area of the pterygium and the planned harvest site for the conjunctival graft. Detachment of the pterygium head and dissection of the overlying Salzmann-like altered epithelium with a hockey knife until the Bowman's membrane is visible.
In case of existing scars or stromal opacities, perform careful debridement using a diamond burr (self-pay package)
Excision of the pterygium tissue using Westcott scissors. Removal of residual pterygium tissue at the limbus and sclera using a hockey knife or diamond burr. Conservative cauterization for hemostasis. Follow with BSS irrigation. Undermine the conjunctiva nasal inferior to the defect and measure the defect using calipers. Harvest a suitable conjunctival graft from the inferotemporal area. Suture in place with EKN Vicryl Rapid® 8-0. Apply bandage contact lens if necessary.
Adhere using TISSEEL®. Apply remaining Tisseel to the cornea for protection.
Floxal® eye ointment and monocle dressing with light pressure.
Procedure
Follow-up examination the next day
Therapy
Pain relief medication
- Mefenacid® 500mg tablet, maximum 3x/day
- Dafalgan® 500mg tablet, maximum 8x/day
- Tramal® 100mg tablet every four hours for the first two nights (maximum 4x/day)
Postoperative management
- After 1 day
- Remove dressing (at reception)
- The graft should cover the defect superiorly, inferiorly, and at the limbus (peripheral dehiscence is not a problem); otherwise, consult the surgeon.
- Remove the bandage contact lens only in case of pain, injected conjunctiva, or chemosis. Debride TISSEEL® residues if they are causing discomfort.
- Floxal® UD eye drops 3x/day and Floxal eye ointment at night until epithelial closure (at least 5 days)
- Lubrication as needed (e.g., Optava eye drops)
- After 4-7 days
- Remove the bandage contact lens
- Discontinue Floxal if necessary
- Dexafree® UD eye drops 4x/day for 2 weeks, then 3x/day for 2 weeks, 2x/day for 2 weeks, 1x/day for 2-4 weeks (increase dosage and taper off more slowly if signs of inflammation occur)
- Lubrication as needed (e.g., Optava® eye drops)
- After 3-6 weeks
- Graft position, early signs of recurrence
- taper topical steroids slowly if necessary
- Rule out melting in the corneal and scleral areas
- After 3 months
- Topography (documentation)
- Rule out recurrence
- After 6 months
- Topography: if stable -> clear for refractive procedures (e.g., cataract surgery, LASIK, etc.)
- Rule out recurrence
- After 6 months
- Topography (documentation)
- Rule out recurrence
Sources
- Bagheri N, Wajda B, Calvo CM, Durrani AF, Friedberg MA. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2016.
- Gulani AC, editor. The Art of Pterygium Surgery: Mastering Techniques and Optimizing Results. New York: Thieme; 2020.
- 1. Terres MT, Hira S, de Avila MF, Pereira EMM, Shamsher E, Wagner F, Ribeiro GdR, Assis MLM, Mannan A, Bertholde GD, Vilela M, Piovezan AP. Conjunctival autograft fixation in primary pterygium surgery: a network meta-analysis of randomized trials. Am J Ophthalmol. 2026. doi:10.1016/j.ajo.2026.02.005.
